Saturday, 17 May 2014

AIDS: Nature and Demography

Introduction

Acquired Immunodeficiency Syndrome (AIDS) emerged
as the most dreaded disease of the century. This is
dreaded not because of the fact that death is certain,
but it is also due to the stigma and social ostracism
that is attached to its very name. AIDS continues to be
a major concern of research, which requires broad
ranging structural analysis of the overall health care
sector as well as the social, political and economical
forces that influence its shape and content both in the
western world and in the developing countries. AIDS is
just the tip of an iceberg of a host of social problems
ranging from poverty, accessibility to adequate health
care, disenfranchisement and discrimination. The time
has come not just to say “no” to unwanted sex or
unprotected sex or unwanted conception, it is time to
say no to inequity, to discrimination and lack of choice.
Human Immunodeficiency Virus (HIV), a lentivirus that
belongs to the retrovirus group, is said to cause HIV /
AIDS. Acquired Immunodeficiency Syndrome (AIDS) has
emerged as one of the most serious public health
problems in the country after first being reported in
1986. The initial cases of HIV/AIDS were reported among
commercial sex workers in Mumbai and Chennai and
injectable drug users in the northeastern states of
Manipur. The disease is spread rapidly in the areas
adjoining these epicenters. Currently Andhra Pradesh,
Tamil Nadu, Maharashtra, and Manipur put together
account for two-third of the total AIDS cases in the
country.
Today, 34.3 million adults and children worldwide are
estimated to be living with HIV. The pandemic is most
severe in sub-Saharan Africa, which has 24.5 million
people infected with HIV-1, accounting for almost 9% of
the total population in the 15 to 49 years age group.
The latest UNAIDS and WHO estimates shows that there
are 38.6 million people with HIV, 63.2% are in sub
Saharan Africa, 21.4% are in Asia, 5.2% in Latin
America, 4.1% in North America/Europe, 3.9% in
Eastern Europe/Central Asia, and 2.2% in other parts
of the world. Conservative estimates way back in 1998
show that eleven men, women and children were being
infected per minute. More than 95% of all HIV infected
people are now living in the developing world.
In this chapter you will be basically introduced to the
nature of HIV and AIDS, its history and origin, the
epidemiology and demography of HIV/AIDS. We will also
discuss how the understanding of the profile of the
disease is important for social workers’ further
intervention in preventing and controlling the spread of
the epidemic.

Nature of Hiv/Aids

People have been warned to be conscious about HIV
and AIDS for over twenty years now. AIDS has already
killed millions of people, millions more continue to
become infected with HIV, and there is still no cure. So
AIDS will be around for a while yet. AIDS is one of the
biggest problems facing the world today and nobody is
beyond its reach. Everyone should know the basic facts
about AIDS.

Understanding HIV/AIDS

The disease AIDS was first detected in 1981. AIDS
(Acquired Immuno Deficiency Syndrome) is a medical
condition. People develop AIDS because HIV has damaged
their natural defenses against diseases. It is caused by
a virus which was isolated and identified in 1983 as
the Human Immunodeficiency Virus (HIV). HIV is a virus
belonging to a family of viruses called retroviruses
(known to mutate randomly) and lentiviruses (long acting
i.e., once they enter the human body, the individual is
infected for life and can transmit the virus to other).
HIV can be passed from one person to another. Anyone
can become infected with HIV through contact with the
bodily fluids of someone who has already contracted
HIV. HIV stands for the ‘Human Immunodeficiency
Virus’. Someone who is diagnosed as infected with HIV
is said to be ‘HIV+’ or ‘HIV positive’. HIV has a number
of tricks that helps it to evade the body’s defences,
including very rapid mutation. This means that once
HIV has been contracted, the immune system can never
fullygetridofit.
There isn’t any way to tell just by looking if someone’s
been infected by HIV. In fact a person infected with HIV
may look and feel perfectly well for many years and
may not know that they are infected. But as the person’s
immune system weakens they become increasingly
vulnerable to opportunistic illnesses, many of which
they would have fought off easily in the past. The only
reliable way to tell whether someone has HIV is for
them to take a blood test which can detect infection
from a few weeks after the virus first entered the body.
A damaged immune system is not only more vulnerable
to HIV, but also to the attacks of other infections. It
would not always have the strength to fight off things
that would not have bothered it before. As time goes by,
a person who has been infected with HIV is likely to
become more and more ill often until, usually several
years after infection, they become ill with one of a number
of particularly severe illnesses. It is at this point in the
stages of HIV infection that they are said to have AIDS
indicative of the number of immune system cells left in
their body dropping below a particular point. AIDS is
an extremely serious condition, and at this stage the
body has very little defence against any sort of infection.
AIDS can only be acquired through the contact of body
fluids from an infected person to uninfected person.
HIV enters the human body and attacks the immune
system; mainly infected certain cells called CD4 cells
(or T4 cells). HIV is found in the blood and the sexual
fluids of an infected person, and in the breast milk of
an infected woman. HIV transmission occurs when a
sufficient quantity of these fluids get into someone else’s
bloodstream. There are various ways a person can
become infected with HIV.

