Could AIDS retard India's development?K Pavri
Centre for AIDS Research and Control (CARC), Parel, Bombay, Maharashtra.
HIV entered and began to spread throughout India approximately one decade later than it did in the US, Canada, Europe, other developed countries, Africa, and the Caribbean. Accordingly, the AIDS epidemic in India continues to evolve, with the spread of HIV infection in many parts of India already reaching epidemic proportions. The long incubation period between HIV infection and the onset of AIDS, however, means that the majority of infected adults will come down with AIDS in the mid-1990s. AIDS in India will have significant adverse economic effects upon the country. Once ill with opportunistic infections as a result of HIV infection, people will require treatment. The costs of such treatment will strain resources. High levels of AIDS morbidity and mortality among individuals in their most productive years will also reduce the overall productive contributions of society to economic development. The extent of the HIV/AIDS problem in India needs to be accurately assessed, then followed by the implementation of appropriate prevention and care programs. The situation will not be able to reversed if responsible parties act only after the existence of HIV/AIDS becomes evident in large numbers of people. Policymakers and program planners working against the spread of HIV throughout India will be called upon to strike and maintain a balance in the allocation of resources for treatment and prevention. They will have to be realistic, yet humanistic, while considering individual rights in the context of more broad social welfare. The authors explain that it is cheaper to prevent AIDS than to treat and manage it, and that urgent measures are needed to protect the productive base of the economy. Sections discuss the role of epidemiology, the spread of HIV through infected needles and syringes, AIDS and HIV in Maharashtra, and the economics of AIDS.
Keywords: Acquired Immunodeficiency Syndrome, economics,epidemiology,prevention &control,transmission,Adult, Developing Countries, Female, HIV Infections, economics,epidemiology,prevention &control,transmission,Human, Infant, Newborn, Male, Risk Factors,
Just like its wide ranging clinical spectrum, AIDS invites a spectrum of wide-ranging responses from people. The responses vary from ignorance and indifference on one hand, to panic on the other. In fact, some knowledgeable professionals (not all prophets of doom) wonder if AIDS could bring us closer to Doomsday. It is essential that much before this day of the last judgement could ever arrive, we attempt to make an accurate assessment of the prevailing situation in different parts of the country. The challenge of AIDS is not only to the medical and social sectors but also to the economic development of the country. Therefore, an accurate assessment followed by an immediate implementation of appropriate programmes for care and prevention is of critical importance.
India has been placed with other countries in Asia in pattern III where the virus of AIDS was introduced and began to spread almost a decade later than it did in the USA, Canada, Europe and other developed westernized countries (Pattern I) as also in Africa and the Caribbean (Pattern II). Because of this late entry, the epidemic of AIDS - the overt disease - is still evolving. However, the spread of HIV infection has indeed reached an epidemic proportion in many parts of India. Because of the long incubation period (151-10 years in adults, though much shorter in babies: < 2-3 years), the majority of the infected adults will come down with AIDS in the mid 90's. Were we to wait till a large number of patients with AIDS (PWAs) are recognised, the situation will indeed be irreversible. One of the criteria in setting priorities is the need for action before a situation becomes irreversible. This can be appreciated through a proper understanding of epidemiology of AIDS and more particularly, of the invisible HIV.
Epidemiology has contributed substantially to the knowledge on AIDS concerning prevention and control. As a matter of fact, a full year before the viral aetiology of AIDS was recognized and, two years before specific serological tests for the human immunodeficiency virus (HIV) became available, epidemiological investigation had identified the major modes of viral transmission. More importantly it has also established how the virus does not spread. For example, it was epidemiological studies, which confirmed experimental evidence that mosquitoes and other insects have no role in the spread of HIV/AIDS. Since contaminated needles could transmit HIV, many people felt that mosquitoes could act as 'flying needles' and spread the virus through bites, i.e intermittent feeding. This means that if a mosquito feeding on an infected person was disturbed before taking a full meal, she can land on a nearby person for completing the blood-meal. The question is whether a mosquito can transmit HIV this way? Epidemiological investigation in household members of index AIDS cases in areas heavily populated by mosquitoes revealed that it could riot does so. The virus was passed on to the spouses only, leaving children and other adults in the household (with no other risk situation) uninfected.
The three major modes of transmission (sexual, parenteral and perinatal) are too well known to be described here. Only some important features are presented. According to the global summary of AIDS cases by WHO, [Table - 1] sexual mode of transmission has been responsible for about 70% of transmission that occurred globally by 1991. Efficiency of this transmission, however is only 0.1% to 1.0% as compared to greater than 90% efficiency recorded for blood transmission.
Another important feature is that efficiency of transmission from infected males to females is at least 2-10 times higher than that from infected females to males. A study spread over a 5 year period recorded that 20% of the women sexual partners of HIV infected men were infected while less than 2% of transmission was noted from infected females to males. This study further supported the finding that genital lesions and bleeding (menstrual blood) or trauma to tissues in and around genitals during intercourse does enhance transmission. Another definitive study from 9 European countries revealed some interesting data. The rate of transmission in either direction was almost the same for both genders when the infected partner was in advanced stage of AIDS. In contrast, transmission from HIV-infected but asymptomatic males to uninfected females was 5(1.7 - 14.7) times more effective than that 1 from HIV - infected asymptomatic females to males The only sexual practice associated with risk during the rarer transmission was intercourse during menses.
Estimate of HIV infection among male clientele of female CSW's in red light area, Bombay.
(Most conservative estimate)
* If 25% of 60,000 CSWs HIV-infected : the number of HIV-infected will be 15,000 CSWs.
