Epidemiology of STI and HIV in India: Priorities and Program Strategies - Essay Example

? EPIDEMIOLOGY OF STI AND HIV IN INDIA: PRIORITIES AND PROGRAM STRATEGIES number: July 30, India is a developing nation and has a population of one billion (Avert 2000). The first case of AIDS was detected in the year 1986 (Avert 2000). Today, HIV infection has been reported in all states and union territories of the country. Again, bacterial STIs like chancroid and gonorrhea seem to be on the decline while viral STIs like HPV and herpes genitalis are on the rise (Thappa et al. 2007). According to the National AIDS Control Organization (2006, 1), currently there are 2.47 million people in the country who are living with HIV. Nearly 88% of these people are in the sexually active and economically productive age group of 15 to 49 years (National AIDS Control Organization 2006, 11). Therefore, most people living with HIV are in the prime of their working lives with many of them supporting families. The remaining 8% of the infected population are above 50 years and another 4% are children (National AIDS Control Organization 2006, 11). The spread of HIV in India has been very uneven. Although the overall rate of infection in India has been very low, certain regions and certain population groups within the country have extremely high rate of infection. The infection rates are extremely high in the southern states of Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka and the far north-east states of Manipur and Nagaland. Together these states account for 64% of the HIV burden in India (National AIDS Control Organization 2006, 14). Prevalence Rates Overall the prevalence of HIV for adult males and females has shown a declining trend in the past five years. In 2006, it was 0.36% while in 2002 it was 0.45% in 2002 (National AIDS Control Organization 2006, 11). The prevalence rate among women declined from 0.36% in 2002 to 0.30% in 2006, while the prevalence rate among men declined from 0.53% in 2002 to 0.43% in 2006 (National AIDS Control Organization 2006, 12). However, HIV has been found to be more prevalent among men than women with 60% of those infected being men, while 40% being women (UNAIDS 2008). The overall decline in the prevalence of STIs has been partially attributed to the improved medical facilities and improved pharmacotherapy of many bacterial STIs (Thappa et al. 2007). One of the major concerns regarding the epidemic of HIV in India is the increase seen in the proportion of infections among children and adults above 50 years. Among children, the prevalence of HIV was 3% in 2002 which increased to 4% in 2006 (National AIDS Control Organization 2006, 13). Similarly, the prevalence of the disease was 6% among adults above the age of 50 which has increased to 8% in 2006 (National AIDS Control Organization 2006, 13). Transmission route In India, nearly 88% of the transmission of STI/HIV happens through heterosexual contact (The World Bank 2008). Other routes of transmission include perinatal (4.7%), unsafe blood and blood products (1.7%), infected needles and syringes (1.8%) and other unspecified routes of transmission (4.1%) (The World Bank 2008). It is interesting to note that in the high prevalence southern states of India, STI/HIV has been found to spread primarily through heterosexual contact while in the high prevalence north-eastern states, the disease has been found to spread mainly among injecting drug users and sex workers (National AIDS Control Organization 2006). Researchers believe that the HIV epidemic in India has followed the ‘type 4’ pattern (The World Bank 2008). This is a pattern where new infections occur among the most vulnerable populations like the female sex workers, men who have sex with men or the injecting drug users. The infection then spreads to ‘bridge’ populations like the clients of sex workers or sexual partners of drug users and finally it enters the general population. Studies have revealed that long distance truck drivers and male migrant workers make up significant proportions of clients of sex workers (UNGASS 2008). In many cases, married men have acted as the bridge population, transmitting the infection from the vulnerable populations to the general population (UNGASS 2008). Who and How are they affected? Although STI and HIV affects all segments of the population in India, the prevalence of the disease is high among certain groups like the sex workers, injecting drug users, truck drivers, migrant workers and men having sex with men (MSM). The infection rates among these groups are about 6 to 8 times higher than the general population. The prevalence of this disease is highest among intravenous drug users with 8.7% followed by MSM with 5.7%, female sex workers with 5.7%, long distance truck drivers with 2.4% and the general population with 0.3% (National AIDS Control Organization 2006, 1). Sex Workers: Women in India often engage in sex work due to poverty, marital break-up or because they are forced into it. Sex work is not strictly illegal in this country but related activities like running a brothel are illegal. However there is a lot of stigma and discrimination against sex workers due to which they find it increasingly difficult to access healthcare, even if they actively seek it (Shetty 2010). The risk of getting infected is high due to the fact that very few sex workers use condoms or any other protective measures. According to a study conducted in Mysore city, nearly a quarter of the sex workers are infected with HIV (Ramesh et al. 2008). This is not surprising considering the fact that only 20% of sex workers had always used condoms with commercial clients in the past (Reza-Paul et al. 2008). This factor highlights the need for increased prevention efforts in this group. Truck Drivers: India has one of the largest road networks and it is used as one of the primary mode of transportation of goods from one state to another. As truck drivers and helpers spend a long time away from home, it is common practice for them to have relations with sex workers while