Others

Sexually Transmitted Infections/Reproductive Tract Infections

Q. Why no reduction has been noticed in the prevalence of Sexually Transmitted Infections in India even though the STD Control Programme has been in operation since 1949 ? Which activities are provided under STD Control Programmes?

Ans. Precise data about the prevalence of STIs in India is not available. However, from the limited number of studies conducted among the ‘High Risk Population’ or ‘Hospital Based Studies’, prevalence rate of STIs in India has been quoted to be about five percent. Now, NACO has planned to ascertain the prevalence of STIs and also health seeking behaviour of persons suffering from this group of diseases by undertaking a country wide community based STI Prevalence Survey. STD Control Programme is based on early diagnosis and prompt treatment of STIs and relies on the health seeking behaviour of individuals with STD.

Health seeking behaviour of those suffering from STDs is directly related to the stigma attached to the disease, because of which individuals with STI desire anonymity. As a result, they seek alternate source of medical aid including self-medication and only a small proportion report to public sector medical set-up. Because of this attitude and behaviour of those suffering from STIs, they continue to transmit infection to their multiple sex partners. This is the main obstacle in converting infectious pool into non- infectious. Under the STD Control Programme, the government has established STD clinics in each district hospital, all over the country. The STI drugs are provided free of cost by the Government of India and adequate confidentiality is ensured for those attending these clinics. Such clinics are managed by experts trained to treat STIs. Another major activity of STD Control Programme is Targeted Intervention under which, special facilities are made available easily to commercial sex workers, truckers, migrant workers and other marginalised segments of society. Partner notification, condom promotion and imparting IEC activities through peer-educators are the interventions organised as a part of the programme. STI management through syndromic approach has been now practiced by trained medical officers at peripheral, middle and even at tertiary levels of healthcare where adequate lab facilities are not available.

Q. What is FHAC?

Ans. FHAC stands for Family Health Awareness Campaign. The campaign is carried out for a period of 15 days once a year. The objectives of the campaign are:

  • To raise the level of awareness on RTI/STI and HIV/AIDS in rural and slum areas, and other vulnerable groups of the population
  • To encourage health seeking behaviour in the general population for RTI and STI
  • To make the people aware about the services available in the public health system for the management of RTI/STI
  • To facilitate early detection and prompt treatment of RTI and STI by mainstreaming the programme with the infrastructure available under the primary healthcare system
  • To strengthen the capacity of medical & paramedical professionals working under healthcare system to respond to HIV/AIDS epidemic adequately.
Q. Does the presence of other sexually transmitted diseases (STDs) facilitate HIV transmission?

Ans. Yes, every STD causes some damage to the genital skin and mucous layer, which facilitates the entry of HIV into the body. The most dangerous are:

  • Syphilis
  • Cancroids
  • Genital herpes
  • Gonorrhoea.
Q. Why is early treatment of STD important?

Ans. High rates of STD caused by unprotected sexual activity enhance the transmission risk in the general population. Early treatment of STD reduces the risk of spread to other sexual partners and also reduces the risk of contracting HIV from infected partners. Besides, early treatment of STD also prevents infertility and ectopic pregnancies.

M & E and Research Surveillance

Q. What is HIV Sentinel Surveillance?

Ans. HIV Sentinel Surveillance is an epidemiological tool by which samples of pre-designed size are collected over time, from among the identified risk groups known as sentinel groups. This sample size represents the larger group with similar risk and other characteristics.

Q. What is “Unlinked Anonymity” in HIV Sentinel Surveillance?

Ans. In HIV Sentinel Surveillance, unlinked anonymity means that the blood is primarily collected for some other purpose and the results are not linked to any individual. This methodology is adopted in order to minimise participation bias in the whole procedure.

Q. Is the HIV Sentinel Surveillance clinic based or community based?

Ans. In order to minimise the selection bias of samples, consecutive sampling procedure is adopted and it is ideally a clinic based approach.

Q. What is the usefulness of HIV Sentinel Surveillance?

Ans. HIV Sentinel Surveillance data is used to understand and monitor time trends, know HIV prevalence levels in various risk groups in states/UTs and work out total HIV burden in various sub-populations.

