Unraveling HIV/AIDS in India: A Unique Perspective by Dr. A. K. Avasarala

1. HIV(seed) SOIL AND SHOWER OF HIV / AIDS IN INDIA DISCUSSION FROM A DIFFERENT ANGLE Dr. A.K.AVASARALA, MD PROFESSOR & HEAD DEPARTMENT OF COMMUNTIY MEDICINE AND EPIDEMIOLOGY PRATHIMA INSTIUTE OF MEDICAL SCIENCES, NAGUNUR, KARIMNAGAR ( A.P.), INDIA – 505417. E_mail : avasarala@yahoo.com ENVIRONMENT (SHOWER) HOST (SOIL))

2. HIV INFECTION • NO DOUBT IT • INVADED • SETTLED • SPREADINGININDIA • UNAIDS FACT SHEET 2003 • HETEROSEXUALS ( SEX WORKERS )-60-70% • ANTENATAL WOMEN - 1 % • HOMOSEXUALS – 27 % ( NACO, INDIA)

3. HIV/AIDS IN INDIAHETEROGENEOUS DISTRIBUTION • GENRALIZED CONCETRATED • EPIDEMIC EPIDEMIC • >5% in high risk groups+ >1% (>5% IN HIGH RISK +<1% IN PREGNANT WOMEN PREGNANT WOMEN • MAHARSHTRA,TAMILNADU,KARNATAKA, GUJARATH,GOA,KERALA,WESTBENGAL • ANDHRA PRADESH,MANIPUR NAGALAND LOW LEVEL EPIDEMIC (<5% IN HIGH RISK+<1% IN PREGNANT WOMEN UTTAR PRDESH,MADHYA PRADESH,BIHAR,RAJASTHAN REST OF INDIA vulnerable WITH HIGH STD PREVALENCE

4. HIV/AIDS IN INDIA • HR > 5 , PW > 1% MAHARASHTRA,TAMILNADU,KARNATAKA,ANDHRAPRADESH,MANIPUR • HR > 5% , PW < 1% GUJARATH, GOA, WESTBENGAL, NAGALAND • HR < 5% , PW < 1% UTTARPRADESH,MADHYAPRADESH,BIHAR, RAJASTHAN

5. SENTINEL SURVEILLANCE DATA IN METROPOLITAN CITIES

6. RURAL SITUATION ALSO NOT SATISFACTORY MORE HIV SEEN DUE TO POOR LITERACY & UNAWARNESS AND LESS CONDOM USE

7. 3 EPICENTRES • MEGHALYA, MANIPUR & MIZORAM • MAHARASTRA • 3. ANDHRA PRADESH & KARANATAKA, • AND TAMILNADU

8. EPICENTRE -1 (SOIL &SHOWER) MEGHALAYA, MANIPUR AND MIZORAM FERTILE SOIL(SUSCEPTIBLE HOST) POOR AND UNEMPLOYED YOUNG AND IMMATURE, ANTISOCIAL TEMPTED TO INJECTABLE DRUG ABUSE CALLOUS , HENCE CONTAMINATION OF NEEDLES SHOWER (FAVOURABLE ENVIRONMENT) FREE AVALIBILITY OF NARCOTIC DRUGS DUE TO DRUG TRAFFICKING ACROSS THE MYANMAR BORDER and POLITICAL INSTABILITY favors HIV INFECTION ? CAN FREE SUPPLY OF STERILE NEEDLES SOLVE THIS PROBLEM ? IS IT ETHICAL?

9. CONFOUNDING SITUATION AT MIZORAM POLITICAL INSTABILITY VIOLENCE FALSE SECURITY FALSE COURAGE UNEMPLOYMENT & IDLE YOUTH HALLUCINATIONS DELUSIONS DRUG ABUSE& HIV FREELY AVAILABLE DRUGS

10. EPICENTRES-2&3 (SOIL &SHOWER) • MAHARASTRA, ANDHRA PRADESH, TAMILNADU, KARANATAKA • SHOWER • POVERTY, • MUMBAI,PUNE,SATARA.CHENNAI, • VIJAYAWADA(AP) • WITH THEIR GROWING URBAN SLUMS AND MOBILE POPULATION, • COMMERCIAL SEX WORK(CSW) • LACK OF BROTHEL LICENCING, • LACK OF MEDICAL EXAM FOR CSW • SOIL • UNSAFE SEX , ILLEGAL SEX • COMMERCIAL SEX WORK • MULTIPLE SEX PARTNERS • LESS CONDOM USE • HUNGER, ILLITERACY, • CARELESSNESS, SEXUAL PERVERSIONS

