Early
Human
Development,
29 (1992)
225
225-229
Elsevier Scientific Publishers Ireland Ltd. EHD 01280
Problems of AIDS in India especially in women N.N. Roy Chowdhury Professor
of Obstetrics
and Gynaecology,
Medical
College,
Calcutta.
India
Summary According to the World Health Organisation survey, 3 million women are already infected with HIV all over the World, but in India the problem of AIDS as a whole is not that acute especially in women. At least it is not that alarming. India, having a very high incidence of STD, it will not take much time for the spread of the HIV infection. No case of mother-to-infant transmission of HIV and resultant clinical disease in the neonate and children has as yet been reported in India. Infected babies, however, face a short life - nearly all die before reaching 2 years of age. Breast feeding is not a significant means of transmitting AIDS. The disease can spread only through sexual contact, use of infected syringe or transfusion of infected blood. Therefore, doctors, nurses and other paramedical staff in hospitals who may have to deal with AIDS patients need not fear the virus if they take adequate precautions. There is no known curative treatment for HIV infection causing AIDS, but improving literacy, avoiding sexual promiscuity and using condoms in heterosexual intercourse are positive steps in keeping HIV infection at a considerably low level. Key worcis: heterosexual promiscuity; HIV; infected blood transfusion; mother-toinfant transmission; training of health personnel; condoms
Introduction The World Health Organisation 1990 survey [l] suggests that by the end of the 199Os,the number of women infected with the human immunodeliciency virus (HIV) causing AIDS, may be double; some 3 million women are already infected with HIV. In the developing countries heterosexual sex is the predominent means of spread of HIV infection and about 60% of HIV infection all over the world has occurred through heterosexual intercourse. By the year 2000,75-80% of all HIV infection will Correspondence to: N.N. Roy Chowdhury, Professor of Obstetrics and Gynaecology Medical College, 4 Chowringhee Terrace, Calcutta 70020, India.
226
occur through heterosexual sex resulting in dramatic increase in HIV infection among women. About 70% of babies born to infected mothers may not be affected during or shortly after birth. But at least 10 million uninfected children under the age of 10 years will be orphaned in the 1990s due to death of their infected mothers, fathers or both of AIDS. Women are specially vulnerable to HIV infection because of their subordinate role in family and society and particularly due to their little say in the sexual matters. AIDS has yet another special hazard for women. If they are infected during pregnancy, not only is there risk of transmission of the disease to the newborns but due to their heavy workload at home or due to HIV infected husband or children their daily life becomes more difficult. World AIDS data as reported by the World Health Organisation [2] (WHO) upto 31st July, 1990 suggest world total number of cases as 2 73 425 (going upto approximately 300 000 by the end of 1990). AIDS cases in India upto August 31, 1990 (Sukumar Mukherjee, unpublished results) show the following distribution: Male lndians Foreigners
28 9
Total
31
Female 8 3
Total 36 12
II
48 (Latest 57)
So in India the problem of AIDS as a whole is not that acute specially in women, at least is still not that alarming. Probable sources of infection in Indians (Sukumar Mukherjee, unpublished results) are shown in the table.
