Profile of direct walk-in and referred clients attending Integrated Counselling and Testing Centre

INTRODUCTION

From a mysterious illness recognized only in the early 1980s, HIV/AIDS has established itself as a global pandemic in less than 20 years. ^1,2 In 2007, following the first survey of HIV among the general population, Joint United Nations Programmes on HIV/AIDS (UNAIDS) and National AIDS Control Organization (NACO) agreed on a new estimate – between 2 million and 3.6 million people living with HIV, which puts India behind South Africa and Nigeria in numbers living with HIV. ^3,4 In terms of AIDS cases, the most recent estimate comes from August 2006, at which stage the total number of AIDS cases reported to NACO was 124,995. Of this number, 29% were women, and 36% were under the age of 30. These figures are not accurate reflections of the actual situation though, as large numbers of AIDS cases go unreported. ^5,6 Overall, around 0.36% of India's population is living with HIV. ⁴ While this may seem a low rate, India's population is vast; hence the actual number of people living with HIV is remarkably high.

The HIV pandemic has had a profound impact on the health and economic conditions of individuals and populations, with potential to further adversely affect the health, productivity and socioeconomic conditions of the nation. In this regard, the potential of HIV and AIDS to affect health and development commands urgent attention and response. People living with HIV/AIDS (PLWHA) are faced with the task of maintaining optimal health status, despite an increasing insult to their immune status. ⁷ Early diagnosis, antiretroviral therapy, chemo-prophylaxis and treatment of opportunistic infections are important for the control of HIV replication, disease progression and ultimately containment of the epidemic.

In order to implement the desired interventions, the epidemiology of HIV/AIDS in a particular region has to be understood, especially with regard to various sociodemographic factors, level of awareness as well as pattern of risk behaviour of the population, because till date the most effective approaches available for the prevention and control of the infection/disease are awareness generation and lifestyle changes. The general consensus among those fighting AIDS worldwide is that HIV testing should be carried out voluntarily, with the consent of the individual concerned. This view has been supported by the Indian government and NACO, who have helped to establish hundreds of voluntary counselling and testing centres (VCTCs), now the Integrated Counselling and Testing Centre (ICTC) in India. By the end of 2005, there were 873 VCTCs in India, compared with just 62 in 1997. ⁸ These centres tested 225,600 people for HIV during 2005. ³ Voluntary counselling and testing for HIV is a cost-effective intervention in preventing HIV transmission and it has become an integral part of the HIV prevention programme. The VCTC is the process by which an individual undergoes confidential HIV counselling to explore his/her risk of HIV infection and exercises an informed choice regarding HIV testing. Now VCTC has been identified as ICTC, to indicate the integration of VCTC activities with other health-care facilities and national health programmes, by NACO. ⁹

The aim of the present study was to study the profile of direct walk-in and referred patients attending the ICTC of a tertiary care hospital, which may provide important clues to understanding the epidemiology of the disease in a particular region.

MATERIALS AND METHODS

The present study was conducted at the ICTC of the microbiology department at Maulana Azad Medical College (MAMC) attached to Lok Nayak Hospital (LNH), which is a tertiary care hospital catering to the needs of Delhi and adjoining states. The study included all attendees of the ICTC referred from hospitals associated with MAMC (LNH, GB Pant Hospital and Guru Nanak Eye Centre) and surrounding hospitals or direct walk-in attendees from January 2007 to December 2007. Following the guidelines of NACO, all attendees were interviewed by the counsellor of the ICTC under strict confidentiality, and information regarding age, sex, pattern of risk behaviour and HIV serostatus of the attendees was recorded on a pre-designed performa.

After obtaining informed consent from the ICTC attendees and after pretest counselling, a blood sample was collected by venepuncture following the usual sterile precautions by the technician either in the Department of Microbiology or in the inpatients wards of the hospital. As per the policy and strategy prescribed by NACO, three rapid HIV tests were used (Immunocomb J Mitra & Co. Pvt Ltd, Delhi, India, Retroquic QUALPRO Diagnostics Goa and Acon Trilene ACON BIOTECH Co. Ltd, China) following the manufacturer's instructions. Samples showing positive test results in all the three tests were declared HIV positive.