Stages of Infection

When a person is infected with HIV, it usually takes
about 3 to 6 months for the antibodies to show in a
blood test. This period is commonly referred to as the
‘window period’. When a blood test detects the presence
of antibodies, the person tested is referred as ‘seropositive’
or ‘anti–body positive’. During this ‘window
period’ an infected person can unknowingly infect others.
The progress of HIV infection varies and should not be
viewed as a definitive cycle of events. However, it is
possible to identify the key elements of the clinical stages
of HIV infection. They can be broadly classified into
three categories.
1. Initial Symptoms of HIV Infection
In the early stages of HIV infection (within weeks), the
person may develop a flu like illness, similar to glandular
fever with symptoms of body ache, rash and swollen
lymph glands. The person appears to get well after a
few days. By this time the person may be considered a
carrier capable of readily passing on the virus to another
person. However, not all infected people (carriers)
develop this kind of initial illness.
2. Asymptomatic HIV Infection Latent Period
As with some other illnesses, this is a period in which
the person who is living with HIV shows no apparent
symptoms. This period, called the latency period, may
range from several months to several years and differ
from individual to individual. The person with HIV may
look and feel healthy, and remains so for many years.
But, the person can pass on the virus to another person
even while he or she looks healthy.
3. Symptomatic HIV Infection
People with HIV begin to feel sick with minor illnesses
such as rashes, infections of the mouth such as oral
thrush, loss of weight (about 10% of the body weight),
persistent fever, night sweats, loss of energy and extreme
tiredness, easy bruising and bleeding and prolonged
diarrhea. This period of symptomatic illness is
sometimes referred to as ‘AIDS Related Complex’ (ARC)
or as the period of active HIV infection.

Transmission of HIV

HIV is transmitted only when contaminated blood and
body fluids come in contact with the blood and mucous
membranes of healthy individuals. Semen and vaginal
secretions, in particular, contain substantial
concentrations of HIV. Though sweat, tears and saliva,
are also body fluids, they contain very low concentrations
of the virus and hence do not present a risk of
transmission of HIV.

HIV/AIDS: Stigma, Siscrimination 6 and Prevention
Ways in which one can be infected with HIV:
l Unprotected sexual intercourse with an infected
person
Sexual intercourse without a condom is risky,
because the virus, which is present in an infected
person’s sexual fluids, can pass directly into the
body of their partner. This is true for unprotected
vaginal and anal sex. Oral sex carries a lower risk,
but again HIV transmission can occur here if a
condom is not used - for example, if one partner
has bleeding gums or an open cut, however small,
in their mouth.
l Contact with an infected person’s blood
If sufficient blood from an infected person enters a
healthy person’s body, then it can pass on the virus.
l Mother to Child transmission
From mother to child HIV can be transmitted from
an infected woman to her baby during pregnancy
(HIV can cross placenta and infect the foetus),
delivery (contact with the mother’s infected blood)
and breastfeeding (breast milk being fluid contain
a certain concentration of the virus). There are
special drugs that can greatly reduce the chances
of this happening, but they are unavailable and
cannot be afforded in much of the developing world.
l Use of infected blood products
If blood or blood product is contaminated, HIV can
be transmitted during transfusion of blood or blood
products. Therefore, blood from all donors should
be screened. Similar precautionary screening should
be done in case of organ or tissue transplants. Many
people in the past have been infected with HIV by
the use of blood transfusions and blood products
which were contaminated with the virus in
hospitals, for example. In much of the world this is
no longer a significant risk, as blood donations are
routinely tested.