11. EPICENTRES 2&3 DHABHAS (WAYSIDE FEEDING CENTRES OF ILLFAME) OTHER SIDE OF THE COIN BIG BUSINESS • LONG DISTANCE • TRUCK DIVERS • CONTRACTORS ENOLL SEXWORKERS AND DROP THEM AT DHABHAS IN THE EVENING AND COLLECT THEM IN THE MORNING THEY COLLECT COMMISSION FROM CSW. • DHABHA OWNER IS ALSO BENFITED DUE TO MORE NUMBER OF CUSTOMERS WEAK ENFORCEMENT OF RESTRICTION OF IMMORAL TRAFFIC ACT IS ANOTHER FACTOR. • LEAVING THEIR • WIVES AT HOME LONELINESS, RESORT TO ILLICIT CHEAP SEX AT DHABHAS HIV SEEDLING ALONG HIGHWAYS

12. WHY HIV INVADED&SETTLED INDIA INDIAN SOCIETY CHANGED IN FAVOUR OF HIV -

13. 5 HIV / AIDS IN INDIA IS NOT JUST DUE TO HIV ALONE(THE SEED)

14. SOCIETAL CHANGE (SHOWER) • ACCULTURATION EFFECTS • CULTURAL CHANGES--INCREASE IN -VE LIFE STYLES REGARDIG SEXUAL PRACTICES • DETERIORATED HUMAN VALUES • SEXUAL PERVERSIONS AND STD ON THE RISE • COSMOPOLITAN NATURE OF CITIES ENCOURAGING -VE LIFESTYLES • URBAN SLUMS & NIGHT CLUBS -MORE OPPORTUNITIES FOR ILLEGAL AND UNSAFE SEX • INCREASING MOBILE POPULATION AT BUSSINESS CENTRES AND CITIES FAVOURING THE SPREAD • COMPLACENCY ABOUT UNIVERSAL PRECAUTIONS &SEXUALLY TRANSMITTED DISEASES

15. DETERIORATION MONOGAMY AT THREAT HUMAN VALUES &VIRTUES AT LOW LEVEL CELIBECY NOT PRACTICED

16. INCREASING SEX ABUSE • ESPECIALLY IN COSMOPOLITAN CITIES • DUE TO • FREE AVAILABILITY OF SEX • COMMERCIAL SEX WORK AND SEX MARKETTING • NIGHT CLUBS AND CALL GIRL SYSTEM • ILLEGAL SEX • MULTIPLE PARTNERS

17. SEXUAL PERVERSIONS • HIV IS A MAJOR BEHAVIORAL PROBLEM • HOMOSEXUALITY -- INCREASE IN • THE LONELY • ORAL SEX • ANAL SEX- CHILD ABUSE

18. CONTROL ASPECTS

19. SPREAD OF HIV CLIENTS OF CSW, STD PATIENTS, PEERS OF I.D.USERS GENERAL POPULATION CSW &INJECTABLE DRUG USERS(IDU) (HIGH RISK) (BRIDGE)

20. HIV (THE SEED) WHY HIV IS PREFERRING T4 CELLS ONLY NOT OTHER CELLS WHAT IN T4 CELLS THAT IS ATTRACTING HIV ? CAN THAT SOMETHING CAN BE ELIMINATED OR NEUTRALIZED ?

21. LIFE STYLE MODIFICATIONS-TOP PRIORITY “ MEND THE MIND MUST BE THE RULE AS HIV IS MAINLY A BEHAVIORAL DISORDER LIFE STYLE MODIFICATIONS ARE NOT GIVEN ENOUGH STRESS AT PRESENT ETHICAL VALUE OF SAFE SEX NOT MUCH EMPHASIZED CHARACTER-BUILDING NOT ATTEMPTED NO STRESS TO CURB DON’TS (-VE LIFE STYLES )

22. LIFE STYLE MODIFICATIONS ONLY THE CHANGE OF BEHAVIOR CAN SOLVE THE HIV PROBLEM PERMANANTLY IT IS NEITHER ADVISABLE NOR ETHICAL TO PROVIDE STERILE SYRINGES FREELY TO A DRUG ADDICT AND ASK HIM TO CONTINUE TO TAKE DRUGS NOR TO PROVIDE A CONDOM AND ASK TO VISIT A BROTHEL,BECAUSE IN BOTH THE STRATEGIES, BEHAVIOR AL CHANGE TO CURB RISKY BEHAVIOR WILL NOT OCCUR BUT WILL CONTINUE. .

