Describe the epidemiology, prevention and control of HIV/AIDS and sexually transmitted infections.

Epidemiology and Prevention of HIV

• The modes of transmission, with their approximate contribution in India — sexual (heterosexual predominating, accounting for the large majority); parenteral, through injecting drug use with shared needles, and through transfusion of unscreened blood; and mother-to-child (vertical), during pregnancy, labour or breastfeeding
• IT IS AS important TO state how HIV IS not transmitted, because misinformation drives stigma — not by casual contact, sharing food or utensils, hugging, coughing, insect bites, toilets or swimming pools
• The high-risk groups in the Indian context — female sex workers, men who have sex with men, transgender people, injecting drug users, and bridge populations such as migrant workers and long-distance truck drivers, who carry infection between high-prevalence and general populations
• The epidemic is concentrated rather than generalised, meaning prevalence is high in key populations and low in the general population — which determines that targeted interventions are more efficient than mass ones
• Diagnosis — by rapid antibody tests, three different tests being required for a positive diagnosis under the national algorithm; with early infant diagnosis by DNA PCR, since maternal antibody persists in the infant and makes antibody testing uninterpretable until about 18 months
• The window period is the interval between infection and the appearance of detectable antibody, during which the person is infectious but tests negative — which is why blood donor screening cannot rely on testing alone and donor selection matters
• Testing must be voluntary, confidential and accompanied by counselling, delivered through Integrated Counselling and Testing Centres (ICTC)
• The prevention strategies:
• Sexual transmission — condom promotion; behaviour change communication; prompt treatment of other sexually transmitted infections, which substantially increase HIV transmission by breaching mucosal integrity; and targeted interventions among key populations, using peer educators, which have been the most successful element of the Indian programme
• Parenteral — 100% screening of donated blood; promotion of voluntary, non-remunerated donation, which is far safer than paid donation; injection safety and auto-disable syringes; and needle-syringe exchange and opioid substitution therapy for injecting drug users, which are evidence-based harm reduction rather than encouragement of drug use
• Mother-to-child transmission — prevention of parent-to-child transmission (PPTCT), by universal antenatal testing, lifelong antiretroviral therapy for every pregnant woman found positive, infant prophylaxis, safe delivery practices and counselled infant feeding
• This reduces transmission from about 30% to under 5%, and is among the most effective interventions in the whole programme
• Occupational — universal (standard) precautions, which mean treating every patient’S blood and body fluids as potentially infectious, rather than testing and taking precautions selectively; and post-exposure prophylaxis, ideally within 2 hours and certainly within 72 hours, given for 28 days
• Pre-exposure prophylaxis (PrEP) for those at substantial ongoing risk

Treatment, the Programme and Sexually Transmitted Infections

• Antiretroviral therapy — India follows the treat all policy: ART is offered to everyone diagnosed, regardless of CD4 count or clinical stage, and is given free at ART centres
• The concept OF "treatment AS prevention" (U=U, undetectable equals untransmittable) IS the most important advance IN the field — a person on effective treatment with a sustained undetectable viral load does not transmit HIV sexually
• Its implications are profound — it makes treatment itself a preventive measure, provides a powerful reason to test and to adhere, and removes much of the rational basis for stigma
• The UNAIDS "95-95-95" targets — 95% of those living with HIV diagnosed; 95% of those diagnosed on treatment; and 95% of those on treatment virally suppressed
• The cascade is instructive because loss occurs at every step, and the first 95 (knowing your status) is usually the weakest link
• Opportunistic infections — tuberculosis is the commonest and the leading cause of death; also cryptococcal meningitis, pneumocystis pneumonia, candidiasis, cytomegalovirus and toxoplasmosis
• Hence the principle of collaborative TB-HIV activities — test every TB patient for HIV, and screen every HIV patient for TB at every visit; with co-trimoxazole preventive therapy and TB preventive treatment
• The national AIDS control programme (NACP) operates through the National AIDS Control Organisation, and its components are targeted interventions among key populations; ICTC testing and counselling; blood safety; STI services; PPTCT; free ART; information, education and communication; and surveillance
• The HIV and AIDS (Prevention and Control) act, 2017 is worth naming — it prohibits discrimination in employment, education, healthcare, housing and insurance, requires informed consent for testing, protects confidentiality, and provides for an ombudsman and for the guardianship of children
• Sexually transmitted infections are managed by the syndromic approach, in which treatment is given on the basis of the syndrome rather than waiting for a laboratory diagnosis
• Its rationale — it treats at the first visit, needs no laboratory, prevents loss to follow-up, and covers the common mixed infections; its cost is some over-treatment, which is accepted as the lesser harm
• The colour-coded kits are provided for urethral discharge, vaginal discharge, genital ulcer, lower abdominal pain, inguinal bubo and scrotal swelling
• The four Cs of STI management should be recited — compliance with treatment; counselling and education; condom promotion; and contact tracing and partner treatment
• Partner treatment is essential and is the step most often omitted, since treating one partner alone guarantees re-infection
• The obstacles to control in India — stigma and discrimination, which deter testing and disclosure; criminalisation and marginalisation of key populations; migration, which interrupts treatment; loss to follow-up and drug resistance; low awareness among young people; and dependence on external funding
• The honest summary — India’s epidemic has declined substantially through targeted work with key populations, but elimination requires closing the first gap — the large proportion who do not know they are infected
• Undetectable equals untransmittable, which turns treatment into prevention and removes much of the basis for stigma
• Treating one partner alone guarantees re-infection, which is why contact tracing is the C most often skipped
• Treat all regardless of CD4 count is the current policy, and antiretroviral therapy is free at ART centres
• The first ninety-five is the weakest link, since many people living with HIV do not know their status
• State how HIV is not transmitted, since misinformation about casual contact is what drives stigma
• The window period means infectious but seronegative, which is why donor selection matters alongside testing
• Infant diagnosis needs DNA PCR, since maternal antibody persists to about eighteen months
• Other STIs substantially increase HIV transmission, which makes STI treatment an HIV prevention measure
• PPTCT cuts transmission from thirty per cent to under five, and is among the most effective interventions available
• Universal precautions treat every patient as infectious, rather than testing and protecting selectively
• Post-exposure prophylaxis within seventy-two hours, ideally within two, and continued for twenty-eight days
• Voluntary donation is safer than paid, which is why remunerated donation was abolished
• Needle exchange is harm reduction, not encouragement, and the evidence for it is strong
• Tuberculosis is the commonest cause of death in people with HIV, which is why the two programmes collaborate
• Screen every HIV patient for TB at every visit, and test every TB patient for HIV
• Syndromic management treats at the first visit, accepting some over-treatment as the lesser harm
• Compliance, counselling, condoms and contacts are the four Cs of STI management and should be recited
• The 2017 Act prohibits discrimination in employment, education, healthcare and insurance, and protects confidentiality
• Testing must be voluntary and confidential, with counselling before and after, which the law now requires
• The Indian epidemic is concentrated, not generalised, which makes targeted interventions more efficient than mass ones
• Bridge populations carry infection outward, which is why migrants and truck drivers are specifically targeted
• Peer educators reach populations that services cannot, and have been the most successful element of the Indian programme
• Migration interrupts treatment, and is a practical obstacle to viral suppression rather than a theoretical one
• Three different rapid tests confirm a diagnosis under the national algorithm, which guards against false positives