Injecting drugs

People who use injected drugs are also vulnerable
to HIV infection. In many parts of the world, often
because it is illegal to possess them, injecting
equipment or works are shared. A tiny amount of
blood can transmit HIV, and can be injected directly
into the bloodstream along with the drugs.
It is not possible to become infected with HIV through:
l Sharing crockery and cutlery
l Insect / animal bites
l Touching, hugging or shaking hands
l Eating food prepared by someone with HIV
l Toilet seats
Test for HIV
The body defends itself against each new viral infection
by manufacturing proteins called ‘antibodies’. The
presence of these antibodies is a positive indicator of
infection. It is similar to HIV. However, after a person is
infected with HIV, it can take up to 3 months for the
antibodies to develop and detected. A person should be
tested only after window period. To detect HIV antibodies
in the blood, a number of different tests have been
developed. Two of the most widely used tests are ELISA
(Enzyme Linked Immuno Sorbent Assay) and the Western
Blot Kit Test. However, a new method of detecting and
identifying the virus in the blood called polymerase chain
reaction (PCR), has been developed.

HIV facts and myths

Around the world, there are a number of different myths
about HIV and AIDS. Here are some of the more common
ones:
‘You would have to drink a bucket of infected saliva to
become infected yourself’ . . . Yuck! This is a typical
myth. HIV is found in saliva, but in quantities too small
to infect someone. If you drink a bucket of saliva from
an HIV positive person, you won’t become infected. There
has been only one recorded case of HIV transmission
via kissing, out of all the many millions of kisses. In
this case, both partners had extremely badly bleeding
gums.
‘Sex with a virgin can cure HIV’ . . . This myth common
in some parts of Africa is baseless and totally untrue.
The myth has resulted in the rape of many young girls
and children by HIV+ men, who often infect their victims.
Rape would not cure anything and is a serious crime.
‘It only happens to gay men / black people / young people,
etc’ . . . This myth is false. Most people who become
infected with HIV did not think it would ever happen to
them. They were proven wrong.
‘HIV can pass through latex’ . . . Some people have been
spreading rumours that the virus is so small that it
can pass through ‘holes’ in latex used to make condoms.
This is untrue. The fact is that latex blocks HIV, as well
as sperm, preventing pregnancy too.

History and Origin of HIV/AIDS

The origin of AIDS and HIV and the first cases of AIDS
The origin of AIDS and HIV has puzzled scientists ever
since the illness first came to light in the early 1980s.
For over twenty years it has been the subject of fierce
debate and the cause of countless arguments, with
everything from a promiscuous flight attendant to a
suspect vaccine programme being blamed. So what is
the truth? Just where did AIDS come from?
Listed below are four of the earliest recorded instances
of suspected HIV infection:
l A plasma sample taken in 1959 from an adult male
living in what is now the Democratic Republic of
the Congo.
l A lymph node sample taken in 1960 from an adult
female, also from the Democratic Republic of the
Congo.
l HIV found in tissue samples obtained from an
American teenager who died in St. Louis in 1969.
l HIV found in tissue samples from a Norwegian sailor
who died around 1976.
The first recognised cases of AIDS occurred in the USA
in the early 1980s. A number of gay men in New York
and California suddenly began to develop rare
opportunistic infections and cancers that seemed
stubbornly resistant to any treatment. At this time, AIDS
did not yet have a name, but it quickly became obvious
that all the men were suffering from a common
syndrome.
The discovery of HIV, the Human Immunodeficiency
Virus, followed soon. While some were initially resistant
to acknowledge the connection (and indeed some remain
so today), there is now clear evidence to prove that HIV
causes AIDS. However we have a research study led by
Paul Sharp of Nottingham University and Beatrice Hahn
of the University of Alabama, which made the discovery
during the course of a 10-year long study into the origins
of the virus. They claimed that this sample proved that
chimpanzees were the source of HIV-1, and that the
virus had at some point crossed species from
chimpanzees to humans. They concluded that wild
chimps had been infected simultaneously with two
different simian immunodeficiency viruses which had
“viral sex” to form a third virus that could be passed on
to other chimps and, more significantly, was capable of
infecting humans and causing AIDS. These two different
viruses were traced back to a SIV that infected redcapped
mangabeys and one found in greater spot-nosed
monkeys. They believe that the hybridization took place
inside chimps that had become infected with both strains
of SIV after they hunted and killed the two smaller
species of monkey.
It has been known for a long time that certain viruses
can pass between species. Indeed, the very fact that
chimpanzees obtained SIV from two other species of
primate shows just how easily this crossover can occur.
Being animals ourselves, we are just as susceptible.
When a viral transfer between animals and humans
takes place, it is known as zoonosis.
Below are some of the most common theories about how
this ‘zoonosis’ took place, and how SIV became HIV in
humans:

