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AIDS: A SMOULDERING VOLCANO
INTRODUCTION: Since independence, a vast Infrastructure for health-oriented schemes has been created in the country, but it needs to be functionally optimised, by harnessing all community resources for health, so as to meet the growing demand of the population. Though the country has effective control over all kinds of diseases yet unfortunately it has not devised any concrete remedial measures to keep control of the latest disease AIDS—which is creating havoc in the life of the common man.
DEVELOPMENT OF THOUGHT: The latest killer disease that is creating nightmares for medical experts is the Acquired Immune Deficiency Syndrome. Its terrifying spread has earned it the title of the ‘pandemic” or an epidemic out of control. According to experts, India’s position is quite grim and if left unchecked it could wreak social and economic devastation. In the absence of medical defences against AIDS, public education is the only weapon in the light to limit the spread of infection. Only by influencing personal behaviour and lifestyle can we hope to minimise the ravages of AIDS throughout.
CONCLUSION: The need of the hour is for the dissemination of basic information in simple and intelligible terms about the causes of AIDS and, the avenues of infection, the essential precautions to be taken, the facilities for treatment and all other related matters. The public must be alerted without generating hysteria about the real menace of the AIDS epidemic and the measures required to combat it.
The internal parts of the human body come in contact with bacteria, protozoa and viruses, etc. via air, water, food or through an open wound. These micro-organisms not only get nutrition from our body but also cause undesirable effects on our health. The immune system of the body is responsible for fighting these effects (which we call `diseases’). The ‘horribleness’ of AIDS lies in the fact that it destroys the immune system itself, thereby exposing the body to all kinds of diseases and infections.
The major pillars of the immune system are leukocytes or white blood cells (WBC). Leukocytes are of two kinds, T-Cells which originate from thymus; and B-cells which are produced in the bone marrow. T-cells are also of two kinds. The (T-helper) cells which cause immunity and Is (T-suppressor) cells which suppress the immunity. Normally, they are in such a ratio that The cells are effective, but in the event of a reduction in the number of B-cells (caused by retroviruses), this balance gets upset. This conditions R called AIDS.
HIV virus combines with receptive molecules on the surface of The cells and destroys those cells. According to researchers, HIV affected cells form lumps with healthy cells which may result in the destruction of the latter also. HIV has a 1/1000-mm diameter spherical body, surrounded by two lipid membranes. The membranes have two layers of two glycoprotein’s: gp4l, and gp120 which have proteins: p24 and p18. Its nucleus has reverse transcriptase enzymes with R.N.A. which act as catalysts during the organisation of its D.N.A.
In 1981, a patient was found whose body had very little resistance to diseases. Many other such cases were found, most of whom had later died or pneumonia. All of them were homosexuals. This condition was given the name of Acquired Immune Deficiency Syndrome or AIDS in 1982. There was a debate on the nomenclature of the virus. The cause of the disease was found to be a virus and was identified independently by two research teams. Dr Robert C.Gallow called it Human T-cell Leukemia Virus while the other team gave it the name of Lymphadenopathy Associated Virus (L.A.P). The matter was resolved by calling it Human Immune Deficiency Virus or HIV.
One of the principal modes of transmission, as is evident from the above description of its history, is homosexual relations. Possible scientific reasons for this have been found. It is believed that the maximum concentration of the AIDS virus is in semen, although it is present in urine, saliva, mother’ milk and womb secretion also. Moreover, semen has the additional effect of suppressing immunity and it gets absorbed more easily during homosexual intercourse because ovary walls have comparatively less tendency to absorb semen. This is why heterosexual relations have a lower rate (one third) of transmission. The chances of transmission from male to female are higher.
Another mode of transmission is by the use of unsterilised needles for intravenous injection of narcotic drugs. The most tragic case is of the people who get AIDS byway of transfusion of infected blood through no fault of theirs. AIDS virus is incapable of penetrating through the skin, there is no danger of transmission through the mere touch of an infected person. But it can be transmitted from mother to child, the chances of which are 25-40 per cent.
Even though it is only a decade old, AIDS has already entered in the category of major killer diseases in many countries. WHO estimates say that the number of people infected with HIV will reach 40 million by the year 2000. The spread of AIDS in the U.S.A., Thailand (more than 5 lakh infected people), many African countries and the Central American island Haiti has become a cause of concern internationally. Presently, the world has 13 million infected people, out of which 5 lakh have developed AIDS Symptoms.
