We know that HIV is transmitted through unsafe sex and contaminated blood. In fact, the virus transmits many hundreds times faster through the blood than through heterosexual coitus. Why then does the 'sex route' dominate our policies and work, and the 'blood route' remain mostly neglected, especially in a country where non-sterile healthcare is so common, ask Mariette Correa and David Gisselquist

Background

It's been over two decades since HIV was first detected in India . Almost as soon as HIV infections were discovered, in 1986, among female sex workers (FSWs) in Chennai, AIDS experts agreed that most infections in India came from heterosexual exposure, and that exposure through blood (other than transfusions and [IDU]) accounted for a negligible proportion of HIV infections. This consensus appears to have emerged with limited supporting evidence, and continues despite mounting evidence to the contrary.

The 'sex' rationale does not explain differences in growth of the epidemic across Indian states, between rural and urban areas, or why sex workers in some parts of the country have a much higher HIV prevalence rate than in others. Nor does it explain differences in HIV prevalence across countries.

We know that HIV is transmitted through sex and blood. The biomedical facts are that the virus transmits many hundreds times faster through the blood than through heterosexual coitus. Why then does the 'sex route' dominate our thoughts and work, and the 'blood route' remain mostly neglected, especially in a country where non-sterile healthcare is so common?

The difficulty in drawing attention to the potential of HIV transmission through unsafe exposure to blood is, in many ways, understandable. The sexual route is a convenient one; it places full responsibility on the HIV-positive person, or someone close to him/her. To a large extent, it becomes a moral issue. When the blood route is addressed, it relates to IV drug users, an already marginalised group.

Lack of alarm over non-sterile healthcare is also excused by arguments that there is no evidence linking healthcare with HIV infection. This is untrue. Further, HIV experts warn that public messages about HIV risks in healthcare could detract from safe sex messages and drive people away from healthcare.

The lack of attention paid to non-sterile healthcare and cosmetic services in India contrasts sharply with what's happening in developed countries. Shortly after HIV was recognised as a bloodborne virus, in the early-1980s, healthcare managers -- responding to public pressure -- cleaned up the healthcare system to protect patients and staff. Similar programmes are required to protect patients in India ; they may also be necessary to reverse India 's HIV epidemic.

Two obstacles to implementing such a programme in India are: lack of information about blood exposure, and acceptance of the National AIDS Control Organisation's (NACO's) estimates that sex accounts for almost all HIV infections in the country.

Accordingly, the two main objectives of this study on HIV from blood exposure in India were:

1. To explore the contribution of blood exposure to the HIV epidemic in India.
2. To assess the reliability of information from AIDS case surveillance on routes of HIV transmission in India .

Method

Following a literature review, we focused our primary data collection on four states in southern India that have high levels of HIV infection -- Tamil Nadu, Karnataka, Maharashtra and Goa . In each of these states, the district with the highest HIV prevalence in the general population was selected. In these four districts, during February to April 2005, we interviewed a total of 280 People Living With HIV/AIDS (PLWHA) -- 70 in each of the four districts -- on their sexual and blood exposures as well as their experiences during counselling. We developed a questionnaire for this purpose, which we translated into the relevant languages. We contacted PLWHA through positive networks, NGOs, private doctors and care homes. We collected information on unexplained cases, ie PLWHA whose HIV infections could not be attributed to heterosexual contact, Men who have Sex with Men (MSM), IDU, or mother-to-child transmission. We identified and documented health and cosmetic practices in the districts that put people at risk of HIV acquisition through blood exposure. We met with groups considered by AIDS programmers to be vulnerable due to their risky sexual behaviour, to understand their exposure to blood during healthcare and other practices that could also be a risk. We examined NACO's AIDS case surveillance system, from doctors assessing routes of transmission through hospital reports to State AIDS Control Societies (SACS) and onward reports to NACO to assess the reliability of estimates on the proportion of HIV from various routes of transmission. The promised cuts, however, are based on the expectation that developing countries will further open up their markets.

Findings

Literature review of evidence and surveillance of routes of HIV transmission

Available evidence from studies in India suggests that an important proportion of HIV infections could be from blood exposure; this does not conform to official theories about India 's HIV epidemic. Virtually all the empirical evidence -- from the mapping of FSWs, from studies on sexual behaviour, and from sero surveys of HIV infection in the general population -- is inconsistent with the view that risky sexual behaviour explains most HIV infections in India .

HIV prevalence is currently higher in rural than in urban India . For example, a 2003 survey found 2.9% of the general population infected in Bagalkot district in Karnataka (Becker M L, Reza-Paul S, Ramesh B M, Washington R, Moses S, Blanchard J F, 'Association between medical injections and HIV infection in a community-based study in India', AIDS 2005; 19: 1334-1336), only slightly less than the 4.0% reported among female sex workers in Chennai in 2004 (Tamil Nadu State AIDS Control Society, 'Activities of TANSACS', Chennai, TANSACS, 2005). Across India , recognised high-risk groups account for only a small minority of HIV infections.