23. MIZORAM HIV CONTROL • CONFOUNDING SITUATION • BRINGOUT THE BEHAVIORAL CHANGE AMONG HIGH RISK GROUPS ESPECIALLY THE YOUTH • USE DEADDICTED PATIENT FOR MOTIVATION OF NEW ADDICTS • SCHOOL CURRICULAM TO INCLUDE THE ADVERSE EFFECTS OF THE DRUG ABUSE AND CONTAMINATED NEEDLE USE • CONTROL DRUG TRAFFICKING ACROSS MYANMAR BORDER • REDUCE THE FREE ACCESSIBILITY AND AVAILABILITY OF DRUGS • UTILIZE PEERS (YOUTH ) TO BRING CHANGE IN YOUTH

24. MIZORAM HIV CONTROL • PROVIDE EMPLOYMENT FOR YOUTH • FREQUENT RECURRENT VIOLENCE LEADS TO INSECURITY ,DESPAIR AND THEREBY RESORTING TO DRUG ABUSE. • DRUG INDUCED HALLUCINATIONS GIVE FALSE SECURITY AND FALSE COURAGE WHICH INTURN BREEDS VIOLENCE- • STEPS TO REDUCE VIOLENCE BY EDUCATING THE PEOPLE ABOUT EPIDEMIOLOGY OF VIOLENCE

25. MIZORAM HIV CONTROL • CONTROLLING DRUG TAFFICKING ACROSS THE BORDER, • STRICT VIGILANCE OVER DRUG TRAFFICKERS, • INCOME GENERATING ACTIVITIES FOR UNEMPLOYED YOUTH, • PERSISTATANT PERSUAVASSIVE METHODS TO REDUCE IV DRUG USE

26. HIV CONTROL AT EPICENTRES 2&3 (MAHARASHTRA,ANDHRA PRADESH, TAMILNADU &KARNATAKA) COMMERCIAL SEX WORK AND HIV CONTROL LICENCED BROTHELS WITH REGULAR SCREENING AND TREATMENT FOR STD , INCOME GENERATING ACTIVITIES FOR CSW, REHABILITATION OF THE CHILDREN AND DEPENDENTS OF CSW, STRICT ENFORCEMENT OF IMMORAL TRAFFIC REGULATION ACT

27. STRICT VIGILANCE AND SCREENING FOR HIV AT DHABAS & NIGHT CLUBS

28. CONDOM USAGE CONDOM USAGE IS A TEMPORARY INTERVENTION . IT IS ALSO NOT ETHICAL TO GIVE SOMEONE A CONDOM AND ASK HIM TOVISIT A BROTHEL . IN THE LONG RUN, IT WILL NOT HELP. BUT IT IS A MOST PRACTICAL AND FEASIBLE INTERVENTION BUT WHY IT IS USED LESS ? WHY LESS ACCEPTABLE? SEX WORKERS COMPLAINING THAT THEY ARE LOOSING THEIR BUSINESSIF THEY INSIST THEIR CLIENTS FOR CONDOM USE .HOW FAR IT IS TRUE? HOW TO IMPROVE COMPLAINCE OF CONDOM USAGE? I.E.C. ACTIVITIES HAVE TO BE MODIFIED TO ENHANCE CONDOM USAGE AND COMPLAINCE.PEER GROUP MOTIVATION MAY BE TRIED CONDUCTING EXHIBITIONS SHOWING VARIOUS MODELS AND SPECIMENS OF SEXUALLY TRANSMITTED DISEASES MAY CREATE INTEREST IN THE PUBLIC AND BECOME SENSITIZED FOR CONDOM USE.

