Dr. Subhahish.Das (Associate Prof. of Pathology,(In-Charge Blood Bank),Sri Devaraj Urs Medical College, Tamaka, Kolar.)
Human immunodeficiency virus (HIV causes the acquired immuno deficiency syndrome(AIDS) has become pandemic. According to WHO estimation,- in Asia about 1 in 250 adults is infected with the virus . Mandatory screening of all donors for such infections have significantly reduced the problem; but not completely eliminated such risk because the donor may be at the window period or lack sufficient response so that our tool can detect the response. The risk of such infection is clearly higher in recipients of blood obtained from commercial source compared to blood from volunteer donors.
The first case of HIV infection in India was reported in Tamil Nadu in 1986 and the first case of Acquired Immuno Deficiency Syndrome (AIDS) was diagnosed in Bombay in 1987 . Number of people infected with HIV is growing faster in India. HIV-AIDS presents an unusual challenge. Unlike other diseases, it selectively and disproportionately affects two groups-young adults who are in their prime reproductive and economically productive years, and the very poor and economically marginalized populations.
Diagnosis of HIV infection remains a challenge. There are unresolved ethical & technical issues around voluntary counseling and testing. Availability of highly active antiretroviral therapy is not an issue since antiretroviral drugs are manufactured in the country and exported elsewhere, but their affordability and the feasibility of monitoring patients taking the drugs are in question.
Poverty creates conditions ripe for HIV transmission. Economic growth has caused rapid urbanization in India, with large urban slum populations composed of migrants, manual laborers'& child laborers. Currently 260 million persons in India live below the poverty line. Those with low incomes cannot afford to buy condoms or treatment for STDs. Poor families send their young women into prostitution to make ends meet. Untreated STDs increase the risk of HIV transmission, as these infections cause mucosal ulceration with an easy entry for HIV.
HIV testing is offered by government institutions and by private hospital-based or independent clinical laboratories. There is no national information grid that collects HIV testing information from clinical laboratories in the private sector, so prevalence estimated are based solely on the sentinel surveillance mechanism. The sentinel surveillance systems uses anonymous unlinked sample screening for HIV antibodies to estimate prevalence of HIV in various states and population groups. Surveys are conducted annually, and survey sites include sexually transmitted disease (STD) clinics, antenatal clinics, sited that target IDUs, and those that target men who have sex with men.
The virus is spreading rapidly along India's coasts and inward to all parts of the country, both rural and urban. The epidemic varies widely among regions, a reflection of the country's great diversity. A survey of randomly selected households in Tamil Nadu found that 2.1% of the adult population living in the countryside had HIV infection compared with 0.7% of the urban population. In the northeastern State of Manipur, HIV has already reached epidemic proportions among IDUs. In 1989 the Government of India declared a ban on the acceptance of blood from professional blood donors- individuals who accept a monetary compensation in return for donating blood. However, this ordinance has not been entirely effective. Although blood banks refuse to transact commercially with these donors, the friends and relatives of those who require blood transfusion regularly bring these donors to blood banks, declaring them voluntary donors or close relatives.
There are many social precursors for the rapid spread of HIV in the country, including inability to talk openly and learn about sex and sexuality, pressures from family to give birth to an heir and an implicit threat to the marriage when a woman is unable to become a mother, the high prevalence and acceptability of domestic violence against women, the moral double standard imposed on men and women, and the lower status of women in general. The pressure to be a mother is so intense that when a woman has to choose between being HIV- sero negative but with out children and possible conception with possible HIV infection, she often chooses the latter.
According to the data supplied by National AIDS Control Organization (NACO), New Delhi surveillance of the HIV cases in India as on 31st August 2006 are as follows: sexual (85.34%), perinatal (3.80%), transfusion of blood and blood products (2.05%), injectable drug users (2.34%) and other unknown reasons (6.46%). In the year 1999, 8% of the AIDS cases were due to transfusion of infected blood and blood products. According to a survey of NACO carried out in the year 2001, this number reduced to 2.99%, in the year 2004 the number was further reduced to 2.43% and in the year 2006 it further dropped to 2.05%.
There is a remarkable steady decrease in the incidence of transmission of HIV infection through transfusion of blood and blood products from 8% to 2.05% in last 7 years. This might be the result of extensive testing of the blood before transfusion, bans on professional donors as well as awareness programs conducted by government, non-government organizations (NGO) and media to improve the awareness about spread of HIV infection among general population. Good awareness about HIV infection amongst the donors is required to increase safe blood donor pool. The awareness is supposed to be more in repeat voluntary blood donors rather than first time donors, because the former group has a better knowledge due to frequent contact with blood centers and related importance of transmissible diseases. The risk of transfusion transmitted AIDS (TTA) infection decreased by 30% per year decreased from December 1987. Safety in the blood supply can be attributed to changes in the donor pool, including increasing numbers of tested repeat donors and their awareness regarding this disease.
Health counseling is a new concept in India. Patients here are much less proactive in seeking health care than in developed countries. In the context of HIV-test counseling, the process of building a risk inventory involves discussing the sexual lifestyle of the client. This falls into the realm of taboo. Worse, high-risk behavior is viewed as morally wrong; hence, few visit the voluntary counseling and testing (VCT) centers .
At the other end of the spectrum are health care facilities that test without consent. HIV testing is performed either as part of a differential diagnosis or, in the case of surgical candidates, to provide reassurance for surgeons. Hospitals are widely known to refuse to perform any invasive procedures on persons with HIV infections. Hence the majority of HIV testing in India is not accompanied by pretest or posttest counseling .
One major issue for any person undergoing an HIV test is realizing that his or her test is neither anonymous nor confidential with scant regard for the privacy that such clients are entitled to, laboratories readily provide test results over the telephone or share them with families and workplace supervisors.
The majority of the laboratories in India do not take part in quality-assurance and quality-control exercise for HIV testing, and poor techniques are commonplace. HIV test results are often inaccurate for several reasons: test kits are used after the expiration dates; kits are not stored at the correct temperature; electricity is shut down at night; air-conditioning for the testing equipments is erratic; poor-quality water is used; and tubes, tips, and other equipments are often recycled. With makeshift laboratories that have scant respect for quality control or assurance, patients cannot necessarily be sure of their test results, especially when these laboratories do not provide patients with an opportunity to discuss their lifestyle and risk histories with a counselor who could help them place the result within that context.
Many clinicians use plasma HIV RNA testing to monitor HIV infection; however, inexpensive assays with faster turnaround time are needed in resource-limited settings. The p 24 antigen level is of potential, but has not been validated as a prognostic tool .
A spate of antiretroviral drugs, evolving incrementally but rapidly and being approved at a brisk pace, has changed the treatment horizon. However, these drugs were not within reach of even middle-class Indians until recently, and they are still inaccessible to most. Although antiretrovirals do not offer a definitive cure, the appropriate use of these drugs in combination has demonstrated a significant decrease in mortality and substantial clinical improvements and has helped individuals lead healthier, longer lives and enjoy a better quality of life.
The exploding epidemic in India calls for radical and courageous steps, and a departure from previous public health planning. We need to remind ourselves of the enormous task at hand: the establishment of quality- assured HIV testing centers, expansion of clinical facilities that provide HIV care, increased access to drugs with attendant laboratory facilities, and enhanced psychosocial support for those living with or affected by HIV.