HIV /AIDS in South Asia; an essential review
As the world enters into the fourth decade of HIV/AIDS, it is becoming clearer than ever that this is the most devastating disease humanity has ever faced. Driven by stigma and inequality the global epidemic makes ever deeper inroads into human security –Peter Piot
HIV/AIDS has been the ultimate challenge for mankind today. The 1.20 nm diametric retro virus has put a big question mark over the ability of biological science. According to the United Nations joint program on HIV/AIDS (UNAIDS), currently there are 34.2 million adults and children living with HIV/AIDS. The highest number of patients is in sub-Saharan Africa. Outside Africa, South Asia remains a potential breeding ground for an epidemic. Recognized high risk groups in the region include, female CSWs (Commercial Sex Workers), IVDUs (Intravenous Drug Users), MSM (Male Sex Male) and migrant workers. Despite still having a low prevalence rate, with a high population rate and low economic growth, an epidemic would take a huge toll in the region.
CURRENT SCENARIO; COUNTRY BY COUNTRY
Outside Africa, India has the highest number of people living with HIV/AIDS. According to UNAIDS country fact sheet 2012 update, the total number of adults and children estimated to be living with HIV and AIDS in India was 2.1-2.8 million with prevalence rates for adults estimated to be within 0.3 - 0.4%. It is also estimated that currently 0.67 to 1.2 million adult women are living with the disease. Deaths due to AIDS are about 1.7 million. There are six high prevalence states, namely; Tamil Nadu, Karnataka, Maharashtra, Andhra Pradesh, Manipur and Nagaland. Even within the states there are high prevalence pockets. The National AIDS Control Organization (NACO) was set up in 1992 to carry out HIV/AIDS prevention, control and surveillance programs more effectively. NACO estimates that 86% of transmissions are due to sexual risks, 2.4% due to Intravenous Drug Users (IVDU), 2.0% due to receipt of blood/blood products and 3.6% due to perinatal transmission.
Pakistan is still considered to be a low prevalence country for HIV, but lack of resources could undermine gains made in the HIV response in Pakistan. Approximately 98,000 people are currently living with the infection with a prevalence rate of around 0.1% (UNAIDS). The number of adult women living with infection is estimated to be between 23,000 – 35,000. The identified high risk groups include: female CSWs and their clients, long distance truck drivers, MSM, recipients of paid blood donors and IVDUs. Estimated number of deaths due to HIV was 5800. The government initiated the National AIDS Program (NAP) in 1987 to coordinate the efforts of tackling the threat of HIV. A multitude of socio-cultural factors including political tension, religious restrictions on discussion of sex, social stigma and extremism limit the accessibility of prevention and control programs to a sizable population.
Bangladesh is also considered to be a low prevalence country for HIV. Number of people living with HIV/AIDS is about 5200-8300 with a prevalence rate of <.1% (UNAIDS). Men women ratio among adults is 3.5:1. Number of deaths are <200. The government of Bangladesh was actively involved in tackling the problem as early as in 1985 by setting up the National AIDS Committee (NAC).
According to UNAIDS about 2800 Sri Lankans were living with HIV by end of 2011. Prevalence is estimated to be less than 0.1%. Altogether there have been 957 reported cases of HIV so far with 177 confirmed dead. Interestingly, the percentage of women with HIV has risen from 21% to 42% between 1991 and 2007. The government of Sri Lanka took the initiative in controlling HIV and other sexually transmitted diseases by establishing the National Sexually Transmitted Diseases and AIDS control program (NSACP) in 1992.
The scenario in Nepal is more dangerous in view of an impending epidemic in comparison to other countries. Number of people living with HIV are about 51000-80000 with a prevalence rate of .3-.5 %. Deaths due to AIDS are about 4700. Cross border trafficking of sex workers is a major problem contributing to increasing HIV rates in both India and Nepal. A National AIDS Coordinating Committee (NACC) was set up in 1992.
Afghanistan, Bhutan and Maldives
Data on HIV infection in Afghanistan is scarce and may be underestimated. By 2008, 478 cases of HIV were reported and 1000-2000 people were estimated to live with HIV. Overall prevalence is estimated to be below 0.5%. In Bhutan, number of people living with HIV are about 1000 with a prevalence rate of .2% and number of deaths are <100. In Maldives, with a prevalence rate of .1%, <100 people are living with HIV.
