6 курс / Кардиология / Kartikeyan_HIV and AIDS-Basic Elements and Properties
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19.1 – INTRODUCTION
Epidemiological surveillance has been defined as “ongoing systematic collection, analysis and interpretation of outcome-specific data” (Thacker & Berkelman, 1988). The WHO has defined it as “continuous scrutiny of the factors that determine the occurrence and distribution of disease and other conditions of ill health” (WHO, 2002). The objectives of surveillance are to provide timely information about changing trends in health status of a population so that appropriate interventions may be devised; and to provide feedback – this may be used for redefining objectives. HIV surveillance continues to be the backbone of surveillance systems since the WHO established the GPA in 1987. Data on incidence and prevalence of HIV seropositivity is more useful as compared with case reporting of AIDS for health planning and programme evaluation (WHO, 2002).
19.2 – TYPES OF HIV SURVEILLANCE
19.2.1 – Population-Based Surveillance
This is the best method of assessing HIV prevalence and includes serosurveillance by HIV testing of blood specimens from a random sample of the given population and behaviour surveillance. For serosurveillance, the health authorities should obtain consent of all persons whose blood is collected. However, this is an expensive method, and participation bias is likely (WHO/UNAIDS, 2000).
19.2.2 – Sentinel Surveillance
This involves systematic collection of data on incidence and prevalence of HIV/AIDS in a given population. It also involves collecting and testing blood samples from people living in a defined area or those belonging to a particular subgroup in the population such as high-risk groups. In general, sentinel surveillance involves two types of testing:
Linked Testing: The blood sample or report is traceable by code to an individual. Consent is required.
Unlinked Anonymous Testing: This is the most commonly used method for HIV surveillance. The blood sample and its report are anonymous and not traceable to an individual. Blood samples collected routinely for other purposes such as blood donation and antenatal check-up is used for HIV testing. There is no need for consent and participation bias is minimised (WHO/UNAIDS, 2000).
19.2.3 – Case-Based Surveillance
This form of surveillance is used in countries where notification of HIV/AIDS is legally required. Information is provided on a standard reporting form.
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Named Case Reporting: The names of individuals with HIV/AIDS are provided to the health authorities to ensure appropriate interventions. This information is to be kept confidential. However, there is a risk of breach of confidentiality.
Unnamed Case Reporting: The health authorities are provided only with information (age, sex, risk factors, and occupation) that is required for disease surveillance and data analysis (WHO/UNAIDS, 1999). The names are replaced by name code made up of first two letters for surname, followed by first two - letters of first name (Kaldor & Crofts, 1997). In order to avoid duplication of reporting, additional information (that does not identify the patient) may be given. For example – date of birth, postal code of residence, AIDS-defining conditions, date of diagnosis of HIV infection, date of diagnosis of AIDS, diagnosing doctor and hospital, prior ARV treatment (Kaldor & Crofts, 1997).
19.2.4 – Behavioural Surveillance
The spread of HIV epidemic is primarily driven by individual behaviour, which puts other persons at risk of getting infected. Individual behaviour is mainly guided or influenced by socio-cultural and religious norms, and economic status. Very little information is available on patterns of sexual behaviour and sexual networking that determines the spread of HIV infection in different socio-cultural groups in the developing countries. Where possible, behavioural surveillance should be used along with surveillance of HIV seropositivity among young people in order to understand the recent trends in HIV incidence and risk behaviour. The changes are first detected in HIV prevalence figures for 15to 19-year-old group.
19.2.5 – Surveillance of Young People
Percentage of infected young people is a useful indicator of recent trends in HIV infection in areas where the epidemic spreads by heterosexual transmission. However, this indicator is not reliable where the infection remains confined to high-risk groups.
19.2.6 – Second-Generation Surveillance
This was launched in order to combine biological and behavioural data to assess trends. Young adults have the highest rates among newly HIV-seropositive individuals. Hence, many heavily affected countries have aimed for a 25 per cent reduction in HIV prevalence among young people, by the year 2005. For monitoring progress towards this goal, surveillance data (grouped by 5-year intervals, e.g. 15–19 and 20–24) are obtained from antenatal clinics (WHO/UNAIDS, 2000; UNAIDS/WHO, 2000).
