HIV & TUBERCULOSIS

“Do you know he has tuberculosis?” A few decades ago, this revelation was shared by friends and acquaintances with deep foreboding, almost with an air of resignation. The disease, simply known as TB, evoked fear and brought visions of prolonged treatment and expensive visits to sanatoriums on hill-stations.

While TB can now be cured with the availability of effective drugs, its socioeconomic impact is huge. Tuberculosis affects people from all backgrounds, but is more common among the poor and economically productive age groups. Consider this: India has a third of the world’s burden of TB. The prevalence of TB in the country has recently been estimated at 8.5 million cases! This implies that over nine persons in each tiny hamlet of 1000 are suffering from TB, at any point of time. Studies have shown that most people get infected as children or adolescents and the prevalence of latent TB infection (LTBI) among adults in India is 50-60 per cent. A high proportion of Indian adults harbour latent TB infection and are prone to re-activation of TB in the presence of any risk factor. In general, about 10 per cent of infected persons develop TB in their lifetime, about half of them in the first two years after infection.

The exact mechanism of latency of this bacterium – Mycobacterium tuberculosis – and the immune mechanisms involved are not clearly understood. However, it is accepted that the bacteria can remain dormant within macrophages for years and gets re-activated in some infected persons, when the conditions are right. What triggers the re-empowerment of this bacterium that lies silently, for years? Risk factors for re-activation of latent TB include HIV infection, diabetes mellitus, silicosis, immunosuppressive drugs, corticosteroids and severe malnutrition. Smoking has also been identified as a risk factor.

The strongest known risk factor for TB reactivation is HIV. The facts speak for themselves. The incidence of TB among HIV-infected persons has been estimated to be 6.9 per 100 person-years in India. This implies that over 10 years (the average lifetime of an infected person), about 70 per cent of them will develop TB. It is obvious that with increasing numbers of HIV-infected people in India, there is likely to be an increase in tuberculosis cases also. The burden of TB in India is therefore likely to increase if the HIV situation worsens.

Diagnosis of TB among HIV+ People

The clinical and radiographic presentation of TB is different in HIV+ persons, especially among patients with advanced disease, making the diagnosis more difficult. At times,sophisticated investigations like computed tomography (CT scans) may be required to diagnose the lesions not visible on plain X-rays. This is especially true for TB of the brain and abdomen. Studies have demonstrated the presence of TB even among asymptomatic highrisk patients despite normal chest Xrays and negative sputum smears, making the detection even more difficult in this high risk population.

HIV co-infection presents us with a challenge on another front. The classical test used to identify TB infection (positive Mantoux or the tuberculin skin test) is not sensitive enough to detect latent TB in HIV+ persons. Moreover, a typical mycobacteria that do not normally produce disease in healthy individuals can do so in immunosuppressed persons. Special diagnostic tests are required for them.

Adverse impact of HIV and TB on each other

HIV and TB have a negative synergy, with each infection having an adverse impact on the other. HIV infection by virtue of reducing the body’s cellular immune defenses makes the individual more susceptible to TB. This could be a flaring up of old dormant TB or a new infection picked up from the environment. In either case, the infection tends to spread within the body and produce disease in more than one site. Once active TB occurs, it stimulates or activates the immune system to produce cytokines. Some of these cytokines further increase HIV viral replication within lymphocytes, thereby increasing viral load and the severity of HIV disease. Untreated TB leads to a rapid deterioration in the clinical condition of HIV+ patients, with increasing viral load and reducing CD4 counts.

Cytokines further increase HIV viral replication within lymphocytes, thereby increasing viral load and the severity of HIV disease. Untreated TB leads to a rapid deterioration in the clinical condition of HIV+ patients, with increasing viral load and reducing CD4 counts. In spite of anti-TB treatment, it has been observed in many studies that about 30- 40 per cent of patients die within two years after developing TB. Prevention as well as early diagnosis and treatment of TB therefore are a priority for improving the quality of life and longevity of HIV+ persons.

Treatment of TB in HIV+ People

The bacteriologic response to treatment with short course anti-TB regimens is as good as in HIV-uninfected persons. Studies comparing six-month short course regimens (daily or intermittent) between HIV+ and negative TB patients have shown similar cure rates. However, it is recommended that regimens employing less than three times a week treatment (twice or once weekly) not be used because of the higher risk of developing drug resistance. At the Tuberculosis Research Centre, a randomised clinical trial is ongoing to compare a six-month vs nine-month intermittent regimen, in order to determine if the Category I regimen used in the Revised National TB Control Program (RNTCP) would be effective in HIV+ persons. A pilot study done at the Centre showed that the smear and culture negativity during the second month of treatment was good, indicating that the drug regimen is effective in killing M tuberculosis. However, the high mortality - during and immediately after treatment of TB was cause for concern. Similarly, the recurrence rate was high and was caused by both reactivation as well as re-infection with a new strain of M tuberculosis.

Both the high mortality and recurrence rate are directly related to the degree of immunosuppression. Hence, one of the important priorities is to determine when to start anti-retroviral therapy (ART) for patients with both HIV and TB? The drug interactions, overlapping toxicities and logistic problems make the co-administration of anti-tubercular and antiretroviral drugs challenging. The best regimen as well as timing of ART in HIV TB co-infected patients needs to be worked out. Directly observed treatment (DOT) has revolutionized the treatment of TB by ensuring compliance and thereby achieving high cure rates. The feasibility and cost-effectiveness of the DOT strategy for administration of antiretroviral drugs needs further study. Preventive Therapy Preventive therapy for TB has been found to be effective in a clinical trial setting, though the optimal regimen and duration are still debatable. More field/ operational research needs to be carried. A path-breaking clinical trial at the Tuberculosis Research Centre is comparing a six-month regimen of drugs Ethambutol and Isoniazid with a three year regimen of Isoniazid alone, among patients with HIV infection.

Though preventive therapy has the potential to reduce the incidence of TB, it has operational constraints. Experience from USA, South Africa and Brazil has shown that the use of ART in populations is associated with reduced risk of TB, other opportunistic infections and death. An observational cohort study from South India also reached similar conclusions.

The war has just begun

This snapshot of the interaction between HIV and TB outlines the issues of concern and the many challenges to be overcome. No one point tactic will help us here; indeed, a combination of strategies including active case finding for TB in HIV-infected persons, improved diagnostic methods, directly observed treatment, preventive treatment and antiretroviral therapy could reduce the burden of HIV-associated TB in India. Clinical and operational research needs to be undertaken in the areas identified above in order to develop scientifically valid, operationally feasible and cost-effective strategies appropriate for implementation in India.

THE ROAD AHEAD

The probable options which may be used in the Indian circumstance to fight with the deadly disease of HIV & AIDS are being discussed here.

It is well know that there are mainly three types of known transmissions related with the HIV virus:

1. By Sexual Activities with the infected person
2. By Use of Contaminated Blood or Blood Products
3. From Infected Mother to her Child

Not discussing in seriatim, the third issue is being dealt with first.

Mostly HIV can be transmitted from mother to child in three ways. It can occur in the womb, at the time of delivery and also when the child is breast-fed.

1. During Pregnancy: When the mother has a high viral concentration in the blood, some of the virus can pass from the mother to the foetus through the placenta. A small number of foetuses get infected through this route.
2. At the time of birth: The lining of birth canal (Vagina) contains a high concentration of HIV. The baby may sustain minor cuts in the mucous membrane and in the skin during the process of birth. Hence the baby can get infected. 30% to 40% children get infection through this route.
3. Breast milk: About 14% of children who are breast fed by HIV infected mothers will contract the infection.

In the aforesaid cases the transmission may only be checked by the early identification of virus in the females and then mothers should be guided in this regard about the probabilities of transmission, probable consequences, how to proceed so that the risk may be minimize and the applicable medication. These all should be done in a very friendly manner and in personal counselling way so that the individual should get environment to think positively about the issue. Whenever required other family members of the individual may be involved in the process of decision making.