Information, Education and Communication (IEC)

Q. Despite all the publicity regarding the AIDS Awareness Campaign, the awareness about AIDS is very low. Where is all the money going?

Ans. The IEC campaign of NACO is operationalised at two levels: the National level and the State level. The activity has been mostly decentralised to the states and each state society is expected to utilise the funds as per the local requirements. Despite all the talk about funds being available for IEC, the fact is that the funds are quite meagre, considering the size of the country and the magnitude of the problem. Funds amounting to about 10 crore are available for the national campaign, which is operated centrally by NACO.

Q. The message of AIDS advertisements is done crudely with a fear approach. What is the process by which NACO decides its messages for various target audiences?

Ans. The fear approach has been completely done away with in all campaign messages. During the early days of the campaign, this approach was used to a certain extent, but the same has been discontinued for quite some time. NACO has a process by which a committee comprising renowned media personnel come together to decide the content and strategies for all campaigns at the national level. Research, in terms of NFHS and BSS surveys conducted by the Ministry, are used to ascertain knowledge levels in the population. Based on the funds available, appropriate media is used for dissemination of the messages.

Q. AIDS is associated with very high profile funds and personalities. In spite of this, there seems to be no control on the spread of the virus. Why?

Ans. Endorsement by well known personalities gives visibility and acceptance to any product (social and commercial), and is a time tested approach in the field of advertising. Prevention of AIDS is related to behavioural change in individuals who are expected to adopt safer sexual practices. This is an extremely difficult action response that the AIDS campaign expects from the target audience. This process is time consuming, however, we have to work more intensively. Given a limited budget available with NACO, all personalities roped in so far have offered their services for free. Media events that are appropriately located and strategised, are necessary to give visibility to the programme and also enthuse participation from target groups like the youth.

Q. AIDS awareness campaign is concentrated mostly in urban areas whereas the rural belts are left untouched. Why?

Ans. The IEC campaign uses a number of media vehicles to spread the messages in the rural belt also. The bulk of the money is spent on Doordarshan and radio which is accessible by both urban and rural population. As recent surveys have shown, the reach of television has far outstripped the reach of even radio and other media. Apart from the mass media, interpersonnel communication methods are used, which cover urban slums and rural areas.

NGOs

Q. With respect to corruption in the selection of NGOs, how does NACO ensure that bonafide NGOs are given work?

Ans. NACO has a very transparent procedure of inviting NGO proposals. Proposals are invited through newspaper advertisements, which are screened by a Technical Advisory Committee which has members from the NGO community. Blacklisted NGOs are kept out and only those with proven track records are considered. Apart from verification of documents submitted, every NGO is physically verified for nature of work and presence in the target community. The final selection is done by the Executive Committee of the SACS, which is headed by the Secretary (Health).

Q. The number of NGOs is adequate but what about quality of work? How does NACO keep a check on defaulting NGOs?

Ans. NACO has a well laid out monitoring and evaluation system which operates at all stages of NGO functioning. Minimum quality standards are set and necessary capacity building done to ensure compliance. Apart from an internal process of evaluation within the NGO, timely reports are received from them in desired formats. Periodic field visits by SACS officials, in teams that also have NGO workers from other NGOs ensure the veracity of the self reports of NGOs. The NGOs have to provide audited statement of accounts for previous money received to ensure receipt of future installments. Every third year the NGO performance is evaluated by an external agency.

Q. Why is NGO work mostly restricted to Targeted Interventions? Doesn’t it lead to identification of High Risk Groups and further stigmatisation?

Ans. Targeted Intervention is a very important strategy of NACP- II to check the spread of HIV. It is a fact that certain groups of people, known to practice high risk behaviour are more likely to carry the virus than others. Groups like the CSWs, IDU, Truckers, Migrants, etc. are also the most marginalised in the society. These groups do not need half baked interventions where one just tells them about behaviour change. BCC is important but that should be accompanied by services like STD treatment, condom provision, creation of enabling environment etc. All these are essential components of NACO’s TIs.

It is felt that once these groups are approached in the right spirit, they are more likely to come out of their shell and join the mainstream and thereby be less stigmatised.

