MPhil Dissertation A STUDY ON AIDS AND ITS CONTROL MEASURES WITH SPECIAL REFERENCE TO RAJASTHAN Dissertation submitted to the Manonmaniam Sundaranar University, Tirunelveli in partial fulfilment for the degree of Master of Philosophy in Life Science By VIJAY SINGH RAJPUT In guidance of DR. L.S. RAJPUROHIT MANONMANIAM SUNDARANAR UNIVERSITY TIRUNELVELI MAY 2005 CERTIFICATE FROM THE GUIDE It is to certify that the present work on "A study on AIDS and its control measures with special reference to Rajasthan" is a bonafide work carried out by Mr Vijay Singh Rajput, a candidate for the degree of Master of Philosophy in Life Science o f t h e Manonmaniam Sundaranar University, Tirunelveli, u n d e r m y guidance and direction. Date: 01-05-05 Signature of Guide Place: Jodhpur Name: Dr. L.S. Rajpurohit, Department of Zoology, Faculty of Science, J.N.V. University, Jodhpur ACKNOWLEDGEMENT This work was carried out for the Master of Philosophy examination in Life Science of Manonmaniam Sundaranar University, Tirunelveli. I would like to thank my guide, Dr. L.S. Rajpurohit, Associate Professor, Department of Zoology, J.N.V. University, Jodhpur, for his invaluable guidance without which this work could not have been carried out. I would like thanking all the authors and publishers of the books, reports, manuals, newspapers etc that I referred to. Names of these articles are listed in the 'References'. I am also grateful to Dr. Saitan Singh, Medical Officer, P.H.C. Chitalwana for providing me relevant literatures. Vijay Singh Rajput CONTENT email@example.com Sr. No. Chapter / Section 1. Introduction 1.1 Historical Perspectives 1.2 Know AIDS- A Review 1.3 The Virus 2. Material and Methods 3. Observation and Results 4. Discussion and Control Measures 5. Conclusion and Recommendations 6. References Summary Appendix Page No. 1 2 3 4 5 6 7 8 9 10 11 1 7 10 13 17 19 31 59 69 71 74 List of Tables: Sr. No. Table Page No. 1 Tab. 3.1. HIV/AIDS situation in India and Rajasthan Tab. 3.2. Probable sources of infection Tab. 3.3. Age group and infection in Rajasthan Tab. 3.4. HIV sero-positivity in blood donors 21 2 3 4 22 23 28 List of figures: Sr. No. Figure Fig. 1.1. Structure of HIV Virus Page no. 1 16 2 3 4 5 Fig. 3.1. Age group Vs percent of HIV/AIDS patients Fig. 3.2. Sex distribution of AIDS cases Fig. 3.3. Median prevalence of HIV in STD cases Fig. 3.4. Median prevalence of HIV in Rajasthan Fig. 3.5. Reported AIDS cases in hospitals of high prevalence 19 20 24 25 6 districts of Rajasthan 7 Fig. 3.6. Yearly collection of blood units in Rajasthan (in lacs) 26 27 Nomenclature and Abbreviations Sr. no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Short Form AIDS DNA WBC HIV HIV+ ARC ELISA W.B.Test SIV STD RTI CDC GRID NACO WHO PHC MPW IEC ANM UGC RSACS ANC AZT BPL TB Full Form Acquired Immuno Deficiency Syndrome Deoxyribonucleic Acid White Blood Corpuscles Human Immuno Virus HIV positive (infected) AIDS Related Complex Enzyme Linked Immuno Absorbent Assay Western Blot Test Simian Immunodeficiency Virus Sexually Transmitted Diseases Reproductive Track Infection Centre for Diseases Control Gay Related Immune Deficiency National AIDS Control Organization World Health Oraganisation Primary Health Centre Multi Purpose (Health) Worker Information, Education and Communication (Bureau) Auxiliary Nursing and Midwifery University Grants Commission Rajasthan State AIDS Control Society Antenatal Care Azidothymidine Below Poverty Line Tuberculosis 1. INTRODUCTION The full form of AIDS is "Acquired Immuno Deficiency Syndrome". It is a group of diseases that are caused due to destruction of disease resistance power of the body. This disease (AIDS) is caused by AIDS virus called Human Immuno Virus (HIV). The HIV destroys the 'T 4' cell or 'CD 4' cells present in human blood. When AIDS virus enters the body, it reaches the DNA of WBC in blood and reproduces and attacks the WBC. Gradually, the total number of WBC decreases and thus destroys the disease resistance power of the body, therefore many infections occurs to the patient. The body cannot resist these diseases and finally it causes the death of the patient. We can detect this virus only after about 12 weeks of the infection. Such patients with the virus in their body are called HIV positive. HIV + persons seem normal for about 6 to 10 years and lead normal life, however, they are capable to spread the disease further. These viruses are found mainly in the T cells of the blood and affect cells of brain and slowly destroy them. After 6 to 10 years the situation becomes such that the body becomes unable to resist the general diseases and invites various infections