The impact of HIV can be categorized as clinical, economic, psychological and social. Discussing the clinical burden of HIV is beyond the scope of this paper. However, we intend to discuss briefly the financial, psychological and social impact of the disease with relevance to South Asian context.
Economic: The economic loss involves the loss of production due to illness while the person is alive, loss of production due to his lost life years plus costs of treatment. A study in India in mid 90s has shown that average treatment cost of a patient with HIV is twice the per capita gross national product despite exclusion of expenses for retroviral therapy. With the availability of highly active anti retroviral therapy (HAART), HIV has become a chronic illness with improved longevity. In a study in India, on average, 43 working days were lost per patient per six months due to illness related issues. It is interesting to note that economic loss due to premature death or loss of productivity of infected population is estimated to be 10 times more than their annual treatment costs. Poverty and HIV have a two-way connection. HIV causes poverty and poverty makes people vulnerable to HIV.
Psychological: The relationship between psychiatric conditions and HIV can be summarized as psychological reactions to a diagnosis of HIV, disorders due to the organic pathology of HIV virus/immunodeficiency (malignancies, opportunistic infections), psychological reactions to drugs, hospitalization, treatment and psychological impact of a long term fatal illness. It is also known that psychiatric illnesses increase vulnerability to HIV. Depression is the most common disorder amongst HIV positive patients with various studies reporting rates between 5-25%. Anxiety disorders (phobias, generalized anxiety disorder, panic disorder) go hand in hand with depression and a study in a tertiary care unit in India has recorded that 40% of its patients suffered from depression while 90% of them fulfilled diagnostic criteria for an anxiety disorder.
Social: In the current social background of South Asia, a ‘label’ of HIV will be an enormous burden on the patient and family. It is seen as a disease of the sexually promiscuous. The patient and family face social isolation and ostracism. Despite many media campaigns and educational programs, the plight and prospects of the average HIV positive patient is still poor. On preventive aspect, cultural taboos on discussion of sex and HIV, retard implementation of educational programs.
South Asia can be considered a resource limited setting with regard to management of HIV. Cost of HAART is a major limiting factor in continuing drugs. However, the price of some first line antiretrovirals has reduced by 37 - 53% over the last decade. World Trade Organization (WTO) agreement on trade-related aspects of intellectual property rights has been modified by consensus allowing countries to produce generic drugs of HAART. Overall, the percentage of antiretroviral therapy coverage in the region is not satisfactory. The treatment problems which we need to tackle in future include; increasing coverage of antiretroviral therapy, ensuring a continuous drug supply, prevention of emergence of resistance by adhering to prescribed therapies (cost is the major factor affecting compliance), more public funding for HAART, lowering cost of second line HAART (5-8 times more expensive than first line therapy) and preventing inequalities to access of treatment at community and family level.
ROLE OF YOUTH: THE VICTIMS AND THE AVENGERS
Young people remain at the centeR of HIV/AIDS epidemic in terms of rates of infection, vulnerability, impact and potential for change. They have grown up in a world changed by AIDS but may still lack comprehensive and correct knowledge about how to prevent HIV infection. Of the 1.8 billion young people worldwide, 5.5 million are estimated to be living with HIV (2010). About 40% of new HIV infections are among young people. Young people are particularly vulnerable to HIV infection for social, political, cultural, biological and economic reasons.
On the other side of the coin, youth are the frontiers in the fight against HIV/AIDS. Where young people are well informed of HIV risks and prevention strategies, they are changing their behavior in ways that reduces their vulnerability. If we could raise awareness about HIV infections among the young people, they can save themselves and can be a valuable weapon to raise awareness among general people. For example, in several countries, targeted education has led to delayed sexual debut and increased use of condoms resulting in a decrease in HIV prevalence in young people. In the age of media and communication, young people can made aware through dramas, concerts, debates, blogs, seminars, campaigns and so on. And surely if we can make awake the youth, we could make a giant step in preventing AIDS.
There is no scope of satisfaction about the low prevalence of HIV in the subcontinent as it is the most vulnerable region of a HIV/AIDS epidemic outside Africa. It is the duty of the governments and non government organizations to commit themselves for a HIV-free future generation through the implementation of comprehensive, evidence-based prevention strategies, responsible sexual behavior, including the use of condoms, evidence and skill-based youth specific HIV education, mass media interventions and the provision of youth friendly health services. And being a doctor, it is an opportunity for us to create awareness among the people in preventing HIV/AIDS.