Introduction
The HIV / AIDS epidemic is now a global crisis and constitutes one of the most formidable challenges to development and social progress. Prevention of HIV / AIDS, its management, and mitigation of the impact of HIV / AIDS on work, care and support to persons affected by it, elimination of stigma and discrimination are now the key areas of action. Rights of a person affected by AIDS and ethical issues also need to be highlighted.
Prevalence
In India the first case was detected in May 1986.1 The number of people living with HIV/AIDS(PLHA) in India in 2017is estimated to be 2.1 million and prevalence is 0.22 and AIDS related death are 69,000.3 Globally, 36.9 million people were living with HIV in 2017.
Pathogenesis
AIDS is caused by the retrovirus i.e. Human Immunodeficiency virus (HIV) characterized by profound immune suppression that leads to opportunistic infection, secondary neoplasia and neurologic manifestations. AIDS is the end stage manifestation of HIV infection.
Risk Groups
Five groups of adults are at risk for development of HIV infection.4 Homo-sexuals and bisexuals are the largest group, followed by I.V. drug abusers, recipients of blood and blood components, haemophiliacs and heterosexual contacts.
Clinical Features
Clinical features of AIDS ranges from mild acute illness to severe diseases. Fever for more than a month without any specific cause, diarrhoea, weight loss, generalized lymphadenopathy are general symptoms.5 There may be opportunistic infections, neurological diseases and various types of neoplasia. Opportunistic infections especially Tuberculosis account for majority of deaths in patients of AIDS. About 15-30% patients with AIDS develop Pneumonia due to Pneumocystitis carini infection which is an opportunistic fungus.4
Lab Diagnosis
A person whose blood contains HIV antibodies is said to be HIV positive or seropositive. A reliable screening test must be sensitive enough to identify to true positive cases while being specific enough to record few “false positive” cases.6 The ideal test needs both the attributes. The ‘ELISA TEST’ (Enzyme – linked Immuno absorbent assay) is the test used since 1985as sensitive screening test for HIV infection while the Western Blot test is the highly specific test for this purpose. At-least one positive screening in secret and one confirmatory test will be required before the HIV status is made sure.
Ethical and Legal Issues
An AIDS patient has right to life, personal liberty and privacy and should not be discriminated due to their HIV status. Example of discriminatory act towards individual with HIV/ AIDS includes denying access to social services and/or medical treatment or having these services delayed because the individual has HIV/ AIDS.
For testing for HIV, written consent of the patient must be taken before the test.7 Information about the result of the test should only be declared after the confirmatory test. Face to face pre-test counseling should be done explaining about the various aspects like what are the screening test, window period etc. Counselling after the test, (when results are declared) is also to be done even if the result is HIV negative. Psychiatric counseling is a very important aspect in positive cases and the person is to be informed about the treatment and physical complications of such infection. The mode of transmission of the disease is explained to the patient who should be specifically advised to lead a restricted life in order to prevent the spread of infection. The duty of the doctor is to treat HIV/AIDS infected persons without any discrimination. It is unethical to refuse treatment to any person who is infected with HIV / AIDS. The doctor should maintain confidentiality and should never reveal about such illness unless it is required by the law of the state. A separate record is to be maintained for this purpose. However, the doctor should also inform the concerned health care professionals who are directly involved as well as to patient’s spouse because if they are not informed, they are likely to be exposed to infection.8 As regards right to marry, the right to get married of a person is deemed to be suspended during the period the person is HIV positive, (IPC 269, 270). People who are infected by HIV while undergoing any medical treatment can seek claim under the Law of Torts. All vaccines and blood products from human sources should thoroughly be checked for AIDS virus before being used on patients.7
Stigma and discrimination
In various studies it is observed that infected men with HIV experience a sense of social death. Social stigma threatens the social and personal interaction & diminishes the social value. In a stigma index study in Portugal one of the highest prevalence place with HIV it was seen that 30% participants reported stigma and discrimination in health system. In 2013, in a study of doctors, nurses and ward staff in govt. and non-govt. clinics in Mumbai and Bengaluru in India, it was found discrimination is common for which the study recommends further programmes targeting health care providers to address stigma.9
Preventive Measures
Educating people regarding mode of transmission is the most important preventive measure. Screening all cases having symptoms similar to AIDS at all health centers, compulsory screening for HIV of all homosexuals, high risk heterosexuals, IV drug users, professional blood donors and regular checkup of seropositive cases are the other preventive measures. All pregnant mothers should be advised to test for HIV infection because this test can protect the baby by treating the HIV positive mothers in early stages of pregnancy.
It is estimated that Five million children died due to HIV since the beginning. Global plan focuses attention on paediatric HIV service & treating 1.6 million children on ART by 2018 and urgent action to be taken at country and global level.