In relation with the next issue of transmission of HIV through Use of Contaminated Blood or Blood Products the most important factors are the various agencies and inputs involved in the process of blood transmission, various vulnerable groups with risk behaviours, other vulnerable groups with different diseases, etc.

It is well known that we get blood and blood products for transfusion from voluntary donors and professional donors. In our country rate of voluntary blood donation is very low so a big part of our blood banks is fed by professional donors who may due to their specific risk behaviours, have HIV virus.

In order to avoid the transmission of HIV virus through blood and blood products the first and the most important thing is that in all cases, the blood must compulsorily be checked for HIV before transfusion. For this the government and voluntary agencies should provide help to the blood banks by educating their staff, by providing proper facilities for testing and by mobilizing the voluntary blood donation by government servants and other persons by providing them some special facilities etc. If we have a very strong system of checking of blood before transfusion then the chances of HIV transmissions may be minimal.

Although in general blood transfusion should be preferred from a known person after proper checks and the general public must be educated in this regard specially by posters or hoardings at sensitive places like hospitals, blood banks etc.

On account of poverty and unemployment and to get money for drugs, liquors etc. some people professionally get involved in the work of blood donation. Some of them due to their risky behaviours of taking drugs, or multiple sexual relationships etc. have chances of getting and transmitting HIV virus. They mostly suffer from very poor health also. But no education or other thing will stop them from doing these except helping them to fulfill their basics needs by various government schemes and voluntary organisations and by establishing very good relations with winning their confidence and then trying to motivate them for behaviour modifications by various practical methods. Only such behaviour modification may have long lasting effects. A team of doctors, psychologists, social workers, educationists, psychiatrists, HIV Educators etc. should be formed for this purpose and they must visit various sensitive areas like slums etc. for this purpose.

For those how are suffering from the diseases like Hemophilia etc. some arrangements should be done to develop a network for them who can donate blood to them whenever they need it after specific time intervals etc. For this the family members, relations, friends related with the individual and social organisations and other persons may be mobilized.

The last but the most sensitive part is the transmission of HIV virus by Sexual Activities with the infected person.

There are mainly three types of sexual activities:

1. Vaginal
2. Anal
3. Oral

It is well known that the HIV virus may enter into the body by breach of mucous membrane which is possible in all the three cases.

Prostitutes, persons who moves from one place to the other mostly like truck drivers, drug abusers, street children are various groups which are very sensitive to the infection due to their or others’ risky behaviours.

In India sex is not considered as a topic of discussion openly in society. People mostly avoid talking about the issue and the topics related with it. Although it can easily gathered from various literatures that all the three types of sexual activities prevail in society in one form or the other, both rural and urban areas, in different form between male and females, males and males, lesbians, or between males and eunuchs. Although mostly we consider that the sexual intercourse should be between the married couples but we cannot deny the presence of other relations in our society too. So any type of sexual relationship outside married couples is a highly risky behaviour for the purpose of transmission of STDs and HIV.

Lack of education, poverty, lack of facilities for entertainment in rural and slum areas, no sex education, improper facilities for identifying and treating STDs and HIV are some of the various factors which effects the issue too.

The various aspects to control the transmission of STDs and HIV like distributing condoms, posturing etc. are only effective upto a very limited extent. But if we study the social, cultural, economical structure of our society, we can easily identify that weaker condition of females in society and risky behaviours are the two main reasons which contribute most in transmission of HIV virus in India.

If we educate females exclusively making separate groups of them like college students, housewives, working women etc. in relation with the aspects of how to live life in a better way to help them and their family may be an effective way to communicate and pass necessary information to them. For this purpose programs should be made by considering the interest of all the areas separately including hygiene, vocational trainings, entertainment etc. With this they should also be provided information related with sex, sexual life, their body, use of contraceptives including female condoms and how to avoid STDs and HIV. This program should be at a large level and in all rural and urban areas to get best of the results.

Similarly, if we program for behaviour modification of the vulnerable groups involved in risky behaviour in a practical manner, we may get the slow result in starting but will get very good and constant results in future. For this various vulnerable groups should be identified and proper studies should be done in respect of their economical, social and cultural backgrounds. Their various basic needs should also be identified. Then with the help of government organizations and schemes and various NGOs and other social organisations and their resources these programs should be run to rehabilitate and readjust them in the society. For these the involved agencies should have to establish very good relations with them. In this way they can be motivated to avoid their risky behaviours and so we can avoid the transmission of HIV.

COSTS TO INDIAN ECONOMY

HIV and AIDS: Speed Breakers on the Economic Superhighway

The potential costs to the economy arising from the continued and unchecked march of the HIV and AIDS epidemic could be quite high, according to a report on The Macroeconomic and Sectoral Impacts of HIV and AIDS in India.

The study, based on a Computable General Equilibrium (CGE) analysis of the likely impact of the epidemic over a 14-year period between 2002 - 2003 and 2015 - 2016, shows that the country’s achievements in terms of economic growth in the next 10-15 years will be noticeably less than its potential.

“According to the model projections, GDP at 2002 - 2003 prices would decline in 2015 - 2016 by Rs. 11,097.93 billion. The GDP per capita (at 2002 - 2003 price), according to projections made using the CGE model, would decline in 2015 - 2016 by Rs. 7,610.61,” the report notes.

The increase in health spending by both households and the governments also causes a drop in their savings, which then crowds out investment and causes growth to slow down.

“It is time to see policy action against AIDS as a growth-enhancing policy endeavor, and, first and foremost, dedicate adequate resources for this purpose,” the report urges.

It says the impact of the epidemic on the economy comes through five routes:

1. Slower growth in population and supply of labour due to AIDS - related deaths. Labour supply is likely to fall by 0.31 percentage points over the 14-year period, with unskilled labour showing the largest decline of 0.35 percentage points and skilled labour the least by 0.22 percentage points.
2. Lower labour productivity of HIV affected workers.
3. Declines in sectoral total factor productivity growth.
4. 10 percent increase in household health expenditure.
5. 5 percent increase in government health spending.

The report states that impoverishment is inevitable as real wages drop by 0.10 percentage points, with unskilled labour taking the greatest hit. It notes that sectors using unskilled labour will be hit relatively harder. The tourism sector is expected to suffer the most, with an 18.31 percent loss in value added by 2015 - 2016. Manufacturing will be affected to the extent of 12.48 percent, services by 10.13 and agriculture by 9.08. Within industry, the sectors that have been identified as most vulnerable are construction, chemicals, mining and quarrying, capital goods and textiles.

In the event HIV/AIDS spreads unchecked over the next decade:

1. Economic growth could decline by 0.86 percentage points
2. GDP could decline by 0.55 percentage points
3. Government saving as percentage of GDP likely to fall by 0.671 percentage points due to increased health spending
4. Household savings likely to decline by 1.15 percentage points
5. Investment decline likely to be 1.16 percentage

WOMEN BEAR THE BRUNT

The social, economic and gender impacts of HIV and AIDS in India was the subject of a nationwide study conducted by the National Council of Applied Economic Research (NCAER), with support from the National AIDS Control Organization (NACO) and United Nations Development Programme (UNDP). The findings, encapsulated in three reports, were released in New Delhi on July20, 2006 by C. Rangarajan, Chairman, Prime Minister’s Economic Advisory Council. Also present were Sujatha Rao, Additional Secretary and Director General, NACO, Maxine Olson, UNDP Resident Representative, and Suman Bery, Director General, NCAER.

The impact of HIV and AIDS is felt far beyond the health sector and has severe economic and social consequences - and it is women who are the worst sufferers. According to an NCAER report titled ‘Gender Impact of HIV and AIDS in India’, biological, societal and economic factors make women and young girls more vulnerable to the epidemic.

The report reveals that the low status of women, poverty, early marriage, trafficking, sex work, lack of education and gender discrimination are factors responsible for the increasing vulnerability of women and girls to HIV infection.