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19.3 – EPIDEMIC PROJECTION PACKAGE
This software package has been developed by UNAIDS/WHO Reference Group on Estimates, Models, and Projections in order to enable standardised and systematic estimation of the burden of HIV and the course of the epidemic. It uses HIV prevalence time series derived from data on women attending antenatal clinics. There are separate models for urban and rural trends. The trend in HIV prevalence is estimated by fitting a simple epidemiological model to the surveillance data. The urban and rural estimates are used to provide a national estimate. The model uses four parameters:
1.Estimated year of commencement of the HIV/AIDS epidemic
2.Rate of spread of infection
3.Initial proportion of high risk (susceptible) adult population
4.Extent to which an individual dying from AIDS is replaced by a new susceptible
Epidemic projection package (EPP) outputs fit into a software package called SPECTRUM (www.futuresgroup.com and www.unaids.org), that can be used to calculate relevant indicators such as trends in mortality due to AIDS, life expectancy, and number of pregnant women needing ARV therapy for prevention of MTCT (WHO, 2002).
19.4 – CASE REPORTING
Reporting is the procedure through which health care providers systematically inform the health authorities about each individual case of HIV infection and AIDS. This is a legal requirement in countries where HIV infection is notifiable (UNAIDS/WHO, 2000; WHO/UNAIDS, 1999).
19.4.1 – Choice of Method of Case Reporting
Countries should choose a suitable method for HIV/AIDS surveillance, as per their needs and resources and the prevailing socio-political environment (Kaldor & Crofts, 1997). Resource-poor countries with inadequate infrastructure to maintain confidentiality should avoid HIV case reporting and opt for sentinel surveillance.
19.4.2 – HIV Case Reporting
Criteria for using this option include:
(a)Wide access to HIV testing and ARV therapy
(b)Presence of mechanisms to maintain confidentiality
(c)Availability of mechanisms for follow-up of clients
(d)Enforcement of legislation to protect the right to privacy and to prevent non-public health use of data
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(e)Periodic scanning to data for detecting extent of overor under-reporting and duplication of data (multiple reporting of same cases)
19.4.3 – AIDS Case Reporting
This is done on an yearly basis. Its limitations are:
●Completeness of AIDS reporting varies from less than 10 per cent (developing countries), to more than 90 per cent (developed countries). This high variability restricts the utility of data for estimating extent of AIDS epidemic.
●There is a wide variation in case definitions (i.e. CDC, WHO, and national) for AIDS between various countries.
●Increasing number of individuals receiving ARV treatment, also affects AIDS reporting (WHO/UNAIDS, 2000).
●This system records cases that became HIV seropositive many years ago. In order to provide early warning of transmission patterns, some countries have adopted HIV surveillance (Kaldor & Crofts, 1997).
19.4.4 – Uses of Case Reporting
In high-income countries, both HIV case reporting and AIDS case reporting are employed. It is possible for these countries to monitor access of seropositive individuals to appropriate services, including the availability of ARV therapy. But, in low-income countries, the data obtained by HIV/AIDS case reporting have not been beneficial for surveillance because
1.Less than 10 per cent of HIV-positive persons have been tested for HIV. Thus, most people are unaware of their HIV status.
2.Many people may not want to know their HIV status due to stigma, discrimination, and lack of access to services including ARV therapy.
3.In named case reporting, there is reluctance of health care providers to report cases by name for reasons of confidentiality and privacy. There is also a problem of under-diagnosis and under-reporting of HIV/AIDS cases.
4.Where unnamed case reporting is employed, multiple reporting of the same cases is a problem (WHO/UNAIDS, 2000).
5.Data accuracy depends on the context in which HIV testing was done, e.g. patients presenting with clinical manifestations suggestive of HIV infection, voluntary testing on individual’s request, testing of donated blood (Kaldor & Crofts, 1997).
6.Insufficient capacity or infrastructure for maintaining confidentiality.