29. MCTC AND THROUGH INFECTED BLOOD • MOTHER TO CHILD TRANSMISSION (MCTC) • AS HIV IS HIGH IN ANTENATAL WOMEN (1%) , • IT IS NECESSARY TO PREVENT MCTC. • PREVENTION TRIALS ARE UNDERWAY IN • ANDHRA PRADESH • HIV THROUGH INFECTED BLODD HAS COME DOWN • INDIA DUE TO • CLEARCUT TRANSFUSION POLICY • STRICT LICENCING OF BLOOD BANKS • AVOIDING BLOOD COLLECTION FROM • PROFESSIONAL DONORS

30. LESS EFFECTIVE CONTROL FIRST GENERATION STD IN INDIA, CONTROL OF SEXUALLY TRANSMITTED DISEASES WAS NOT SERIOUSLY CONSIDERED THINKING THAT THEY ARE OF PERSONAL IN NATURE CLINICS FOR VENEREAL DISEASES WERE STARTED VERY MODESTLY HIGH LEVEL SECRECY WAS MAINTAINED REGARDING STD,HENCE POOR PUBLIC AWARENESS AND INTURN LEAD TO RUMORS AND SUPERSTITIONS e.g. INTERCOURSE WITH A CHILD WILL RELIEVE STD & OPEN AIR URINATION CAUSES GONORRHEA TALKING ABOUT STD ITSELF USED AS A SIGN SOCIAL DEMORALISATION SCREENING FOR STD IN HIGH RISK GROUPS AND TREATING THE CASES WILL REDUCE THE VULNERABILITY FOR HIV AND THEREBY HIV INCIDENCE STD SYNDROMIC MANGEMENT SHOULD BE REALLY PRACTICED IN THE FIELD STD CONTROL AS IT IS INCLUDED IN NATIONAL AIDS CONTROL IS NOT GETTING ENOUGH ATTENTION .

31. AIDS CONTROL SOCIETIES • FOR COMMUNITY INVOLVEMENT • HOW FAR THEY ARE SUCCESSFUL • IN REDUCING THE HIV INFECTION? • COMMUNITY PARTICIPATION HAS NOT REACHED ITS DESIRED LEVEL . • AS EVIDENCED BY • INCREASE IN HIV INFECTION • POOR USAGE OF CONDOMS • POOR AWARENESS AMONG BOTH URBAN AND RURAL POPULATION • ENRICH AND JUVENATE COMMUNITY INVOLVEMENT EITHER BY INCENTIVES OR DISCENTIVES.OR BY STRICT LEGISLATION • COORDINATION COMMITTEES SHOULD NOT BE CONFINED TO PAPER. • REAL INTERSECTORAL COORDINATION WITH RESPOSIBILITIES,WHICH ARE ACCOUNTABLE AND MONITORABLE, TO BE FIXED ON ALL SECTORS

32. MASS MEDIA STRONG POSITIVE ROLE ESSENTIAL TV 9 CHANNEL INTERVIEWED CSW AT EAST GODAVARY DIST (AP) . CSW COMPLAINED THAT THEY ARE LOSING THEIR CLIENTS DUE TO HIV? FLIMS -SOME MOVIES ARE GIVING FALSE MESSAGES ABOUT HIV TRANSMISSION THROUGH THE COMEDIANS. EVEN FOR JOKE, WRONG MESSAGES SHOULD NOT BE GIVEN AS THEY BREED RUMORS AND SUPERSTITIONS AS HALF OF THE INDIAN COMMUNITY IS ILLTERATE. SUICIDES AFTER HIV POSITIVE DECLARATION ARE STILL HAPPENING.EFFECTIVE POST-TEST COUNSELLING IS IMPERATIVE

33. CONCLUSION AS IT IS SECOND GENERATION STD, IT NEEDS TACKLING AT PERSONAL LEVEL FIRST AS IT IS A LIFE STYLE DISEASE , LIFE STYLE MODIFICATIONS ARE ESSENTIAL AS LONG AS FAVORABLE ENVIRONMENT AND SUSCEPTIBLE HOST IS AVAILABLE IT WILL BE SPREADING.HENCE NEED FOR STRESS ON LONG TERM STRATEGIES INSTEAD OF TEMPORARY BENEFITS TREATING AIDS PATIENTS IS ONLY HALF OF THE ANSWER AGRESSIVE HEALTH EDUCATION AT SCHOOL LEVEL (PRIMORDIAL PREVENTION ) IS RIGHT INTERVENTION BEFORE FIXED IDEAS DEVELOP. .