Download Towards a health agenda for women in sex work : Vijaya V

EPIDEMOLOGY OF
HIV/AIDS-WOMEN'S
PERSPECTIVES
Author:V. SUJA
ABSTRACT---HIV infections including AIDS have now become an almost developmental and
security problem in most developing countries, in addition to its medical, social and economic
consequences affecting the individual, home, society and country. AIDS, first reported in women
in 1981, is a major concern for women and girls affecting their motherhood also. Globally, to
date 48% of people living with HIV are women and this rate is gradually going up Biologically
women are more susceptible to get the infection, even though not much difference is seen in the
progression of the disease.
Introduction:
HIV infections including AIDS are one of the pandemics affecting the st world in the 21 century.
It had its origin in early 1980’s. No other disease has gained so much “popularity” within this
short period. It is even threatening the security of countries especially the underdeveloped and
developing ones which have more than 95 % of this infective disease. It is worth quoting here the
words of Peter Piot, Executive Director of the Joint United Nations Programme on HIV /AIDS
(UNAIDS),“ We do not have a cure; we do not have a vaccine. The primary strategy to reduce
the spread of HIV is behavior change. And it is much harder to change an adult’s behavior than it
is to help young people adopt safer behavior from the very start of their sexual lives”. The UN
secretary general has called the HIV /AIDS epidemic “The most formidable development
challenge of our time which needs a global commitment for intensified and coordinated action”.
“You can’t get AIDS by kissing, hugging or holding hands. We are normal human beings. We
can walk, we can talk, we are all the same. When I have an open wound, that is the only time
people need to be afraid of me”. These are the words of the 11year old Nkosi Johnson at the
opening ceremony of the International AIDS Conference in the city of Durban in the year 2000.
This was the poor young South African boy who got infected at birth. What he said is true also.
Eventhough much awareness has occurred in this field , the problem of HIV /AIDS is
growing in magnitude worldwide and the cost in human life and suffering is staggering. HIV
/AIDS which was regarded primarily as a serious health crisis, a decade ago, is now clearly a
development crisis and in some parts of the world is becoming a security crisis too. This will
have a profound impact on infant, child and maternal mortalities , life expectancy and economic
growth. Raising public awareness on change in moral behavior is the key factor in prevention
programmes. HIV / AIDS epidemic affects and kills people in their more productive years ( 2045 yrs ). HIV infection leads to increased morbidity and mortality in their most reproductive ages
and it will have serious economic consequences on the family, the community and the nation.
There will be a drop in life expectancy and a loss of skilled forces across all levels. The
catastrophe of HIV /AIDS can undermine the achievements we have gained in the health field,
like increase in life expectancy, decrease in infant and maternal mortality rates etc. Even the 4
million people currently living with HIV /AIDS in India will be in an extra burden on the already
over stretched health care system.
The AIDS epidemic has a profound impact on growth, income and poverty. It is estimated
that the annual per capita growth in half the countries of sub-Saharan Africa is falling by 0.5–
1.2% as a direct result of AIDS. By 2010, per capita GDP in some of the hardest hit countries
may drop by 8% and per capita consumption may fall even farther. Calculations show that
heavily affected countries could lose more than 20% of GDP by 2020. People at all income
levels are vulnerable to the economic impact of HIV/AIDS, but the poor suffer most acutely.
One quarter of households in Botswana, where adult HIV prevalence is over 35%, can expect to
lose an income earner within the next 10 years. A rapid increase in the number of very poor and
destitute families is anticipated. Per capita household income for the poorest quarter of
households is expected to fall by 13%, while every income earner in this category can expect to
take on four more dependents as a result of HIV/AIDS. In the worstaffected countries, steep
drops in life expectancies are beginning to occur, most drastically in sub-Saharan Africa, where
four countries (Botswana, Malawi, Mozambique and Swaziland) now have a life expectancy of
less than 40 years. Were it not for HIV/AIDS, average life expectancy in sub-Saharan Africa
would be approximately 62 years. In South Africa, it is estimated that average life expectancy is
only 47 years, instead of 66, if AIDS were not a factor (see Figure 2). And, in Haiti, it has
dropped to 53 years as opposed to 59. The number of African children who had lost their mother
or both parents to the epidemic by the end of 2000— 12.1 million— is forecast to more than
double over the next decade. These orphans are especially vulnerable to the epidemic, and the
impoverishment and precariousness it brings.As more infants are born HIV-positive in badly
affected countries, child mortality rates are also rising. Unequal access to affordable treatment
and adequate health services are some of the main factors accounting for drastically different
survival rates among those living with HIV/AIDS in rich and poor countries and communities.
This holds good for our country also.
What is HIV / AIDS ?
The Human Immunodeficiency Virus (HIV ) causes a chronic infection that leads to
profound immunosuppression. The course of the infection may vary somewhat, with some
individuals developing immunosuppression within 2-3yrs and others remaining free of
immunosuppression for 10-15 yrs. Eventually the infected individual develops early
symptomatic HIV, which progresses to AIDS.AIDS is the acronym for Acquired Immune
Deficiency Syndrome which forms one fatal end stage in the natural progression of HIV
infection. HIV infection means any individual harbouring the organism, who may or may not
have any disease manifestation ,which includes AIDS also. But at the same time they can
transmit the infection to others in certain peculiar circumstances which we will discuss later. So
the outward appearance of an individual need not tell us whether he is harbouring the virus or
not. After acquiring the virus, the mean duration by which it progress to AIDS is 10 yrs.
