Diverse realities: sexually transmitted infections and HIV in India -- Hawkes and Santhya 78 (Supplement 1): 31 -- Sexually Transmitted Infections
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HIV Infection/AIDS
Sexually Transmitted Infections Sex Transm Inf 2002; 78 :i31-i39
© 2002 Sexually Transmitted Infections
SYMPOSIUM
Diverse realities: sexually transmitted infections and HIV in India S Hawkes 1 and K G Santhya 2
1 Clinical Research Unit, London School of Hygiene & Tropical Medicine, London, UK
2 Population Council India, New Delhi, India
Correspondence to:
Dr Sarah Hawkes, Clinical Research Unit, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
Accepted for publication 30 November 2001
ABSTRACT
TOP
ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
There are many features that make India a vulnerable country as far as a sexually transmitted infection (STI)/HIV epidemic is concerned. These include the lack of a strong evidence base on which to formulate decision making, a pluralistic and often unregulated health sector, and a highly vulnerable population. Nonetheless, India has shown strong commitment to other areas of a comprehensive reproductive health care programme, and may be able to do so in the field of STI/HIV control. Vast numbers of people in India are severely disadvantaged in terms of income, education, power structures, and gender. Addressing these basic issues of human rights lies at the core of achieving better health outcomes.
Keywords: sexually transmitted disease; India; HIV
Policy makers ideally set health sector priorities according to a number of variables including: burden of disease; whether effective "solutions" are available; and the calculated cost–effectiveness of those solutions. 1 In the case of sexually transmitted infections (STI) in India, the epidemiological evidence base informing calculations of the burden of disease is limited. In this paper we highlight the known extent of the epidemic of STIs, including HIV, in India, risk factors and vulnerabilities to these infections, and the multifaceted responses to the epidemics. While in an ideal world it would be possible to talk about the "phases" (rising, stable, declining) of STI/HIV epidemics in India, in reality there is a dearth of longitudinal data from many areas of the country, and the exact phase of epidemics can only be guessed at.
SOCIOECONOMIC VULNERABILITIES
TOP
ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
In May 2000, India joined China as one of only two countries with a population of more than one billion. National demographic characteristics reflect an environment vulnerable for STI transmission, including the following: a young population, with 36% aged below 15 years 2 ; more men than women in the population (a ratio of 1000:933 in the 2001 census) 3 ; and an increasing pace of urbanisation. 4 Migratory patterns are generally from impoverished rural areas to prospective urban destinations, especially in the more developed South. Most of the (predominantly male) migrants are married, and they leave behind their families in the villages and occasionally return to visit them. 5 The highest reported prevalence of STIs during the period 1984–88 was in the southern/central states of Maharashtra and Tamil Nadu, which were the most urbanised states in the country at the time of the 1981 census. 6
A 1990s World Bank study of 50 low income countries noted that eight structural and behavioural level variables could explain up to two thirds of the variation in HIV prevalence between countries. 7 India displays vulnerability in several of these variables: it is a low income country, with a GDP per capita of US$465 in 1997 8 ; absolute poverty is compounded by inequalities in income distribution—during the period 1990–96, while the poorest 40% shared 21% of the total household income, the richest 20% shared 43% of household income. 9 Despite various initiatives to achieve universal primary education, in 2001 nearly half the adult female population was classed as non-literate. 3
Women's status is low and their access to education, paid employment, and appropriate health care is limited. Life expectancy is almost equal between men and women, 10 although a slight improvement in women's life expectancy over men's has been observed from the 1980s onwards. Disability Adjusted Life Years (DALYs) lost per annum are greater for women than men 11 and the highest level of DALY disparity is in the reproductive age groups (15 to 44 years).
BEHAVIOURAL RISK FACTORS
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ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
Published reports on behavioural risks for STI/HIV transmission must be interpreted with several methodological caveats. The definition of "sex" or "sexual partner" is not clearly articulated in many studies, thus raising difficulties with interpretation across and between studies. In addition, the prevailing family system in India is based on monogamous marital sex, with a high value placed on premarital chastity and marital fidelity, especially for women. Such cultural norms may influence respondents' willingness to report sexual activity. Despite these limitations, recent studies have provided valuable insights into the nature and extent of patterns of sexual behaviour in selected populations. A review of published studies highlights certain key areas.