Q. Many NGOs are harassed for their activities. What does NACO do about it?

Ans. NGOs are normally harassed by police personnel. This is true mostly in states where adequate efforts to sensitise the law and order machinery are not being made. Although NACO has equivocally condemned all such instances of excesses by certain authorities, it is not in a position to become a supercop. NACO on its part has worked out elaborate plans for a sustained advocacy initiative with police personnel at all levels. Efforts are also on to see if relevant provisions of the IPC can be modified in the context of today’s requirements.

Q. What does NACO do about regional disparities in the number of NGOs operating?

Ans. The NGO movement is operating at different levels in different states. While some states have a committed group of NGOs the others have few credible NGOs to talk of. States like Bihar, Uttar Pradesh, Jharkhand etc. have a few NGOs and these organisations by and large are not perceived to be credible. The task is challenging and complex. The process is ongoing. Capacity building of NGOs is one activity that is to be done vigorously. The state governments are also expected to provide an environment that builds trust between the government and the civil society and ensures long term partnerships.

Integrated Counselling and Testing Centre (ICTC)

Q. What is ICTC?

Ans. ICTC stands for Integrated Counselling and Testing Centre.

Q. What is the role of ICTC in the prevention of HIV/AIDS?

Ans. As the HIV problem intensifies, the issues of care and support for affected individuals, and prevention of HIV transmission to those who are not affected, become even more critical. Integrated Counselling and Testing (ICT) is now seen as a key entry point for a range of interventions in HIV prevention and care. It provides people with an opportunity to learn and accept their HIV sero status in a confidential and enabling environment and to cope with the stress arising out of HIV infection. ICT should become an integral part of HIV prevention programmes, as it is a relatively cost-effective intervention in preventing HIV transmission.

The potential benefits of ICT are:

  • Earlier access to care and treatment
  • Providing factual information about HIV /AIDS and clearing misconceptions
  • Reduction of fear and stigma through counselling
  • Creating enabling environment for PLHA
  • Emotional support
  • Better ability to cope with HIV related anxiety
  • Improved health status through good nutritional advice
  • Motivation to initiate or maintain safer sexual practices and behaviour change
  • Prevention of HIV related illness
  • Motivation for drug related behaviour
  • Safer blood donation
  • Motivating HIV infected person to involve spouse/partner for future spread and care.
Q. What is the setup at ICTC?

Ans. ICTC is not a place just for testing a sample for HIV, but much more than that. One of the basic elements involved is a confidential discussion between the client and the trained counsellor and the focus is on emotional and social issues related to possible or actual HIV infection. The aim of the ICTC is to reduce psycho-social stress and provide the client with information & support necessary to make decisions, therefore it needs a private and peaceful setting.

Separate enclosures for male & female clients have been set up to provide confidential environment for encouraging disclosure and providing IPC.

For the effective functioning of the ICTCs, two trained counsellors and one laboratory technician have been provided in each ICTC.

In order to ensure that the result of the HIV test is given on same day to the individual after post-test counselling, Rapid HIV Test Kits have been supplied to these centres or the client is asked to meet the same counsellor for post test counselling on appointed date.

Waiting space, trained Microbiologist/Pathologist, training to staff functionaries of ICTC, two trained counsellors and one laboratory technician have been provided in each ICTC.

In order to ensure that ICTCs provide quality counselling services, stress has been laid on pre-placement in-service training of counsellors & technicians by master trainers & resource persons.

Orientation training is also conducted for these functionaries.

Q. What has been done to make ICTCs user-friendly?

Ans. In order to make the services more user-friendly following efforts are being made:

  • ICTCs are located in easily accessible areas mostly in OPDs.
  • Informed consent in local language is taken before HIV testing. Clients are informed about the nature and consequences of HIV test before their consent is taken. It is emphasised that testing should not be forced but left at the will of the client.
  • Here it is emphasised that counsellors should not be rotated from centre to centre and from one day to another since the rapport between the counsellor and client is very essential.
  • Adequate supply of condoms is made available in these counselling centres. Individuals attending the ICTC are also made aware about the outlets from which they can get condoms under various schemes.
  • Counselling is integrated into other services, including STI, antenatal and RCH clinics.
  • Referral system has been developed in consultation with NGOs, community based organisations, hospitals and PLWA networks.
  • Counsellors are provided adequate training and ongoing support and supervision to ensure that they give good quality counselling and avoid burnout.
  • Linkages with NGOs for social support, follow-up counselling and care for those tested sero positive are emphasised.
  • Innovative ways of scaling up ICT services and making them more accessible and available is the endeavour.
  • There is an emphasis to make it more client-friendly and service based by augmenting the following services:
  • Anti retroviral drugs in PPTCT
  • Anti-tubercular treatment in HIV-TB co-infection
  • Free treatment of STI & opportunistic infections
  • Follow up services & networking among patients living with AIDS.