and cause cancerous growth of the cells. This situation is called AIDS. REASONS OF AIDS AIDS is caused by HIV1 and HIV2 viruses. These viruses are very minute which is about 1000 times thinner than our hair. According of "AIDS" - by Gurjot Kaur (1997), the structure of this virus is like an organism called 'Selly'. If HIV virus is found in anybody's body, it does not necessarily imply that the person is suffering from AIDS. But scientists believe that once a person gets infected by HIV, s/he will at last get AIDS. MODES OF TRANSMISSION OF AIDS The main modes of transmission of AIDS are: 1. unsafe sexual intercourse 2. unsafe blood transfusion 3. use of infected syringe and needle 4. infected mother to the child · Unsafe sexual intercourse The main reason for transmission of AIDS is unsafe sexual intercourse with the HIV + partner. This virus is found in large number in the vaginal discharge of the female and semen of male. When a healthy person comes in sexual contact with an infected person there is a possibility of infection in the former. Sexual contact may be heterosexual or homosexual but the possibility of infection always lies. The virus can be infected to any male or female. The virus is easily transmitted from male to female and vice versa and male to male during the sexual contact. · Unsafe blood or blood product Other reason of transmission of AIDS is when the blood of HIV + person is transfused to a healthy person the possibility of infection is 100%. Similarly infection occurs by organs transplantation and dialysis without HIV test. · Infected syringe and needle If medical instruments are not properly cleaned and sterilized the virus is further transmitted. Similarly, when drug addicts use a syringe for injecting drug and the same syringe is used by another addict, there is a high possibility of infection, so that HIV virus is infected from one person to other. · HIV + mother to child When HIV + female get conceived, the HIV is transmmited to the child embryo or during delivery. It is seen that about 30-35% of the children of HIV + mother are infected with HIV + i.e. among every three HIV + female any one child get infected. This infected child is found to be remaining alive for about less than 2 years. · Other probable modes of infections. Infection through flies Scientists have given threatening information that blood-sucking flies also can infect people with HIV virus. Up to now, it was believed that all the blood-sucking insects including mosquitoes were safe as concerned to transmission of HIV. But now, the scientists have declared blood-sucking flies to be sensitive towards transmission of HIV. It is believed that in 20th century in Middle and West Africa, the infection occurred in human through the open wounds of the hunters from chimpanzees. This virus was SIV (Simian Immunodeficiency Virus), which is the apian counterpart of HIV. Now the German scientists believe that this infection was done by blood sucking flies. According to an article published in the New Scientists, most of the mosquitoes do not transmit HIV because they use different sucking tubes (proboscis) for sucking blood and releasing saliva. While the flies make a wound on the skin and next time also it sits on the same wound to suck blood. In this process the possibility of infection is very high. Moreover, these flies cannot digest this sucked blood while almost all the mosquitoes can digest it. According to Grehard Bandnar of Freeburg University, Germany these flies only collect the blood. The possibility of infection is very high due to lack of digestive enzymes in this blood. (Source: Rajasthan Patrika, Hindi daily) SYMPTOMS OF AIDS Due to loss of immunity, many diseases are caused. Thus there are so many symptoms of AIDS. A person having infection of HIV may not show symptoms of AIDS and lead a normal life or may show many symptoms and does not live a normal, healthy life. Person infected with HIV may be classified into three categories based on severity of infection or symptoms. · A person who has recently got infected with HIV will not show any symptom of AIDS, and will appear normal and healthy. However, such HIV + people act as carriers and can transmit the virus to other healthy persons. · After many months of infection, some HIV + person will show a few visible symptoms of AIDS. These symptoms are: * Pain and fatigue for about four weeks. * Fever during this time for four or more weeks. * Diarrhoea with blood. * Loss of appetite * Loss of weight. These symptoms are called AIDS related complex (ARC). Many of these people become full-fledged patients of AIDS. · The full-fledged patients of