Origin of the Disease :
The medical community was surprised in the early 1980’s, by reports of a particular type of
pneumonia caused by Pneumocystis carini in 5 otherwise healthy young men from Los Angeles
between October 1980 and May 1981 and a series of other 26 cases of a particular skin cancer
called Kaposi’s sarcoma, again in healthy young men. Prior to these reports these diseases were
seen in elderly persons with immunosuppression and that also equally in males and females.
Further it was found that all these young otherwise healthy were homosexuals, thus attributing
something related to sexual activity as the cause. Later it was also detected in those who received
blood transfusions, and in intravenous drug abusers (IVDU). Research work later identified a
peculiar type of virus belonging to the group of retroviruses as the cause by Montagnier and
Galo. In 1983 the virus was isolated from a patient with lymph node enlargement. In 1984 it was
confirmed to be the cause of AIDS.
When and how the disease originated is controversial. Retrospective analysis done on stored
blood showed that the earliest case identified dates back to 1959. Eventhough various theories of
origin of the disease are there,the most reliable is that the virus was present in certain
chimpanzees in Africa ( Pan troglodytus troglodytus ) from ancient times without producing
disease in them but getting transmitted among them from generation to generation – leading to
mutations making them pathogenic. In certain African forest areas these animals were
slaughtered for food purpose and, by injuries in hand the organism might have entered the human
being and from that individual to his sexual partner. When both of them die the virus also gets
arrested there. But due to the behavioral th pattern of man in the latter half of 20 century, with
much travel for education and job and due to increasing promiscuous sexual behavior, the virus
might have spread first among homosexuals and gradually to bisexuals. The virus might have
moved from forest to cities.Now it has become a heterosexual disease causing concern for all
group of individuals irrespective of age or sex or race. So it is the behavior of the human
population which paved the way for its spread. In New York, in the Stonewall Inn , by the gay
revolution it spread among homosexuals.So initially it was thought that homosexuals are more
affected by the disease. Now it is seen equally in homo and heterosexuals world wide, but in the
US even now the main mode of transmission is homosexual contact and intravenous drug abuse
(IVDU).
Virus and the Disease :
HIV is a retro virus belonging to lentivirus family and is icosahedral in shape. It consists of
RNA and a peculiar enzyme called reverse transcriptase. This is covered by an inner protein and
an outer lipoprotein membranes, in which are seen the important antigenic determinants — gp120 and gp –41 in the outer cover and p18 & p24 in the inner cover. There are two types of HIV
ie HIV –1 & HIV –2. HIV –1 is more common in the US. After it enters human body,the ideal
site in which it likes to reside, host cell is a peculiar type of lymphocytes, one type of white
blood cells, called CD 4 T cells with CD 4 molecule on its surface. These lymphocytes are
important in preventing infections and in immune surveillance and tumor prevention normally.
This primary infection occurs by entry of organism through sexual / other routes. Gradually the
virus increases in number in the body and leads to an “ acute HIV syndrome” simulating a viral
fever. In this stage the patient is highly infectious because of high levels of virus in blood, but at
the same time the disease cannot be detected by blood tests. Then gradually immune response
occurs against the virus and the virus gets trapped in lymph nodes and viremia and the acute
symptoms stop and patient goes into a latency stage, on the average of 10yrs. Gradually the
metabolism of the virus inside these cells leads to progressive quantitative and qualitative
deficiency of CD 4 cells.Then slowly CD4 cells decrease and when it reaches a particular level
the patient develops various infections and cancers. Initially these may not be life threatening,
but when the CD4 count drops to very low levels, the patient develops serious infections and
malignancies and succumbs to that. This fatal stage is called AIDS. Even though various groups
of drugs are there to decrease viral multiplication, drug treatment is costly and is with various
side effects, needing constant supervision of a specialist.
Transmission:
The main modes of transmission of HIV are:
1. Sexual contact – homosexual,heterosexual &bisexual
2. Blood & blood products transfusion and organ transplantation
3. Intravenous injections and drug abuse
4. Mother to foetus
5. Occupational exposure
More than 80 % of HIV cases are transmitted by sexual contact. Intimate body contact
during the sexual act leads to minute abrasions and injuries in the skin and mucosa.Through
these injuries the body fluids of one partner can enter the other and the virus can enter the
body.Semen and vaginal fluids contain plenty of organisms. Also if there is an ulcer in the
genitalia or urethral discharge the chance for transission of the infection increases. That is why
the presence of other sexually transmitted infections as syphilis, herpes genitalis and gonorrhea is
said to increase the chance of tranmission. Through vaginal mucosa it can be transmitted
especially if traumatized. So there is 20 times more chance of HIV transmission from man to
woman than from woman to man by vaginal intercourse. This is because in females there is
increased exposure of vaginal and cervical mucosa as well as endometrium of uterus to infected
semen. In males the penis and urethral orifice are exposed only to a brief period to the infected
vaginal fluid. Persistent and proper use of condoms can significantly reduce this mode of
transmission. In receptive anal intercourse due to increased trauma and due to some other
reasons the chance of transmission is increased more than that by vaginal intercourse. Vaginal
mucosa is several layers thicker than rectal mucosa. The chance of transmission by oral sex is
less but the disease can occur and cases have been reported. Behaviors that bring the highest risk
of infection in Asia and the Pacific are unprotected sex between clients and sex workers, needle
sharing and unprotected sex between homosexual men. But infections does not remain confined
to those with higher-risk behaviour. Many countries have seen major epidemics grow out of
initially relatively contained rates of infection in these populations. Northern Thailand’s
epidemic in the late 1980s and early 1990s was primed in this way. Over 10% of young men
became infected before strong national and local prevention efforts, including the ‘100% condom
programme’, reduced high-risk behaviour, encouraged safer sex and lowered HIV prevalence.