The main route of HIV transmission in India is through sexual contact and it accounts for about 86 percent of HIV infections in the country. Blood transfusion, parent-to-child transmission and drug use, particularly in the northeastern states and some metropolitan cities, account for the remaining 14 percent.

VULNERABILITY OF WOMEN AND GIRLS:

There are a number of factors - biological, socio-cultural and economic - which make women and young girls more vulnerable to HIV and AIDS. Women are at a biological disadvantage of contracting the virus as HIV is more easily transmitted to a female body as compared to men. In sub-Saharan Africa, young women in 15-24 age group were 2.5 times more likely to be infected as compared to men of the same age group.

Gender inequality and poverty are responsible for the spread as well as disproportionate impact of the epidemic on women. The gender inequalities get reflected in the sexual relations between husband and wife.

In India, women do not have the right to decide when to have sex; as a result, they cannot negotiate safe sex and ask men to use condoms. There is also lack of availability of female-controlled HIV preventive methods.

Cultural norms and attitudes condoning multiple sexual partners for men, and their pre- or post-marital sexual relationships increase women’s risk of getting infected with the virus.

IMPACT ON SCHOOL CHILDREN:

The study reveals that as compared to non-HIV households, the gender gap in the dropout percentages is more among students from HIV households in the 6-14 age group and for rural children in the 15-18 age group.

In HIV households, boys are mostly withdrawn from school to take up an income-earning activity and girls are discontinuing the schooling in order to take care of younger siblings and household chores.

In the case of boys, in more than 40 percent of the cases, "had to take up jobs" is reported as a reason for dropping out and in the case of girls, the percentage is nearly 33 percent.

Though the gender difference is not very significant in HIV households among junior students, in the case of older children, 32 percent of boys had to absent themselves from school due to their parents’ ill health. But more than 40 percent of the girls had to drop out from the schools to care of their ailing parents.

The study also found that since expenses in government schools are comparatively lower, children of HIV-infected parents opt for such schools. From a gender perspective, the percentage of girls attending government schools is much higher than boys.

While 67 percent of girls are studying in such schools, in the case of boys it is below the 60 percent mark. Such schools are much cheaper, if not free, and also come with other benefits like uniforms, mid-day meals and free books.

STIGMA AND DISCRIMINATION:

The study says that though stigma and discrimination are faced by a bulk of the HIV-infected people, there is evidence to show that women are targeted to a significantly greater degree.

The study tried to find out how the affected persons and their families reacted when they come to know about the presence of an HIV-infected person in the household.

More than 65 percent of people living with HIV and AIDS (PLWHA) were shocked to know they were positive. Interestingly, however, the percentage of families shocked when the PLWHA is a male is higher than when it is a female.

This could be indicative of the fact that a large number of women tested positive after their husbands had already tested positive. Hence the spouse and the family probably expected it and the disclosure of the status did not come as a shock, the report notes.

In what can be termed as an encouraging sign, the survey reveals that 74 percent of male and 70 percent of female have reported that their families are quite supportive despite an initial hesitation. However, it says gender discrimination is noticeable in that while nearly 5.5 percent of the HIV-infected women were asked to leave home, only 1.9 percent of the male PLWHA were subjected to similar treatment.

Again, while 12.4 percent of women are supportive of their HIV positive husbands, only 8.5 percent men support their infected wives. The percentage reporting problems like “deprived of using basic amenities” is more in the case of women - irrespective of place of residence.

Discrimination in the form of neglect, isolation or abuse was reported by a higher percentage of women in both urban and rural set-ups.

Quoting a UNAIDS Inter-Agency Task Team on Gender and HIV and AIDS, the report states that equality and non-discrimination should not only be important principles of human rights law, but are also vital for disease prevention and for ensuring equitable access to care, treatment, and support for those affected by the infection.

KNOWLEDGE OF HIV AND AIDS:

Gender differences are also visible when it comes to knowledge about HIV and AIDS infection, the modes of transmission, with men being better informed that women. While 58 percent of the men know about all the modes of transmission, only 54 percent of women had the same knowledge. Misconceptions about the modes of transmission were also higher among women. Knowledge about the linkages between sexually - transmitted diseases and HIV and AIDS was not only low among the general public, but in most of the surveyed states women were far less knowledgeable.

STATUS OF HIV - POSITIVE WIDOWS:

The survey discloses that households of HIV - positive widows are poorer than other HIV households. The families of HIV - positive widows have less income and they spend lesser than others on food. Their savings are also less and most of them are below the poverty line. The lack of income and employment opportunities could push them to making sub minimal choices like entering the sex trade, the report remarks.

The report also mentions that hardly 10 percent of the widows are living with their husbands’ families. While 40 percent of the widows are living alone, almost none of them are living with their natal family.

HIV - positive widows face double the stigma and are discriminated against by both their family as well as society at large. Most widows complained that they were thrown out of their houses after they were widowed.

Encouragingly, however, in spite of low incomes HIV - positive widow households are spending more on the education of children as compared to other households. In these households, almost an equal percentage of boys and girls study in government and private schools.

The report says that wherever possible they are giving equal opportunities to girls and it is possible that being HIV - positive widows, they realize the importance of educating their daughters.

But the drop-out rate is higher in these households and the report suggests this could be due to two reasons - in the absence of earning members, children may have had to take up jobs; or they have to take care of ailing family members.

REGIONAL STRATEGY 2006 - 2015

WHO’s global strategy

WHO recently launched its Global Strategy for the Prevention and Control of Sexually Transmitted Infections for 2005-2010. The global strategy provides strong economic and public health justification for an accelerated response to STIs, and shows how such action can contribute to achieving Millennium Development Goals of reversing the spread of HIV and lowering maternal and child mortality.

The technical content of the global strategy deals with methods to promote healthy sexual behaviour, the provision of barrier methods, how to deliver effective and accessible care for STIs and how to improve methods for monitoring and evaluating STI control programmes. It points out that STIs occur with the highest frequency among marginalized populations who frequently have poor access to services and emphasizes that the public health benefits of improving coverage to these groups can be substantial.

The strategy also makes a strong case for expanding the provision of good quality STI care more widely into primary health care, reproductive health services and HIV services. It emphasizes opportunities to increase coverage by working collaboratively with c o m m u n i t y - b a s e d organizations, private providers and other government sectors. The steps needed to develop health systems capacity are explained as is the need for reliable STI surveillance to guide control efforts.

An STI control strategy for South-East Asia WHO/SEARO has developed a 3-point strategy for
accelerating STI control in the Region. The strategy provides direction for countries to review their STI epidemics and the status of their STI control programmes, and to set realistic priorities and targets. Regional experiences have been highlighted to help countries adapt successful strategies for their STI programmes. Technical guidelines and tools are available to support interventions and services promoted in the strategy.

WHY INVEST IN STI PREVENTION AND CONTROL NOW?

1. To prevent adverse pregnancy outcome. The fourth Millennium Development Goal to reduce child mortality by 2015
2. To prevent serious complications in women. The fifth MDG seeks to reduce maternal mortality by three-quarters by 2015.
3. To prevent HIV infection. The sixth MDG calls on nations to reverse the spread of diseases, especially HIV/AIDS.

GUIDING PRINCIPLES

1. Public health orientation
   Sound public health principles provide the framework for efforts to control STIs and monitor progress.
2. Enabling environment
   Active involvement of affected communities is essential both in creating the sense of ownership and increasing acceptance of the programme.
   Broad support of other community stakeholders to reduce marginalization and vulnerability and to increase access to interventions.
   Attention to gender and cultural realities that influence norms and behaviour.
3. Commitment to a multi-sectoral response
   Active involvement of civil society and international partnerships contribute to successful and sustained response.
   Involvement of private health care providers in the public health response to STIs is crucial.
4. Strong leadership
   A strong level of political and financial commitment to controlling STIs at national and local levels is needed to implement new programmes and to scale up existing programmes to reach wider populations.
   Effective programme management with sufficient technical support is most critical to ensure effective interventions and services.