Hetero-sexual promiscuity Blood Transfusion Blood products infusion Homosexual contact Spouse of an AIDS patientkeropositive Professional Blood Donor Total
person
In India
Abroad
15 2 I 0 2 I
12 I I 1 0 0
21
15
India is on the brink of an AIDS crisis which could explode into an uncontrollable epidemic unless timely steps are taken to prevent its spread and increase public awareness about this fatal disease. The recent increase in the incidence of Human Immuno-Deficiency Virus (HIV)
221
in some parts of the country indicates that concerted efforts are required if it is not to go the way of some of the African countries as opined by Dr I.S. Gilada, Secretary of the Bombay based Indian Health Organisation (IHO) [3]. The rise in HIV positive cases was also marked by a rise in cases of tuberculosis, malaria, filaria and other infectious diseases. The example of New York City is worth mentioning where there has been a ten-fold increase in the prevalence of T.B. with the number of AIDS cases going up. India, which has a high incidence of sexually transmitted diseases (STD), with one in every four STD afflicted persons in the world being Indian, the spread of the AIDS virus would be even faster, he said. Dr Bhashini Rao from the University of California, Los Angeles, said in 1990 [4] that no efforts had been taken in India to offer any kind of effective protection to women against the spread of the disease which lowers the body’s resistance to infections. The rise in the prevalence of HIV virus among prostitutes in Bombay had been recorded in an Who-Indian Council of Medical Research (ICMR) study [5], which found that their numbers had increased from 0.5% in 1986 to 20% in 1990. Referring to the myths about AIDS, Dr Gilada said the disease could spread only through sexual contact, use of infected syringe, transfusion of infected blood or from an infected mother to the child. Therefore, doctors, nurses and other staff in hospitals who have to deal with AIDS patients need not fear the virus if they take certain precautions, Dr Gilada said. Time bomb Accusing the Government of not taking up the AIDS issue seriously, he warned that this is a time-bomb which we are sitting on. No case of mother-to-infant transmission of HIV and resultant clinical disease in the neonates and children has as yet been reported in India. Inadequate recognition of HIV infection in pregnant women and progression to AIDS among infants in India may be due to: 1 Limited facilities of HIV antibody testing. 2 General absence of neonatal screening programmes for HIV infection. 3 Frequent occurrence of other childhood infections with similar signs and symptoms. 4 Inadequate training of health personnel in diagnosis of HIV infection. 5 Limited access to the Medical Profession in the developing countries particularly in the vast rural areas. 6 Incomplete understanding of the history of HIV infection among the women and children. The risk of transplacental transfer of HIV infection from the infected mothers to the infants range from 12 to 60°h depending on duration of maternal infection and clinical stages of the disease. Infected babies face a short life during which they will be acutely ill most of the time. Nearly all will die before reaching two years of age. There will, therefore, be
228
a dramatic rise in infant mortality rate in countries where AIDS is a wide spread problem. Breast feeding is not a significant means of transmitting AIDS although there have been a few reports of infants infected through breast milk [6]. Babies at risk from AIDS Twenty percent of the mothers infected with the human immunodeficiency virus (HIV) which causes AIDS, pass on the virus to their newborn babies according to Marie-Louise Newell from the Institute of Child Health, London, UK [7]. Her finding is based on a study involving HIV-infected mothers in 10 European cities, The survey revealed that the risk of mother-to-child transmission of HIV infection is much lower than previously thought. Earlier studies suggested that 40-50% of the HIV-infected mothers passed the virus on to their babies. The World Health Organisation (WHO) [8] estimates that 3 million women of childbearing age, throughout the world, are HIV-positive. Most of these women live in sub-saharan Africa and may have already infected some of their children. WHO predicts that 10 million or more children will be HIV-infected by the year 2000. Identification of these children poses a problem as the newborn child of an HIVinfected mother cannot be tested for the virus until the age of 18 months. Before that, children may still carry antibodies from their mothers, which confuse test results. Moreover, there is no cure for AIDS and no vaccine against it. So, identification does not change the prognosis for a child, but only indicates that he or she may need supportive therapy. At present, it is not clear why the baby of the particular HIV-positive mother acquires the infection, while the child of another does not. Researchers speculate that babies born to women who have another sexually transmitted disease, along with the HIV-infection, are at a greater risk. Also, women, whose infection has progressed to AIDS, are more likely to infect their babies than those who have not developed the condition. AIDS orphans HIV is the most dangerous killer virus today as neither is there any vaccine against it nor is there any effective therapy. Children born to AIDS-infected parents face a double disaster: one in three die, the rest are orphans. In Africa and Caribbean Islands, there is an increase in the number of AIDS orphans at an alarming rate. By the year 2000, there will be three to five million AIDS orphans - one in every 10 children under 15 in sub-Saharan Africa alone, as estimated by UNICEF. In New York City, one in 61 pregnant women is infected with HIV; in some of its neighbourhood areas the infection rate is 2.5%. Many of them will leave behind AIDS orphans some of whom will turn to prostitution to survive unless something positive is done soon, AIDS threatens to wipe out all the progress made in child survival in the last 10 years.
