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Expert Speak

AIDS – Current Status and the Year Ahead.

Dr Sunithi Solomon, an authority on HIV and AIDS in Asia, speaks on the current situation on the various aspects of HIV infection and plans for the year ahead in AIDS Research and Treatment.

Are we better equipped today to screen AIDS cases early?

Most of our diagnostic centers have equipment to diagnose HIV. But I doubt if all the diagnostic centers have tests that are quality assured. I have had people who have been diagnosed as HIV positive and I have found them to be negative. The reverse has also happened.

It is important to tell the patient about the window period. The patient may come after a couple of days after the exposure and the test comes out negative. The lab or counselor must and ask him/her to come again in three/six months for further testing.

I also strongly believe counseling is important before HIV testing. Most people who are diagnosed as positive believe it is a death sentence. This has even driven people to suicide.

Even in mandatory testing routines, such as health check ups or tests before a major surgery, counseling must be provided if the patient is found HIV positive. Otherwise the patient is completely unable to cope.

You have seen nearly 20, 000 patients in the past six years. The treatment options for AIDS have not changed very much. What is the prognosis that you give your patients?

Unfortunately, with all the media projection, AIDS is equated with death. The first thing my patients ask me is “ When am I going to die, doctor?” To this question I reply lightheartedly, “ I do not know when I am going to die. How can I tell you when you are going to die!”

Though there is no cure and a patient has to take medication and be prepared for opportunistic infection, there is hope of prolonging life with quality.

I get them to meet people who have been living with a reasonably good quality of life for the last 12 years. That really amazes them. I tell them that having the HIV infection does not mean that they have AIDS. Our counselors brief them on precautions and keep them in a positive frame of mind. This helps them gain confidence and increases compliance. It is almost like managing a chronic ailment.

Now that you compare AIDS with a chronic disease, is it economically feasible for a poor population as in India to afford long term treatment?

Treatment model at YRG CARE is a low cost one.

We believe:

  • Cost of patient care decreases with training and experience of doctors.
  • Early detection of HIV optimizes the prevention of opportunistic infection.
  • Management focuses on common opportunistic infection.
  • Counseling focuses on nutrition.
  • Prevention of mother to child transmission of HIV through effective psychosocial intervention and medical management.
  • Anti retroviral drugs are used if affordable, or not at all.

The first phase of Clinical Trials for an indigenously developed AIDS vaccine ( Indian Council for Medical Research in collaboration with International AIDS Vaccine Initiative) for the HIV strain C, prevalent in India, are expected to start early next year. What is your opinion on the Vaccine experiment?

There is much research on vaccines today to prevent HIV infection though I do not think it will be available in the market within the next five years.

Getting a vaccine may be quicker than finding a cure. One of the problems that face scientists is the efficacy of the vaccine. Even if the vaccine is fifty percent efficacious it would still help to reduce the number of new infections and reduce the infection growth rate. “The excellent must not become the enemy of the good”. Like we say, “Something is better than nothing.”

I have some reservations regarding the vaccines. We have been trying to prevent the spread of the infection through appropriate behaviour change messages. The vaccine should not give the public a false sense of security, leading them to believe that they can continue taking risks. Awareness about the vaccine needs to be informed to the people before launching it.

India is said to be a major producer of anti retroviral drugs used for treatment of AIDS. Yet the drugs are too expensive for Indians. How are the poorer patients expected to cope with this?

In the last ten years the prices of antiretroviral drugs have come down drastically. From around Rs.15,000/- a month it has come down to around Rs 1,500/- per month. But even this is out of the reach of many patients. Sometimes the man and woman in a family may be infected. In that case the preference goes to the man, as the family may not be able to pay for both.

We just have to help such people take good nutritious food; help them manage the infections better and help them sustain as good a quality of life as possible apart from prolonging it. Our volunteers make home visits and keep in touch with patients in the long term.

What are the special problems of women with AIDS?

As I said, a third of our patients are women. Ninety percent are monogamous. They get it from their husbands. But the stigma is more severe in the case of the women. The husband’s family quite often rejects the woman. She is driven to her parents’ home. The parents resent this. “ Who will marry your sister if they know you have AIDS?” they say. They make it plain that the woman can’t come home. We see so many women patients who do not have a place to go to.

There are women who do not know or are helpless when they know that their husbands are bisexual. The husbands have their homosexual binges in lodges without the knowledge of their wives.

Then there is a question of pregnancy. A woman needs support, medication and guidance at this time to enable her to take steps that will prevent the child from acquiring the virus. This assumes that they will have family support, some financial assistance and knowledge of the situation. Attitudes are changing very slowly.

Though the high risk categories for HIV spread are sex workers, drug users and homosexuals, there is a feeling that there is an increased proportion of victims found in the general population in states like Maharashtra…

A person testing positive for HIV is not a victim, he or she is living with the virus. Yes, there is a greater proliferation of the disease among general population. At our center we have patients from all strata of society: rich, poor, film stars, politicians… even doctors…

Some men who come for screening tell me, “ I have slept with 2,500 women and nothing has happened to me.” Some others come, absolutely grief stricken to say “ Dr just once I have made a mistake and I have caught the virus.”