Few countries are acting vigorously enough to protect sex workers and clients from the HIV
virus. Yet, it is from the comparatively small pool of sex workers first infected by their clients
that HIV steadily enters the larger pool of still-uninfected clients who eventually transmit the
virus to their wives and partners. Although recent behaviour surveillance surveys show that in 11
out of 15 Asian countries and Indian states, over two-thirds of sex workers report using a
condom with their last client, the need to boost condom use remains. In Bangladesh, Indonesia,
Nepal and the Philippines, for instance, fewer than half of sex workers report using condoms
with every client.
The best way to prevent transmission by sexual means is to follow certain principles in life.
These are – never have sex before marriage and be faithful to the spouse after marriage. These
should be stressed especially in early adolescence ie. before starting any sexual activity. It is seen
that sexual activity before marriage is more common and begins more early in boys. ie, between
the ages of 10 and 15. If one cannot follow these things, advise about safer sex, as proper and
consistent use of condoms. Also try to avoid contact with promiscuous individuals, commercial
sex workers and unknown persons. Semen during artificial insemination can also transmit
infection.
Blood and blood product transfusions and organ transplants, if infected, can transmit the
disease by direct entry of organism into the body. The chance of transmission by transfusion of
one bottle of infected blood is nearly 90 100%. The chance of transmission by an unprotected
sexual contact from an infected individual is 1in 1000. But more than 80 % of HIV cases are
sexually transmitted. Blood transfusions leading to transmission are becoming rare because of
proper screening of blood before transfusions. Also blood from high risk individuals should be
avoided. Intravenous injections using infected syringes and needles also can transmit the
infection. Government has put forward various directions to prevent these modes of
transmission. By using properly sterilized glass syringes and needles, cleaned and sterilized in
boiling water for 30 minutes or by using reliably new disposable syringes and needles this can be
averted. HIV virus can be killed by one minute boiling, but Hepatitis organism is killed only by
10 minutes and various spores can be killed only by 20 –30 minutes boiling. The disease can also
be spread through the skin or mucosa of an individual coming in contact with infected material
from another individual as blood, semen, vaginal secretions, other body fluids as urine, feces etc
contaminated with blood. Even though the organism won’t enter through intact skin or mucosa,
care should be taken to handle these materials because minute injuries in the skin or mucosa are
usually not visible to naked eye. Usually tears are noninfectious, but in the case of saliva it is
controversial. So proper care should be taken, as using gloves, in handling open wounds in any
situation. Also it is advisable, as far as possible, not to come in direct skin contact with any body
secretions or excretions of another individual.
Using of improperly sterilised needles and syringes or sharing of these equipments among
intravenous drug abusers is another important cause of transmission. Sharing injecting
equipments is a very efficient way of spreading HIV, making prevention programmes among
injecting drug user populations another top priority. Upwards of 50% of injecting drug users
have acquired the virus in Manipur in India, Myanmar, Nepal, Thailand and China’s Yunnan
Province. Extensive harm reduction programmes can and do work. By the late 1980s, Australia
had prevented a major epidemic from occurring among injecting drug users and, quite likely,
from spreading beyond them. Such examples are being followed by several other countries but in
an isolated fashion. The SHAKTI Project in Dhaka, Bangladesh, offers injecting drug users
needle exchange, safer injecting options and safer sex education, as well as condoms.
Transmission of the infection from mother to the child can occur in utero, more commonly
during vaginal delivery due to trauma in vagina and coming in contact with cervical and vaginal
secretions, and after delivery. The chance of materno fetal transmission is 20 –30 % for each
pregnancy. Breast feeding by an infected mother can transmit the disease to a baby through
breast milk, if it is already not infected. So in developed countries they advise an infected mother
not to breast feed and to give completely artificial feeding. But in developing countries like India
where artificial feeding is not feasible always, and improper feeds can lead to malnutrition and
progression of AIDS more rapidly in the child, this is debatable. Another point to remember is
that a pregnant lady if HIV positive has to take drugs which decrease transmission of the virus to
the fetus, under supervision. Most often such a child will invariably become an orphan within a
few years because the father and mother might be infected in such cases.
To our knowledge till now, HIV is not transmitted by casual body contact as shaking hands
or by insect bites or mosquito bites.
High Risk Groups :
The following are the high risk individuals in society who should be monitored.