229
Positive measures As uptil now there is no known curative treatment of HIV infection causing AIDS. WHO has suggested following preventive measures particularly for women: 1 Increasing knowledge among women about stopping the spread of HIV infection particularly through heterosexual sex. 2 Improving literacy and their knowledge about their health services, social and legal rights. 3 Increasing men’s understanding of importance of preventive measures in heterosexual sex by using condoms and thus saving the women from the assult of HIV infection and AIDS. Finally to-quote Dr Merson of the World Health Organization [l] one thing is certain ‘Whether through direct infection of women or mothers, partners of infected men, care-givers, health workers and educators, the HIV-infection will leave its imprint on the lives of untold millions of women around the world’. References 1 2 3 4 5 6
WHO features (1990): Global incidence of AIDS. November, N 151 pp. 45-48. WHO (1990): Data on AIDS. December Ist, pp. 81-86. Gilada, I.S. (1990): Indian Health Organisation Conference on AIDS, Bombay, pp. 103-105. Rao, B. (1990): Indian Health Organisation Conference on AIDS, Bombay, pp. 53-57. ICMR (1990): ICMR study on AIDS in India. ICMR Bull., 20, 29-35. Department of Health and Social Security (1988): HIV infection and Breast feeding. DHSS Publication, PL/CMO (88), pp. 13-17. 7 Newell, M.-L. (1989): The State of the World’s Children. UNICEF, Paris, pp. 19-22. 8 WHO (1989): Implication of AIDS for mothers and children: Epidemiology, WHO/GPA, Geneva, pp. 63-70.
Human
Development,
29 (1992)
225
225-229
Elsevier Scientific Publishers Ireland Ltd. EHD 01280
Problems of AIDS in India especially in women N.N. Roy Chowdhury Professor
of Obstetrics
and Gynaecology,
Medical
College,
Calcutta.
India
Summary According to the World Health Organisation survey, 3 million women are already infected with HIV all over the World, but in India the problem of AIDS as a whole is not that acute especially in women. At least it is not that alarming. India, having a very high incidence of STD, it will not take much time for the spread of the HIV infection. No case of mother-to-infant transmission of HIV and resultant clinical disease in the neonate and children has as yet been reported in India. Infected babies, however, face a short life - nearly all die before reaching 2 years of age. Breast feeding is not a significant means of transmitting AIDS. The disease can spread only through sexual contact, use of infected syringe or transfusion of infected blood. Therefore, doctors, nurses and other paramedical staff in hospitals who may have to deal with AIDS patients need not fear the virus if they take adequate precautions. There is no known curative treatment for HIV infection causing AIDS, but improving literacy, avoiding sexual promiscuity and using condoms in heterosexual intercourse are positive steps in keeping HIV infection at a considerably low level. Key worcis: heterosexual promiscuity; HIV; infected blood transfusion; mother-toinfant transmission; training of health personnel; condoms
Introduction The World Health Organisation 1990 survey [l] suggests that by the end of the 199Os,the number of women infected with the human immunodeliciency virus (HIV) causing AIDS, may be double; some 3 million women are already infected with HIV. In the developing countries heterosexual sex is the predominent means of spread of HIV infection and about 60% of HIV infection all over the world has occurred through heterosexual intercourse. By the year 2000,75-80% of all HIV infection will Correspondence to: N.N. Roy Chowdhury, Professor of Obstetrics and Gynaecology Medical College, 4 Chowringhee Terrace, Calcutta 70020, India.