In India, about 7 thousand people have been confirmed to have the HIV virus, but unofficially the figure is put as high as 5 lakh. According to WHO, this number might reach 50 lakh by the end of the century. The reason for such a situation is the fact that in Indian cities, especially Bombay, there are a large number of prostitutes and homosexuals. About 5 per cent men in Bombay are supposed to be homosexual! It is the way of life of these people rather than their number which is the source of the danger. They are unaware of the total potential of AIDS and do not take even the most elementary of precautions like the use of condoms. Moreover, the conditions in our hospitals are far from hygienic, exposing the population to all kinds of infection including HIV. In spite of it being widespread in the U.S.A., AIDS poses a much greater danger to poor countries, because developed countries are much more prepared to meet this challenge, having an efficient health network as well as high level of education and awareness.
An AIDS carrier is not the same as AIDS patient as there is a time lag (sometimes up to several years) between infection and the appearance of symptoms, major symptoms, of course, is that the patient’s body is unable to fight even ordinary diseases like pneumonia and colitis. There are other symptoms like swelling in lymph nodes, white spots on the face, perspiration while sleeping, but these can be due to many other reasons.
A number of testing methods have developed to detect HIV, both before and after the appearance of symptoms. Two such techniques are ELISA (Enzyme-Linked Immunosorbent Assay) and Western Blot based on the discovery by Gallows and associates that 90% of AIDS victims have HIV antibodies in their blood. Another technique developed by Milton Tom costs one-eighth of ELISA. In this method, a shoulder-shaped strip which has HIV-I peptides on its eight teeth is placed in specimen blood for ten minutes. The HIV antibody, if present, combines with a peptide antigen. The strip is then placed in signal reagent and if it shows a red spot, ‘the test will be considered positive. This method which takes 20 minutes and is 98 per cent effective, is being developed by the Development Research Institute (Canada). India is the first country where the commercial manufacture of its kit has begun.
World’s leading pharmaceutical firms are presently engaged in a fierce competition to capture the market for AIDS testing kits. A great variety of products is being offered. Sixty firms displayed their kits using blood, urine or even saliva, some even claimed to have developed a single test for both HIV-I and HIV-II. The director of National Institute for Allergy and Communicable Diseases in the U. S., Dr Antony Panci has found that at a certain stage of infection, HIV accumulates in the lymph of the affected person and is difficult to detect. The above institute and Hopkins Medical School have developed a technique by which AIDS can be detected effectively in infants.
On the one hand, mankind has triumphed over diseases like. T.13. Plague, Tetanus and Small Pox and psychological problems are assuming bigger I proportions. Even then completely new diseases such as AIDS have come into existence. Extensive research is going on to develop weapons to fight this new challenge to the medical world but success so far has been limited to putting off death by a few years and to make the victim’s life a bit easier.
An interference gives some relief to the patient. Presently, the most used drug for AIDS is AZT-3 which restricts the organization of virus DNA by obstructing the work of reverse transcriptase enzyme. Another drug called di-deoxycytidine reduces side effects when used along with AZT, but the problem of debilitating anaemia still remains. A drug tetrahydrobeazo-dizopynon is five times more effective than AZT. It has been recommended by Japanese researchers Dr Takashi Kitamura and British scientists. Other drugs are CD-4 (used by U.S. scientists) and A-71 (developed in Hyderabad).
Another controversy about its origin in attracting attention. An article in a magazine Roiling Stones alleges that the polio vaccine given to3 lakh people in Africa in the fifties by Hilary Koprowski was developed with the help of the kidney cells of a ‘Macaque monkey which had AIDS virus. Koprowski has disputed this, saying that the same vaccine was given to 70 lakh people in Poland too, where AIDS is not much Prevalent. The debate is still on.
The best weapon against AIDS would be a vaccine which can make the human body resistant to HIV. Very little progress has been made in this direction. Very few vaccines developed until now have not achieved even partial success. One such vaccine is based on the surface glycoprotein GP 160 which the virus used to stick to a human cell. In test 19 out of 30 patients showed increased immunity after its use. Jonas Salk, who developed polio vaccine in 1954 has presented a theory which, if true, would make it possible to develop vaccines for not just AIDS but many other diseases. The human immune system works in two phases. First is based on cells and is called TH-I (e.g., the appearance of red spots on skin after injection) and the second is humeral, called Th-2, in which in antibodies are produced. The theory says that vaccine can be found in the immune system is frozen into TH-I response.