1. Patients with other sexually transmitted disease as syphilis, herpes genitalis, gonorrhoea
which can produce
genital ulcers /or urethral symptoms
2. Individuals in the high risk category - Intravenous drug abusers, homosexual and bisexual
males, those undergoing
regular blood transfusions, regular sexual partners of such high risk individuals, sexual
partners of a known HIV
patient, commercial sex workers and their sexual partners, heterosexual persons with
multiple sexual partners or
unprotected intercourse.
3. Persons who consider themselves at risk
4. Health care workers who perform invasive procedures
5. Donors of blood, semen and organ. 6. History of transfusion after 1985 of unscreened
blood or blood products. It is
advisable to screen these individuals.
How to detect HIV infection ?
1. Enzyme Linked Immuno Sorbent Assays - the commonly called ELISA test – are widely
used to screen the presence of HIV infection. In this the test detects presence of antibodies in the
blood of a patient harbouring HIV. This is important because clinically the patient may not have
any symptoms/signs to diagnose HIV and so the infection goes unnoticed . But such an
individual can spread the infection in certain particular risk behaviors as discussed above .But in
the initial 3-4 weeks of infection it may not produce a positive result because for development of
HIV specific antibodies, it takes about 3-4 weeks after acute infection. Also conditions other than
HIV infections can lead to a false positive result. So any individual who is undergoing an ELISA
check up for HIV is advised to have a pretest and post test counselling by a trained counsellor. In
the pretest counselling patients should be made aware of the ‘ window period ‘ for the HIV test that a period of 12 weeks since the last possible exposure to HIV should have elapsed by the time
of the test or otherwise it may be a false negative one.
2. Western Blot tests : This is used to confirm an ELISA reactive serum as a true positive or
not. It detects antibodies and the specific HIV proteins against which it is directed. It also may
not be positive in the initial 3 to 4 weeks of infection.
3. Other tests which can be done include: antigen detection ( p24 assays), CD4 counts to
assay the level of immunosuppression to decide on treatment and Polymerase Chain Reaction
(PCR ) for measuring the amount of viral particles and rarely viral culture.
Manifestations :
Most often an individual harbouring the virus doesn’t have any initial manifestations and go
on transmitting the disease under the high risk behavior states previously discussed, if proper
protective measures are not taken. Only years after acquiring the infection, a majority will show
symptoms and will be diagnosed. After a prolonged period of asymptomatic stage the patient
develops various infections and malignancies and finally AIDS. The important symptoms
include loss of 10 % body weight, chronic diarrhea of one month duration, some types of
tuberculosis, a ‘thrush ‘like fungal infection in the oral cavity and oesophagus, certain neurologic
manifestations and some peculiar types of skin diseases.
Burden of the Problem :
Global burden : Twenty years after the first clinical evidence of acquired immuno deficiency
syndrome was reported, AIDS has become the most devastating disease mankind has ever faced.
Since the epidemic began, more than 60 million people have been infected with the virus.
HIV/AIDS is now the leading cause of death in sub-Saharan Africa. Worldwide, it is the fourthbiggest killer. The diversity of HIV’s spread worldwide is striking. But in many regions of the
world, the HIV/AIDS epidemic is still in its early stages. While 16 subSaharan African countries
reported overall adult HIV prevalence of more than 10% by the end of 1999, there remained 119
countries of the world where adult HIV prevalence was less than 1%.UNAIDS latest statistics
shows that globally 40 million adults and children were living with HIV / AIDS at the end of
2001. Of infected adults, 48 % were women. In 2001, the global adult HIV prevalence rate was
1.2 %. During2001, 5 million people were newly infected. There were 3 million adult and child
deaths due to HIV /AIDs in 2001. Since the beginning of the epidemic, there have been 25
million AIDS deaths.
The Sub- Saharan Africa has the maximum number of HIV positives 28.1 million with a
percentage prevalence of 8.8 in adults. In this area 55% of infected adults are women. HIV
prevalence rates have risen to alarming levels in parts of southern Africa, where the most recent
antenatal clinic data reveal levels of more than 30% in several areas. In Swaziland, HIV
prevalence among pregnant women attending antenatal clinics in 2000 ranged from 32.2% in
urban areas to 34.5% in rural areas; in Botswana, the corresponding figures were 43.9% and
35.5%. In South Africa’s KwaZulu-Natal Province, the figure stood at 36.2% in 2000. This
notwithstanding, in some of the most heavily affected countries there is growing evidence that
prevention efforts are bearing fruit. One new study in Zambia shows urban men and women
reporting less sexual activity, fewer multiple partners and more consistent use of condoms. This
is in line with earlier indications that HIV prevalence is declining among urban residents in
Zambia, especially among young women aged 15– 24. Progress is also being made on the
treatment and care front. In the southern African region, relatively prosperous Botswana has
become the first country to begin providing antiretroviral drugs through its public health system,
thanks to a bigger health budget and drug price reductions negotiated with pharmaceutical
companies.
In Australia, Canada, the United States of America and countries of Western Europe, a
pronounced rise in unsafe sex is triggering higher rates of sexually transmitted infections and, in
some cases, higher levels of HIV incidence among men who have sex with men. The prospect of
rebounding HIV/AIDS epidemics looms as a result of widespread public complacency and
stalled, sometimes inappropriate, prevention efforts that do not reflect changes in the epidemic.
In Japan, meanwhile, HIV infections are also on the rise.