Commercial sex
Prostitution, or sex work, has a very long history in India; the topic was discussed in texts written as far back as the third century BC. 12 Today, female sex workers can broadly be categorised into four groups: brothel based; home based and part time; street based; and call girls. 13 Women work in a variety of locations, and have different levels of independence or restrictions accordingly.
The male clients of sex workers are a similarly heterogeneous mixture, representing all socioeconomic strata of society. Studies and longitudinal behavioural surveillance survey (BSS) data that have examined the number of clients served by sex workers reported that they see, on average, three clients a day, 14– 17 although one study reported 10 to 12 a day. 13 A study in Orissa found that 15% of men (urban and rural) reported payment for sex at some point in their lifetime, and other cross sectional studies have found between 8% and 29% of men have paid for sex. 18 One common feature observed in all the studies is that men often go to sex workers in groups. 19 Tamil Nadu BSS data (1996–2000) have shown a decrease in the percentage of truckers/helpers and male factory workers who report payment for sex in the past one year (from 38% in 1996 to 18.3% in 2000; and from 7% to 2.4%, respectively). The most recent round of the BSS included young men living in slums and young male students: 11% and 1.1%, respectively, reported payment for sex in the past year. 17
Non-commercial, non-marital sex
"General population" surveys have reported premarital sexual activity among 7–48% of male respondents and 3–10% of female respondents, 18, 20– 27 while among predominantly unmarried school and college students (mostly in urban centres) sexual activity is reported by 8–39% of male students and 1–20% of female students. 28– 36 Generally higher levels of premarital sexual activity for boys/men may be a reflection of their later age of marriage. Some have argued that premarital sex is not the norm, and that for the majority of people, their first sexual experience occurs within marriage. 19 A recent population based survey in Orissa among over 2000 urban and rural men reported that 25% had sex before marriage, and the overall mean age at first sex was 23 years. 18 Men have a wide variety of premarital sex partners including sex workers, friends, relatives, and future spouses. 18, 20– 22, 25, 26, 30, 31, 37 Among girls, reported premarital sexual contact is mainly with future spouses, friends, and relatives. 21, 31
A few studies have looked at the extent of non-spousal sex among married people in the general population and found relatively low reported levels: 2–6% of women and 4–12% of men. 18, 20, 21, 25, 26, 31, 38 While extramarital sex with friends and relatives has been reported, some studies suggest that men often pay for extramarital sex. Small scale studies among groups such as STI clinic patients and truck drivers have reported higher levels (81–98%) of premarital and extramarital sexual experience. 38, 39
Male to male sexual activity in India
Male to male sexual activity (MSM) has been described in India since the time of the Kama Sutra , but open discussion of MSM is not well tolerated. Recent research has concentrated on describing the practices, lifestyles, and cultures of MSM in India, with the most recent Tamil Nadu BSS data (2000) reporting on prevalence of MSM in the past one year: 2% of factory workers, 5% of truckers/helpers, and 12% of young men residing in slums. 17 Studies have found that most men reporting MSM are married, and they meet their sex partners in covert and discreet surroundings. 40, 41 Most of the interviewees first had sex with another man/boy at a relatively young age and reported non-penetrative sex most commonly. Use of condoms is reported to be relatively infrequent, 19 although Khan 40 reported 15–20% of older men regularly used condoms, and the BSS survey found that over 60% of truckers/helpers and 40% of young men in slums used condoms during anal sex. 17
EPIDEMIOLOGY OF STIS AND HIV
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ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
India displays a remarkable level of heterogeneity in all aspects, including the epidemiology of STIs and HIV. Such diversity is a reflection of the size of the country, the "phase" of the STI/HIV epidemic in any one place, the highly variable broader contextual factors influencing prevalence and incidence rates, and the ability of the health care system to record and respond to these rates. While HIV surveillance exists, there is no fully functioning STI surveillance system; thus predictions and estimates are made on the basis of ad hoc surveys, often among facility based or convenience samples. There are few systems for passive surveillance of STIs in operation, and even fewer longer term surveys in existence which might be able to show trends with time. Given this, it is difficult to describe an "Indian scenario" per se, or even to hypothesise about the "epidemic phase" of STIs that any one geographical area may be experiencing. Tables 1 and 2 summarise results of published surveys and studies of STI/HIV prevalence in India.