Care and Support

Q. Do AIDS cases require a separate ward?

Ans. NACO does not support separate ward for AIDS patients. AIDS patients are to be treated at par with the general patients and there should be no discrimination.

Q. If testing has to be done in the hospital, is the consent of the patient required?

Ans. Yes. Whenever HIV test is done, the consent has to be taken. In case of unconscious patients, the consent of the relatives has to be taken.

Q. What is the importance of ICTC in care and support?

Ans. ICTC is an entry point for care and support of HIV/AIDS. Whenever a person feels, he can walk to an ICTC and get himself tested. If tested positive, follow up counselling is suggested at the ICTC for referrals and treatment of HIV/AIDS patients.

Q. Is the government considering to provide anti retroviral therapy for AIDS cases?
Q. What efforts are being made to integrate HIV/AIDS/STD prevention and control activities into primary healthcare?

Ans. Integration into primary healthcare is a priority because it is necessary for ensuring sustainability. Two examples of an integrated approach are the implementation of HIV/AIDS care and STD prevention and control. For example, a continuum of HIV/AIDS care is being promoted as part of primary healthcare, with linkages to be established between institutional, community and home levels. In the area of STD prevention and control, a syndromic approach to STD diagnosis is most suitable in the developing world as it does not require laboratory tests, and treatment can be given at the first contact with health services. WHO strongly advocates that all primary healthcare workers be trained in the syndromic approach to STD management.

Q. What steps has the Government of India taken to tackle the dual epidemic of HIV-TB?

Ans. Recognising the serious threat posed by HIV-TB co-infection, the Government of India has emphasised the need for strengthening collaboration between TB and AIDS control programmes for better management of HIV-infected patients with TB. An Action Plan for tackling this dual epidemic has been drawn up at the Centre between both the programmes which is initially focussed on the six high prevalence states and is under implementation at the moment by both the National Programmes. Efforts are being made to establish Integrated Counselling & Testing for HIV, diagnosis for TB and Directly Observed Treatment–short course for TB under the same roof to make such services available to the needy patients.

Q. What precautions should be taken while treating HIV and TB at the same time?

Ans. Certain anti-TB medications may affect the levels of anti-HIV medications and vice versa. Hence treatment of both diseases should be under the supervision of an experienced physician, the dosages should be closely monitored and adjusted as needed. If possible, treatment of TB should be completed before starting anti retroviral.

Blood Safety

Q. Is there a National Blood Policy?

Ans. Yes, a National Blood Policy has been formulated and is now being implemented with the mission to ensure easily accessible and adequate supply of safe and quality blood collected from voluntary non-remunerated regular blood donors.

Q. What are the infections for which blood is tested?

Ans. The Drugs & Cosmetics Act provides mandatory testing of blood for five major infections viz. HIV, Hepatitis B, Hepatitis C, Syphilis & Malaria. Every unit of blood is tested for all these infections.

Q. What does the term ‘Service Charge’ means in blood banks?

Ans. No charges for blood as such can be levied by any blood bank. However, the blood that is collected from a donor at no cost, needs to be processed to make it free of infection, to ensure that it has certain minimum quality standards. It also needs to be stored and tested with recipient’s blood before transfusion. Besides all these, establishment costs for the blood bank like infrastructure maintenance, salaries etc. add to the overall costs of providing a safe unit of blood to the patient. Blood banks attempt to recover these costs as service charge from the consumer.

Q. Is there some uniform service charge fixed for a blood unit?

Ans. There are some guidelines developed by the National Blood Transfusion Council and circulated by NACO, on the amount of service charge that can be charged by blood banks functioning in any sector in the country. These guidelines specify that no blood bank will charge more than Rs.500/- for one unit of whole blood. However, since these are mere guidelines and have no legal

Q. NBTC was constituted subsequent to Supreme Court judgment in 1996 with the focus of catering to Nation’s blood security. The prime objective was to phase out professional donors and focus on voluntary donations. How far has this policy been successful and how much voluntary blood is collected in the country?