ART
Global related deaths continued to decline 48% due to global scaling up of ART.3 There is no potent vaccine developed yet for prevention of AIDS, but the antiretroviral treatment ART has proved to be helpful in prolonging life of ill patients. There are more than 20 drugs used for this purpose since 1987.10 The major strategy of National Strategic Plan HIV is to accelerate uptake of ART to ensure Universal access to ART.11
But achievement of optimal drug adherence and patient retention has become a major challenge for management. Adherence to medication is influenced by many factors. The main of non-adherence seen are due to simply forgetting, staying away from home, falling sick and fear of stigma, etc. In a study of Ethiopia, it was observed that social support is positive predictor where as depression and substance abuses are negative predictions of drug adherence. In India in seven cross sectional and one retrospective study enrolling 1660 participants it is seen that ART adherence rate is around 70%.
Autopsy Care
The risk of transmission of HIV infection during autopsy is low compared to HBV &HCV.8 All persons performing or assisting autopsies of HIV patients should follow the universal precautions to prevent themselves from contacting the infection12, 7, 1 The staff members transporting the body to mortuary should be wearing protective clothing. Autopsy surgeons doing autopsy should be properly protected with “AIDS / HIV suit”. The contents of HIV kit are disposable head cap, face mask, plastic apron, shoes, gloves, protective glasses etc. Leak proof bottles to be used for collection of samples. Sharp instruments should be kept in puncture proof containers. 2% aqueous Glutaraldehyde (Cidex)should be used for disinfection of re-usable instruments. Mortuary should be disinfected by Sodium hypochlorite solution. Biological stuffs to be disposed of as per the guidelines of Bio-medical waste management Rules 1998.Body should be wrapped in polythene after autopsy.
Scenario in Odisha
(The HIV/ AIDS Prevention and Control Act 2017 came into force in India on Sept 10th, 2018. Aim of this Act is to prevent and control the spread of HIV and securing rights of individuals diagnosed with HIV. It also seeks to protect the rights of healthcare providers. The Act provides a robust grievance redressal mechanism ombudsman at the state level.)
Odisha is a state in eastern part of India with population of 4.6 crore (mid 2020). It is 8th largest state by area and the 11th largest by population. National HIV/AIDS control programme was operational in the state since 1992. Now Odisha State AIDS control society (OSACS) in implementing the HIV/AIDS activities. Odisha is a low prevalence state as far as HIV/AIDS is concerned, but it is identified as a highly vulnerable one.
As per the latest HIV estimates report of GOI, India is estimated to have 23.49 lakh people living with HIV/ AIDS in 2019. In this state, it was 49,000 by 2019. AIDS related deaths by Nov-2021 are 10,177 in Odisha. There are 232 ITCT (Integrated Counselling and testing) centres in the state which are the gateway of all services of national AIDS control programme. The services imparted are counselling, testing post exposure prophylaxis and referral etc. There are 15 ART (Anti Retroviral Therapy) centres present in the state where treatment free of cost is imparted and counselling is done regarding treatment related subjects.
Activities
OSACS initiated the targeted intervention programmes among high risk population i.e. female sex workers, injecting drug users, transgenders/ hinjra, truck drivers etc. Targeted intervention programmes are a set of programmes under NACP.
HIV-TB coordination- TB is a common infection in HIV infected individuals. HIV and TB together have extremely high death rate. To reduce it, in the state there is a state level coordination committee meeting under chairmanship Secretary (Health and FW) and officials of OSACS and TB organised on quarter yearly basis.
Prevention of parent to child transmission: - Programmes of UNICEF several steps were taken like universal screening programmes, logistic supply to 580 delivery points in the state .
IEC (Information Education Communication) strategy focused on fostering attitude and behavior to prevent discrimination against those who are infected with HIV/AIDS and promoting solidarity among PL HIV.
Government of Odisha has some special state sponsored programmes named MADHUBABU PENSION YOJANA, MO KUDIA YOJANA, ANTODOYA YOJANA . More than 40,000 people living with HIV have taken monetary help, getting houses through said programmes.
The state is marching ahead to fulfil the targets of UNAIDS global commitment of 95-95-95 that means 95% of all people with HIV should be diagnosed, 95% of all diagnosed to start ART and 95% of ART should reach to suppress viral load by 2030.
Evidence based planning and interventions have been the key for achievements made so far in the state. Efforts have been made for inter sectorial coordination with other line departments to control and prevent the spread of HIV and to lead a stigma free life.
Every year 1st December is celebrated as World AIDs Day with awareness programs. (Figure 1, Figure 2)
Summary & Conclusion
AIDS is now recognized as a developmental issue with long term economic and social implications. In order to fight this dreadful epidemic awareness generation in the community about the mode of transmission, legislative frame work to fight discrimination, along with adequate support to PLHA is need of the hour.