An STI control strategy for South-East Asia

WHO/SEARO has developed a 3-point strategy for accelerating STI control in the Region. The strategy provides direction for countries to review their STI epidemics and the status of their STI control programmes, and to set realistic priorities and targets. Regional experiences have been highlighted to help countries adapt successful strategies for their STI programmes. Technical guidelines and tools are available to support interventions and services promoted in the strategy.

STI REGIONAL STRATEGY 2006-2015

Goal

To reduce STI-related morbidity and mortality

Objectives

1. Cut incidence in high transmission networks to interrupt transmission and reduce prevalence at population level;
2. Improve STI case management for all to further reduce morbidity and mortality; and
3. Ensure reliable data to guide the response.

Objective 1 - Cut incidence in high transmission networks

Experience from the region shows that STI transmission can be rapidly controlled by reaching sex workers and their clients with effective interventions. The main components of such interventions include:

1. Peer outreach to reach at least the most active sex workers. The most effective outreach involves sex workers themselves - female, male and transgender - to promote condoms and services to their peers.
2. Condom programmes. The most important outcome to reduce sexual transmission in commercial sex networks is to achieve high rates of condom use (see 100% CUP). Every effort should be made to influence the structure of sex work to make condom use the norm for all clients.
3. STI services. Treating STIs in sex workers and clients reduces secondary transmission and helps reduce STI prevalence as condom use is increasing; and lower STI prevalence reduces risk of HIV transmission when condoms are not used or fail.
4. Enabling environment. Sex work is illegal in most places and police action or interference from organized crime can prohibit access or disrupt interventions. Sex workers themselves may be isolated and have little power to decide whether condoms are used or how sex is performed. Sex work interventions should thus include advocacy to explain the public health objectives of the interventions.

Increasingly, these different elements are being combined in successful interventions in different settings.

In areas where STI transmission is high and existing services poor or inaccessible to those who need them, short-term interventions may be indicated to rapidly bring down high rates of curable STI. Presumptive (or epidemiologic) treatment strategies targeting core groups with high STI prevalence and exposure have been effectively used for short-term reduction of STI rates. As STI rates decline, other interventions (increased condom use, effective STI case management) are needed to sustain control.

Objective 2 - Improve STI prevention and case management for all

STI services should provide comprehensive STI prevention and case management, which includes early detection, effective treatment and prevention interventions for anyone who seeks care in any health care setting. Comprehensive STI case management limits the spread of infection to uninfected sexual partners, reduces congenital transmission and prevents the development of long-term complications among those already infected. By raising general awareness of STIs and by improving STI services in primary health care, reproductive health, youth clinics and among private providers, the community burden of STI-related morbidity and mortality can be further reduced.

People should be able to recognize STI symptoms, realize the importance of seeking care early and have easy access to accurate diagnosis and effective treatment. STI programmes should thus widely promote accessible and acceptable services which offer comprehensive and effective case management. Special attention should be paid to reaching people at high risk who are not addressed under objective 1, including young people, migrant workers and other male bridging
populations.

Health care seeking behaviour

A major problem in STI control is that many individuals infected with STIs are unaware of their infection or delay seeking treatment. People with STI symptoms frequently attempt to self-medicate or buy antibiotics directly from pharmacies before seeking treatment at a health care facility. Healthcare seeking behaviour can be improved by raising awareness of STIs and promoting early treatment at medical facilities. Education to raise awareness of STI symptoms and promote early use of health care facilities should be disseminated widely in communities, through outreach other counselling activities.

STI case management

The components of comprehensive case management of STI patients include:

1. making a correct diagnosis by syndrome or laboratory diagnosis
2. provision of effective treatment
3. reduction/prevention of future risk through education and counselling
4. promotion and provision of condoms, and
5. ensuring that sexual partners are notified and treated

Whenever an infection is diagnosed or suspected, effective treatment for STIs should be provided promptly to avoid development of complications and to break the chain of transmission. Patients should receive education and counselling on treatment compliance, partner management, risk reduction and condom use. Treatment or referral should be provided
for any complications.

Primary health care

STIs and other reproductive tract infections remain significant causes of preventable reproductive tract morbidity and mortality, and improved services in primary care clinics - starting with syndromic case management and antenatal syphilis screening - are cost-effective for these reasons alone.

Reproductive health care

STIs and other reproductive tract infections (RTIs) contribute significantly to women’s ill-health by increasing risk of infertility, ectopic pregnancy, cervical cancer, spontaneous abortions and HIV infection. STI prevention, detection and early treatment are thus key elements in women’s health services. Maternal and child health, and family planning clinics serve many women of reproductive age and can greatly extend the reach of STI services.

Youth friendly health services

Sexually transmitted infections are a major health risk to all sexually active adolescents. Every year one in 20 adolescents contracts a bacterial STI, and the age at which infections are acquired is becoming younger. Services for and outreach to young people should be improved.

Private providers
Efforts should be made to improve STI services wherever they are provided and to involve private and informal sectors where many people seek care.

Objective 3 - Ensure reliable data to guide response

STI control efforts should be guided by reliable STI data and information on programme coverage. Trends of short duration STIs are a more sensitive indicator of high-risk sexual activity than those based on HIV prevalence and can be monitored widely, even in underserved areas where STI control may be poor. As markers for HIV transmission, STI surveillance is a recommended component of second-generation surveillance. Yet STI surveillance remains very weak in many countries.

Where STI surveillance is not functioning well, there is insufficient information for planning, implementing and evaluating STI and HIV prevention and control programmes. The regional strategy urges countries to adopt a two-phase approach to

1. ensure that basic STI surveillance and monitoring activities are in place and are used to track trends and coverage, and
2. build on and improve the basic system to develop better estimates of STI prevalence, antimicrobial resistance, etc.

incorporating the following elements:

1. STI case reporting
2. STI prevalence assessments and monitoring
3. Monitoring aetiologies responsible for STI syndromes
4. Measuring anti-microbial resistance patterns to determine whether STIs such as gonorrhoea are sensitive to recommended treatments
5. Surveys to monitor behaviours, ideally together with STI and HIV, in key populations
6. Operations research to answer questions not addressed by routine surveillance

Special initiatives and areas of focus

The global strategy proposes several initiatives for control or elimination of specific STIs. Because of high prevalence, morbidity and mortality related to some of these infections, these initiatives are highly relevant to the South East Asia Region.

1. Control of genital ulcer disease (GUD)
2. Elimination of congenital syphilis

In addition, the regional strategy promotes several special areas of focus to improve STI control and prevent HIV transmission. These include:

1. Strengthened HIV-related services
2. Roll-out of effective vaccines
3. Wider access to drugs and appropriate technology

Next steps

Reducing the high burden of STIs in South-East Asia region is feasible and would yield large public health benefits. To accomplish this will require commitment from countries to assess their situation and take steps to improve STI prevention and control. Countries are encouraged to review their national STI control programmes and to adapt the regional strategy to their local situation. Attention should be given to setting appropriate priorities and feasible targets, with an eye to improving STI control at sufficient scale to have public health impact.

Milestones

Countries should set milestones for progress in line with their specific STI control objectives. As a starting point, the regional strategy proposes the following broad milestones for SEAR countries in 2006-2010.