The rise in new HIV infections among men who have sex with men is striking. In
Vancouver, Canada, HIV incidence among young men who have sex with men rose from an
average of 0.6% in 1995– 1999 to 3.7% in 2000. In London, reported HIV infections among gay
men are also on the rise. Rising incidence of other sexually transmitted infections among men
who have sex with men in places like London confirms that more widespread risk-taking is
eclipsing the safer-sex ethic promoted so effectively for much of the 1980s and 1990s. Similar
trends are being detected among the heterosexual populations of some countries, especially
among young people. Diagnoses of gonorrhoea and syphilis among men and women have hit
their highest levels for 13 years in England and Wales, for instance. But in high income countries
since 1996 the life saving anteretroviral drugs which are costly are in use.Deaths attributed to
HIV in the USA, for instance, fell by a remarkable 42% in 1996– 97, since when the decline has
levelled off.
However, this wide access to antiretroviral therapy has encouraged misperceptions that there
is now a cure for AIDS and that unprotected sex poses a less daunting risk. High-risk behaviour
is increasing, as a result. In high- income countries there is evidence that HIV is moving into
poorer and more deprived communities, with women at particular risk of infection. Young adults
belonging to ethnic minorities,including men who have sex with men, face considerably greater
risks of infection than they did five years ago in the USA. African-Americans, for instance, make
up only 12% of the population of the USA, but constituted 47% of AIDS cases reported in 2000.
As elsewhere in the world, young disadvantaged women, especially African-American and
Hispanic women, in the USA are being infected with HIV at higher rates and at younger ages
than their male counterparts. In USA, sex among males is still the main mode of transmission
accounting for some 53% of new HIV infections in 2000. But almost one-third of new HIVpositive diagnoses were among women in 2000. In this latter group, an overlap of injecting drug
use and heterosexual intercourse appears to be driving the epidemic. Indeed, injecting drug use
has become a more prominent route of HIV infection in the USA, where an estimated 30% of
new reported AIDS cases are related to this mode of transmission. In Canada, women now
represent 24% of new HIV infections, compared to 8.5% in 1995.
The HIV epidemic in western and central Europe is the result of a multitude of epidemics
that differ in terms of their timing, their scale and the population they affect. Portugal faces a
serious epidemic among injecting drug users. Of the 3733 new HIV infections reported there in
2000, more than half were caused by injecting drugs and just under a third occurred via
heterosexual intercourse. Reports of new HIV infections also indicate that sex between men is an
important transmission route in several countries, including Germany, Greece and the United
Kingdom. Unfortunately, HIV reporting data are uneven in several of the more affected
countries, including some of those believed to be most affected by the epidemic among injecting
drug users. In Japan, Germany and United Kingdom, the number of HIV infections detected in
men who have sex with men has risen sharply in recent years, with male-male sex now
accounting for more than twice as many infections in men as heterosexual sex. This is a major
departure from past patterns: until two years ago, the number of new infections reported in both
groups was roughly equal. Eastern Europe— especially the Russian Federation— continues to
experience the fastest-growing epidemic in the world, with the number of new HIV infections
rising steeply with increase in other sexually transmitted diseases and increased rate of IV drug
abuse.
Developing Countries :
More than 95 % HIV infections are now in the developing countries. In many parts of the
developing world, the majority of new infections occur in young adults, with young women
especially vulnerable. About one-third of those currently living with HIV/AIDS are aged 15– 24.
Most of them do not know they carry the virus. Many millions more know nothing or too little
about HIV to protect themselves against it. In Asia and the Pacific, an estimated 7.1 million
people are now living with HIV/AIDS. The epidemic claimed the lives of 435,000 people in this
region in 2001. The apparently low national prevalence rates in many countries in this region are
dangerously deceptive. They hide localized epidemics in different areas, including some of the
world’s most populous countries. There is a serious threat of major, generalized epidemics. But,
Cambodia and Thailand have shown that prompt, large-scale prevention programmes can hold
the epidemic at bay. In Cambodia, concerted efforts, driven by strong political leadership and
public commitment, lowered HIV prevalence among pregnant women to 2.3% at the end of
2000— down by almost a third from 1997.
In Asia & India :
The heavily populated countries in the world such as India, China and Indonesia registered a
marked increase in HIV cases, eventhough HIV/AIDS had a late arrival to Asia. Until the late
1980s, no country in the region had experienced a major epidemic. This situation is now rapidly
changing. In 2001, 1.07 million adults and children were newly infected with HIV in Asia and
the Pacific. At the end of 2000, the national adult HIV prevalence rate in India was under 1%,
yet this meant that an estimated 3.86 million Indians were living with HIV/AIDS— more than in
any other country besides South Africa. Indeed, median HIV prevalence among women
attending antenatal clinics was higher than 2% in Andhra Pradesh and exceeded 1% in five other
states– Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu– and in several major cities
including Bangalore, Chennai, Hyderabad and Mumbai. India’s epidemic is also strikingly
diverse, both among and within states.