Controversial theory on the origin of HIV/AIDS

The ‘Hunter’ Theory

The most commonly accepted theory is that of the
‘hunter’. In this scenario, SIVcpz was transferred to
humans as a result of chimps being killed and eaten or
their blood getting into cuts or wounds on the hunter.
Normally the hunter’s body would have fought off SIV,
but on a few occasions it adapted itself within its new
human host and become HIV-1. The fact that there were
several different early strains of HIV, each with a slightly
different genetic make-up (the most common of which
was HIV-1 group M), would support this theory: every
time it passed from a chimpanzee to a man, it would
have developed in a slightly different way within his
body, and thus produced a slightly different strain.

The Oral Polio Vaccine (OPV) Theory

Could production of the oral polio vaccine have
contributed to the spread of HIV? Some other rather
controversial theories have contended that HIV was
transferred iatrogenically (i.e. via medical interventions).
One particularly well-publicized idea is that polio
vaccines played a role in the transfer.
In his book, “The River”, the journalist Edward Hooper
suggests that HIV can be traced to the testing of an oral
polio vaccine called Chat, given to about a million people
in the Belgian Congo, Ruanda and Urundi in the late
1950s. To be reproduced, live polio vaccine needs to be
cultivated in living tissue, and Hooper’s belief is that
Chat was grown in kidney cells taken from local chimps
infected with SIVcmz. This, he claims, would have
resulted in the contamination of the vaccine with chimp
SIV, and a large number of people subsequently becoming
infected with HIV-1. The fact that the OPV theory
accounts for just one (group M) of several different groups
of HIV also suggests that transferals must have
happened in other ways too. This indicates the fact that
HIV seems to have existed in humans much much before
the vaccine trials were ever carried out.

The Contaminated Needle Theory

This is perhaps an extension of the original ‘Hunter’
theory. In the 1950s, the use of disposable plastic
syringes became commonplace around the world as a
cheap, sterile way to administer medicines. However,
to the African healthcare professionals working on
inoculation and other medical programmes, the huge
quantities of syringes needed would have been very
costly. It is therefore likely that one single syringe would
have been used to inject multiple patients without any
sterilization in between. This would rapidly have
transferred any viral particles existing (within a hunter’s
blood for example), from one person to another, creating
huge potential for the virus to mutate and replicate in
each new individual it entered, even if the SIV within
the original person infected had not yet converted to
HIV.

The Colonialism Theory

The colonialism or ‘Heart of Darkness’ theory is one of
the more recent theories to have entered into the debate.
It is again based on the basic ‘hunter’ premise, but more
thoroughly explains how this original infection could
have led to an epidemic. During the late 19th and early
20th century, much of Africa was ruled by colonial forces.
In areas such as French Equatorial Africa and the
Belgian Congo, colonial rule was particularly harsh and
many Africans were forced into labour camps where
sanitation was poor, food was scarce and physical
demands were extreme. These factors alone would have
been sufficient to create poor health in anyone, so SIV
could easily have infiltrated the labour force and taken
advantage of their weakened immune systems to evolved
into HIV. A stray and perhaps sick chimpanzee with
SIV might have made a welcome extra source of food for
the workers.