The main problem is, most people who are not sex workers/drug users/ homosexuals think that they can never contract the HIV virus. One patient, a company executive, told me, “ I have sex with my secretary, but I am sure she does not sleep with anyone else…” Can one be so sure? More pathetic are the cases of women: They might be absolutely faithful but can contract it from irresponsible husbands. One third of our patients are women. Ninety percent are monogamous.

In all our awareness programmes we tell the audiences to follow the ABC rule:

Abstain from sex as much as you can.

Be faithful to your partner.

Condom must be used for safe sex.

You have camps in rural areas. Do you think that there are more cases of AIDS in the cities than in the villages?

There is no significant difference in the rates, in my observation. Truck drivers, migrant laborers, who are high risk groups travel frequently between rural and urban areas. The spreading of the disease happens both ways.

It is said that 20 to 25 million Indians infected with HIV by 2010. Such forecasts have often gone wrong in the past. Do you think these are alarmist attitudes?

I do not think that statistics about AIDS could be called alarmist. Think of every epidemic that has broken out in the past in any part of the world, the plague or cholera or any such infection. The numbers that died in those epidemics compared the patients already dead due to AIDS is negligible. (16.3 million people had died due to AIDS by 1999)

If prediction sound exaggerated, we must remember that routes of infection like blood transfusions have been plugged. Awareness is also on the increase. These may have contributed to slower growth rate in HIV infection.

There is also an opinion that the funds provided for people living with HIV/AIDS might be better deployed to provide care to some other rampant infections like TB?

60 percent of my patients get TB as an opportunistic infection. While treating them you are treating both TB and AIDS. Funding for AIDS is funding for a raising the awareness for better health, hygiene and sexual behavior. It not only helps in treating AIDS patients but also contributes to the increase in the general health in the society.

UNAIDS slogan for the year 2002-2003 is “ Live and Let Live”. This focuses on the Stigma that undermines the proper understanding of the disease and its management. Apparently even doctors hesitate in treating HIV patients . What is your effort in countering stigma?

We have a very strong counseling unit that speaks not just to the person living with HIV/AIDS (PLHA) but also to the spouse, family and even institutions where required to explain a AIDS patient is not a killer. They touch the patient while they talk, to inspire confidence. Our counselors make home visits. When people living with HIV/AIDS (PLHA) are thrown out of jobs they help them find lawyers to fight for their rights, if so required.

Yes, When I started out I could not get counselors, workers or other institutions to participate in our efforts to treat PLHA. Now we have a complete network of institutions that help us fight opportunistic infections.

What is your plan for the year Ahead?

The organization’s vision is that people with HIV and AIDS and their families live with dignity, and there are no new HIV infections. To meet with this vision, YRGCARE provides patient-centered services.

An Intensive Care Unit:

The latest service in our centre is the inauguration of an Intensive Care Unit to provide our patients with the care and treatment they require. Common opportunistic infections like pneumocystis carinii pneumonia (PCP), toxoplasmosis and meningitis, to mention just a few, often require a ventilator for assisted breathing and emergency intensive care. Lack of accessibility of such services for our patients at private hospitals within the city have led to the need to start this service within our system.

Helpline service:

YRGCARE is starting this helpline service to respond to the increasing need for information and to relieve their fears and anxieties especially of adolescents and youth on issues related to HIV risk behaviour and sexuality. Eventually we hope to extend this service to a round-the-clock 24-hour service. Those requiring information on HIV/STDs, sex and sexuality and reproductive health can call on this helpline {044- 2542929} for further assistance.

Other current research projects, which will directly benefit our patients, are:

A Longitudinal study on HAART associated body composition, metabolic and quality of life changes.

This study aims to determine whether medications for HIV like HAART which generally improves the patient’s immunity and reduces their viral load, can also cause fat redistribution and changes in fat and glucose metabolism thereby affecting their quality of life.

The NIMH Collaborative HIV/STD Prevention Trial

This is a multi-site study in collaboration with the National Institutes of Mental Health, USA. The study aims to provide the community with intervention strategies using community popular opinion leaders (CPOLs) who will be trained to deliver accurate and positive messages and information on the prevention of HIV/AIDS. The study also aims to determine the level of risks of the target community to HIV and other sexually transmitted infections.

A Randomized Controlled Trial to compare the effects of Structured Intermittent Antiretroviral Therapy (SIT) versus Highly Active Antiretroviral Therapy (HAART) in HIV-positive patients in Southern India.

This study aims to find out the effectiveness of antiretroviral therapy if given in an interrupted way under constant supervision.

HIV Prevention Trial Network – HPTN 033 – HIV Prevention Preparedness Study. Statistics are growing in importance and there is much debate over such discussions. YRG CARE is doing an incidence study to determine the number of new cases being infected within Chennai city from a cohort of 250 males and 250 females with high-risk behaviour.

Dr. Suniti Solomon, Director - YRG Care, is one of Asia's leading authorities on HIV and AIDS. She has worked as a pathologist in the UK and USA. In 1986, she encouraged a post-graduate to undertake a surveillance on HIV/AIDS. Her team documented the first evidence of HIV infection in India. In 1986, with financial support from the Indian Council for Medical Research, she set up the first voluntary testing and counselling centre and an AIDS Resource Group in Chennai, which has served as a model since. She founded YRG Centre for AIDS Research and Education in 1993. YRG Care now functions from a separate block in VHS Campus, Chennai, providing comprehensive care for people living with AIDS.

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