Actionable items: highest priority & Targets

1. Cut incidence in high transmission networks - Reach 80% coverage of sex workers and 80% of high-risk MSM by 2010
2. Improve STI case management for all - Cover 90% of relevant primary point-of-care sites and patients by 2010
3. Ensure reliable data to guide the response - Regional and country plans: 2007. Training and implementation 2007-2010

Actionable items: second level & Targets

1. GUD control and chancroid elimination - Regional and country plans by 2007
   ● Regional chancroid elimination by 2010
   ● Reduction of ANC syphilis prevalence to below 1% in all SEAR countries by 2015
2. Congenital syphilis elimination - Regional and country plans by 2007. Implementation 2007-2010 to attain 90% ANC coverage
3. Effective vaccine roll out - 5-year plan by 2007; pilot studies: 2007-08; scale-up: 2009-10
4. Prevention strategies/programmes for HIV positive persons - Strategies, curricula and materials by end 2006; implement interventions in 90% HIV clinical services by 2007
5. Provider-initiated HIV testing and counseling for STI patients - Facilitate development and implementation of universal coverage of HIV T&C for STI patients by 2010

SEXUALLY TRANSMITTED INFECTIONS IN SOUTH EAST ASIA

Sexually Transmitted Infections (STIs) are important health problems

Worldwide, nearly one million curable STIs occur each day, half of them in Asia. Where they are common, STIs are major causes of infertility, ectopic pregnancy, congenital infections and HIV/AIDS. Millions more incurable STIs add to the heavy burden of morbidity and mortality for women, men and children.

In addition, several STIs are potent cofactors that amplify transmission and facilitate spread of HIV epidemics. STIs are also sensitive markers of high-risk sexual activity that can indicate where HIV may be spreading.

STI surveillance is incomplete in most countries. In some areas with active prevention programmes, STI patterns are reportedly changing from high rates of curable and ulcerative STIs to lower overall rates with higher proportion of viral STIs. However, both intervention coverage and surveillance remain patchy; continued high transmission in underserved areas may go undetected and sustain high prevalence rates.

STIs in South-East Asia

Although STI rates are generally high in the Region, patterns are variable. Some countries have very high prevalence of curable STIs while others have low rates more typical of developed countries. Some countries have high rates of ulcerative STIs while others have few ulcers but high prevalence of gonorrhoea and chlamydia. While all countries can benefit from strengthening their STI control efforts, different epidemiological patterns call for different approaches.

Poor STI control has also facilitated HIV transmission in the region. Beginning in the 1980s, HIV took off quickly in several Asian countries under conditions of poverty, injecting drug use, commercial sex and population mobility. High rates of partner change with low condom use in such situations overwhelmed existing STI control efforts. STI patterns at the time were characterized by high rates of bacterial and ulcerative infections. High HIV incidence among sex workers and their clients rose quickly and clients spread infection to their lower risk partners.

1. Sex workers: The highest STI prevalence rates in the Region continue to be seen among sex workers. Prevalence of 20-50% for gonorrhoea and chlamydia and 10-20% for syphilis are common.
2. High-risk men: Males, particularly those who travel frequently or are separated from families for long periods, may serve as efficient bridging populations for STI transmission to the general population.
3. Pregnant women: High STI rates can be found in lower-risk populations if transmission among high-risk and bridging populations is not interrupted. Antenatal syphilis data can be a good marker of STI transmission in the general population.

Regional experience

In South-East Asia region, experience supports the combination of approaches outlined in WHO’s global strategy. Improved outcomes have been seen as a result of improving STI services, reaching the highest-risk populations and basing programmes on reliable data.

The 100% Condom Use Programme (CUP) in Thailand has enabled sex workers to demand condom use and access STI care. It has also had large-scale public heath impact. Rates of curable STIs fell by over 95% during the 1990s. By 2002, an estimated 5.7 million HIV infections had been averted; this includes sex workers and their clients but also - taking into account averted secondary infections - far larger numbers of people at lower-risk. Similar results are being reported to a varying degree where this approach is being adapted in Myanmar and other Asian countries.

The benefits of better STI control are within the reach of all countries in the South-East Asia region. The Regional Strategy builds on successful regional experience and global evidence to promote replicable interventions and feasible targets for STI control in South-East Asia.

Some successful initiatives of the region are:

Sex worker involvement

1. Sonagachi: STI/HIV services are one part of a broader effort to improve conditions for members of the community (community-led structural interventions). Sex workers participate actively in all aspects of community interventions and clinic-based services. HIV prevalence remains low in Kolkata compared to other Indian cities. Over 60,000 sex workers participate throughout the state of West Bengal, savings and credit schemes have reduced dependency on sex work, and self-regulatory boards effectively address a range of abuses from trafficking to child prostitution.
2. Avahan India AIDS Initiative: In order to scale up effective interventions for sex workers and other high-risk populations in India’s 6 highest HIV prevalence states, Avahan supports NGOs to organize outreach, community mobilization and dedicated clinics for sex workers. These clinics provide STI services including syndromic case management, regular checkups and treatment of asymptomatic infections. Condoms are promoted and distributed by outreach and clinic teams. Local advocacy work is carried out with police and others to promote enabling conditions for prevention work. Sex worker involvement is promoted in intervention activites from community outreach to provision of clinical services.

100% Condom use in commercial sex

1. Thailand 100% CUP: Implemented through a network of public health STI clinics, the 100% CUP achieved early success by saturating coverage of direct (brothel-based) sex establishments where condom use was mandated. The responsibility for enforcing condom use was on the establishment, which could be closed if non-compliant (although this was rarely done). One of the most important activities was local advocacy with police and other gatekeepers. As sex work changed to less direct forms (massage, karaoke and bar-based), interventions were adapted to include more outreach and increase involvement of sex workers. The Thai response highlights the importance of political commitment and public
   investment, a rapid response based on reliable epidemiological information, and multi-sectoral collaboration.
2. Myanmar 100% targeted condom promotion: Adapted from 100% CUP experience in Thailand and Cambodia, the 100% TCP in Myanmar attempts to reach sex workers and their clients through peer outreach, establishment visits and STI clinics. A clear plan of startup activities – formation of condom core groups, training of peers and clinical staff, etc – is rolled out in new sites. In 5 years, 100% TCP has been scaled up to cover 154 out of 350 townships in the country

RESPONSE TO HIV/AIDS

STOP AIDS: KEEP THE PROMISE

Universal access to health care and HIV/AIDS

The World Health Organization has been committed to the goal of universal access to health care for many years beginning with a resolution adopted at the Thirtieth Health Assembly (1977) when countries committed themselves to the attainment by the year 2000 of a level of health that would permit all peoples of the world to lead socially and economically productive lives.

1. The primary health care strategy, formulated a year later at the 1978 International Conference on Primary Health Care, recognized that primary health care is based on practical, scientifically sound and socially accepted methods and technology made universally accessible to individuals and families in the community.
2. The Declaration of Commitment at the 2001 United Nations General Assembly Special Session on HIV/ AIDS has led to increased international commitment and considerable success in some countries in ensuring access to HIV /AIDS services. However, reaching the Millennium Development Goals related to HIV/AIDS requires that HIV prevention, treatment, care and support interventions be scaled up much further.
3. In 2003, WHO declared the lack of access to antiretroviral treatment (ART) a global health emergency. Subsequently, WHO and the UNAIDS Secretariat announced a global initiative to support countries in delivering ART to 3 million people living with HIV/AIDS in low- and middle-income countries by the end of 2005. In May 2004 the “3 by 5” target was unanimously endorsed by all 192 WHO Member States at the Fifty-seventh World Health Assembly.

“3 by 5” Initiative: Lessons Learnt

The “3 by 5” target has had an important catalyzing effect at the global level, and has been acknowledged as an important step in a longer-term global effort to realize the objectives set out in the Millennium Development Goals. It has demonstrated that providing treatment is possible in even the most resource-challenged settings, but that sound planning and well-supported infrastructures are both essential. Perhaps most importantly, “3 by 5” illustrates that expanded international financial support, improved international coordination and communication, clear milestones, robust monitoring and evaluation, enhanced partnership structures, improved implementation of lessons learnt and an intensified focus on strengthening health systems are all essential elements to achieving universal access by 2010. The “3 by 5” initiative has highlighted the importance of using existing opportunities and health infrastructure to deliver ART and scale-up HIV prevention in resource-limited settings, notably in the areas of tuberculosis, sexual and reproductive health, prevention of mother-to-child transmission of HIV and management of substance dependence.