The results were analysed to correlate between HIV positivity, age, sex, route of transmission and direct walk-in/referred patients. Descriptive analysis of the data was done among different groups of patients. Risk for HIV positivity was compared by calculating odds ratio (OR) and 95% confidence interval. To compare the proportions of patients in different groups, chi-square/Fisher's exact test was applied. A P value of <0.05 was deemed statistically significant.

RESULTS

A total of 3755 clients visited the ICTC, Department of Microbiology, MAMC from January 2007 to December 2007 for pretest counselling. Among these total clients, 2440 (65%) were males and 1315 (35%) were females. Out of 3755 ICTC attendees, 2739 (72.9%) were referred from various departments of LNH, whereas 1016 (27.05%) were direct walk-ins. Among the referred patients, the majority (32%) were from the medicine department followed by 29% from the skin department and only 2.5% of patients were referred from the surgery department. Out of all the referred patients, 922 (33%) were in-bed patients for whom bedside counselling was done and the sample was collected in the ward only in the presence of a counsellor. The direct walk-ins visited the ICTC for the following reasons: high-risk behaviour (31.3%), spouse of positive patients (16.8%), children of positive parents (11.9%), occupational exposure to blood (6.6%), AIDS phobia (4.1%), intravenous drug users (2.5%), chronic ill health (1.9%), recipients of blood transfusion (1.7%), referred by non-government organizations (NGOs) and parents of positive children (0.3% each).

As regards HIV positivity, 312 (8.3%) out of 2440 males and 164 (4.3%) out of 1315 females were HIV positive (P = 0.765). Two samples (0.05%) showed indeterminate results and were submitted to the National Reference Laboratory (NRL) for confirmation; both were reported as negative for HIV antibodies by NRL. Out of 2739 referred patients 224 (8.1%) were HIV positive, whereas in the direct walk-in group 252 (24.8%) out of 1016 patients were HIV positive (P = 0.0001). Among the referred HIV-positive patients 162 were males and 62 females (P value = 0.02), whereas among the direct walk-in HIV-positive patients 150 were males and 102 females (P value = 0.059) (Table 1).

The majority of HIV-positive patients belonged to the sexually active age group as reported by earlier studies. Whereas the major route of transmission among <14 years HIV positives was mother-to-child transmission (56.8%), 77.6% patients among the >14 years age group HIV-positive patients had heterosexual transmission.

Among 3755 ICTC attendees who underwent HIV testing, only 3084 (82.1%) came for post-test counselling. Of the total HIV-positive male attendees 273 (87.5%) came for post-test counseling, whereas of the total HIV-positive female attendees 163 (99.4%) came for post-test counselling. Regarding other support services provided to the ICTC attendees, all the HIV-positive patients were referred to the antiretroviral therapy (ART) clinic and community care home centres. Out of all the ICTC attendees, 106 patients clinically suggestive of tuberculosis (TB) (2.8%) were referred to Revised National Tuberculosis Control Programme (RNTCP)/chest clinic, out of whom three (2.8%) turned out to be positive. All HIV-positive individuals were advised to bring their spouses for counselling and testing. The spouses of only 116 (24.3%) HIV-positive patients came for HIV testing, out of whom 48 (41.3%) were HIV positive.