7.Case reporting requires expensive infrastructure and trained manpower.
8.By itself, case reporting does not improve access to supportive services. Hence, in low-income countries, resources should be set aside for developing health and social support services, before they are utilised for case reporting.
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19.5 – HIV SENTINEL SURVEILLANCE IN INDIA
19.5.1 – Chronology of Events
1.1981 – AIDS was first recognised in the United States.
2.1985 – India joined the ranks of the first few countries that initiated serosurveillance among high-risk groups. Screening of blood samples for HIV was started in 1985 in Christian Medical College, Vellore (Tamil Nadu) and National Institute of Virology, Pune (Maharashtra).
3.April 1986 – The first group of seropositive individuals (10 female sex workers) was detected in April 1986 in Madras (now Chennai) and subsequently among sex workers in Mumbai. Within a short period of 18 months, it became apparent that heterosexual promiscuity was the major mode of transmission in India and that the seropositivity was low (approximately 4 per 1,000). HIV seropositive pregnant women (first detected in 1986) and their infants were followed up and HIV-infected children were detected in 1987–1988 (Ramachandran, 1990).
4.1986 – The first case of AIDS was detected in Mumbai.
5.1990 – Maharashtra and Manipur became “medium-prevalence” states.
6.1994 – Maharashtra and Manipur became “high-prevalence” states. Gujarat and Tamil Nadu came in as “medium-prevalence” states.
7.1998 – “High-prevalence” states were Maharashtra, Manipur, Nagaland, Tamil Nadu, Karnataka, and Andhra Pradesh; while “medium-prevalence” states were Gujarat and Goa.
8.2001 – 49 districts in eight states were identified as “high-prevalence” districts.
9.2005 – 95 districts in India were identified as “high-prevalence” districts. After the detection of HIV infection in the country in April 1986, the testing facilities for HIV were made available in different parts of India through 62 centres and nine reference centres. The results of HIV screening indicated that HIV infection had reached almost all parts of the country and that the major mode of its transmission was through the heterosexual route. Once these findings were known, the objectives of surveillance were redefined to monitor the trends in HIV infection and a National HIV testing policy was adopted. India’s prevalence estimates are solely based on sentinel surveillance data. Since HIV/AIDS is not a notifiable disease in India, HIV testing information from the private sector is not compulsorily reported to the national information system (Fredricksson-Bass & Kanabus, 2006).
19.5.2 – Technique for Sentinel Surveillance
●The surveillance is best carried out by annual cross-sectional survey of the same risk group in the same place over few years by unlinked anonymous testing by two ELISA, rapid, and simple (E/R/S) tests.
●The number of samples to be screened must represent the risk groups under study. Adequate numbers of samples are collected within the shortest possible time period.
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●Clinic-based approach has many advantages, including the procedure for collecting samples, which need to be repeated every year. This approach avoids selection and participation bias.
●Each sentinel site conducts an annual round of surveillance with 250 samples from high-risk groups and 400 samples from low-risk groups.
●Patients attending STI clinics, IDUs, and MSM represent the high-risk groups in the population. The low-risk group comprises women attending antenatal clinics.
●If the sample size is not adequate, the number of samples collected “up to 3 months” is taken as “adequate” sample size. After each round of surveillance, the collected data are compiled and analysed.
19.5.3 – Number of Sentinel Sites
●Based on the National Testing Policy for HIV, the sentinel surveillance system was initiated in 55 sites in 22 states and Union Territories in the year 1994.
●It was found that these 55 sites did not produce adequate data for estimating the degree of spread of HIV/AIDS in the country. Thus, the sentinel sites for HIV surveillance were increased from time to time to provide adequate representation to high-risk and low-risk groups in urban, as well as rural population.
●In 2005, the number of sentinel sites was increased to 703.
19.5.4 – Prevalence of HIV Infection
The prevalence of HIV infection has been worked out for each year, based on data from annual rounds of HIV surveillance using consistent methodology (i.e. number of samples for different risk groups, inclusion and exclusion criteria, number of sites from urban and rural areas).
