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In Haryana, India, with a geographical area of 27 632 square miles, an HIV sentinel surveillance was carried out, on a regular basis (1998–2002), on consecutive serum samples of 400 antenatal clinic (ANC) attendees (three sites) and 250 sexually transmitted diseases (STD) clinic attendees (four sites). This was done for each 12 week period per year as unlinked anonymous testing with one of the ELISA/rapid/simple tests. A sample that was positive with two tests of different assays was considered HIV positive. The other STDs were diagnosed clinically and using appropriate laboratory tests.1,2
Of the 7933 men and women who participated in the HIV sentinel surveillance from 1998–2002, 15 (0.3%) of 5200 ANC attendees and 48 (1.8%) of 2733 STD clinic attendees had HIV. Though HIV prevalence is still below 1% among the ANC attendees, a gradual increase over these 5 years has been observed though statistically it was not found to be significant (table 1). With increasing HIV infection among antenatal women, paediatric AIDS is poised to become an important public health problem.3,4
HIV prevalence rates for the attendees tested in sentinel surveillance programme, 1998–2002
The odds ratios (ORs) of HIV infection for men compared to women decreased by age; men aged 20–29 years were nearly thrice as likely as women the same ages to be HIV infected (OR 2.68 (95% CI 1.1 to 6.7)). When we combined the literacy status for both men and women, the HIV prevalence was statistically significant among the literate of more than fifth grade (p value = 0.0416) but was not found to be significant when combined for ANC attendees. School or college education, therefore, does not have any impact on this epidemic. Emphasis has to be given to educate the general public about AIDS.
Among the STD clinic attendees presenting with genital ulcer, HIV reactivity (3.9%, 7/181) and VDRL reactivity (11.6%, 21/181) were found to be statistically significant (p<0.05, χ2 test used). Therefore, in India, where the overall level of HIV is still low, a high level of STDs in certain states makes for a continuing potential for the epidemic to become generalised among all sexually active adults. Differences across the states may just be a matter of time.4
As per the sentinel surveillance data in the year 1998, there were seven moderate prevalence states (prevalence among ANC attendees <1% but prevalence among the STD clinic attendees >5%) and 19 states were of low prevalence compared to two states only with moderate prevalence rates and 24 states with low HIV prevalence rates (prevalence among the STD clinic attendees <5%) in the year 2001 while six states stayed as high prevalence states (prevalence among ANC attendees >1%). Haryana is still maintaining itself in a low level epidemic category. It is speculated that the effect of STD control and screening of ANC attendees for HIV transmission may decrease with the maturation of the HIV epidemic as experienced in trials in Tanzania and Uganda.5 Therefore, we should increase intervention programmes in all high risk groups as well as in the general population of this city while it is still in the early epidemic phase to ensure that this cost effective opportunity is not missed.
Acknowledgments
The authors wish to thank the senior technician in charge, Shri Satpal Singh, for his assistance in the fieldwork and laboratory procedures throughout this study. The statistical help provided by Shri R C Goel, PGIMER, Chandigarh, is duly acknowledged. We also thank Professor Narottam Sharma from the Regional Institute of English Chandigarh, UT for proof reading of the manuscript. We also acknowledge National AIDS Control Organisation (NACO) for its continuing guidance and the supply of free kits for HIV testing.
Contributors DRA, BA, protocol development for field implementation, final approval of manuscript; VG, PG, field implementation of clinical and laboratory procedures, writing; DRA, BA, VG, VGu, analysis and interpretation, critical reviewing of manuscript.