HIV/AIDS IN INDIA - Some facts

 Current Scenario

Although the presence of HIV was not noticed in Asia and India until the late 1980s, South-East Asia has now become the epicenter of the HIV/AIDS pandemic. It has been predicted that by 2000 AD, the majority of new infections will occur in South-East Asia. Current evidence indicates that the doubling time of the epidemic in India is less than 2 years. Although constituting only 1% of the population, the 4 million infected in India make it the second largest HIV-infected population in the world .

Epidemiology

The spread of HIV in India is predominantly by the heterosexual route and the infection is spreading rapidly among women.

Reports quote that the prevalence of HIV infection among male patients suffering from various sexually transmitted diseases (STDS) has increased from 3.31% - 3.5% in 1988 to 8.6%-14% in 1992 in metropolitan cities like Madras and Mumbai. A much faster increase in seroprevalence of HIV infection has been observed among the female sex workers in Mumbai with an increase from 1.1-1.3 percent in 1986 to 8 - 10% in 1988-89 to 34-41% in 1991- 92.

Another report estimates that the prevalence of HIV has risen in female sex workers from less than 10% in 1990 to between 40% and 50% in 1996 in Mumbai, Pune, Madras, Vellore and other cities, and has risen in men attending STD clinics to 20% to 30% in these cities.

In a study conducted in Pune between May 1993 and October 1995, 5321 persons attending two STD clinics were screened for HIV-1 infection. The overall prevalence was found to be 21.2%, being higher in females (32.3%) than in males (19.3%).

Since 1986, the prevalence of HIV infection in female sex workers and patients attending clinics for sexually transmitted diseases in India has continued to rise. A high prevalence of HIV-1 has also been observed in monogamous, married women, suggesting that the HIV epidemic in India has begun to affect other risk groupS. Reports indicate that the epidemic has now begun to spread out of high-risk groups in the major cities to the general population and to rural areas.

The second most important, and preventable, mode of transmission is through infected blood and blood products. Intravenous drug users (IVDUS) constitute a major proportion (13%) of all reported HIV infections, and this is the main mode of spread in Manipur, where intravenous drug use is common.

 The predominant HIV-1 subtype in India is C, which has previously been found in East and South Africa. Molecular epidemiological studies in India show limited inter-patient nucleotide sequence divergence, which suggests a recent and rapid spread of closely related HIV-1 genotypes across the country. The ability of HIV-1 subtype C, like subtype E, to replicate especially well in langerhans cells, which are found in genital mucosal epitheliurn and are suspected to be the cells through which vaginal infection occurs, may account for its propensity for heterosexual spread. To be effective in India, an HIV vaccine would need to incorporate epitopes from subtype C but immune responses to this subtype have scarcely been studied.

Data suggest that the prevalence of HIV-2 remains much lower than HIV- 1. Some studies have suggested that HIV-2 infection may represent 3% to 9% of all HIV infection in Mumbai and other parts of Maharashtra. These studies have also reported dually active serology in 6% to 29% of all HIV infection.

Risk Factors

Epidemiologic studies conducted in India suggest that genital ulcer disease is associated with a four-fold or greater risk of HIV infection and that non-ulcerative STDs may carry a two to three fold greater risk of HIV infection. Thus, clinical diagnosis of genital ulcer disease, cervicitis or urethritis is important for identifying a biological risk for HIV infection.'

Data show that a significant increase in HIV-1 incidence is associated with a corresponding increase in the presence of other STDS. This indicates that aggressive treatment, early follow-up, and prevention of both ulcerative and nonuicerative STDs may significantly reduce the risk of sexual transmission of HIV. A study has shown that condorn use was associated with a 56% reduction in the risk of HIV acquisitions.

In an Indian study conducted at Pune, current or previous history of genital ulcer disease or genital discharge was found to be independently associated with HIV-1 infection. In addition, high risk sexual behaviour, including lack of condom use and high number of sexual partners were commonly reported. Both receptive anal intercourse and tattooing were found to be independent risk factors. Homosexuality, use of injected drugs, or transfusion were rare in this study. Yet another study found that receptive homosexual contact was found to be associated with a higher seroprevalence of HIV infection. No authentic statistics are available on the homosexual population of India.

Clinical Presentation

A recent collaborative study between the Department of Infectious Diseases and Department of Biostatistics, John Hopkins University, Baltimore, the National AIDS Research Institute, Pune, and the National Institute of Allergy and Infectious Diseases, Bethesda has analyzed data collected from the largest group of subjects identified in the seroconversion window period. This study suggests that symptoms generally may occur within 2 weeks of the exposure that led to HIV acquisition. As much as 80% of patients complained of a current, symptomatic STD. Fever was reported in 48% of 58 HIV antibody- negative and p24 antigen-positive subjects and in 18% of 290 p24 antigen-negative matched control subjects. lyrnphadenopathy was found in 67% of p24 antigen-positive subjects and in 54% of p24 antigen- negative controls. Joint pain was reported in 10% of p24 antigenemic subjects and in 2% of controls. Night sweats were reported in 9% of p24 antigenemic subjects and in 1% of controls. Inguinal, but not extrainguinal, lymphadenapathy was associated with p24 antigenemia. When these signs and symptoms were adjusted for presence of STDS, fever, joint pain and night sweats were independently associated with p24 antigenemia. Other signs and symptoms, such as generalized lymphadenopathy, pharyngitis, diarrhoea, oral thrush and rash, previously described as associated with acute retroviral syndrome, were not clearly associated with p24 antigenernia in this study.

The clinical presentation of AIDS in India is broadly similar to that found in other developing countries, with tuberculosis the most important HIV- associated infection. Particular problems in India are the large size of urban populations co-infected with HIV and tuberculosis and the recent emergence of multidrug resistance.

The future

The incidence of HIV infection observed in various studies is very high. A high incidence rate would indicate that new infections have continued to occur. The public health impact of rapid accumulation of HIV infected persons is likely to be very serious, because this infectious pool will keep the epidemic expanding and result in the epidemic reaching persons with low risk behaviour. Within 5 to 10 years, a large number of AIDS cases will start presenting from the current pool of HIV infected persons which will also continue to expand and this large influx of AIDS cases will put a lot of pressure on the health care delivery system. A worsening of the tuberculosis scenario at the national level is already being experienced. Increasing HIV infection in women will eventually result in more children being born with HIV infection and AIDS.

AIDS care Clinics in India (incomplete list)

• UNISON MEDICARE & RESEARCH CENTRE Maharukh Mansion, Alibhai Premji Marg, Grant Road (East), Mumbai-400007 Tel: 3061616; Fax 3000016
• TB Sanatorium, at Tambarram, Chennai.
• Michael's Care Home in Delhi, a home for AIDS patients run by an NGO, Sahara House.
  
  
  

HIV/AIDS IN INDIA - Some facts

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