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Table 1 Published prevalence of sexually transmitted infection in men in India
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Table 2 Published prevalence of sexually transmitted disease in women in India
Epidemiological diversity
A lack of standardisation in laboratory criteria can influence rates reported, 90 and studies cited do not use either comparable sampling methods or laboratory diagnostic tests. In the case of syphilis, for example, some studies report all rapid plasma reagin (RPR) positive cases, while others report only those confirmed by the Treponema pallidum haemagglutination assay (TPHA). Diagnosis of other pathogens, such as Chlamydia trachomatis , shows an even wider variation in methods. In many studies the laboratory methods used are either inadequately explained or are not detailed at all. Retaining this critical perspective on the published data is important for both understanding the current reported figures and designing future research and control programmes.
A close review of the epidemiology highlights the following points.
Data on STI prevalence in men are lacking, especially men in the "general population"; we located only two surveys of STIs in men in communities in India. The majority of facility based and community based studies have thus far focused on examining STI rates in women, and even these data are relatively patchy and incomplete.
There are wide variations in both the reported prevalence of syphilis and diagnostic criteria used. Although variations in sample size and diagnostic procedures account for some of the differences, the high prevalence of syphilis among women in some parts of the country is in little doubt. Despite this, prevention of mother to child transmission of syphilis (through antenatal screening of all pregnant women) is unevenly implemented over the country.
Little research has been carried out on the epidemiology of the viral infections (apart from HIV). Recent studies on hepatitis B infection found an average estimated carrier rate of 4% in the general population. 91 With the major transmission route for this virus believed to be mother to child or childhood, researchers have recommended universal immunisation of neonates as the appropriate strategy for India. 92 There are no community based seroepidemiological studies on the prevalence of antibodies to HSV-2.
Cervical cancer contributes significantly to the burden of morbidity and mortality in Indian women, with an estimated 90 000 new cervical cancer cases arising annually. Despite this, few data exist either on the prevalence of different types of cervical dysplasia among women, or on the number of women (and men) infected with human papilloma virus (HPV). Only one community based study among women in a Delhi slum has reported on the prevalence of HPV subtypes.
Above all, there are remarkably few data reflecting trends of STIs with time. Therefore, the ability of policy makers and programme managers to select "phase appropriate" strategies 93 is highly limited.