In 2001, the Government of India appointed a core group of experts to estimate the HIV prevalence. It was decided to present a range estimate instead of a point estimate, since the former is more scientific and reflects the actual situation in the field. The range estimate also helps planners to formulate specific interventions for HIV-affected persons. The upper limit of the range was 20 per cent higher than the lower limit in order to take care of unaccounted number of HIV-positive persons in high-risk groups and the other age groups.
19.6 – HIV SENTINEL SURVEILLANCE – 2005
HIV sentinel surveillance was conducted in 703 sites across the country. Using the same methodologies and assumptions an in previous years, the number of adults (aged 15–49 years) living with HIV was estimated at 5.21 million. The adult HIV prevalence in 2005 (0.91 per cent) is comparable with that in 2004 (0.92 per cent) and 2003 (0.93 per cent). Women comprises 39 per cent of the adults (15–49 years) living with HIV. The prevalence of HIV infection in rural
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and urban inhabitants was 58.7 per cent and 41.3 per cent, respectively. The number of children under 15 years of age who were newly infected in 2005 was 59,007. The high-prevalence states were Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu. Gujarat, Goa, and Pondicherry were categorised as medium-prevalence states, while all the remaining states and Union Territories were low-prevalence states (NACO, 2006).
19.6.1 – Prevalence Among Antenatal Clinic Attendees
Prevalence of HIV infection among pregnant women is indicative of HIV prevalence in the general population. HIV prevalence was more than 1 per cent among antenatal clinic attendees in 95 districts, including nine districts in lowprevalence states. The median prevalence in this subgroup has remained more than 1 per cent in all the high-prevalence states with the exception of Tamil Nadu, where the prevalence has dropped to less than 1 per cent during the last 4 years. In the low-prevalence state of Mizoram, HIV prevalence among antenatal clinic attendees has steadily declined from 2.08 per cent in 2003 to 0.88 per cent in 2005 (NACO, 2006).
19.6.2 – Trends in High-Risk Groups
The median prevalence among STI clinic attendees increased significantly, as compared with that in 2004, in the low-prevalence states of Delhi, Rajasthan, and Orissa. Among STI clinic attendees, the prevalence was more than 10 per cent at 34 sites across the country indicating multiple heterogeneous epidemics. During 2003–2005, HIV prevalence among STI clinic attendees has remained between 5 and 6 per cent in highand moderate-prevalence states with the exception of Nagaland, Pondicherry, and Gujarat (NACO, 2006).
Assam, Chandigarh, Delhi, Kerala, and West Bengal revealed an increase in HIV prevalence among IDUs between 2002 and 2005. Frequency of HIV infection increased between 2003 and 2005 among female sex workers in Bihar, Nagaland, Rajasthan, and West Bengal. HIV seropositivity among MSM was higher in 2005, relative to that in 2004, in Delhi, Goa, Gujarat, and Kerala (NACO, 2006).
REFERENCES
Fredricksson-Bass J. and Kanabus A., 2006, HIV/AIDS in India. www.avert.org. Last updated 19 July.
Kaldor J.M. and Crofts N., 1997, Epidemiological surveillance for HIV/AIDS. In: Managing HIV (G.J. Stewart, ed.). North Sydney: Australasian Medical Publishing.
National AIDS Control Organisation (NACO), 2006, HIV/AIDS epidemiological surveillance and estimation report for the year 2005. New Delhi: Government of India, pp 1–11.
Ramachandran P., 1990, HIV infection in women. ICMR Bulletin 20 (11&12): 111–119.
Thacker S.B. and Berkelman R.L., 1988, Public health surveillance in the United States. Epidemiol Rev 10: 164–190.
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UNAIDS/WHO, 2000, Opening up the HIV/AIDS epidemic. Geneva: UNAIDS/WHO. WHO, 2002, HIV surveillance and global estimates. Wkly Epidemiol Rec 77(50): 425–430.
WHO/UNAIDS, 1999, Questions and Answers on Reporting, Partner notification and Disclosure of HIV and/or AIDS sero-status. Public Health and Human Rights implications. Geneva: WHO/UNAIDS.