In spite of the above rays of hope, AIDS continues to be an incurable disease. Even so, it is possible to control this menace by practising a certain amount of discipline and take every measure to stop its spread. Indeed, it will force the modem society to reduce certain moral imbalances. Considerable improvement is imperative in the medical and ‘educational field, especially in developing countries. Lastly, we will have to give an AIDS victim the same treatment as we give to any other patient. It is totally unjustified to consider them untouchables as AIDS cannot be transmitted by touch.
A recently held World AIDS conference highlighted the reports about possible new viruses. Up to now only two viruses: HIV-1 and HIV-2, had been identified but a California University researcher Sudhir Gupta claimed to have identified a new virus. This was preceded by reports that some patients had -AIDS-like symptoms although they were tested negative for HIV. A debate is on about whether this is due to a new AIDS virus (HIV-3) or a completely new disease. In another development, a virologist Jerald Myers declared recently that AIDS virus can be divided into five regions of the world. Identification of all the viruses causing AIDS is important for developing vaccines against them.
Six years after the first case of AIDS was detected in India, WHO estimates that in India around 3-5 lakh people are infected with the virus. At present, the virus is spreading in India, with Maharashtra, Manipur and Tamil Nadu leading the percentage count. The highest incidence of HIV infection has been reported from Maharashtra where 4,616 people have the virus. However, in terms of the percentage of the survey sample recently conducted by the National AIDS Control Programme, Manipur heads the list. In North East states prevalence rose from 1% to 5% in just one year. In these states, 141V infection is primarily associated with the use of infected needles by drug users. Tests among drug users show an increase from 23% in 1990 to 45% in 1991 in Manipur. The survey lists two states without a single case of HIV infection—Bihar and Orissa. 10,730 people have been infected with the AIDS virus, out of a total of 14 lakh individuals surveyed in the country. 242 full-blown cases of AIDS have been reported in India till Oct. 1992.
AIDS virus spreading in Maharashtra and Goa has been showing similarities to the pattern of spread in some African countries. Prevalence of the second type of human immunodeficiency virus (HIV-2) in a blood sample from Bombay and Goa is reported to be high. Out of 388 blood samples of known AIDS carriers, it has been found that 300 were infected with HIV-I, 14 with HIV-2 and 74 infected with both HIV-1 and HIV-2. This type of virus was totally unexpected from the Asian continent and now India can no longer be considered free of the HIV-2 virus.
India will have the largest number of people infected by the human immunodeficiency virus (HIV) before the turn of this century; if adequate precautions are not taken immediately. In India, it is mainly a sexually transmitted disease. And therefore the country may have a lot to fear. Every fifth person carrying sexually transmitted disease in the world is an Indian. The largest number of HIV positive cases in India are in the 20-40 age group—the most productive period in the human life cycle. And the strata of society most likely to be hit hardest are the lower middle and middle classes, which constitute a bulk of the country’s skilled labour.
In India, seropositivity rates are doubling every year. In Dec. 1986 it was 2.5 per thousand people tested. By 1991 it had ballooned to 5.23. And now is close to 8 per 1,000.
Despite warnings, the country’s blood distribution system continues to be highly unsafe. Globally as well as in India it is estimated that blood and blood products are responsible for approximately 3-5% of all infections. it has been found that professional blood donors are more often infected with HIV than either family members or voluntary donors. (A person can not be infected with HIV by donating blood if a sterile needle is used to take the blood.)
Hospital wastes have been identified as a potential cause for the spread of AIDS in India. All categories of wastes, including pathological and infectious wastes are being disposed of in the open ground or in open municipal cans without pre-treatment, rendering them accessible to rag pickers and intravenous drug users. With the rapid rise of AIDS cases in India, the virus escaping from hospitals through wastes is a possibility, to avoid which a modernized waste disposal system is necessary. The damage this negligence can cause will be enormous.
There is a strategic plan for AIDS control in India. The National AIDS Organisation (NACO) formed in 1993 is spearheading this effort. This organization the focus for the implementation of National AIDS prevention and control pros Also NACO will help focus on the issue, help implement a strategic plan achieving set goals, bring in the systematic evaluation and monitoring of multi-activities. The programme components of a strategic approach are:
(ii) Screening of blood and blood products.
(iii) Information, education and communication.
The first two components are involved with setting-up of facilities and component deals with communication exercises.