The Conspiracy Theory

Some say that HIV is a ‘conspiracy theory’ or that it is
‘man-made’. A recent survey carried out in the US for
example, identified a significant number of African
Americans who believe HIV was manufactured as part
of a biological warfare programme, designed to wipe out
large numbers of black and homosexual people. Many
believe that this was done under the auspices of the US
Federal ‘Special Cancer Virus Program’ (SCVP), possibly
assisted by the CIA. Linked in to this theory is the belief
that the virus was spread (either deliberately or
inadvertently) to thousands of people all over the world
through the smallpox inoculation programme, or to gay
men through Hepatitis B vaccine trials. While none of
these theories can be definitively disproved, the evidence
given to back them up is usually based upon speculation.
Moreover, it ignores the clear link between SIV and HIV
or the fact that the virus has been identified in people
as far back as 1959.

The Pattern of the Spread of HIV Infection: Global
Scenario

There are said to be a number of factors that may have
contributed to the sudden spread of HIV, most of which
occurred in the latter half of the twentieth century.
They are listed as follows:
Travel
International travel has undoubtedly played a major
role in the spread of HIV.
Both national and international travel undoubtedly had
a major role in the initial spread of HIV. In the US,
international travel by young men making the most of
the gay sexual revolution of the late 70s and early 80s,
would certainly have played a large part in taking the
virus worldwide. In India, the virus are supposedly
spread along truck routes and between towns and cities
within the country itself. Similarly, war bases of the
US Army in Phillipines and Taiwan, where soldiers
decamped, later evolved into brothels, hinting of a
similar route of spread. We also witness an inadvertent
growth of sex related tourism in destinations such as
Goa, Thailand and Kovalam. Thus, the process of
transmission in a global pandemic is simply too complex
to blame on any one group or individual.

The Blood Industry

As blood transfusions became a routine part of medical
practice, an industry to meet this increased demand
for blood began to develop rapidly. In some countries
such as the USA, donors were paid to give blood, a policy
that often attracted those most desperate for cash;
among them intravenous drug users (IDUs). During the
early stages of the epidemic, doctors were unaware of
how easily HIV could be spread and blood donations
remained mostly unscreened. This blood was then sent
worldwide, and unfortunately most people who received
infected donations went on to become HIV positive
themselves.
Drug Use
The 1970s witnessed an increase in the availability of
heroin. It was the respective wars especially the Vietnam
War, the civil war in the African subcontinent and later
the other conflicts in the Middle East that stimulated a
growth in intravenous drug use. This increased
availability together with the development of disposable
plastic syringes and the establishment of ‘shooting
galleries’, where people could buy drugs and rent allied
equipment, provided another route through which the
virus could be passed on.
Urbanisation, Migration and Alienation
The rapid industrialization forced large populations to
migrate from the rural to urban area and settlement in
slums bordering the cities and industries. Moving away
from primary groups into secondary groups has lead to
alienation. Such moving away from the family, the
absence of social control (community mores) and the
inability to gain sexual gratification rendered individuals
vulnerable to prostitution. Thus, brothels close to these
squalors owing to the unprotected and indiscriminate
sex too fuelled the epidemic.
Epidemiology
Definition of AIDS case
WHO and National AIDS Control Organization (NACO)
have given the definition of AIDS on the basic certain
criteria which are given below:
Clinical AIDS in an adult
Positive test for HIV antibody detected by two separate
tests using two different antigens and any one of the
following criteria:
1. a. Weight loss of greater than 10% of body weight
or cachexia.
b. Chronic diarrhoea of more than 1 month
duration, chronic coughs for more than 1 month
duration.
2. Disseminated, military or extra – pulmonary
tuberculosis.
3. Neurological impairment that restricts daily
activities.
4. Candidiasis of the esophagus diagnosable,
Dysphagia with oral candidiasis.
5. Kaposi’s sarcoma.