HIV in India
The first HIV positive person was identified in India in 1986, and there has since been a rapid spread of the epidemic in some parts of the country. Accurately estimating the number of HIV positive people is difficult, in part because of the wide national variation in factors which put people at risk. However, HIV surveillance has allowed policy makers and programme managers to monitor trends with time. As of June 2001, there had been a total of 24 087 people diagnosed with AIDS and 98 451 HIV positive people identified through HIV serosurveillance, 94 and it is estimated that there are approximately 3.7 million HIV positive persons in India. Most infections have been acquired through sexual transmission (80.8%), with 5.1% acquired through injecting drug use, 5.5% associated with blood or blood products, and less than 1% of cases infected through mother to child transmission. 95
India has multiple epidemics of HIV in different geographical settings and among people with different types of risk. Initial cases were reported among female sex workers in the cities of Mumbai and Chennai, and injecting drug users in the north east of the country (especially in the state of Manipur 96 where rates have risen dramatically). Since then, however, there has been a diffusion of the epidemic away from recognised "risk groups" and into the so called "general population" in some areas. In 1998, the estimated male:female ratio of HIV infection in India was approximately 1.8:1. 97 Studies show that the number of cases in women infected through heterosexual transmission within marriage is increasing. Seroprevalences of 13–24% HIV have been reported among female STD clinic patients who did not report themselves to be selling sex. 61, 98– 100 In addition, a number of small scale studies have reported that anywhere from 6% to 85% of wives of HIV infected intravenous drug users and STI clinic patients were HIV positive. 101– 103 Studies which have examined the prevalence of HIV infection in married women have found that husbands' reported behaviour was the major risk factor for many women. 61, 99, 104, 105
The seropositivity rate among pregnant women in selected sentinel sites ranges between zero and over 2% (in the States of Maharashtra and Karnataka), and as high as 6% in some slums in Mumbai. 106, 107
Responses to risk and infection
Despite the lack of a firm evidence base for both the epidemiology and the underlying risk factors for most of the STIs in India, policy makers and programme managers are nonetheless charged with designing and implementing programmes and interventions which are both effective and phase and context appropriate. The following sections explore what is known about the control of STIs from both the individual and programme level perspectives, and include a description of the health services in India.
Individual level responses
Primary prevention of STIs: barrier methods
Until 1996, India's strong family planning programme had method specific contraceptive targets. 108 One outcome of a target driven approach has been the predominance of permanent contraceptive methods, and as a result the use of condoms is very limited. The 1998–9 National Family Health Survey (NFHS-2) reports that 48.2% of all married couples were using any (traditional or modern) method of contraception, which in 71% of cases was female sterilisation and in only 6.4% (3.1% of total population) was it condom use. 109 The number of married couples who use condoms to prevent transmission of infection is not recorded.
The use, especially the consistent use, of condoms in non-marital sex is also reported to be very low. Studies among the "general" male population who reported non-marital sexual experience found that between 50% and 88% never used condoms during such encounters, with only 4–13% always using condoms during non-marital sexual liaisons. 18, 21, 25, 34 Studies among groups at perceived or known higher risk (sex workers and their clients) have found a wide variation in rates of reported condom use, either at last sexual intercourse or over longer periods of time. 61, 110, 111 For example, the Tamil Nadu BSS survey data have shown a rise in the percentage of sex workers and truckers/helpers who report condom use at last "non-regular" sex (from 56% to 91% and from 44% to 67% between 1996 and 2000, respectively). Female factory workers and female students also report higher levels of condom use compared with five years ago, but among male factory workers and male students there has been a more recent decline in the percentages reporting condom use at most recent "non-regular" sex. 17
Reported morbidity, health care seeking, compliance with treatment and partner communication
Much information on the prevalence of morbidity associated with STI/RTI (reproductive tract infection) in India comes from studies on self reported gynaecological morbidities. A series of six studies found that between 13% and 57% of women in the general population reported a current abnormal discharge. 112 A large scale, population based survey of more than 2000 men in rural and urban Orissa found that the most common health concerns among men related to sexual health in general, and psychosexual concerns in particular. 18 The poor correlation between self reported symptoms and laboratory confirmed infections 113, 114 is compounded in India by the widely prevalent Ayurvedic belief system which equates discharge syndromes ( dhatu loss) with loss of bodily power. Studies among both men and women have found a high prevalence of reported "abnormal discharge," but often with no biomedically defined cause for these symptoms. 113, 115
Treatment-seeking in India is determined by a number of variables, among which are: perceived seriousness and causality of symptoms; availability and accessibility of health care; costs (including opportunity costs) of treatment; perceived and actual quality of care; and beliefs about the appropriate provider to consult. There is a strong and prevalent system of indigenous medical care in India and a multitude of different providers in the formal and informal sectors.