Moving Towards Universal Access

1. To maintain momentum and build upon the progress made so far, in July 2005 leaders of the G8 group of industrialized countries announced their intention to “work .... with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010”. This goal was subsequently endorsed by all UN Member States at the High Level Plenary Meeting of the Sixtieth Session of the UN General Assembly in September 2005.
2. The World Health Organization takes the lead within the UN system in the global health sector response to HIV/AIDS. WHO provides technical, evidence-based support to Member States for a comprehensive and sustainable response to HIV/AIDS treatment, care, and prevention through the health sector. In 2003, the Fifty-sixth World Health Assembly endorsed the Global Health Sector Strategy for HIV/AIDS, 2003-2007, and requested WHO to support Member States in implementing the strategy. The Strategy defines the “Core Components of a Health-Sector Response to HIV/AIDS”.
3. WHO’s global plan on the Contribution to Scaling Up towards Universal Access to HIV/AIDS Prevention, Treatment and Care 2006-2010, was released in 2006.
4. A regional strategic plan was developed to guide the WHO South-East Asia Region’s contribution to scaling-up HIV/AIDS prevention, care and treatment responses in Member countries in order to achieve the targets by 2015. It provides direction to the Organization at regional and country levels to work together and in cooperation with partners to achieve the goal. It relates particularly to the assistance that WHO will provide to ensure that the health sector in each country makes an effective and sustainable contribution to HIV prevention, treatment and care. It acknowledges the crucial need for increased cooperation and coordination between global partners.
5. Scaling-up of the HIV/AIDS strategy in the Region involves developing a comprehensive response to HIV/AIDS that includes prevention, treatment and care as well as addressing the need to expand coverage geographically, to reach more people. It also focuses on increasing coverage to different population types, improving the quality and scope of services, and ensuring that the involved systems are accountable. The ultimate goal is to guarantee the delivery of a comprehensive range of interventions and programmes to reduce the transmission of HIV/AIDS and lessen its impact on individuals and societies.

WHO - Leading the Health Sector Response to HIV/AIDS

Goals

The regional strategy is to strengthen health system capacities in all countries to effectively scale up interventions for the prevention, care and treatment of HIV/AIDS and sexually transmitted infections (STIs).

The objectives are:

1. To prevent HIV transmission
2. To improve the quality of life of those living with and affected by HIV/AIDS, and
3. To alleviate the impact of HIV/AIDS on individuals, households and local communities.

Regional Strategic Plan for HIV/AIDS, 2007-2015

Strategic Directions:

Strategic Direction 1: Maximizing the health sector’s contribution to HIV prevention

Priority interventions:

1. Prevention of sexual transmission
2. Prevention of HIV transmission through injecting drug use
3. Prevention of parent-to-child transmission (PPTCT)
4. Prevention of HIV through the healthcare setting

Strategic Direction 2: Enabling people with HIV to know their status through HIV testing and counselling

Priority interventions:

1. Voluntary testing and counselling
2. Provider-initiated testing and counselling

Strategic Direction 3: Accelerating the scale-up of HIV/AIDS treatment and care

Priority interventions:

1. Antiretroviral therapy
2. Prevention and management of opportunistic infections
3. Care, including nutrition, palliative care and end-of-life care
4. Prevention for people living with HIV
5. Linking HIV and TB services

Strategic Direction 4: Investing in strategic information to guide a more effective response

Priority interventions:

1. Epidemiology and surveillance of HIV and STIs
2. HIV drug resistance transmission surveillance and monitoring as part of ART programmes
3. Monitoring and evaluation of the health sector’s progress towards universal access
4. Operational research

Strategic Direction 5: Strengthening and expanding health systems

Priority interventions:

1. Advocacy, leadership and stewardship
2. National strategic planning and management
3. Procurement and supply management
4. Laboratory strengthening
5. Human resource management
6. Strategies for sustainable financing

HIV/AIDS SITUATTION

Global Burden

Worldwide, 39.5 million people are estimated to be living with HIV/AIDS, 17.7 million are women and 2.3 million are children.

Of all HIV/AIDS sufferers, during 2006, an estimated:

1. 3.8 million are newly-infected adults
2. 530 000 are newly-infected children
3. 2.4 million adult deaths
4. 380 000 child deaths

The HIV/AIDS epidemic continues to grow worldwide. Currently, it accounts for the highest number of deaths by any single infectious agent.

1. About 95% of all HIV infections occur in low- and middle-income countries.
2. The highest burden of HIV/AIDS is in Sub-Saharan Africa, followed by South-East Asia.
3. One fifth of the HIV-infected people of the world live in Asia.
4. Young people (15-25 years) account for half of all new HIV infections.

Burden in South-East Asia

An estimated 7.2 million people are living with HIV/AIDS in the Region, 2 million are women and 120 000 are children.

Of these, during 2006, an estimated:

1. 730 000 are newly-infected adults
2. 39 000 are newly-infected children
3. 520 000 adult deaths
4. 26 000 child deaths

Estimations by UNAIDS/WHO, December 2006

The HIV/AIDS epidemic continues to grow worldwide. Currently, it accounts for the highest number of deaths by any single infectious agent.

1. About 95% of all HIV infections occur in low- and middle-income countries.
2. The highest burden of HIV/AIDS is in Sub-Saharan Africa, followed by South-East Asia.
3. One fifth of the HIV-infected people of the world live in Asia.
4. Young people (15-25 years) account for half of all new HIV infections.
5. South-East Asia has the second-highest number of HIV-infected persons (7.2 million) followed by Sub-Saharan Africa.
6. Although the overall HIV prevalence is low, the large population of the Region makes the magnitude of the HIV epidemic (in terms of the numbers of infected persons) huge.
7. HIV epidemics are largely concentrated among population sub-groups with high-risk behaviours, namely, sex workers and their clients, injecting drug users, and men who have sex with men.
8. Four countries - India, Indonesia, Myanmar, and Thailand - account for the majority of the estimated HIV burden.
9. India has the highest burden with an estimated 5.2 million (15-49 years) persons living with HIV/AIDS.
10. In India, HIV prevalence in some settings is 52% among sex workers and similar high rates are reported among injecting drug users in the North-East.
11. Indonesia is showing an alarming increase in HIV prevalence among injecting drug users - up to 50% in some sites in urban and rural areas.
12. In Myanmar, the HIV prevalence among injecting drug users and sex workers remains high at 34% and 32% respectively.
13. In Thailand, the HIV prevalence among injecting drug users has remained at levels around 40% since the beginning of the epidemic. Recent data pertaining to men having sex with men in Thailand show that the HIV prevalence among this group in urban areas is as high as 28% whereas HIV prevalence among sex workers has decreased to less than 6%.

BASICS OF HIV/AIDS

What is HIV?

HIV or human immunodeficiency virus is a virus that infects humans. A person with HIV is infected for life and can infect others. The virus attacks the immune system and slowly weakens the body’s defence against diseases. An HIV-infected person can look and feel well for a long time without developing AIDS.

What is AIDS?

AIDS or acquired immunodeficiency syndrome is a disabling and deadly disease caused by HIV. (“Acquired” means something not inherent in the patient’s body but transmitted from others; “immunodeficiency” refers to the weakened ability of the body’s immune system that helps it ward off infections and diseases; and “syndrome” is the group of signs and symptoms associated with the disease.) AIDS occurs as a collection of infections (called opportunistic infections) that are usually severe, such as pneumonia or tuberculosis, manifest more often during the late stages of HIV infection. An HIV-infected person may not develop AIDS until 8 to 10 years after being infected.

How is HIV transmitted?