Clinical stage progression

Stage I : HIV infection - asymptomatic/acute
primary infection (sero conversion)
Stage II : Early (asymptomatic) disease (CD4 count
>500/mm3)
Stage III : Intermediate HIV infection (CD4 200-500/
mm 3)
Stage IV : Late stage HIV disease (CD4 50-200/mm3)
Stage V : Advanced HIV Disease (CD4<50/mm3)
Clinical case definition for AIDS in Children
At least two major signs associated with at least two
minor signs in the absence of known cases of immunosuppression.
Major Signs
a. Weight loss or abnormal slow growth
b. 1. Failure to thrive;
2. Recurrent/persistent diarrhoea of over one
month duration;
3. Recurrent bacterial infections, e.g., lower
respiratory infection.
4. Recurrent fever of over one month duration
c. 1. Candidiasis
2. Tuberculosis
3. Herpes Zoster
Minor Signs
a. Generalized lymphadenopathy
b. Oropharyngeal candidiasis
c. Repeated common infection
d. Persistent cough for over a month
e. Generalized dermatitis
f. Confirmed maternal HIV infection.
Risk of Transmission
Transmission dynamics reveal how HIV-1 spread in a
population. Such an understanding helps in designing
control program. The basic reproductive rate RO, is the
average number of infectious contacts by one infected
individual. An infectious contact is a person who would
transmit the infection if his/her partner is non-infected.
For an epidemic to occur, each infected individual must
on an average make infectious contacts with more than
one individual (RO must exceed 1). RO = B(C+D), where
C is rate of partner change, and D is the infectiousness.
This equation is affected by individual, social and
psychological factors (partner selection, sexual and
social network), family dynamics (type of family,
economic conditions, etc.), community factors (type of
neighbourhood, social capital, health services, etc.), and
national and international factors (war, development
and health policies)
The problem of injectable drug use through needles has
emerged as a serious problem firstly in Manipur and
other North Eastern States and also in metropolitan
cities such as Mumbai, Chennai, Kolkata and Delhi.
The problem of HIV/AIDS has added a new dimension
as sharing of injection equipment for narcotic drug use
is one of the most efficient routes of HIV transmission
and is considered to be much more risky than
unprotected sexual contact. While most of the Injecting
Drug Users (IDUs) are male, their female partners are
not known to be in the habit of injecting drug use. The
latter therefore suffer from the risk of sexual
transmission from HIV–infected IDUs without their
knowledge. It has also been noticed that majority of the
IDUs are youth in their most productive age group of 15
– 25 years. Government therefore considers it as a
serious issue and is committed to adopt appropriate
strategies for preventing the risk of transmission through
injecting drug use.
Demography and Prevalence of HIV/AIDS