AIDS show the following symptoms: * About 10% loss of weight due to unknown reasons. * Severe fever that lasts for 4 or more weeks. * Fever that cannot be diagnosed with any certainty. * Diarrhoea with blood for 4 or more weeks due to unknown reasons. Some other symptoms may also be visible other than those stated above. These symptoms are: * Occurrence of Herpes simplex and Herpes zoster. * Fungal infection in mouth and upper part of throat. It is note worthy that TB virus is also one of the viruses that attack an AIDS patient, so the patients may suffer from TB DIAGNOSIS of AIDS: AIDS can be diagnosed by following laboratory tests: · Elisa Test: ELISA means Enzyme Linked Immuno Sorbent Assay. The blood sample is examined by Elisa test. The reliability of this is to extent of 80 % accuracy. After 15 days of infection, HIV antibodies can be detected in the blood. However, in certain cases, the laboratory test may show negative results even for six month of infection. So it is necessary that this test be repeated at short intervals. · W.B. Test: W.B. Test stands for Western Blot Test. This is the most reliable test to detect whether a person is HIV + or not. This is an expensive test yet it is a sure test. · Rapid Test (Spot test) is also a familiar test for the diagnosis of HIV. 1.1 HISTORICAL PERSPECTIVE In1979, doctors in New York identified a tumour- Kaposi sarcoma in a young man. Then, the Center for Diseases Control (CDS) reported a rare form of skin cancer called Kaposi's sarcoma in homosexual men in New York and Los Angeles. After that in 1981, the CDC reported that healthy homosexual men in Los Angeles suffered from a rare type of Pneumonia caused by Pneumocystic carinii. These parasites are normally harmless to human. This disease was called as Gay Related Immune Deficiency (GRID) because the disease was caused due to disorder in human immune system. Later it was discovered that AIDS was caused by Human Immunodeficiency Virus. Epidemiologists considered this as an epidemic that was transmitted by infected agents through intimate sexual contact or blood contact. This was the beginning of the fatal disease AIDS which caused great public health problems. Gradually, this disease spread all over the world and it became a global epidemic (pandemic). But the question arise that from where had this virus come. Many scientists started researches into this matter. At the international conference on retrovirus and opportunist infection held from 31 January to 4 February, 1999, at Chicago, Dr Hon suspected that HIV was transmitted in human when a chimpanzee might have bit some human, or when human ate its meat, or by infection from open wounds. However, many scientists after experimenting with this type of transmission of HIV proved this theory incorrect. Now it has been proved that the HIV has been present in many people thousands of years as an unidentified and inactive form. And it is believed that man himself has activated this virus by experimenting with the vaccines for immunising the body against various diseases. This is proved by the report of WHO, volume 47 of the bulletin, of 1972. It was reported that a virus had been discovered which attacked the immune system of human and animals. In November 1978, in New York more than 1000 homosexual and heterosexual people were experimented with hepatitis B vaccine. Just after three months in the same area, a person was reported with AIDS. Then in 1980, a similar experiment was conducted in Los Angeles, San Francisco and other cities. After some months, a homosexual man was reported with AIDS. In 1981, CDC, informed that the first 26 cases of AIDS have been reported in USA. According to a story that was published in the London Times in 1987, the vaccination programme against small pox in Africa had led to quick spread of AIDS in African countries. Dr Robert Gailo suspected that this small pox vaccine had activated the HIV in the people of Africa. Thus the vaccination programme helped to get rid some diseases but gave rise to more fatal diseases. In 1983, the HIV was first identified and photographed using an electron microscope at Pasteur Institute, Paris. Blood tests to diagnose HIV were developed in 1985. The disease AIDS was spread from high risk population to general population and from urban to rural areas. The major factors to spread AIDS intensively were migration of people, low literacy, reproductive tract infections (RTI) in women, extramarital relations, unsafe blood transfusion practices etc. According to the NACO report 1999-2000, the HIV/AIDS epidemic continues its expansion across the globe with about 16,000 new infections everyday. According to WHO report, in early 1989, more than 1,40,000 AIDS/HIV cases were reported and 1997, the figure skyrocketed to 1,544,067 cases. The first HIV + person in India was found in Chennai (Madras) in 1986. And in Rajasthan, the first HIV + person was found in 1987 in Pushkar (Ajmer). In Rajasthan, from 1987 to March 1994, blood samples of 65,564 persons were tested and 277 were found to be HIV +. 