To, focus attention on the alarming spread and to stop AIDS through collective efforts, Dec. 1 was observed as World AIDS. Day. While the AIDS epidemic only a limited window of opportunity for prevention and control measures, most India have not understood the colossal misery it can bring. The delay in combating can be disastrous. So for India, the time to act is now.
Owing to a fearful and misinformed public, AIDS victims and those suspected of harbouring the HIV infection suffer severe social ostracism. Discrimination in to impair public health efforts to cope with the AIDS epidemic and check the so the virus because the infected individual will be reluctant to reveal his identity undergoing testing and treatment.
Municipal and state-aided hospitals fall within the definition of “State” in 13 of/he constitution as expansively interpreted by our Supreme Court. Refusal to accept HIV cases as a matter of policy would be discriminatory and thus contravene Article 14 of the Constitution which guarantees equality of treatment and freedom discrimination. Besides, such an inflexible policy is tantamount to laying down unfair procedure in the treatment of AIDS victims which may well deprive them of their life. That is clearly violative of Article 21 of the Constitution which guarantees protection against deprivation of life by a procedure which is arbitrary and unfair.
To refuse treatment to AIDS patient because of a remote possibility of into irrational because, in effect, it demands an absolute guarantee of safety, something that never is. Some of the steps taken by the Indian Government to combat AIDS are as follows:
AIDS task force established by 1CMR (Indian Council for Medical Research 1985 to determine if HIV infection had arrived in India.
In 1986, the first Indian to be HIV seropositivity was detected in Tamil Nadu first full-blown AIDS case was reported in May 1987.
Govt. launched National AIDS Control Programme in 1987.
Assistance from the World Bank was sought and US $ 100 million projects drawn up with the World Bank loan acting like a start-up investment.
For nationwide implementation of US $ 100 million projects, National Control Organisation (NACO) was set up.
`Universities Talk AIDS’ (UTA) project was launched in November 1991 project, a joint programme of the NSS and the WHO covered to universities across Country.
There are 162 AIDS surveillance centres in the country and special facilities for the clinical management of AIDS patients are available in 13 hospitals.
On November 8, 1992, the Vice President of India Mr.K.R.Naryanan formally inaugurated the second International Congress on AIDS in Asia and the Pacific held at New Delhi. It was jointly organised by the UNDP, WHO, the AIDS Society of Asia and Pacific and the Ministry of health and family welfare, Government of India. The five-day international congress was attended by over 2,000 delegates from 68 countries. The congress was yet another major initiative to combat the dreaded disease.
The Congress focussed on the theme of reality, challenges and opportunity in AIDS prevention and control. It described at length the major hurdles in the fight against the spread of AIDS—Ignorance and Discrimination. The participants concluded that all the legislative response to curb AIDS through compulsory testing, registration, quarantine and punishment for being positive from STD apply only to prostitutes but not clients. On topics of HIV prevention strategies among prostitutes, it was felt the’ barriers to communication and trust building should be overcome, dissolving all forms of moralistic and judgmental messages concerning lifestyle and culture. A report “AIDS and Asia A development crisis” was released by the UNDP’s Global HIV and Development Programme Director Ms Elizabeth Reid. Another significant presentation was a study titled ‘who is bearing the cost of the AIDS epidemic in ASIA; by a team of professors from Columbia University.
The gay delegates at the Congress accused the organisers of employing a pejorative and superficial approach to their problems. Homosexual groups organised a parallel meeting, where they discussed their isolation and repression by society.
The President of the AIDS Society for Asia and Pacific, Prof. John M. Dwyer warned India on the spreading menace and observed that there are million infected people in the Asian region. Dr. M.H. Merson, director, a global programme on AIDS stressed that prevention is the only known ‘cure’ to AIDS as yet.
Globally the number of persons infected with the Human Immuno-Deficiency Virus (HIV) has multiplied a hundred times over in less than a decade. An estimated 10-12 million men, women and children have been infected with HIV. One in 250 of the world’s adult population. By the end of the century, the death toll is expected to be at least 400,000 a year. And by then at least 100 million people are expected to have been infected by HIV.
The first disquieting fact is that 80 per cent of new AIDS infections is in developing countries. Just 10 years ago it was primarily a disease of homosexuals and male drug users in the U.S. and Western Europe, which made health officials in other parts of the world, especially Asia, smug. By 1995, it is estimated that the developing world would account for 84% of the cumulative global total of HIV infections. WHO estimates that life expectancy in Sub-Saharan Africa could fall to 47 years by end of the century, compared to 62 without the HIV/AIDS factor. Also, it predicts that the under-five mortality rate in central and east Africa is likely to rise between 159 and 189 per 1,000 live births instead of dropping to 132. Africa has nearly half the world’s HIV/ AIDS victims.