* Each female on an average has 6 male : there would be 90,000 male clients.
* If only 0.1 % of the 90,000 get HIV infection : there would be 90 males infected every day.
* Thus every hour : there would be 3-4 males acquiring HIV infection.
One male is infected with HIV every 15-20 minutes.
CSW = commercial sex worker
The above data viewed in the context of female prostitutes or commercial sex workers (CSWs) should remove the misconception that holds them entirely responsible for the spread of HIV. Obviously, clients would not go to sick-looking prostitutes in advanced stages of AIDS. Thus, the preventive education and messages regarding how to use condoms effectively should indeed be targeted to males in general and youth in particular. Infected young men are the most likely candidates creating high risks situations in different ways. They not only spread the infection among fresh CSWs through their promiscuous behaviour of indulging in unsafe sex, they would do so as husbands and donors of blood. An idea regarding the magnitude of this vicious spiral can be obtained by estimating the number of men getting infected every hour in the 'Red-light' area of Bombay. Even the most conservative estimate reveals that one male client would be infected every 15- 20 minutes if safer sex is not practiced, These are the youthful work force engaged in various commerce and industry in the city. When they come down in large numbers with progressive AIDS, their loss is bound, to have a profound impact not only on our society, but on India's development programme.
As perthe WHO summary, sharing of needles by IV drug users (IVDUs) and such has contributed to 5-10% of the world total, although this mode is efficient only at the level of 0.5 - 1.0%. In the north-eastern part of India, as in the countries of the notorious 'golden triangle' nearly 50% of over 20,000 IVDUs are reported to be HIV infected. Although injectable drug abuse is not yet common in Bombay, one should be prepared to face an insidious entry of this phenomenon in the city.
In Africa, many countries have recorded spread via hospitals and more particularly, through medical injections. Hopefully in Bombay, most doctors and hospitals follow good practices employing clean and sterile items of equipment. The use of disposable material has become quite common. However, utmost care needs to be taken to ensure that the use is not turned into abuse. In an economically developing country like India, some peoples' waste becomes others' wealth. In the absence of any organized waste disposal services, there is always a possibility of people being tempted to reuse discarded material. Therefore, knowledge about proper and safe discard of all disposable material is extremely important. Until the time when reasonably priced good quality disposable items are available in required quantities, it would indeed be preferable to employ glass syringes with needles to ensure their proper cleaning and sterilization. (For further details please see 'Standard Biosafety Guidelines' and 'Wall Chart on Safety Guidelines' prepared by CARC).
By the end of September 1992, the total number of AIDS cases in Maharashtra is reported to be 95 (7 among foreigners), which is over 40% of the AIDS cases reported in India. One of the contributory factors for this high proportion could be greater efficiency of surveillance network as compared to that in many other states. Even granting this, one can safely assume that only 10% of the actual number was recognised/reported. There could have been at least, 950 - 1000 cases in Maharashtra (majority in Bombay) alone. Since the virus started spreading in the mid-'80s, a preponderance of asymptomatic HIV-infected persons is expected. On a conservative estimates, if we consider it to be 150 fold, then the total number of HIV infected would be around 142,000 150,000 in Maharashtra, All these will not be from 'high risk situations'; a proportion will be from the general population with no established risk. This latter group of low-risk population can be estimated for males and females separately.
HIV seropostivity among 20-40 year old males and females in the general population in Bombay.
* Population of Bombay: 12.5 million
* 28.5% in 20-40 years age group: 3562500 total
* 51.8% of these (i.e: 1845375) would be males - 5.111000 male voluntary blood donors (also 20-40 years of age) are HIV seropositive (unpublished data, Institute of Immunohaematology)
* Therefore, there would be approx., 9411 HIV-infected males.
* 48.2% of the total (i.e 1717125) would be females. - 0.8711000 antenatal mothers are found HIV seropositive.
* Therefore, there would be approx., 1493 HIV-infected females.
* Total no. of HIV infected 20-40 years old adults: 10904
Based on these, one can assume at least 10,904 adults between 20-40 year age group to be HN-infected although with no established known risk.
It is obvious from the above that given the growing number of AIDS cases even costs of treating only opportunistic infections will strain our scarce resources. In fact, WHO has recently commissioned a report on 'The economic impact of AIDS: an assessment of the available evidence'. Such surveys will have to be undertaken urgently so as to facilitate development of appropriate strategies including a realistic planned budget for health delivery services. Medical treatment alone will put an extreme burden on our already sagging economy. One of the most difficult problems will concern distribution of allocation between prevention on one hand, and caring of patients on the other. A fine balance will have to be maintained between realism and humanism, and also individual rights versus welfare of the society. WHO listed the following six areas as important for research. It is hoped that several post-graduates will be able to take up research on some of the important areas given below:
i. The cost of treating HIV and opportunistic infections.
ii. The relative cost of care in different setting (e.g. hospitals, patients' homes, hospices, etc.)
iii. Out-of-pocket spending on treatment and care measures.
iv. Implications for drug and foreign exchange budget.
v. Costs of social and support services.
A comparison of costs of prevention versus treatment and management of AIDS is bound to favour the former. Indirect costs of the epidemic are likely to be overwhelming. Already several business houses have started testing their workers - some even for recruitment. If the trend continues, that will add to unemployment and under-employment of the nation's youth. On the other hand, there will be a loss of young, actively productive men (and women) from the work-force of the nation. There is indeed an urgent need to ensure that the productive base of our economy, and development of the nation are not sacrificed at the altar of complacency and inaction.
[Table - 1]