202 of these were residents of Rajasthan while the others were from other states or countries. Upto November 1997, the number increased to 340. During the year 2005, the total number of persons infected with HIV was above 50,000 and 1284 AIDS patients. 1 st December of every year is being celebrated as World AIDS Day for prevention and control of AIDS. 1.2 KNOW AIDS- A Review This book presents the various aspects of the dreaded disease, AIDS in a lucid clear, simple and understandable language- with special emphasis on human migration, epidemiology, transmission and special target populations' vis-a-vis the disease. It is hoped that the project will go a long way in achieving its objective of information dissemination to the medical professionals and probably also to nonmedicos interested in knowing the medical aspects of AIDS. The author Dr. Kunal Kothari is a graduate and postgraduate in medicine from SMS Medical Collage, Jaipur. trained in Cardiology from University of Manchester, U.K. presently working as professor medicine and incharge of Hypertension Clinic, SMS Medical Collage, Jaipur and editing monthly news magazine 'Rajasthan Medical Probe'. The author says that the need to know AIDS is perceptibly felt. AIDS has created fear, prejudice and discrimination. Prevention is the only way to cope up with the menace of AIDS. Medical and paramedical personnel need to be conversant with all the aspects of this disease. We all need to learn. Ignorance in this matter is definitely not bliss. This book is to introduce different horizons of AIDS in a reasonably simple format to fellow colleagues. Epidemiology is discussed in detail informing the beginning of AIDS in developed countries as well as developing countries are also discussed. Migration study is very important to know who is carrying HIV and to where. Migration in Africa and migration in cities are major factor for HIV infection. According to the author if we understand the migration routes, the profile of the migrants, their motivation their needs, we can decrease their vulnerability to HIV and other diseases, a goal from which everybody would be benefited. There are 5 known human retroviruses. The HIV1 and HIV2 cause AIDS. The author has described the structure of HIV1 virus. The modes of transmission of HIV are mainly through sexual transmission. The sexual acts include heterosex, homosex and oralsex The other transmission path identified are- mother to child, post natal transmission, transfusion of blood and blood products, intravenous drug abuse and occupational transmission of HIV. Immunology is discussed and diagnosis of HIV infection by HIV antibody testing strategy is explained in detail. Relation between tuberculosis and AIDS is also given. After presenting the clinical manifestation the treatment is discussed by antiretroviral treatment is palliative care. In syndromic approach to STD/RTI combined treatment is prescribed for all pathogens that are commonly found to be causing a syndrome this include urethral discharge, genital ulcer, inguinal swelling and lower abdominal pain. Psychiatric problems in AIDS are identified and relation of children and women with AIDS is discussed. Giving Rajasthan scenario, the author says that the endeavour should be to adopt a holistic approach to empower woman not only to protect against HIV but also to: * Increase women's access throughout the life cycle to free or affordable, good quality health care. * Strengthen preventative programmes directed against threats to women's health. * Undertake widespread initiatives to reduce sexually transmitted disease, including HIV infection and AIDS. * Promote research and dissemination of information and increase resources and monitor follow up. Perhaps possible solution to prevent AIDS to this group is to regulate and license and not prohibit prostitution and brothels. Most societies have learnt that prostitution cannot easily be stopped, so it is better to think of regulation through administrative measures rather than criminal sanctions of at least those aspects of the industry that directly affect health. Health services should be entirely de-linked from the work of the police and prosecuting agencies. Justice Ashok A. Desai, Judge High Court of Judicature Bombay said that the vital interests of the community could not be allowed to suffer for the claim of human dignity of an individual. The author identified education, counselling and behaviour modification as the corner stones of prevention of HIV infection. 