The virus is carried from an infected person to a healthy person by blood, semen, vaginal fluids and breast milk.
HIV is transmitted in several ways:

1. By having unprotected sexual intercourse (vaginal, anal or oral sex); in other words, by having sex without a condom with someone who is HIV-infected. Although most cases of sexual transmission involve men and women, men having sex with men are equally at risk.
2. By using (or being injured by) needles, razor blades or other medical/surgical equipment which have been recently contaminated by the blood of a person infected with HIV.
3. By sharing needles and syringes used by an HIV-infected injecting drug user or by using needles/syringes that have been used in health care settings.
4. By receiving blood transfusions, blood products or organ transplants from an HIV-infected person.
5. By an infected mother to her baby during pregnancy, delivery or breastfeedinG.

HIV does not spread through ordinary social contact. For example, shaking hands with or traveling in the same bus with an HIV-infected person, or eating from the same plates an infected person has used, or hugging and kissing an HIV-positive individual will not spread the disease. Mosquitoes and insects do not carry the virus nor is the disease water-borne or air-borne.

Are women at equal risk of being infected with HIV?

Women are in fact more at risk of getting infected because of their social and economic vulnerability. Often their low social status and lack (or low level) of empowerment within the family further heighten their vulnerability to infection. In countries severely affected by HIV/AIDS, women are becoming increasingly more prone to infection. The number of AIDS cases among women in Thailand doubled between 1995 and 2003. Women in the South-East Asia Region who are engaged in sex work and those who are extremely poor are at increased risk of getting infected. There are two million women in sex work in India alone, and about 5000 to 10000 women are trafficked into India for sex work each year from other countries. Recently, HIV prevalence rate among Nepalese sex workers returning from Mumbai, India, was found to be 50%. It is, therefore, important that women, in particular young women, have access to information about HIV/AIDS to protect themselves.

Does the presence of other sexually transmitted infections (STIs) facilitate HIV transmission?

Yes, many sexually transmitted infections (STIs) increase the risk of acquiring HIV infection as well as the chances of transmitting it to others. For example, the risk of infection increases by as much as 50 to 300 times per each sexual contact with a person who has a genital ulcer.
It is important to keep in mind that HIV transmission is more likely to occur in combination with other sexually transmitted infections for many reasons:

1. HIV can easily pass through breaks and lacerations in the skin and mucous membranes caused by genital ulcers.
2. HIV can attach to the white blood cells usually present in genital discharges caused by STIs.
3. Large amounts of HIV are found in ulcers and genital fluid (semen, secretions from the cervix) of people with infections such as gonorrhoea, genital herpes, syphilis, and chancroid.

Why are early detection and treatment of sexually transmitted infections (STIs) important?

Early and effective treatment of STIs decreases the amount of HIV in genital secretions and reduces the risk of its spread to other sexual partners. Early treatment also reduces the risk of contracting HIV from infected partners. Furthermore, early diagnosis and treatment of STIs are important because they can prevent serious complications, such as infertility, ectopic pregnancy, genital cancer, blinding eye disease, and major nervous system infections in infants, that can occur as a result of an untreated STI.

How is HIV transmitted from a mother to her child?

Transmission from an infected mother to her baby occurs in about 30% of cases, in the absence of a preventive treatment, during pregnancy, delivery and breastfeeding.

1. Pregnancy: Through the mother’s blood. The baby is more at risk if the mother has been recently infected or is at a later stage of AIDS.
2. Delivery: At the time of birth when the baby is exposed to the infected mother’s blood.
3. Breastfeeding: The virus has been found in breast milk in low concentrations and studies have shown that children of HIV-infected mothers can get HIV infection through breast milk.

Children can be both infected by HIV and affected by AIDS. Over 2.5 million children worldwide are now infected with HIV. If HIV continues to spread across the world, there will be a greater increase in deaths among infants and children. It is also estimated that by the year 2010, 25 million children will be orphans because of AIDS.

How can people prevent themselves from being infected?

A person can avoid HIV infection by abstaining from sex, by having a mutually faithful monogamous sexual relationship with an uninfected partner or by practising safer sex. Safer sex involves the correct use of a condom during each sexual encounter; it also includes non-penetrative sex.

Both men and women share the responsibility for avoiding behaviour that might lead to HIV infection. They also share the right to refuse sex and assume responsibility for ensuring safe sex. In many societies, however, men have much more control than women do over when, with whom and how they have sex. In such cases, men need to assume greater responsibility for their actions.

Babies born to HIV-infected mothers can be protected against HIV infection if the mother receives antiretroviral drugs during pregnancy and at delivery. While avoiding breastfeeding seems logical when a mother is HIV-infected, the benefits of breastfeeding for the baby cannot be ignored. Exclusive breastfeeding, usually recommended during the first months of life, should be discontinued as soon as it is feasible. Replacement feeding is recommended only where it is acceptable, available, feasible, affordable, sustainable and safe.

Is there a vaccine for HIV/AIDS?

While there is no effective vaccine to prevent HIV/AIDS yet, many scientists agree that an AIDS vaccine is possible. Vaccines are used either to protect humans from disease or infection. Most scientific efforts focus on developing an AIDS preventive vaccine for people who are not infected with HIV. The vaccine would prepare the immune system to respond in case of an exposure to the virus.

In the past few years, AIDS vaccine research has gathered momentum and today it has become a global effort. Clinical trials of different vaccines are continuing as patients, health care workers, scientists, institutions and governments eagerly wait for an AIDS vaccine. In the South-East Asia Region, candidate vaccines are presently undergoing clinical trials in India and Thailand.

Is there a cure for HIV/AIDS?

There is no cure for HIV/ AIDS. Since AIDS is a collection of “opportunistic” infections, there are medicines that can prevent and control these infections in persons affected by HIV/AIDS. While opportunistic infections would be either harmless or at least easily managed in healthy people, they can kill people with damaged and impaired immune systems, as for those with HIV/AIDS. The prevention and treatment of opportunistic infections have a beneficial impact on the progression of HIV infection.

With the advent of antiretroviral drugs today, people living with HIV are receiving treatment that can slow the pace at which HIV multiplies in the body. Antiretroviral drugs, along with prevention and treatment of opportunistic infections, have helped make HIV/AIDS a manageable chronic disease. However, taking antiretroviral means following a rigid schedule: they must be taken daily for the rest of the life. If a patient misses even 1 dose in a regimen of 50, the virus can become resistant to the medicines and the drugs lose their effect. A strict adherence to regimen and proper care and treatment has been shown to prolong survival and improve the quality of life of people living with HIV/AIDS.

Antiretroviral therapy is only effective if a combination of three or four antiretroviral drugs is used. Single drugs are used only for the prevention of mother-to-child transmission.

Why is HIV testing and counselling important?

More than 90% of people infected with HIV do not know their HIV status. Voluntary testing and counseling have proved to be an effective public health strategy as they result in reduced risk behaviours and increased condom use. Testing and counselling serve as entry points to HIV/AIDS care and support.

UNAIDS/WHO POLICY STATEMENT ON HIV TESTING, June 2004

UNAIDS/WHO recommends

1. Voluntary counselling and testing to learn HIV status as a critical part of HIV prevention.
2. Diagnostic HIV testing, for a person who shows signs or symptoms consistent with HIV-related disease.
3. Routine HIV testing by health care providers for all patients who are on antiretroviral treatment, in prevention of mother-to-child transmission programmes, or community based settings, such as injecting drug use treatment services, hospital emergencies.
4. Mandatory screening for HIV and other blood borne viruses of all blood that would be used for transfusion or for manufacture of blood products. Mandatory screening of donors is required prior to all procedures involving transfer of bodily fluids or body parts, such as artificial insemination, corneal grafts and organ transplant.

Why is counselling important for treatment adherence?

Counselling is important for effective antiretroviral treatment, as it is critical that all prescribed medicines are taken regularly and at the same time of the day. Some drugs require special instructions, as they are to be taken before or after a meal and with a certain amount of fluid. The counsellor plays an important role in assessing the patient’s readiness for antiretroviral treatment, treatment literacy and adherence. All antiretroviral medicines have side effects. The counsellor can refer a patient to a physician with antiretroviral treatment experience to determine if a treatment should continue or be interrupted.