According to a survey by the Asian Development Bank (ADB), by the year 2000, the majority of a projected 40 million AIDS virus infections and 10 million adult AIDS cases worldwide will be in Asia.
The population growth rate will either stagnate or fall, especial as the proportion of infected young women rises. The main reason identified for the `AIDS explosion’ in Asia is large populations, poverty, ignorance about the disease, thriving sex industries, extensive intravenous drug abuse, increasing mass migration of labour and rapid growth of business travel and tourism. Unless necessary multi-sectoral alliances are built throughout the Asia Pacific region the social and economic damage caused by AIDS and HIV will pose a severe crisis to human and economic development in the region. The epidemic will have a major impact on the workplace, particularly in Thailand and India, with companies and industries experiencing losses in work days, in trained manpower, in recruitment costs and burden on benefit schemes. Thus there is a strong urge in this region that the policymakers should focus their attention on the broader social, economic and political determinants which lie behind the spread of the AIDS infection.
Women have now been recognised as one of the major groups requiring help. Now 30-50% of all seropositivity people have been found to be women. In many countries, specifically in South Asia and in the Sub Saharan regions women I, have little control over sex when and how they have it. If a woman is pregnant; land infected with HIV, it is speculated that the progression to AIDS will move faster. A pregnant woman who is HIV positive has a 20-30% chance of passing on the infection to her child. By the year 2000, WHO estimates that 50% of all adult HIV infected and AIDS cases will be in women and children. Women who have asymptomatic STDs are at increased risk. Though the infection rate for women is increasing, surprising new evidence from studies shows that women do not die of AIDS faster than men, as had been thought, and that there are no gender differences in the occurrence of HIV related illnesses.
The cost of caring for an AIDS patient is stupendous. The African experience has shown that it costs about Its 12,000 per person per year. AZT(aerosolised Pentamidine), the only drug known to prolong life by about 36 months has to be imported and costs Rs 3 lakh a year per patient. And should the patient develop cytomegalovirus, which causes blindness and certain death, an additional Rs? 6.9 lakh per year needs to be added.
Those who potentially bear the costs of the HIV/AIDS are individuals who are affected and their families and friends, employers of the AIDS sufferers, health, and life insurance companies, health care providers, taxpayers and international agencies and charitable organisations. AIDS case costs about US $ 11,000 in India, US $ 16,000 in Indonesia, and US $ 41,000 in Thailand. With the cumulative total of 1 million AIDS cases expected in India by the year 2000, the cost of the—direct or indirect, is projected at the US $ 11 billion.
Indirect costs of AIDS-related mortality and morbidity are considerably larger than the direct medical care costs. Indirect costs to India have been estimated U-1 be about $ 10,000 per case of AIDS while direct costs to cover diagnosis and treatment of various infections that strike on AIDS patient will be about $1,100 per The socio-economic characteristics of A ‘Ds sufferers in conjunction with the current distribution of costs is likely to promote increased inequality. The infection is spreading in a non-random pattern with the poor being most at risk rather than those who are economically better off. The projected worldwide spending on AIDS/year is of epic proportions, this would sap the entire health budget of most Third World Countries, draining resources from other health and development priorities. In addition to a country with an initial HIV prevalence of five per cent, its national output could decline by 13 to 27 per cent in 15 years.
Figures released by the WHO global programme on AIDS show that around $ I12.0 million was spent in developing countries on AIDS prevention in 1991.
The total cost of just AIDS medical care in India, including treatment and counselling, projected for the year 2000 is US $ 1.6 billion, of which the Indian government will absorb the US $ 1.3 billion and the private sector will absorb the remaining US$300 million. As treatment costs are heavily concentrated upon individual sufferers and their families, who are mainly from the poorer segments of society, there should be a more practical approach to solve this problem. Existing hospital facilities need to be expended to cope with demand. Right now, the best cure is still prevention.
Given the nature and spread of AIDS, and the spread that the world has I witnessed since 1981 it is a clear indication of the task ahead. Containing it in a largely illiterate and poverty-stricken population is mind-boggling. In the absence of medical defences against AIDS, public education is the only weapon in the fight to limit the spread of the infection. Only by influencing personal behaviour and lifestyle can we hope to minimise the ravages of AIDS throughout.