DISCUSSION

This study included all the referred and direct walk-in attendees of the ICTC at the Department of Microbiology, MAMC, from January 2007 to December 2007. The majority of ICTC attendees were males as also reported by others. ^10,11 A low proportion of ICTC attendees (27%) in our study were direct walk-ins. Although studies from India on the profile of ICTC attendees have not dealt with direct walk ins and referred categories separately, one study conducted exclusively on police personnel reported a much higher proportion of direct walk-ins (78%). ¹⁰ As ICTC is being recognized as a crucial component of effective strategies for HIV/AIDS prevention and care, this low percentage of persons voluntarily attending the ICTC clearly reflects the low level of awareness about HIV/AIDS that exists among the general population. Furthermore, self-stigma and fear of discrimination are often central to individuals not seeking HIV tests or treatment. Efforts should be made to publicize the existence of the ICTC facility for HIV in order to encourage people to avail of the services, particularly by marginalized and vulnerable segments of the population.

Among the referred attendees in our study, the majority were from medicine, skin and sexually transmitted disease (STD) departments and only a few patients were from surgical departments. Prolonged symptoms suggestive of opportunistic infections of AIDS and increased likelihood of HIV infections in patients presenting with STDs could be the reasons for the higher number of patients from medicine and STD departments. It is to be noted that the main objective of the ICTC is to make testing services available to those who wish to know their HIV status because of indulgence in some risk behaviour. Therefore, it must be ensured that these centres are not utilized for the screening of patients prior to surgery or admission to hospitals. Counsellors may be directed to discourage HIV testing in such situations during pretest counselling. The motivation to visit ICTC in most of our direct walk-ins was high-risk behaviour or because spouses were HIV reactive, as also highlighted by other studies. ^6,10,11

A higher seropositivity in males was reported from our study, similar to other studies. ^6,10,11 Among the total clients who tested HIV reactive in our ICTC, the positivity was marginally more for inpatients than for outpatients (≈56% for inpatients and 44% for outpatients). The higher positivity in inpatients than in outpatients could be understood by the fact that almost 80% of these inpatients were from the Medicine Ward (10% each from paediatric and surgery wards), in whom the probability of suffering from AIDS-associated illnesses was higher.

A greater proportion of direct walk-ins were seroprevalent as compared with referred cases. This is a very expected result in our setting as the walk-in clients of our ICTC mainly comprised people with high-risk behaviour for HIV infection (intravenous drug abusers, commercial sex workers, men having sex with men, etc.), spouses of HIV reactive individuals or sometimes even people who have been tested reactive from outside and who want to confirm their HIV serostatus. To the best of our knowledge, no Indian reference is available for comparison of referred and direct walk-ins in relation to HIV seroprevalence; one study, however, has reported a much lower overall prevalence of HIV than ours (2.5% versus 12.5%) ¹⁰ while others have reported a higher prevalence than ours. ¹¹ One reason for the high prevalence in our study could be the fact that a large proportion of our patients (35%) were known HIV positives (tested from outside) and referred to our ICTC. We test all the clients coming to our ICTC irrespective of whether they are already tested from outside or not. This is done because once a client is reactive, he/she is registered with the ART (antiretroviral therapy) centre for further follow-up, and registration in the ART centre is done only on the basis of testing results obtained from an ICTC following NACO. A large proportion of referred clients to our ICTC consists of inpatients, i.e., patients who are relatively unwell and for whom in-bed collection of samples and counselling is done.

The majority of HIV-positive patients belonged to the sexually active age group, as reported by earlier studies. ^6,11,12 There was a statistically significant correlation between HIV seropositivity and age of referred males (P value = 0.0001), OR being the highest for males between 30–39 and 40–49 years. A statistically significant correlation between HIV seropositivity and age was also found in referred females (P value = 0.008) and direct walk-in males and females (P values of 0.0001 and 0.001, respectively), with ORs being the highest for 25–29 and 30–39 years for referred females and direct walk-in males, respectively. On comparing referred males with direct walk-in males, the risk of acquiring HIV infection was highest in the age group of 30–39 years (OR = 4 and 1.9, respectively) in both the groups. Among females, the risk of acquiring HIV infection was highest in the age group of 25–29 years in the referred females (OR = 2.6) and above 50 years in the direct walk-in females (OR = 1.0).