226
occur through heterosexual sex resulting in dramatic increase in HIV infection among women. About 70% of babies born to infected mothers may not be affected during or shortly after birth. But at least 10 million uninfected children under the age of 10 years will be orphaned in the 1990s due to death of their infected mothers, fathers or both of AIDS. Women are specially vulnerable to HIV infection because of their subordinate role in family and society and particularly due to their little say in the sexual matters. AIDS has yet another special hazard for women. If they are infected during pregnancy, not only is there risk of transmission of the disease to the newborns but due to their heavy workload at home or due to HIV infected husband or children their daily life becomes more difficult. World AIDS data as reported by the World Health Organisation [2] (WHO) upto 31st July, 1990 suggest world total number of cases as 2 73 425 (going upto approximately 300 000 by the end of 1990). AIDS cases in India upto August 31, 1990 (Sukumar Mukherjee, unpublished results) show the following distribution: Male lndians Foreigners
28 9
Total
31
Female 8 3
Total 36 12
II
48 (Latest 57)
So in India the problem of AIDS as a whole is not that acute specially in women, at least is still not that alarming. Probable sources of infection in Indians (Sukumar Mukherjee, unpublished results) are shown in the table.
Hetero-sexual promiscuity Blood Transfusion Blood products infusion Homosexual contact Spouse of an AIDS patientkeropositive Professional Blood Donor Total
person
In India
Abroad
15 2 I 0 2 I
12 I I 1 0 0
21
15
India is on the brink of an AIDS crisis which could explode into an uncontrollable epidemic unless timely steps are taken to prevent its spread and increase public awareness about this fatal disease. The recent increase in the incidence of Human Immuno-Deficiency Virus (HIV)
221
in some parts of the country indicates that concerted efforts are required if it is not to go the way of some of the African countries as opined by Dr I.S. Gilada, Secretary of the Bombay based Indian Health Organisation (IHO) [3]. The rise in HIV positive cases was also marked by a rise in cases of tuberculosis, malaria, filaria and other infectious diseases. The example of New York City is worth mentioning where there has been a ten-fold increase in the prevalence of T.B. with the number of AIDS cases going up. India, which has a high incidence of sexually transmitted diseases (STD), with one in every four STD afflicted persons in the world being Indian, the spread of the AIDS virus would be even faster, he said. Dr Bhashini Rao from the University of California, Los Angeles, said in 1990 [4] that no efforts had been taken in India to offer any kind of effective protection to women against the spread of the disease which lowers the body’s resistance to infections. The rise in the prevalence of HIV virus among prostitutes in Bombay had been recorded in an Who-Indian Council of Medical Research (ICMR) study [5], which found that their numbers had increased from 0.5% in 1986 to 20% in 1990. Referring to the myths about AIDS, Dr Gilada said the disease could spread only through sexual contact, use of infected syringe, transfusion of infected blood or from an infected mother to the child. Therefore, doctors, nurses and other staff in hospitals who have to deal with AIDS patients need not fear the virus if they take certain precautions, Dr Gilada said. Time bomb Accusing the Government of not taking up the AIDS issue seriously, he warned that this is a time-bomb which we are sitting on. No case of mother-to-infant transmission of HIV and resultant clinical disease in the neonates and children has as yet been reported in India. Inadequate recognition of HIV infection in pregnant women and progression to AIDS among infants in India may be due to: 1 Limited facilities of HIV antibody testing. 2 General absence of neonatal screening programmes for HIV infection. 3 Frequent occurrence of other childhood infections with similar signs and symptoms. 4 Inadequate training of health personnel in diagnosis of HIV infection. 5 Limited access to the Medical Profession in the developing countries particularly in the vast rural areas. 6 Incomplete understanding of the history of HIV infection among the women and children. The risk of transplacental transfer of HIV infection from the infected mothers to the infants range from 12 to 60°h depending on duration of maternal infection and clinical stages of the disease. Infected babies face a short life during which they will be acutely ill most of the time. Nearly all will die before reaching two years of age. There will, therefore, be