The proportion of symptomatic women who seek care is highly variable, ranging from a minority to a majority in different studies. 20, 21, 57, 59, 116– 121 Some symptomatic women may delay seeking treatment 21, 121 : women in rural Tamil Nadu waited, on average, for a month before seeking any treatment. 21 BSS data from Tamil Nadu have shown a relatively consistent percentage of men in different groups who report symptoms of urethritis in the past year, but while the percentage of symptomatic truckers who sought care from a qualified allopathic doctor has increased, it has correspondingly decreased among male factory workers and male students. Less than one in six of all symptomatic students had sought care from a qualified doctor. 17
Other studies have found a variable proportion of symptomatic men who seek care. 21, 27, 122, 123 Even when men do seek care, the pattern of their treatment-seeking appears inadequate for a complete cure: one study 124 reported that just over one third of patients completed the recommended treatment regimen and nearly one third had self treated with antibiotics before seeking treatment from STI clinics.
Communication between partners on sexual matters, including morbidity, is often restricted. Women are often, as noted by Ramasubban, 125 "too afraid and confused to bring this [symptoms] to the notice of the family ..., both because they are not supposed to have such problems in the first place and also because they are socially deemed to be polluters, the originators of sexual problems." As a result, some studies have found that women do not inform their husbands about their gynaecological symptoms, 21, 121, 126 and a study among married women and men in rural Tamil Nadu reported that only slightly more than one third (37.3%) of women with symptoms of possible reproductive tract infections, and one fifth (19.9%) of the symptomatic male respondents informed their spouses about their illness experience. 21 Moreover, communication was generally indirect, using symbolic expressions and gestures, thus leaving "informed" spouses to guess about their partners' illnesses.
HEALTH SYSTEM RESPONSE TO STI
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ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
The public sector
Public health in India has been a stated government priority since independence. Current spending in the broad health sector is 0.7% of GNP, 127 with a per capita health expenditure by central government of approximately $US1 per annum. 128 The share of central government expenditure spent on health and family welfare has remained at less than 2% of the total during the last decade. In contrast, the share of expenditure on debt interest payments has increased from 23.9% in 1991–2 to 29.9% in 2000–1, and the share of defence expenditure out of the overall expenditure has risen from 14.7% in 1991–2 to 17.3% in 2000–1. 129
According to public health specialist Qadeer, India's pluralistic health system has undergone a series of changes as a result of both internal pressures (the demands of the growing middle classes fostering the development of private services, for example), and external forces (the donor driven policies of the 1990s, for example). 130 While primary health care services have always been intended to be relatively comprehensive in scope and coverage, the reality of service delivery in India has varied according to the perceived competing demands of national priorities. Thus for most of the 1970s and 1980s, much of the reproductive health service delivery was directed at achieving family planning targets. However, the Government's commitment to policy change following the International Conference on Population and Development in 1994 and the 1995 Beijing Women's Conference has recently resulted in a move towards the provision of comprehensive integrated reproductive health care at all levels of the health sector. 131 "Client centred, demand driven, high quality, integrated services" 132 are the principles guiding service delivery. Public health services are free at the point of delivery, although patients usually have to pay for drugs and diagnostic services.
The private sector
In recent years the already prolific private sector has expanded in India. This sector includes a widespread system of indigenous medical practitioners. The importance of the private sector is highlighted with the official estimate that only 5–10% of patients (across all economic classes) with STIs present to public sector care. 106 Despite the size and complexity of the private sector in India, its functions, motivations, and general structure are relatively poorly understood and documented. However, in allopathic medicine at least there are integral links between the public and private sectors. Both are often staffed by the same practitioners—a survey of 258 physicians in New Delhi found that among those employed in the public sector, 81% also worked in private practice. 133 Patients attending public sector services may find themselves referred to the private sector for diagnostic services, "second opinions," or services not offered by providers in their public sector guise.
The private sector is currently largely unregulated and is not subject to safeguards that exist within the public sector (assuring access to services, for example). Most of the services are curative: the private sector is rarely involved in prevention of illness, but one recent exception has been the growth in the "social" marketing of condoms. Moves are under way to try and implement some degree of control and ensure standardisation of service delivery, but, as in many countries, the exact mechanisms for achieving this are not clear. One of the difficulties in achieving regulation within the private sector is the relative stakeholder strength. The allopathic private sector has grown considerably in the recent past, and the ability of the state to exert control over this sector is increasingly questioned. One possible procedure for increased state regulation which is now being discussed is to develop public–private collaboration through, for example, the government subcontracting services from the private sector. However, the ability of the state to be both partner and regulator of the private sector remains unclear.