In India with more than 1 billion population, national prevalence loses its meaning. In India
it is in the rising or trajectory stage with many case hidden under the iceberg with the estimated
ones forming only a part of the cases.India has several HIV epidemics with different patterns and
prevalence. The epidemics vary significantly from state to state. Heterosexual transmission is
more in Maharashtra and Tamil Nadu, whereas those associated with injecting drug use is most
common in Manipur. In general, there is a comparatively high HIV prevalence in western and
southern India and low in the eastern and northern parts.This heterogeneity together with big
differences in social structures and the enormous size and population of India, make it difficult to
monitor the various epidemics and institute effective interventions. This has probably contributed
to the rapid and continuing spread of HIV in India despite the ten year grace period India
experienced from the start of the epidemic in western countries and in Africa in the early 80’s
until the prevalence rose abruptly in India.The Indian states of Maharashtra, Andhra Pradesh and
Tamil Nadu,each with at least 55 million inhabitants, have registered HIV prevalence rates of
over 2% among pregnant women in one or two sentinel sites and over 10% among sexually
transmitted infection patients— rates far higher than the national average of less than 1%. In the
absence of vigorous prevention efforts, there is considerable scope for further HIV spread. Even
HIV prevalence rates as low as 1% or 2% across Asia and the Pacific,which is home to about
60% of the world’s population, would cause the number of people living with HIV/AIDS to soar.
Kerala:
In India due to the diversity in social and cultural factors the state of HIV also differs. States
as Arunachal Pradesh has reported almost no HIV infection, and in general other states have
reached an adult HIV prevalence rates of 2% or more. In most of our states and in Kerala often it
is seen that the infection in females including pregnant women is from husbands who had been
infected in turn by sex workers, and these are more in those who travel much for job purposes.
NACO estimates that in Kerala 70,000 to 1 lakh people are living with HIV. Patients having an
STD has 10 % more risk. In Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu & Manipur
the antenatal rate is greater than 1 %. In Kerala , in antenatals the rate is less than 0.2%, but in
STD cases it is greater than 5%. In Kerala most of the cases are from outside, because at least in
40 % of families in kerala atleast one member is living outside. The other peculiarities seen is
that most often ladies get infection from their husbands and the male female ratio is 3:1. In other
parts of India it is more seen in urban places but in Kerala it is prevalent equally in urban and
rural areas.
In India 50 % of the cases are seen in those less than 25 yrs of age but in Kerala infection in
those aged less than 25 yrs is less. More than 70% of HIV infections world wide are estimated to
result from sex between men and women. Nearly 80% of cases in India and 95% of cases in
Kerala are reported to be caused by heterosexual transmission. According to sentinel surveillance
Kerala comes in group 3 in which HIV infection in any of the high risk groups is still less
than5% and less than 1% in antenatal women. Now HIV infection is percolating from very high
risk to low risk groups.In the Indian context due to varied cultural characteristics, traditions and
values with special reference to sex related risk behaviour, infection shifts from high risk
population to general population over a period of time.
HIV and Women :
HIV affects both women and men. AIDS was first reported in women in1981. World wide,
more men are living with AIDS, but women are contracting HIVat a faster rate. Women are
biologically more vulnerable to transmission. Of the total 40 million affected in the world,48 %
are now women. Women are more susceptible to HIV because of the behaviour of men
especially in sexual life . On the average, men have more sex partners than women either male or
female and so more oppurtunity to contract and transmit the disasese. Also men have more
influence over whether or not to have safer sex. Gender inequalities are important. In most
societies women have less access to health care, education and employment. Their unequal
situation is reinforced in many societies by the double standards of sexual morality . When
women are subjected to violence or sexual abuse, it is conveniently said that women ‘get what
they deserve.’ In certain societies the double stand is that women are expected to preserve their
virginity until marriage, but young men, on the other hand , are encouraged to gain sexual
experience and indeed having many sexual relationships may make a man popular in the eyes of
his peers. In some societies having sex with a young girl is believed to increase virility and is
seen as a risk minimization strategy by older men or is thought to cure HIV . Yet older, sexually
active men are more likely to be HIV infected. While trying to decrease their risk of ‘ becoming
HIV infected, they are in fact putting young girls at risk of HIV, other sexually transmitted
diseases and unwanted pregancies. Many women who test positive for HIV face the twin
prospects of coping with their diagnosis and finding a way of informing their husbands or male
partner. In such situations men and their family members may accuse the woman of bringing
HIV into the house hold – even though it is much more likely that the man is responsible. In
extreme cases, women with HIV may be ejected from their home by their husbands or by the
husband’s family after his death. Now the male female ratio is nearly becoming equal with a
rapid increase in female cases. An estimated 13.2 million children have been orphaned due to
AIDS till now.
Gender Issues in HIV /AIDS :
1. Male violence against women – In most societies there is a double standard of sexual
morality, which ensures that women can be viewed as creatures that lead men ‘astray ’.
Sometimes, dressing and appearing attractive suffices to earn a woman the label of ‘sexual
promiscuousness’. When women are subjected to violence or sexual abuse , it is conveniently
said that women ‘ get what they deserve ’.
2. Women’s economic dependency on men – In many societies women have less access to
health care, education and employment. Women are also likely to have less formal education,
less knowledge of HIV, language barriers and financial issues. In most societies they are
dependent on males economically and socially, in their health seeking behaviour.