they are on the road (Pandey et al. 2008). Findings from a study conducted on long distance truck drivers, who frequent the national highways of India, reveal that one third of the drivers paid for sex in the past one year (Pandey et al. 2008). Sometimes, roadside ‘dhabas’, where truck drivers typically stop to dine, act as brothels, while in other cases, the drivers may pick up women by the side of the road and drop them off at another location after availing their services (Christensen 2002). In this way, both the truck drivers and the sex workers move from one area to another, often unaware that they are infected with STI/HIV. This is one way how the disease is transferred from urban to rural settings. Injecting Drug Users: The national HIV prevalence rate among injecting drug users has risen to 9.2% in 2010 from 7% in 2006 (UNGASS 2010). However, due to the tough regulations on drug users, it is extremely difficult to survey the injecting drug users and therefore the prevalence of HIV among this group may be much higher than what is recorded in the official records (UNGASS 2010). This transmission route is a major driving factor in the spread of HIV in India, especially in the north-eastern states of Manipur and Nagaland. One of the major concerns regarding this dangerous trend is that injecting drug users are also sex workers or truck drivers. Since many of them are sexually active, they tend to transmit the infection to their partners. The National AIDS Control Organization has been able to link the increase in HIV prevalence among sex workers in North-East India to the high HIV prevalence among injecting drug users in the region. Men Who Have Sex with Men (MSM): Homosexuality is highly stigmatized in India and therefore is not openly talked about. It is estimated that the prevalence of HIV among this group of men who have sex with men in India is 7.3% (Dandona et al. 2005). In India, many MSM do not consider themselves as homosexuals and have female partners (Dandona et al. 2005). Based on a large study conducted in Andhra Pradesh – one of the southern states that has high prevalence of HIV/STI – researchers found that 42% of MSM were married, 50% had had sexual relations with women in the past three months and less than half MSM had had unprotected sex (Dandona et al. 2005). Due to the stigma associated with this group, it is extremely difficult to survey MSM and therefore the prevalence of HIV among this group may be much higher than what is stated in the official records (Department of AIDS Control 2010). Since many of the MSM in India also have heterosexual relationships, there is a strong possibility of it increasing the HIV epidemic in the general population (Chatterjee 2006). Migrant Workers: People migrating for employment are very common in India. Based on some estimates, 258 million adults in the country are migrants and most of them are men (Saggurti et al. 2008). This group has been linked to having multiple sexual partners and increased HIV transmission (Saggurti et al. 2008). Factors like long working hours, separation from their families and travelling from one place to another increases their chances on engaging in casual sexual relationships, thereby increasing their chances of being infected with STI/HIV. One alarming fact about migrant workers is that they have the lowest perception of risk in all high prevalence states (UNGASS 2010). For example, in the southern high prevalence state of Andhra Pradesh, although 60% of female sex workers are aware of the risk of HIV infection, only about 5% of male migrants are aware of the same (UNGASS 2010). A significant number of this population has been found to have unprotected sex which underscores the need for increased prevention efforts in this group (Saggurti et al. 2008). Important factors in the spread of HIV and STI There are several factors that make India vulnerable towards STI and HIV epidemic. 1. There is significant disparity in the population with respect to income, education, power structures and gender. Therefore the weaker side of this divide is at risk. 2. Social norms restrict women from making decisions about their sexual relations (UNGASS 2008). The culture of silence, ideality of family, marriage and motherhood all adds up to the vulnerability of women in this country. In fact, studies have also revealed that intimate sexual partner violence and increase in gender-related sexual violence is also a risk factor for women (Silverman et al. 2008). 3. The health sector in India is pluralistic and mostly unregulated. Lack of coordination between the national programs, academia and private health care providers has resulted in an inadequate structure in curtailing the STI and AIDS epidemic in the country (WHO 2000). 4. In India, the curriculum for general medical education lacks in-depth training in STI and AIDS. Also the private sector and academic institutions, which treat a large number of the patients with infections, use varying prescribing practices with no systematic documentation of treatment outcomes (WHO 2000). Addressing these basic issues is very crucial in achieving better health outcomes in the population at large. Funding There are many private and public agencies involved in conducting research in this area. They include research institutions, medical colleges, hospitals and voluntary organizations. Funding for the research comes from various national sources like the National AIDS Control Organization, ICMR, Department of Biotechnology and the Department of Science and Technology. International agencies that fund research in India include WHO, USAID, UNAIDS, National Institute of Health in the United States, the UK Medical Research Council, the UK Department of International Development and Indo-French collaborations. International foundations like the International AIDS vaccine initiative, Gates foundation and Clinton foundation also support research of AIDS in India. Priorities and Programs for Prevention against STI and HIV Target Population: Based on the above information, if I had a generous budget