The NGO sector
The not-for-profit NGO (non-governmental organisation) sector in India plays an influential and important role in many of the social sectors. In health, there is a predominance of NGO activity in the delivery of interventions in the field of reproductive health in general, and HIV/AIDS in particular. The programmes initiated by NGOs tend to have a greater degree of flexibility and more opportunities for innovation than can be provided in the public sector. The NGO scene ranges from small grass roots organisations working in defined locations to large scale institutions with multiple sites and target populations.
STD/HIV PREVENTION AND CONTROL PROGRAMMES
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SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
A national STD control programme has been in operation since 1946. The main objectives of the current programme are to reduce STD cases and thereby control HIV transmission, and to prevent short term and long term morbidity and mortality from STDs. 106 Programme highlights include the following areas.
Surveillance activities
HIV surveillance began in 1985 with screening of blood from "high risk groups" in two cities. Sentinel surveillance was introduced in 1993. AIDS case surveillance is an important component of the surveillance activities and all medical institutions are required to report suspected AIDS cases, and referral institutions report all identified patients, to the National AIDS Control Organisation.
STD surveillance through syndrome based reporting from peripheral health institutions and aetiological information from STD clinics is due to be introduced. Behavioural surveillance has recently been incorporated into HIV surveillance activities, and baseline surveys are currently under way in various settings. The first wave of behavioural surveillance surveys in India was launched in Tamil Nadu in 1996 and was followed up by successive surveys (five rounds so far in Tamil Nadu) to observe trends in high risk behaviour among selected subpopulation groups such as female sex workers, truck drivers and helpers, male and female factory workers, and students. 17 Similar surveys are now under way in other states.
STD case management
The main strategy aimed at achieving effective management for people with established infections has been to integrate STD services into the existing health care system, with a special emphasis on integration at the primary health care (PHC) level. Syndromic management is recommended by the National AIDS Control Organisation (NACO) for case management at this level. 106 The effectiveness of syndromic management in women is currently under debate. 134, 135 Recent reviews of the effectiveness of syndromic management found only one such study from India. 136, 137 This was carried out in New Delhi among over 300 symptomatic women seeking care in an NGO reproductive health clinic. 80 The STI prevalence in this clinic population was reasonably high with 22% of women having an STI (chlamydia, trichomonas, or syphilis; none with gonorrhoea) diagnosed in the laboratory, including 12% with Chlamydia trachomatis . As with other studies, the recommended syndromic flow charts performed well for the management of vaginal infections, but the STIs were poorly managed, with only 5% of women infected with chlamydia receiving appropriate treatment.
Quality of care in public sector services is a current programme priority. However, moving beyond rhetoric to actually implementing change has not yet been noticeably achieved in many parts of the country. 138 Studies in STD clinics have found that the quality of case management, especially counselling for prevention, is inadequate and poor. 139– 141 Observations of STD consultations in Madras revealed that advice on condom use was given during only 30% of the consultations. Instructions on how to use condoms were imparted to 6% of the clients, and condoms were provided to 1%. 139 Similarly, in one Tamil Nadu study only 15% and 28% of the symptomatic women and men, respectively, who had sought treatment from a health care facility were informed by the providers about the cause of their symptoms or the precautions to be taken to avoid the illness. 21
Partner notification is a cornerstone of effective STI management, but studies in India have shown that this procedure is rarely discussed or initiated by health care providers. A clinic based study in Chennai 139 observed that advice on partner notification was given during only 27% of the consultations. Likewise, a study in Delhi reported that none of the 100 male and female STD patients was advised about partner notification, 140 and in a study in rural Tamil Nadu, none of the symptomatic women and only 5.7% of the symptomatic men were advised to have their spouses examined for a possible infection. 21
Other public health control measures for STI control
Aside from strengthening case management, the other pillars of public health interventions for STI control are implemented more patchily throughout the country. There has been a public sector syphilis screening programme for pregnant women since the 1950s; however, this is applied unsystematically and is further compromised by the fact that nationally only 57% of women receive antenatal care in the public sector. 142 Even women seeking antenatal care are likely to only receive a limited range of services—less than half have their blood pressure checked, for example. 143 In rural India, only 33.6% of births are attended by a health professional, 109 and less than a quarter of births are in institutional settings, thus reducing the impact of prevention programmes for ophthalmia neonatorum for example.