3. Ideologies of motherhood. In most parts of India especially North India and other
developing countries, early pregnancy and delivery are very common, at an age in which the girl
is not mentally and physically prepared for motherhood
4. Traditional norms which make it difficult for women to seek treatment and information
about sex –In many societies, cultural barriers can inhibit public discussions of sexuality and
therefore prevent a better understanding of women’s needs.
5. Forces which dictate that good women should be ignorant about sex: In many societies the
belief is that women shouldn’t take any decision on sexual activities, and most often the males
dominate in taking decisions.
6. The culture of silence that surrounds sex – In many societies , women are at incrased risk
of HIV because lower social or economic status renders them dependent on their husband or
male partner or places them in a diminished position to request that a husband or male partner be
faithful or use condom, to prevent HIV transmission.
The above forces render women susceptible to HIV /AIDS.Eventhough it was seen early that
women appear to progress to AIDS and die faster than men, it is not true. However their deaths
are due to unequal access to care and treatment. Cumulative evidence indicates that women are
about four times as susceptible to HIV infection as heterosexual men, based on biological /
anatomical factors.
The leading cause of death in NewYork city for women aged 25-44 is HIV. The stigma
surrounding HIV is very tragic. Even now people appear afraid to reveal their sero status . For
women the effect of AIDS stigma is usually very severe that relatives usually force women to
leave their marital home after the death of a husband with a history of AIDS. One important
effect of HIV/AIDS in the demographics is that, it produces a “population chimney”, with young
people including women dying or becoming infertile, and so less babies, and one third of infants
born to HIV positive mothers will succumb to infection. Infection is usually acquired by children
of the age group 10 to 15 years who develop AIDS within 10 years. So the population of women
above 20 and men above 30 decrease radically and the total population gradually decrease. HIV
is highly stigmatized in India. In many countries the association between HIV and “promiscuous
“ sexual behaviour has created a belief that people who are infected with HIV somehow
“deserve” their fate. Paradoxically, a recent study of attitudes shows that women – who are often
monogamous wives infected by their husband – are especially stigmatised. They are frequently
blamed by their infected spouse, even in cases when they themselves are not infected. If a man
dies of AIDS, his wife risks being thrown out of home by their in-laws.
Preventive Measures:
From the previous discussions it is clear that the only way of keeping away from HIV /
AIDS is to prevent it by avoiding certain risk behaviors. Sex education delays first sex and
decrease risk taking behaviour in both men and women. So young people both men and women
should be given proper sex education as early as possible. It is most effective when given before
the young begin their sexual lives. Well planned sex education can help reduce the risk of
contracting sexually transmitted diseses, including HIV and unwanted pregnancy.So motivate
men and women to talk openly about sex, sexuality , drug use and HIV/AIDS. Parents should
talk to their children. Pressured to have sex , most are poorly informed about sexuality and
reproduction. Parents need to talk more with their children abut sex, sexuality and gender roles.
Boys need to be taught that responsible sexual behaviour is a positive aspect of masculinity and
both boys and girls should be offered the chance to acquire the life-skills needed to refuse sex or
negotiate safer sex. AIDS prevention and care programmes are widespread but often promote
broad messages that are not rooted within the context of of men’s and women’s life. While
abstinence and mutual fidelity are effective ways of preventing HIV infection , not every one
can, or wants to adopt these options. Even the consistent use of condoms is difficult for many
men and women. So messages must reflect the realities in men’s and women’s lives. To be
successful, prevention programmes must respond to realities in life. Women and men should be
addressed separately and messages should be delivered to the young, the old, the rich, the poor,
the urban and the rural. In some societies young women exchange sex for urgent needs for
money or gifts offered to them in exchange for sex for clothing, to attend school or for food.
Young girls need to be taught skills to help them reject sexual advances from men or at least to
negotiate the use of condoms.
United Nations General Assembly Special Session on HIV/AIDS in June 2001 set in place a
framework for national and international accountability in the struggle against the epidemic.
Each government pledged to pursue a series of many benchmark targets relating to prevention,
care, support and treatment, impact alleviation, and children orphaned and made vulnerable by
HIV/AIDS, as part of a comprehensive AIDS response. One of the target aimed is to have by
2003,strategies that begin to address the factors that make individuals particularly vulnerable to
HIV infection, including under-development, economic insecurity, poverty, lack of
empowerment of women, lack of education, social exclusion, illiteracy, discrimination, lack of
information and/ or commodities for self-protection, and all types of sexual exploitation of
women, girls and boys. Young people and women are a priority on this front. Twenty years into
the epidemic, millions of young people know little, if anything, about HIV/AIDS. According to
UNICEF, over 50% of young people (aged 15– 24) in more than a dozen countries have never
heard of AIDS or harbour serious misconceptions about how HIV is transmitted. Vigorous
prevention efforts are needed to equip young people with the knowledge and services such as
HIV/ AIDS information, condom promotion, life-skills training they need to protect themselves
against the virus. Given that young people especially women are bearing the brunt of the
economic transitions in the region, socio-economic programmes that can reduce the vulnerability
of young men and women are also vital.