228
a dramatic rise in infant mortality rate in countries where AIDS is a wide spread problem. Breast feeding is not a significant means of transmitting AIDS although there have been a few reports of infants infected through breast milk [6]. Babies at risk from AIDS Twenty percent of the mothers infected with the human immunodeficiency virus (HIV) which causes AIDS, pass on the virus to their newborn babies according to Marie-Louise Newell from the Institute of Child Health, London, UK [7]. Her finding is based on a study involving HIV-infected mothers in 10 European cities, The survey revealed that the risk of mother-to-child transmission of HIV infection is much lower than previously thought. Earlier studies suggested that 40-50% of the HIV-infected mothers passed the virus on to their babies. The World Health Organisation (WHO) [8] estimates that 3 million women of childbearing age, throughout the world, are HIV-positive. Most of these women live in sub-saharan Africa and may have already infected some of their children. WHO predicts that 10 million or more children will be HIV-infected by the year 2000. Identification of these children poses a problem as the newborn child of an HIVinfected mother cannot be tested for the virus until the age of 18 months. Before that, children may still carry antibodies from their mothers, which confuse test results. Moreover, there is no cure for AIDS and no vaccine against it. So, identification does not change the prognosis for a child, but only indicates that he or she may need supportive therapy. At present, it is not clear why the baby of the particular HIV-positive mother acquires the infection, while the child of another does not. Researchers speculate that babies born to women who have another sexually transmitted disease, along with the HIV-infection, are at a greater risk. Also, women, whose infection has progressed to AIDS, are more likely to infect their babies than those who have not developed the condition. AIDS orphans HIV is the most dangerous killer virus today as neither is there any vaccine against it nor is there any effective therapy. Children born to AIDS-infected parents face a double disaster: one in three die, the rest are orphans. In Africa and Caribbean Islands, there is an increase in the number of AIDS orphans at an alarming rate. By the year 2000, there will be three to five million AIDS orphans - one in every 10 children under 15 in sub-Saharan Africa alone, as estimated by UNICEF. In New York City, one in 61 pregnant women is infected with HIV; in some of its neighbourhood areas the infection rate is 2.5%. Many of them will leave behind AIDS orphans some of whom will turn to prostitution to survive unless something positive is done soon, AIDS threatens to wipe out all the progress made in child survival in the last 10 years.
229
Positive measures As uptil now there is no known curative treatment of HIV infection causing AIDS. WHO has suggested following preventive measures particularly for women: 1 Increasing knowledge among women about stopping the spread of HIV infection particularly through heterosexual sex. 2 Improving literacy and their knowledge about their health services, social and legal rights. 3 Increasing men’s understanding of importance of preventive measures in heterosexual sex by using condoms and thus saving the women from the assult of HIV infection and AIDS. Finally to-quote Dr Merson of the World Health Organization [l] one thing is certain ‘Whether through direct infection of women or mothers, partners of infected men, care-givers, health workers and educators, the HIV-infection will leave its imprint on the lives of untold millions of women around the world’. References 1 2 3 4 5 6
WHO features (1990): Global incidence of AIDS. November, N 151 pp. 45-48. WHO (1990): Data on AIDS. December Ist, pp. 81-86. Gilada, I.S. (1990): Indian Health Organisation Conference on AIDS, Bombay, pp. 103-105. Rao, B. (1990): Indian Health Organisation Conference on AIDS, Bombay, pp. 53-57. ICMR (1990): ICMR study on AIDS in India. ICMR Bull., 20, 29-35. Department of Health and Social Security (1988): HIV infection and Breast feeding. DHSS Publication, PL/CMO (88), pp. 13-17. 7 Newell, M.-L. (1989): The State of the World’s Children. UNICEF, Paris, pp. 19-22. 8 WHO (1989): Implication of AIDS for mothers and children: Epidemiology, WHO/GPA, Geneva, pp. 63-70.