1.3 THE VIRUS The HIV virus is one of the 5 known human retroviruses (HIV1 and HIV2, HTL-I, HTL-II and HTL-IV). HIV 1 and HIV 2 causes AIDS. Retroviruses are found in nearly all animal species and share several common features. HIV - 1 has pronounced cytopathic properties for lymphocytes causing syncytia formation and cell death. They are characterized by a unique life cycle that involves reverse transcription of RNA into DNA, the process being facilitated by an enzyme known as reverse transcriptase. Many of the approaches to treatment of HIV infections are targeted at blocking the activity of this enzyme. HIV - 1 is the prototype of the lentivirinae subfamily of retroviruses affecting humans. HIV is about 90-120 nm spherical enveloped virus. There is nucleocapsid with outer cosahedral shell and inner coneshaped core containing the ribonucleoproteins. The genome is diploid. It is composed of two similar single stranded, positive sense RNA copies. The major virus coded envelope proteins are the projecting knob like spikes on the anchoring transmembrane pedicles. The genome of HIV contains the three structural genes gag, pol and env. The products of these genes acts as antigens. Genes coding for structural proteins: The gag gene determines the core and shell of the virus. It is expressed as a precursor protein, p55. It is cleaved into three proteins, p15, p18 and p24. These make the viral core and shell. The env determines the synthesis of envelop glycoprotein, gp 160. It is cleaved into two envelopes, gp 120 and gp 41. The pol gene codes for the polymerase reverse transcriptase and other viral enzymes. It is expressed as precursor protein, cleaved into proteins p31, p51 and p66. Non-structural and regulatory genes: 1. tat (trans activating gene) enhancing the expression of all viral genes. 2. nef (negative factor gene) down regulating viral replication. 3. rev (regualtor of virus gene) enhancing expression of structural proteins. 4. vif (viral infectivity factor gene) influencing infectivity of viral particles. 5. vpu (in HIV - 1) and vpx (in HIV - 2) believed to enhance maturation and release of progeny virus from cells. 6. vpr reported to stimulate the promoter region of the virus. 7. LTR (long terminal repeat) sequences, one at either end, containing sequences giving promoter, enhancer and integration signals. HIV - 2 first identified in 1986 in West - Africa has since been reported from all over the world including India (Bombay). It is less virulent and phylogenetically resembles simian immuno deficiency virus (SIV) more closed than HIV - 1. The human immuno deficiency virus (HIV) is a human retrovirus that infects T helper lymphocytes and over the period of years, causes both the numeric reduction of these cells as a progressive severe and irreversible immunodepression. ##### A figure missing ##### 2. MATERIALS AND METHODS Study Area Present study was made in Jalore district of Rajasthan state (India). Jalore district is situated at the south west end of Rajasthan. Though the hospitals and offices of the medical officers from where the data were collected are situated in Jalore district, the data include the information from all the districts of Rajasthan and also from various states of India. This study is related mainly to the state of Rajasthan and partially to the whole of India. It has been assumed that this study, result and recommendations of HIV/AIDS in Rajasthan, are applicable to the whole of India. Survey Method The given data were collected from the office of the Chief Medical and Health Officer (CM&HO), Jalore and the literatures that are being distributed to the hospitals from time to time. These literatures and information are published and propagated by IEC Bureau (Government of Rajasthan) and the data were collected by NACO, RSACS etc. Therefore the reliability of the data is very high. Information provided by the government of Rajasthan (Medical and Family Welfare Department) and various national / international research institutes via newspapers are also the sources of information for this study. The data, thus, is secondary data. Informal interviews of the medical officers, nurses and other health workers were taken for discussion on modes of infection, helps given by the hospital for prevention and control of HIV/AIDS and also on recommendations for prevention/control of HIV/AIDS.