As shown by previous studies, ^9,11–13 our study shows heterosexual and mother-to-child transmission to be the most common routes of transmission of HIV infection in >14 and <14 years of age, respectively. Although HIV infection is predominantly transmitted through the sexual route, mother-to-child transmission is by far the largest source of HIV infection in children below the age of 15 years and affects approximately 5,00,000 infants per year all over the world, the majority of whom are in developing countries. ^14,15 Mother-to-child transmission rates have been shown to have wide variations in different populations. Within India too, due to inherent economic diversity these rates range from 24% in Mumbai to as high as 48% among tribal women. ¹⁵ Considering 25 million births per year in the country and a seroprevalence rate among pregnant ladies of 1% and a vertical transmission rate of 30%, we would expect to have 75,000 HIV-infected neonates born every year. ^14,15 Thus, in India, HIV in children is unchecked and will keep on rising till an effective PPTCT (prevention of parents to child transmission) programme is in place. In developing countries where access to even basic antenatal care is unavailable, screening for HIV, which involves counselling with subsequent assessment and care, may not be feasible. In areas where will and resources permit, interventional programmes should be aimed at making PPTCT a priority in order to reduce the incidence of paediatric HIV infection and improve child survival.

Our study reveals that 82.1% of the ICTC attendees came for post-test counselling. An interesting fact that emerges from our study is the greater proportion of reactive females than males who came for post-test counselling. The low number of patients turning up for post-test counselling at our ICTC could be possibly due to financial constraints, gender bias, and social stigma and neglect attached with the disease. However, in spite of all these hurdles our counselors, with their best efforts, try to inform as many clients as possible about their HIV reactive serostatus through home visits or through the involvement of some NGOs. The biggest problem in our setting is the migrant population, who live away from family and hometown for jobs. In addition to the above situations, some other very obvious reasons for the low percentage of clients for post-test counselling could be the death of the patient, testing done from multiple places for confirmation, repeated testing done or registration of the patient in some other ART centre.

All the reactive patients were referred to the community-based group and physicians for medical advice. Previous studies ⁶ have also highlighted the importance of offering community-based support to PLWHA, which could include non-discrimination in employment opportunities, increased access to required health services as well as applied food and nutrition programmes. Out of all the cases clinically suggestive of TB who were referred to the chest clinic, only 2.8% turned out to be TB positive and all were HIV non-reactive.

In our study, spouses of only one-fourth of HIV-reactive patients came for testing, of whom 41.3% turned out to be reactive for HIV. A low awareness about HIV infection among the rural population (especially females), death of the spouses due to AIDS, of some HIV seropositive individuals and the majority of the male clients of the ICTC being migrants from adjoining states (Uttar Pradesh, Bihar, Himachal Pradesh) could be some of the factors responsible for this low percentage of spouses being informed. Another study from India has reported a low baseline knowledge of HIV-1 among women and that there is a need for the primary prevention of HIV-1 infection among adolescent girls and women of reproductive age, before initiation of sexual activity and before pregnancy. ¹⁶ However, our counsellors, with their best efforts, manage to convince most of the reactive clients during their follow-up visits to bring their spouses for testing. As has already been discussed only in the migrant population it becomes difficult to call spouses for testing. However, this is also done in due course during follow-up visits, or sometimes clients, on counseling, get their spouses tested in their hometowns and, in turn, inform the counsellors about the serostatus.

Voluntary counselling and testing is now seen as a key entry point for a range of intervention HIV prevention and care. ¹⁷ Self-stigma and fear of discrimination are often central to individuals not seeking HIV tests or treatment. ¹⁸ Experience within India and in several other developing countries has shown that ICTC helps people to cope with their HIV infection, to a access care and to plan for the future. In addition to scaling up VCTC services, it is also important to promote the benefits of ICTC and raise awareness by wide publicity via aggressive health education programmes and awareness campaigns, integrating ICTC into other health services and linking it to various community organizations. ¹⁹