Most of the available evidence from India points to an important contribution from non-sterile invasive healthcare and cosmetic procedures. A WHO-sponsored model estimates that medical injections account for 24% of HIV infections in South Asia ( Hauri A M, Armstrong G L, Hutin Y J F, 'The global burden of disease attributable to contaminated injections given in healthcare settings, Int J STD AIDS 2004; 15: 7-16). A national study of injection practices by the All India Institute of Medical Sciences found that 65% of injections in the country were unsafe, and that 23.5% of injections were administered using reused non-sterile or unreliably sterile needles and/or syringes, thereby posing the risk of transmitting bloodborne viruses ( Arora N K, Mathew T, Devi S R et al , 'Assessment of Injection Practices in India [2002-03]: An InCLEN Program Evaluation Network Study', New Delhi, All India Institute of Medical Sciences, 2006. Available at: http://www.ipen.org.in/index.php?option=content&task=view&id=189&Itemid=232&parent=225.)

We found five studies on risks for prevalent or incident HIV in India that report information on blood exposure (other than IDU and transfusions) among STD patients, outpatients, blood donors, injection drug users, and the general population. In these studies, people reporting greater blood exposure -- injections, tattoos, or blood donations -- were consistently more likely to be or become HIV-positive than were people not reporting these risks.

The handful of studies on vulnerable communities in India that have asked about blood exposure (except IDU) as risks for HIV, have found evidence of HIV transmission through medical injections and tattoos. Studies among FSW and STD patients show a high prevalence of infection with hepatitis B and C viruses, frequent parenteral (that which occurs outside of the alimentary tract, such as in subcutaneous, intravenous, intramuscular, and intrasternal injections) exposure, and a tendency towards HIV co-infection with Hepatitis B (HBV) and Hepatitis C (HCV), suggesting that they may be contracting not only HBV and HCV but also HIV through parenteral exposure.

A number of published studies as well as unpublished information describe nosocomial (hospital acquired) and unexplained HIV infections in India .

The recent expansion of HIV testing to most pregnant women and their spouses through the Prevention of Parent-to-Child Transmission (PPTCT) programme has found an unexpectedly large percentage of HIV-positive women with HIV-negative husbands. For example, from data on more than 500,000 women tested for HIV in several southern states during 2001-05, 23% of all men tested (with HIV-positive wives) were HIV-negative.

Governments of many countries collect information from people living with AIDS on the factors that may have led to them contracting HIV. They use this information to estimate the contribution of various routes of infection to HIV epidemics. In the US , AIDS case surveillance attributes HIV infections to categories based on reported behaviour. These categories are listed in a hierarchy from high-risk to low-risk behaviour, and the rules for reporting leave very little room for subjectivity. In contrast, AIDS case surveillance in India assigns almost all HIV infections in adults to heterosexual risks, on the basis of much less exact and persuasive evidence of sexual exposure to HIV.

Documenting blood exposure as a risk for HIV transmission

The 280 PLWHAs interviewed reported multiple possible exposures to HIV through sex and blood, making it difficult to attribute their infection to any specific exposure. Their counsellors or doctors asked mostly about sexual exposure. Although a majority (73% of women and 61% of men) of PLWHAs we interviewed believed that they had acquired the virus through sex, a substantial minority (18% of women and 26% of men) had no idea how they had become infected, or believed they had been infected through a non-sexual route. Many PLWHAs were not even aware of the non-sexual risks for HIV acquisition. This was particularly noticeable among women in Namakkal, where 64% were unaware of non-sexual risks of HIV transmission.

We found many unexplained and suspected nosocomial HIV infections that had neither been recorded nor investigated.

We found that healthcare providers and the general public have been misinformed (and the risk factors dangerously underestimated) on the survival of the HIV virus outside the human body and its transmission efficiency through exposure to infected blood.

Although there has been a substantial move in the last five to 10 years towards safer healthcare procedures (notably, blood transfusions and injections) and in cosmetic services (notably, shaving by barbers), through a combination of government, private and NGO initiatives, the potential contribution of these changes to the reported slowing of HIV growth in India over the last five years has been ignored.

And so the problems remain. Reuse of non-sterile and unreliably sterile syringes and/or needles continues on a massive scale; infections through blood transfusions continue; and professional blood donors still go about their business. Furthermore, the recent changes focus on a limited range of procedures, largely ignoring other common invasive procedures. Unsafe disposal of medical waste still takes place.

We found that government health officials were aware of common infection control lapses in public and private settings but had no power to take action against private providers. NACO's emphasis on infection control in hospital settings has focused on the safety of healthcare providers; less attention has been paid to reducing the risk of patient-to-patient transmission.

People who are considered vulnerable to HIV infection, due to their risky sexual or drug-injecting behaviour -- FSWs, MSMs, truck drivers, migrant workers and IDU -- remain marginalised and stigmatised and are therefore at much greater risk of experiencing non-sterile healthcare than are people in the mainstream. People who indulge in unsafe sexual activity seek more (unsafe) healthcare. Also, because members of vulnerable groups often frequent the same healthcare and cosmetic facilities, high HIV prevalence among patients at these facilities enhances the risk of contracting HIV from non-sterile healthcare .