What is post-exposure prophylaxis for HIV?

Prophylaxis is the treatment to prevent the onset of a particular disease or the recurrence of symptoms in an existing infection. Post-exposure prophylaxis is a short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally (as in health care settings or workplaces) or through sexual intercourse. The medications used depend on the exposure to HIV, and should be taken ideally within 2-24 hours and no later than 48-72 hours following the possible HIV exposure.

How many antiretroviral drugs are prequalified by WHO, and how many (and which ones) are available as generic drugs?

As of 29 September 2005, the number of antiretroviral drugs on the WHO list of prequalified HIV/AIDS medicines stands at 68. Out of those, 34 are from generic manufacturers and 34 from brand name suppliers.

Antiretroviral products on the list that are exclusively available from originator companies are: abacavir, amprenavir, didanosine, nelfinavir, ritonavir and saquinavir, as well as the following combination products: lamivudine+zidovudine+abacavir and ritonavir+lopinavir. Prequalified antiretroviral drugs that are available from both generic and originator companies are: lamivudine, nevirapine, stavudine and zidovudine, as well as the combination of lamivudine+zidovudine. Meanwhile, the following combination products are exclusively available form generic producers: lamivudine+stavudine and lamivudine+stavudine+nevirapine. The list of prequalified HIV/AIDS medicines is regularly updated. The latest version is available on the WHO website at the following URL

http://mednet3.who.int/prequal/documents/prodmanuf/hiv_suppliers.pdf

Who are the manufacturers of antiretroviral drugs in South-East Asia?

It is difficult to know the number of manufacturers of HIV/AIDS medicines, since manufacturers do not have to report to WHO which medicines they are producing. However, as of 29 September 2005, five manufacturers in India have products included on the WHO list of prequalified HIV/AIDS medicines. These are: Aurobindo, Cipla, Hetero, Ranbaxy and Strides.

It is to be noted that WHO prequalification is a product and production-site specific listing. In other words, while one product of a certain company may be prequalified, another product of the same company may not. It is advisable to always check the details of products when visiting the WHO website.

What is the HIV/AIDS prevention, care, support and treatment continuum?

The HIV/AIDS prevention, care, support and treatment continuum regards HIV/AIDS as a chronic disease requiring treatment throughout life. Experiences from several countries have demonstrated that a continuum of prevention, care and treatment from hospital to home is the optimum for those affected. WHO South-East Asia Regional Office (SEARO) is promoting a patient-centred approach through a continuum of prevention, care, support and treatment by decentralization of services, which includes an adequate referral and collaborative care network from hospital to the community and home.

Management of opportunistic infections and antiretroviral treatment cannot be seen in isolation. HIV-infected patients, including those with active tuberculosis, should benefit from additional care needs, including clinical and nursing care in particular for the prevention and treatment of opportunistic infections, ongoing psychosocial support and counselling, financial and employment support, assistance for housing and living in enabling environment, legal assistance, and care and support for orphans as promoted by WHO SEARO.

What is a patient-centred approach to HIV/AIDS care?

The public health approach to HIV/AIDS chronic care is patient-centric. As with other chronic illnesses, such as diabetes and hypertension, patients manage their care. Patients need to be educated about the disease so that they can make informed decisions on adherence and management, and be prepared to deal with the challenges of living with a chronic disease. They need to know when and how to interact with the health services available in the community. For example, a person on treatment who may experience diarrhoea should know when to rush to the health facility for medical attention, that is if blood is present or there is associated fever, or when to relieve the symptom with a locally available remedy.

What is treatment preparedness?

Treatment preparedness stems from the concept of a patient-centric approach and applies to building up of adequate resources and actions at the level of the individual as well as the community. It involves preparation of the community to the disease by effective messaging using mass media, effective use of community resources, ensuring inputs of people living with HIV/AIDS. At the level of the individual, it involves building of skills to enable people on treatment and their supporters to contribute to the patient-centric approach to prevention, care and treatment and to support their peers. Treatment preparedness provides a platform for enhancing the ability of civil society to deal with the disease.

What role does the community/civil society play in HIV/AIDS control?

Community participation is required for every aspect of HIV prevention and control, and includes advocacy, delivery of services and support to patients. A strong community leadership or an effective civil society involvement in policy/decision-making will lead to better and more sustainable health outcomes. This is because HIV/AIDS is not only a medical issue. People with HIV/AIDS face other psycho-social challenges, such as stigma and discrimination, which are best addressed through strong community support. In partnership with the health sector, civil society groups (including faith-based groups) can offer a wide range of support services, education, home-based care, training in income-generating activities and treatment adherence counselling.

What role do nongovernmental organizations (NGOs) play in HIV/AIDS control?

The close interpersonal interaction that nongovernmental organizations (NGOs) have with people in the communities they work in is extremely useful for implementing the behavioural interventions necessary for HIV/AIDS prevention and care. NGOs are also not under the same political constraints as government programmes are. They, therefore, have greater flexibility and the capacity to accommodate changing programmes and public needs, and can innovate and implement new initiatives more easily.

What role do people living with HIV/AIDS play in alleviating the impact of HIV/AIDS?

People living with HIV/AIDS can promote a positive image of people affected by the disease in order to eliminate prejudice, isolation, stigmatization and discrimination associated with AIDS. In addition, the community of people living with HIV/AIDS should be supported for building capacity to contribute effectively as equal partners to the response. They can help with peer counselling, education and treatment. They can be meaningfully included in all national and international HIV/AIDS policy-making bodies. There is a need to inform, mobilize, and sensitize communities to produce actions that can strengthen the lives of persons living with HIV/AIDS, in addition to providing unrestricted protection to their human rights.

What are the rules of HIV/AIDS at the workplace?

HIV/AIDS is a workplace issue because it affects labour and productivity due of loss of skills, costs of hiring and retraining, health and death benefits, and the potential of workplace conflict.

If a worker has HIV infection, should he or she be allowed to continue work?

Workers with HIV infection who are still healthy and those with AIDS or AIDS-related illnesses should be treated in the same way as any other worker who is ill. It is not a reason in itself for termination of employment.

Is it safe to work in the same office/place with someone infected with HIV?

Yes. Most workers face no risk of getting the virus while doing their work. If they have the virus themselves, they are not a risk to others during the course of their work. This is because the virus is mainly transmitted through the transfer of blood or sexual fluids. Since contact with blood or sexual fluids is not part of most people’s work, most workers are safe.

What about working in close contact with an infected person?

There are no risks involved. You may share the same telephone with other people in your office or work side by side in a crowded factory with other HIV-infected persons. You may even share the same cup of tea, without any risk of infection. You cannot be infected by dirt and sweat of an infected person.

How can HIV transmission be prevented in health-care settings?

Risk of HIV transmission in the health-care setting occurs in the following ways:

1. To Patients - Through contaminated instruments that are re-used without adequate disinfection and sterilization; transfusion of HIV-infected blood, skin grafts, organ transplants; HIV-infected donated semen; and contact with blood or other body fluids from an HIV-infected health care worker.
2. To health care workers - By piercing the skin with a needle or any other sharp instrument which has been contaminated with blood or other body fluids from an HIV infected person; exposure of broken skin, open cuts or wounds to blood or other body fluids from an HIV infected person; and splashes from infected blood or body fluids onto the mucous membranes (mouth or eyes).

The risk of HIV transmission from infected health care personnel, such as surgeons, is considered low. As a general practice, limiting the practice of HIV-infected care professional is not necessary unless there is evidence of transmitting infection through inability to meet basic infection control standards, or unless they are functionally unable to care for patients.

Health care workers in medical or dental settings where HIV may be present should practise "universal standard precautions" for protecting themselves and patients from HIV and all other blood-borne infections. Universal standard precautions require the consistent use of sterile techniques and garments, whenever and wherever blood or body fluids may be present. Creating a safe work environment by practising universal standard precautions in care of patients at all times can reduce the risk of transmission of blood-borne infections.