Special steps are needed to include HIV-related life-skills education in school curricula and
to extend peer education to vulnerable young people who are in institutions or out of school and
employment and among housewives. Much more comprehensive efforts are needed to address
the complex issues related to HIV and injecting drug use among young people. Prevention is the
best to avert the future cost of treating and caring the HIV affected ones. A particularly effective
intervention is the prevention of mother to child transmission which is the most significant
source of HIV infection in children below 10 years. This can be achieved by the primary
prevention of HIV infection in parents, the prevention of unwanted pregnancies in HIV infected
women and by preventing HIV transmisssion from HIV infected women to their infants. HIV
infected women should have access to information, follow up clinical care and support, including
family planning services and nutritional support. These can be achieved by educating and giving
information and support to develop life skills to each and every girl and woman at an early age in
their life that is before sexually active stage.
There is ample evidence that early, large-scale and focused prevention programmes, which
include efforts directed at both those with higher-risk behaviour and the broader population, can
keep infection rates lower in specific groups and reduce the risk of extensive HIV spread among
the wider population. Cambodia’s prevention measures, which began in earnest in 1994– 95, saw
highrisk behaviour among men fall and condom use rise consistently in the late 1990s. As a
consequence, HIV prevalence among pregnant women declined from 3.2% in 1997 to 2.3% at
the end of 2000, suggesting that the country is beginning to bring its epidemic under control.
In developing countries, which cannot afford antiretroviral therapy, the following are the
preventive measures :
1. Access to condoms for all groups of high risk individuals.
2. Prophylaxis and treatment of infections including STD s and Tuberculosis.
3. Sex education at school and beyond.
4. Access to voluntary counselling and testing.
5. Counselling and support for pregnant women and efforts to prevent mother to child
transmission.
6. Blood saftey and safe injection practices.
Why women centered preventive programmes?
Compared to men, women are likely to have less formal education, less knowledge of HIV,
language barriers and financial issues. Women are less likely to have a regular source of health
care and are frequently unaware that they have any risk factors. Women account for a higher
proportion of marginalised people with HIV, such as homeless. Also women must contend with
social barrier of sexism and often dual barriers of sexism and racism.Access to treatment also is
less especially to those with lower socio economic status. Women tend to have more depression.
Clinical depression in HIV positive women drastically affects quality of life and greatly
increases the chance of nonadherence to medications. In many societies women are at increased
risk because lower socio-economic status renders them dependent upon a husband or male
partner or places them in a diminished position to request that a husband or male partner be
faithful or use condom, the most widely available method to prevent HIV transmission during
intercourse. Many studies show that a majority of women get the infection from their sole sex
partners, usually their husbands. Often women with more than one partner include those who are
driven by economic necessity into sex work and they are at risk for acquisition of HIV through
multiple, often unprotected, sexual exposures. So there should be an effective female controlled
method so that women may protect themselves.
Future :
Ultimately the most important long term goal on HIV education and prevention involves the
prevention of infection. The strategies in trial include vaccines and microbicides. Female
condoms has been marketed for several years, but it is expensive for most women. Vaginal
microbicides are still under research; they are extremely promising. Their advantages include
non delectability including lack of smell and taste, safety and efficacy, antimicrobial properties
against HIV and other STDs, and as spermicide. This may be a cream, gel, film suppository,
vaginal ring or diaphragm. But all these are in the experimental field only.
Around half of the people who acquire HIV become infected before they turn 25 and
typically die of the life threatening illness called AIDS before th their 35 birthday. This age
factor makes AIDS uniquely threatening to children. The number of AIDS orphans are gradually
increasing in the world AIDS orphans means those who have lost their mother before reaching
15. Stigma is there in the provision of health care also. A majority of hospitals are reported either
to turn away HIV infected patients or refuse to serve their needs. In a study of discrimination, in
the health system, many health workers are of the opinion that treating patients with HIV was a
waste of time and money because the patients are destined to die anyway. In this climate of
irrational fear and discrimination prevention work is difficult. For prevention to be effective,
culturally sensitive issues as extramarital sex and condom use must be tackled head on.
Promotion of responsible reproductive health behaviour among the youth is very important.
Adolescent ignorance about the sexual behaviour is compounded by the reluctance among
parents and teachers to impart relevant information. Mothers expect their adolescent children,
particularly daughters to remain uninformed about sex and reproduction. Sex and puberty were
considered to be embarressing and dirty subjects not to be discussed with their adolescent
children. The education system is also important in sex education. Teachers also usually by and
large find the topic embarrassing and try to avoid it. As a result of the reluctance on the part of
parents and teachers the main source of such information is from peers and mass media. These
always need not give correct information. So education becomes important in imparting
knowledge on reproductive health, STDs, HIV /AIDs , moralities and principles to be adopted in
life which helps to prevent transmission of HIV. If not the youth should be given information
about the ways of safe sex especially the consistent use of condoms .
The objective of an AIDS control Progamme should be :
1. to bring about change in behavioural practices ( unsafe sex, sharing of needles)
2. to persuade people to take action which will sfeguard them from getting infected
3. to care for the already infected without creating panic.
REFERENCES
UNAIDS Statistics 2001
UNAIDS Aids Update 1999
AIDS News.
MMWR.
Contributor
V. SUJA Associate Professor, Department of Dermatology & Venereology and faculty, Regional
Clinical Epidemiology and Resource Training Centre, Medical College, Thiruvananthapuram.
Has taken M Phil in Clinical Epidemiology and M.D. in Dermatology & Venereology. Has
organized various conferences. Has conducted many research projects and published papers.