for use, in a non-government organization in India, I would target two sets of population groups - the vulnerable population of female sex workers, MSM and injecting drug users and the bridge populations of long distance truck drivers and migrant workers. Targeting these populations especially the ‘bridge’ population is extremely important to curtail the spread of STI and HIV since it is through them that the disease is transmitted into the general population. Targeting female sex workers is also important since women have traditionally been very vulnerable and they need to be equipped with healthier and safer options. Although creating awareness among the two important vulnerable population groups of MSM and injecting drug users is equally important, evidence shows that it is very difficult to gain access in these groups: 1. MSM: The Indian government and several non-government organizations in the country have found it extremely difficult to reach the MSM with information about HIV due to the stigma surrounding this group. In fact outreach workers and peer educators have often been harassed by the police on false charges of promoting homosexuality and sometimes have even been imprisoned (Chatterjee 2003). Although in July 2009, the Indian government abolished the law that criminalizes homosexuality, the effect of this change is yet to be seen (UNAIDS 2009). 2. Injecting Drug Users: Traditionally, the Indian government has approached this group with law enforcement and prosecution. However, in 2008, the government adopted the ‘harm reduction’ strategy which includes substitution therapy as a means to minimize the risks associated with injecting (UNODC 2009). As a result, a pilot program was implemented by the UNODC in partnership with the Indian Institute of Medical Sciences in Tihar prisons which is the largest prison complex in South Asia (UNODC 2009). Although the results have been encouraging, a substantial number of Indian states continue to implement tough regulations on this population making it difficult for organizations to reach this group with STI/HIV prevention messages. Main Priorities of the program: 1. The main priority of programs targeting female sex workers, MSM and injection drug users are to educate them about health and hygiene, improve their self esteem (for female sex workers) and improve access to healthcare. 2. The main priority of programs targeting long distance truckers is to encourage healthier choices and prevention strategies among them. 3. The main priority of programs targeting migrant workers is to overcome the language barriers and increase awareness about STI/HIV related issues and prevention strategies. Outline of Programs for prevention of STI and HIV These programs would be implemented all across the country and not just the five high STI/HIV prevalence states. 1. General awareness programs: These programs for the public at large will use both the print and electronic media. A daily one hour time slot will be purchased on prime time television where doctors, specialists, researchers, activists and patients suffering from HIV/STI will share their expertise and knowledge on the subject. Considering the fact that there are 22 major languages in India, the program will also be telecasted in regional languages in their respective channels. The print media will include newspapers and magazines – both national and regional to educate and create awareness about the diseases and promote abstinence and other prevention strategies to prevent the spread of disease. 2. Online counseling: A formal website would be launched to provide more information on the subject to MSM and injection drug users. This website would give a neutral platform for MSM and injection drug users to communicate with health educators and healthcare providers. The target population will be informed about this resource through electronic and print media. Clients would be handled on a case by case basis by a panel of professional health educators and healthcare providers and prevention and relevant treatment options can be discussed online. 3. Peer-education for female sex workers: This best practice model of the ‘Sonagachi’ project of Kolkata will be implemented across the country. This project has been credited with reducing the prevalence rate of HIV among sex workers from 11% in 2001 to less than 4% in 2004 (UNAIDS 2005). This project is based on respecting sex workers, relying on them to run the program and recognizing their professional and human rights (Mukerjee 2006). Training would be provided to sex workers so that they can educate their peers in brothels about STI/HIV and the importance of having safe sex. Madams and pimps would also be educated about the economic benefits of enforcing safe sex in their brothels (Mukerjee 2006). 4. Workplace awareness model for long distance truck drivers: The program for long distance truck drivers will use the workplace awareness model. This will be a mandatory program for all long distance truck drivers and will be held in association with the regional transport authority. This is where the drivers come annually to renew their driving licenses. The licenses will be provided only after the driver attends an STI/HIV awareness and prevention program. This will include educating the drivers about behavior change and importance of safe sex. They will be required to get a complete examination following which any treatment or intervention (if required) can be provided. Once a driver is diagnosed with the disease, regular follow-up will be ensured by medical personnel though individual case management. 5. Workplace awareness model for migrant workers: The primary focus of this program is to create awareness among migrant workers through prevention strategies and providing treatment options. The key is to provide these services in their native language. It would be mandatory for migrant workers to attend these programs when they join the organization. Medical test and follow-up programs will be held annually. 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