Ans. Soon after setting up of the National Blood Transfusion Council (NBTC) at the Centre and State Blood Transfusion Councils (SBTCs) in each state/UTs, a complete ban has been imposed on collection of blood from paid donors, with effect from 1st January, 1998. A number of steps were taken by NBTC to keep a strict check on exploitation of the blood users by commercial and private blood banks. SBTCs were provided funds by NBTC to mobilise blood collection through voluntary blood donations. Extensive awareness programmes for donor motivation through Information, Education, Motivation, Recruitment and Retention of voluntary donors was launched. Each state is given an annual target for collection of blood through voluntary sources and this is regularly reviewed by NACO.

Q. Is the blood issued by blood banks safe?

Ans. Yes. As per the National Blood Safety Programme of NACO, it is mandatory on the blood banks to test every unit of blood properly for grouping, cross matching and testing for HIV, Syphilis, Hepatitis B & C and Malaria before it is issued for transfusion. Facilities have been provided by NACO to all the government and charitable blood banks like Red Cross to carry out these tests.

Q. Can one acquire HIV infection if one donates blood?

Ans. No, this is not possible as all materials used for collection of blood are sterile and disposable. Donating blood is a noble gesture. People who are healthy should come forward for donating blood voluntarily.

Q. Who can donate blood?

Ans. Only a healthy person between the age group of 18 – 60 years, weighing 45 kg or more with haemoglobin content of 12.5 gm per 100cc or more can donate blood.

Q. Is there any inspection of blood banks?

Ans. Yes. The blood banks can only function if they are licensed by the Drug Inspectors of the Food and Drug Administration of the respective states. The Drugs & Cosmetics Act provides a legal framework under which the blood banks are inspected and issued a proper license, which is renewed every alternate year. Every blood bank has to prominently display its license for anyone to check.

Condom Promotion

Q. What is the government’s policy on condoms?

Ans. The government policy has been that condoms are an effective, protective measure to prevent the spread of HIV. The government believes that it is necessary to be focused in the promotion of condoms since a large number of infections occur through unsafe sex. For the general population the dual use of condoms for contraception and disease prevention is emphasised by both National AIDS programme and Reproductive & Child Health programme. For the high risk groups, targeted social marketing and free distribution of condoms is being promoted through NGOs.

Q. How safe are condoms in preventing HIV?

Ans. Consistent and correct use of Latex condoms are fully effective in preventing the spread of HIV through the sexual route.

Antiretroviral Therapy

Q. Is the Government of India planning to introduce anti retroviral therapy free of cost in government hospitals? Who will be eligible for the supply of drugs?

Ans. Union Minister for Health & Family Welfare convened a dialogue with the manufacturers of anti retroviral for HIV/AIDS, with a view to examine the feasibility of procuring and delivering ARVs through the public health system. As a result, a Working Group was constituted, chaired by Secretary Health, with the Director General, Health Services and Additional Secretary & Project Director NACO as members, together with CII, FICCI, and representatives of the different manufacturers of anti retroviral. The Working Group has completed its deliberations. If government does proceed to introduce anti retroviral through the public health system, these will be delivered free of cost to the end consumer in government hospitals. While we estimate over people living with HIV/AIDS at the end of the year, we necessarily have to prioritise the beneficiary population which include HIV positive mothers who access the government health system through the Prevention of Parent to Child Transmission clinics, HIV positive children below 15 years of age, and full blown AIDS cases who seek treatment in government hospitals.

Prevention of Parent to Child Transmission (PPTCT)

Q. What is the government’s stand on breast feeding in case of HIV positive mothers?

Ans. Best practice as recommended by UNICEF and supported by NACO is followed. Messages will be consistent with the related programme of RCH. Every effort should be made to promote exclusive breast feeding for upto four months in the case of HIV positive mothers followed by weaning, and complete stoppage of breast feeding at six months in order to restrict transmission through breast feeding. However, such mothers will be informed about the risk of transmission of HIV through breast milk and its consequences, and would be helped for making informed choice regarding infant feeding.

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