Burden of HIV/AIDS

India has experienced a sharp increase in the estimated
number of HIV infections, from a few thousand in the
early 1990s to steeply increasing 3.5 million in 1998.
3.86 million in 2000, 4.58 million in 2002 and 5.21
million in 2004. In 2005, it was reported that there
were 5.7 million people infected with HIV in India. With
a population of over one billion, the HIV epidemic in
India will have a major impact on the overall spread of
HIV in Asia and Pacific and indeed worldwide.
Globally India has the second lagest population in the
world as far as numbers of HIV positive cases (2.5
million) are concerned. South Africa (5.4 million) ranks
first. Controversy prevails regarding the absolute
number of HIV cases in India. The UNAID in 2006
emphasized that India is having approximately 3.7
million HIV cases instead of 5.7 million. Recently, the
Indian Government corrected the numbers and stated
that it was 2.5 million and that estimates were
calculated wrongly previously (NACO 2007).
The following are the estimates of the AIDS epidemic in
the country:
l The UN Population Division projects that India’s
adult HIV prevalence will peak to 1.9% in 2019.
There were 2.7 million AIDS deaths in India between
1980 and 2000 as per UN estimates. As per
projections, 12.3 million AIDS death will occur
during 2000-2015, while 49.5 million deaths are
expected to occur during 2015 – 50 (UN 2003). NACO
reported 1,11,608 AIDS cases in July 2005.
l India is experiencing multiple epidemics. More than
100 districts have sentinel sites reporting sero
prevalence of more than 1% among women visiting
antenatal clinics. The epidemic is slowly moving
beyond its initial focus among sex workers. Sub
epidemics are evolving with potentially explosive
spread among groups of injectable drug users (IDUs)
and among Men having Sex with Men (MSM). It is
now seen in all age group and sexual route is the
major cause of transmission. The number of women
are far on the increase.
l About 89% of the reported cases are occurring in
sexually active and economically productive age
group of 15 – 44 years.
l Recent research shows that many men are bisexual,
i.e. they have sex with men as well as with women.
In 2002, behavioural surveillance in five cities
among men who have sex with men found that 27%
were reportedly married, or living with a female
sexual partner. In a study conducted in a low income
group of Chennai in 2001, 7% men who have sex
with men were HIV positive. 76% of the Indian
population had heard of HIV/AIDS; the figure was
93% for urban males and 65.2 % for rural women.
In Bihar, only 21.5% of the adult population and in
UP only 27.6% had ever heard of HIV/AIDS. While
71% of Indians were aware of the sexual route of
HIV transmission, only 18.6% of rural women had
heard of the linkage. Attention and research
currently focuses on areas with high recorded
prevalence, but there is concern about what might
be happening in the vast areas of rural India, for
which especially there is little data.
l The annual sentinel surveillance surveys have
divided States and Union territories in India into
four broad categories:
l High prevalence: Maharashtra, Tamil Nadu,
Manipur, Andhra Pradesh, Karnataka and Nagaland
States which have HIV prevalence rates exceeding
5% among groups with high–risk behaviour and 1%
among women attending antenatal clinics in public
hospitals.
l Moderate epidemics: Gujarat, Pondicherry and Goa,
where HIV prevalence rates among population with
high risk behaviour has been found to be 5% or
more, while HIV prevalence remains below 1%
among women attending antenatal clinics.
l Low prevalence:
High vulnerable states: these states are where
migration was rampant, and where weak health
infrastructure existed. HIV prevalence rates among
vulnerable population are below 5 percent and less
than 1 percent among women attending antenatal
clinics.
Vulnerable states: All other states and Union Territories
fall into the low prevalence category.
The HIV/AIDS situation in Different States
Andhra Pradesh has one of the fastest advancing HIV/
AIDS prevalence rates in India. In 2002, the ANC
prevalence rate was 1.25% and NACO has
estimated that more than 400,000 people are living with
HIV in Andhra Pradesh, the second highest number after
Maharashtra State. This is 10% of the total HIV cases
in India and ninety percent of the infections in the state
occur through sexual transmission.
HIV infection has increased noticeably in Goa in the
past couple of years. The ANC prevalence rate increased
from 0.5% in 2001 to 1.38% in 2002. This could be due
to tourism.
In Karnataka the mean prevalence among ANCs was
1.13 % in 2001 and 1.75% in 2002. In 2001 there were
four districts with an ANC prevalence of 2 percent or
more, and these are located in the southern part of the
state, in and around Bangalore, bordering with Tamil
Nadu, or northern Karnataka’s “Devadasi belt”. Devadasi
women are a group of women, who historically, have
been dedicated to the service of gods. Over the years,
this evolved into sanctioned prostitution – as a result
many women from this part of the country are supplied
to the sex trade in big cities such as Mumbai.
The geographical proximity of Manipur to Burma, and
therefore to the Golden Triangle, has made it a major
transit route for drug smuggling owing to its availability.
However, the transmission route to the state is no longer
confined to injecting drug users. It has spread further
to the female sexual partners of IDUs and their children.
The prevalence of HIV/AIDS in ANC cases in Manipur
was 1.12% in 2002 and among injectable drug users at
three surveillance sites, the HIV prevalence was
extremely high - 39.06%. Similarly high prevalence of
HIV among drug users was recorded in Mizoram (70%),
Nagaland (10.28%) and Tamil Nadu (33.8%).
Affected Population
The majority of the reported AIDS cases occurred in the
sexually active and economically productive 15 - 49 year
age group. Although HIV/AIDS is still largely
concentrated in at risk populations, including
commercial sex workers, injecting drug users, and truck