Cervical cancer screening is another example of a programme that is only in its infancy. The absence of a nationwide screening programme means that many women do not present for care until the cancer is at an advanced stage (Institute of Cytology and Preventive Oncology, Indian Council for Medical Research, unpublished data). Establishing a screening programme is problematic in a setting where those women most at risk (that is, older women) are unlikely to attend public sector health care settings (which are predominantly for maternal and child health care).
STI prevention and care outside the public sector
Perhaps as a result of a stimulating and innovative NGO climate, this sector has some of the best known and potentially most successful interventions to slow the spread of STIs, including HIV, in groups at higher risk of infection. The types of intervention undertaken range from promotion of information, education, and communication (IEC) material, provision of health services, and home based care for people with HIV/AIDS. Possibly the best known is an intervention among sex workers in Calcutta. Known as "Sonagachi" (after the district in the city where many of the brothels are located), this intervention has become globally recognised for the innovative approach it has taken to risk reduction. Recognising that sexual behaviour is not determined by individual-led parameters alone, the intervention has sought to address a wide range of social, economic, health, and other concerns of the women working in the brothels, and includes activities targeted at male clients. The project is now run largely from within the brothel community, and has succeeded in a number of areas, increased literacy being one of the major achievements. HIV rates in women selling sex in the Sonagachi area have remained relatively stable, and are currently around 5%. Rates of other STIs have fallen during the lifetime of the project. 143 These figures compare, for example, with data from Mumbai, which showed an increase in HIV prevalence in female commercial sex workers from 21.1% to 71% over the period 1990 to 1997. 144
Other targeted interventions carried out with the assistance of NGOs have concentrated on reducing risks for injecting drug users and people working along highways (truck drivers and their assistants, for example). Injecting drug use has been a significant problem in India's north east states (bordering Myanmar), and HIV rates among injecting drug users are currently over 80%. Once thought to be a relatively contained problem, injecting drug use (especially of buprenorphine) is currently thought to be on the increase throughout the country (Panda S, personal communication).
Voluntary HIV counselling and testing
The Government of India's policy statement on HIV testing emphasises that no individual should undergo mandatory testing for HIV, adequate voluntary testing facilities with pre-and post-test counselling should be made available throughout the country, and there should be at least one government run HIV testing centre per district. 145 To implement these objectives, the public sector has been collaborating with NGOs that have taken the lead in developing anonymous HIV counselling and testing centres.