WHO/UNAIDS, 2000, Guidelines for Second Generation HIV Surveillance. Geneva: WHO/UNAIDS.
CHAPTER 20
COUNSELLING
Abstract
Counselling is indicated in all conditions where client is likely to be under psychological stress. Any person who has the necessary aptitude, values, attitude, knowledge, and skills can undertake this challenging task. The purpose is to provide the means to overcome the stress-inducing condition and to take personal decisions that are not affected by moods, emotions or sentiments. In HIV medicine, both counselling and medical intervention are accorded equal importance. HIV-related counselling is somewhat unique because it starts before HIV testing (pre-test counselling) and continues for the spouse/partner and family members even after the death of the HIV-infected person. A counsellor should have a non-judgemental approach and help clients to reach for sources of support. Respect for confidentiality protects the privacy of clients. The process of counselling should continue for persons living with HIV infection. Special situations for counselling include that for the infected client’s partner(s), accidentally exposed health care providers, victims of partner violence, victims of rape, and IDUs. Recording of counselling sessions will permit continuity even if there are different counsellors for subsequent counselling sessions and prevent the client from having to repeat the same information from the previous session. The quality of counselling can be evaluated in the areas of interpersonal relationships, gathering information, giving information, and ability to handle special situations.
Key Words
Confidentiality, Contact tracing, Counselling in special situations, Crisis counselling, Empathy, Evaluation of counselling, Food safety, Home care, International travel, Nutrition, Partner counselling, Personal hygiene, Pre-test counselling, Post-test counselling, Recording counselling, Referral, Safer sex, Shared confidentiality, Source client
20.1 – INTRODUCTION
Counselling is a “confidential dialogue between the client and the health care provider, which is aimed at enabling the client to cope with stress and to take realistic personal decisions” (UNAIDS/WHO, 2000). Counselling is indicated in all conditions where client is likely to be under psychological stress. The purpose is to provide the means to overcome the stress-inducing condition and to take personal decisions that are not affected by moods, emotions, or sentiments. Any person (professionally trained counsellor, doctor, nurse, paramedical worker, or volunteer) who has the necessary aptitude, values, attitude, knowledge,
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and skills can undertake counselling. This is a challenging task that requires patience, dedication, and commitment.
20.1.1 – Need for Counselling
In the past, traditional systems were in place for counselling apparently healthy persons, patients, and their families for stress-related problems. Usually, respectable elderly persons who had the necessary aptitude and know-how undertook this challenging task within their own communities. Social support systems were also community-oriented and well known to members of the community. A classic example of counselling is depicted in the Hindu scripture Bhagavad Gita, where Lord Krishna advises the hesitant Pandava Prince Arjuna and helps him to overcome his doubts, anxiety, and predicament about fighting his own kith and kin on the battlefield. In recent times, the need for counselling has increased due to breakdown of traditional support systems and values, and stressful situations caused by “modern” lifestyle. Counsellors have to develop a wide range of skills in order to provide services to individuals from varying social backgrounds.
20.2 – FUNDAMENTALS OF COUNSELLING
20.2.1 – Dos and Don’ts
1.Ensure privacy so that the client can ventilate his or her personal feelings without being inhibited.
2.Use a form of address that is appropriate to the client’s age.
3.Give undivided attention to the client and make eye contact.
4.Ideally, the same counsellor should provide both preand post-test counselling.
5.At first, speak to the client alone. Later on, others (spouse/sexual partner and/or family members) may be involved, with the prior consent of the client.
6.Client’s personal particulars including marital status and lifestyle are to be recorded.
7.Find out the emotional, social, medical support systems of the client.
8.Be familiar with local terms for sexuality.
9.Encourage the client to ask questions and to come back, as soon as possible.
10.Never give advice, but give information. Likewise, never frighten a client.
11.Use a language, which is understood by the client.
12.Repeat the client’s message clearly and summarise to show that you have understood.
13.Encourage the client to speak, by showing that you are listening attentively.
14.Use humour or other “ice-breaking” techniques to reduce tension and stress.
15.Use gestures occasionally.
16.Keep suitable conversational distance.