drivers, the surveillance data suggests that the epidemic
no longer confined, but is moving beyond these groups
in some regions and into the general population through
bridging population. It is also moving from urban to
rural districts.
The epidemic continues to shift towards women and
young people. It has been estimated that 38% of adults
living with HIV/AIDS in India at the end of 2003 were
women. In 2004, it was estimated that 22% of HIV cases
in India were house wives with a single partner. The
increasing HIV prevalence among women can
consequently be seen in the form of increased mother
to child transmission of HIV and paediatric HIV cases.
Sex workers: Mumbai, the country’s largest brothel
based sex industry, with over 15,000 sex workers poses
a major challenge for HIV prevention. A study in Surat
found that HIV prevalence among sex workers had
increased from 17% in 1992 to 43% in 2000.
Injecting Drug Users (IDUs): HIV infections among
Injecting Drug Users (IDUs) first appeared in Manipur.
Here, in the city, the level of HIV infection was 61% in
1994 and increased to 85% in 1997. In 1998, it stabilized
around 80.7%. Injectable drug use is also a major
problem in urban areas such as Mumbai, Kolkata, Delhi
and Chennai. Recent survey data indicate that most
IDUs had at some stage shared their needle and syringe.
A majority of drug users are male. However, females
are also involved and presented more HIV positives as
compared to non – drug addicts females. There is
increased number of widows of addicts, many of them
are HIV positives.
Migrants: According to the 1993, National Sample
Survey in India, 24.7% of the population had migrated,
either within India, to neighboring countries or overseas.
Applying this percentage to the mid – 2003 population
about 264 million Indians are mobile. Being mobile in
itself, does not present a risk factor for HIV transmission.
The migrants often live in unhygienic conditions in urban
slums. Long working hours, relative isolation from the
family, and geographical mobility may foster casual
sexual relationships that make them highly vulnerable
to STDs and HIV/AIDS. Migrant workers tend to have
little access to HIV/STD information, voluntary
counselling and testing, and health services.
Regionalism, as well as cultural and language barriers
cuts their access to such services. Returning or visiting
migrants, many of who do not know their status, may
infect their wives or other sexual partners in their home
community.
Truck Drivers: India has one of the largest road
networks in the world and an estimated 2 to 5 million
long distance truck drivers and helpers are part of this
network. The extended period of time that they spend
away from their families placed them in close proximity
to “high risk” sexual networks, and often results in their
increased number of sexual contacts. During their
journeys the driver often stop at ‘dhabas’, roadside hotels
that usually provide food, rest, sex workers, alcohol and
drugs. They pick up the women, have sex with them
and leave them at some other ‘dhabas’, where they
encounter other drivers, get picked up and get used by
other drivers and local youth. As a result truck drivers
also play a crucial role in spreading STDs and HIV
throughout the country.
Conclusion
The history of AIDS is a short one. As recently as the
1970s, no one was aware of this deadly illness. Since
then the global AIDS epidemic has become one of the
greatest threats to human health and development. At
the same time, much has been learnt about the science
of AIDS, as well as how to prevent and treat the disease.
Although HIV and AIDS are found in all parts of the
world, some areas are more afflicted than others. The
worst affected region is sub-Saharan Africa, where in a
few countries more than one in five adults is infected
with HIV. The epidemic is spreading most rapidly in
Eastern Europe and Central Asia, where the number of
people living with HIV increased 150% between 2001
and 2007.
AIDS is caused by HIV, a virus that can be passed from
person to person through sexual fluids, blood and breast
milk. Certain types of behaviour carry a higher risk of
HIV transmission. People particularly vulnerable to HIV
include injecting drug users, commercial sex workers
(CSWs) and men who have sex with men (MSM). In many
people’s minds, HIV and AIDS are closely linked with
these groups, which can lead to even greater prejudice
against people already treated as outsiders. Yet, the
vast majority of HIV infections are transmitted through
sex between men and women. Nearly half of all adults
living with HIV are female. As a sexually transmitted
infection, HIV particularly affects adolescents and young
adults. Deaths of young adults have an especially
damaging impact on their families and communities:
skills are lost, workforces shrink and children are
orphaned. Apart from inadequate funding, major
obstacles in tackling the global AIDS epidemic include
weak infrastructure and shortages of health workers in
the worst affected countries. Political or cultural
attitudes also cause significant damage; for example,
some authorities oppose condom promotion, while others
refuse to support needle exchanges for injecting drug
users. Many are reluctant to provide young people with
adequate education about sex and sexual health.
Another very serious issue is stigma and discrimination.
People known to be living with HIV are often shunned
or abused by their very own community members,
employers and even health workers. As well as causing
much personal suffering, this sort of prejudice
discourages people from seeking HIV testing, treatment
and care.
Based on recent trends it is likely that AIDS around the
world will keep getting worse for many years to come.
Millions more will become infected with HIV and millions
will die of AIDS. Therefore, Social Work as a profession
needs to focus more on the prevention and control of
the epidemic by generating awareness and removing
the various myths and misconceptions. We also need to
adopt an approach where in the stigma and
discrimination attached to the disease would be
eliminated.