Care for people living with HIV/AIDS
As the absolute number of people living with HIV/AIDS increases, provision of health care and social support to people living with HIV/AIDS has become a more pressing issue, and has been adopted as an integral component of the national AIDS prevention and control policy. The measures taken by the government to meet the growing needs for care and support of people living with HIV/AIDS (PLWHAs) include: provision of drugs, free of charge, for the management of opportunistic infections in patients at government health care settings; counselling services for HIV infected people; and supporting NGOs and community based organisations in providing hospice care. Nonetheless, isolation, stigmatisation, and other forms of discrimination characterise the experience of the vast majority of PLWHAs in India and pose severe constraints on people revealing their HIV/AIDS status and availing health care and support. Compounding these problems is the high cost of most treatment options. Although antiretroviral drugs are currently produced by Indian pharmaceutical companies and sold at prices well below those in industrialised countries, only 3–5% of the known HIV infected individuals are currently able to afford such treatment in India. 146
EXPENDITURE FOR STI/HIV PREVENTION AND CARE
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ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
Expenditure in one state
A recent survey undertaken among a random selection of 1100 households in and around the city of Udaipur (Rajasthan) looked at household level expenditures on reproductive and child health. 147 The State of Rajasthan spends a total of 6% of its GDP on health care, of which just over 21% is spent on reproductive and child health services. The largest source of financing for health care in Rajasthan comes from household (out-of-pocket) expenditure—71% of the total spent on health, and a total of 80% of expenditure in the reproductive and child health sector. In Rajasthan, "RTI [reproductive tract infection] services" constitute the third leading use of public sector (government and donor) funds in reproductive and child health, but the top expenditure for households in their purchase of all types of reproductive and child care. Thus families surveyed spent more of their own money on seeking care for symptoms (not aetiologically proven) of reproductive tract infections than they spent on child health care, and all forms of safe motherhood (pre-and postnatal, obstetric, and abortion services).
Expenditure nationally
Funding for the HIV/AIDS programme comes from a variety of sources, including central Government and multilateral and bilateral donors. During the 1990s the major expenditures of the HIV/AIDS control programme were in promoting IEC activities and in ensuring blood safety. The year 1998–99 witnessed an increased financial allocation, but utilisation of funds has been suboptimal until very recently. For example, only around 50% of the total allocation for HIV/AIDS control was used during 1992–5. 106
Clinical management of people with HIV/AIDS and surveillance for these infections currently receive less than one sixth of the AIDS control programme budget. This figure may be expected to rise in the future: not only will the number of people requiring clinical care increase, but the local cost of patented drugs may rise when India's patent regime becomes Trade Related Intellectual Property Rights (TRIPS) compliant in 2005. At present the current cost of locally produced fluconazole in India is $55 for 100 tablets, compared to $697 in Malaysia, and $817 in the Philippines. 148
CONCLUSIONS
TOP
ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
India, united through many aspects, displays remarkable diversity—something that is apparent from even a cursory review of the known epidemiology of STIs in the country. It is hard to overestimate the scale of the challenge faced by policy makers and programme managers charged with designing effective, accessible, and affordable programmes for STI control in the country. As such, it is important to realise that there is no "Indian scenario" of sexually transmitted infections, including HIV, per se. Instead there is a complex interplay and overlap of different STI/HIV epidemics at different stages of development, with varied underlying causes. One of the strongest challenges to the design of appropriate prevention and intervention strategies in the absence of longitudinal data is that there is no indication as to where on an epidemic curve any cross sectional results should be placed. Is STI prevalence rising or falling? Are current patterns of sexual behaviour changing or staying constant? Are interventions needed more in one geographical location than another? These, and other fundamental questions forming the basis of evidence based health care planning, are often left unanswered when programmes are designed.
As we have seen in detail throughout this paper, there are many features that make this a vulnerable country as far as an STI/HIV epidemic is concerned. These include the lack of a strong evidence base on which to formulate decision making, a pluralistic and often unregulated health sector, and a highly vulnerable population. Nonetheless, India has shown strong commitment to other areas of a comprehensive reproductive health care programme, and may be able to do so in the field of STI/HIV control. Vast numbers of people in India are severely disadvantaged in terms of income, education, power structures, and gender. Addressing these basic issues of human rights lies at the core of achieving better health outcomes 149 (including reproductive and infectious diseases) in India. Such a challenge is formidable in terms of its required scope and coverage, but lies at the heart of improving sexual health for the greatest number of people in India.
REFERENCES
TOP
ABSTRACT
SOCIOECONOMIC VULNERABILITIES
BEHAVIOURAL RISK FACTORS
EPIDEMIOLOGY OF STIS AND...
HEALTH SYSTEM RESPONSE TO...
STD/HIV PREVENTION AND CONTROL...
EXPENDITURE FOR STI/HIV...
CONCLUSIONS
REFERENCES
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