Assessing routes of HIV transmission from AIDS case surveillance

We examined AIDS case reporting systems, with particular attention to reliability in assessing and reporting routes of HIV transmission. We found that NACO's format for monthly AIDS case reports from hospitals do not facilitate accurate or objective reporting. Only a few risk categories record exposures that reliably point to high-risk exposure. The format makes no distinction between low- and high-risk sexual exposure, or between IDU and medical injections. With no category for blood exposure (other than blood transfusions and injections), the format discourages and blocks the reporting of such exposure. Consequently, NACO's data on routes of transmission -- derived from AIDS case reporting -- reflects assumptions and subjective assessments and are incomplete and unreliable.

Within hospitals, we found no standardised format to collect information from AIDS patients on sources of infection, and no standardised system for reporting that information. Doctors and counsellors who are responsible for assessing and reporting routes of infection have not been trained to do so. Moreover, we found widespread misinformation about the relative risks of HIV transmission through blood and sexual exposure.

During meetings with AIDS patients, doctors and counsellors often ask about blood transfusion and IDU as risks, but pay little attention to medical injections and other blood exposure. There is a clear bias towards attributing HIV infection to sexual behaviour based on assumptions about sexual behaviour, moral judgements, and the belief that sex is almost solely responsible for India 's HIV epidemic. Counsellors are unwilling to recognise and report that many AIDS cases have an unknown route of HIV acquisition based on the available evidence.

Over the last few years, official reports from the four districts in this study attribute no adult AIDS case to any specific non-sexual route, although every health facility reported such cases to the research team. Unexplained infections were not reported or investigated for various reasons -- they were viewed as exceptions; the investigations were not part of the mandate of the reporting hospitals; they could implicate the health facility.

Recommendations

Response to unexplained cases of HIV

Suspected nosocomial and other unexplained HIV infections should be recognised and recorded in a registry, and reviewed to consider possible routes of transmission. The government should investigate suspected nosocomial infections. When multiple nosocomial infections are documented or suspected at a specific institution, investigations must be carried out to pin-point possible sources of infection at the institution. Testing for Hepatitis C (HCV) infections should be extended to identify infection control lapses in healthcare and cosmetic services. Where blood transfusion is a possible cause of HIV infection, the donor should be traced and retested.

Prevention

Evidence of an association between blood exposure and HIV infection and messages that blood exposure is a risk for HIV infection should be disseminated to the general public and to targeted high-risk groups through NGOs and public health services. People should be encouraged to insist on safe practices, and to complain to the provider and district health office if they observe unsafe practices.

The Ministry of Health and Family Welfare should establish ways to ensure, monitor and promote infection control in all healthcare and cosmetic settings. In order to develop district-level mechanisms to promote infection control in healthcare and cosmetic services, action research could be carried out in selected districts with high HIV prevalence.

Hospital infection control committees and systems should be strengthened and extended to include all categories of workers. Pre-service and in-service training for health practitioners should impart accurate information about HIV survival and transmission through blood exposure, and standard precautions. Attention currently focused on infection control during blood transfusions and medical injections should be extended to all invasive healthcare and cosmetic procedures. All programmes working with targeted groups should ensure effective infection control during invasive procedures such as STD treatment. Policies and programmes are needed to ensure safe disposal of medical waste.

Research

Additional research is required to ascertain the variety and frequency of non-sterile blood exposure in healthcare and cosmetic procedures, and to assess the contribution of non-sterile blood exposure to India 's HIV epidemic. NACO, NGOs, and other organisations should make relevant data on India 's HIV epidemic available to the public. The protocol for future studies on the risk factors for HIV infection should be designed to ensure that samples are not biased, and improving the value of information collected.

Improving information on routes of transmission from AIDS case surveillance

AIDS case reporting formats should be designed and procedures established to collect objective information on the exposure risks. Questionnaires, guidelines and training should direct counsellors to ask about a wide range of parenteral exposure and to collect enough information about sexual exposure to identify specific high-risk exposure, if any (eg MSM, paid sex, sex with someone who has tested positive). Risk assessment may be extended to people accessing ART centres. Those responsible for AIDS case reporting should evaluate the reliability and accuracy of the data they report.

Conclusion

NACO's surveillance estimates have, over the years, contributed to the belief that heterosexual transmission is responsible for almost all HIV infections among Indian adults. The repetition of unreliable data has influenced international, regional, national and local agencies into focusing almost exclusively on the sexual risks. More reliable information about the relative contribution of sex and blood exposure to India 's HIV epidemic could provide a better basis for prevention efforts. Public education about the danger of non-sterile healthcare, and about how to ensure safe care, would allow people to protect themselves better. Addressing all routes of HIV transmission could help reduce the stigma that the near exclusive focus on sexual behaviour may have inadvertently intensified.

(This article is a summary of the study. The full report is available at: http://www.indiabusinessonline.com/ncasa/hivindiareport.pdf. Mariette Correa and David Gisselquist are independent consultants, based in India and the US respectively. Mariette has been involved in HIV/AIDS programming for NGOs in Goa and South Asia . David has researched blood exposures as risks for HIV in Africa .)

InfoChange News & Features, March 2007