Profiles of Attendees in a VCTC in Darjeeling Dist of West Bengal

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Profiles of Attendees in the Voluntary Counselling and Testing Centre of North Bengal Medical College in Darjeeling District of West Bengal

Indian Journal of Community Medicine. Vol. 31, No. 4 (2006-10 - 2006-12)

G. K. Joardar(1), A. Sarkar(2), C. Chatterjee(1), R. N. Bhattacharya, S. Sarkar(2), P. Banerjee(2)

Abstract

Research Question: What are the socio-demographic profi les, HIV serostatus and risk behaviour pattern of the attendees in the VCTC of North Bengal Medical College? Objectives: To identify the socio-demographic profi les, HIV serostatus and risk behaviour pattern of the attendees in the VCTC of North Bengal Medical College in Darjeeling district of West Bengal. Study Design: Cross-sectional observational study. Setting: The Voluntary Counseling and Testing Centre (VCTC) in the Microbiology department attached to North Bengal Medical College in the Darjeeling district of West Bengal. Participants: All the 545 attendees attended the VCTC between August 2002 and December 2003 were included in the study. Study Variables: Age, sex, marital status, level of education, occupation, place of residence, HIV serostatus and pattern of risk behaviour in relation to HIV/AIDS. Statistical Analysis: Proportions. Results: An overall 17.06% of the VCTC attendees were HIV positive. About 84% of the HIV positives belonged to the age 20 – 39 years. For the males 51.32% and for the females 88.23% of the HIV positives were married; 52.94% of the female sero-positives were illiterate. Among the male sero-positives, 31.59% were involved in business and 30.27% in unskilled work as occupation. An overall 70.97% of the HIV positives were from the rural areas. For the male sero-positives, 81.58% were visiting the Commercial Sex Workers.

Key words: HIV serostatus, Bridge population, Voluntary Counseling and Testing Centre (VCTC), Priority Targeted Interventions.

Introduction

From a mysterious illness recognized only in the early 1980s, HIV/AIDS has established itself into a global pandemic in less than 20 years1. Since its detection for the fi rst time in 1986, HIV infection is growing very fast in India2; the number of people living with HIV/AIDS was estimated to be 5.1 million by December 2003, and the total number of reported AIDS cases reached to 86,028 by 31st August 20043,4. The distribution and spread of the disease in India is highly uneven5,3.

In order to implement the desired interventions, the epidemiology of HIV/AIDS in a particular region has to be understood specially with regards 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. Voluntary counselling and testing for HIV is a cost effective intervention in preventing HIV transmission and it has become an integral part of HIV prevention programme. The Voluntary Counselling and Testing Centre (VCTC) is an entry point to care, which provides people with an opportunity to learn and accept their HIV serostatus in a confi dential environment6. The data generated in the VCTC, may provide important clues to understand the epidemiology of the disease in a particular region.

Material and Methods

The present study was conducted among the attendees of the VCTC of North Bengal Medical College which was attached to the Microbiology department of the college. This centre is very close to the city of Siliguri. The geographical location of the city and its role in the inter-state and international trade are crucially important with regard to transmission of HIV. It is the gateway of all the North Eastern states of India and is close to the international borders with Nepal, Bhutan, Bangladesh and interstate borders with Bihar and Sikkim resulting in high population movement (between states and between countries) as well as infl ux of a very large number of trucks with their drivers and helpers. More over large number of injecting drug users are moving into the city from neighbouring areas of Nepal and hills of Kurseong, Kalimpong and Darjeeling. As this institute is the only apex hospital in the region, the information gathered from the attendees of this centre may throw light on the epidemiology of HIV transmission in this area.

The study included all the 545 attendees who attended the centre between August 2002 to December 2003 either voluntarily or being referred from various departments of this institute. Anonymous information was collected on a pre-designed schedule by interviewing the subjects. The variables studied are age, sex, marital status, level of education, occupation, place of residence, pattern of risk behaviour and HIV serostatus of the attendees. Prior testing of the schedule was done among the clients in the STD clinic of the hospital. Following the guide lines of the National AIDS Control Organization (NACO) the counselor of the VCTC interviewed the attendees under strict confi dentiality. After pre-test counselling and after getting consent from the attendees, their blood samples were collected by laboratory technician under direct supervision of the counselor either in the department of Microbiology or in the in-patient wards of the hospital (in case of in-patients). As per the policy and strategy prescribed by NACO, the fi rst Test/ Rapid test done on the serum was Immunocomb. The persons showing negative test results were referred to the counselor in the centre. The serum samples showing positive test results were subjected to a second Test / Rapid test called Tridot. Those samples showing positive test results in the second Test also were declared HIV positives; and the persons showing negative results were advised to come after one month for review. Data was collected, compiled and analyzed using standard statistical methods.

Results

Out of 545 attendees studied, 428 i.e. 78.53% were male. With regards to the HIV serostatus of the attendees 93 out of 545 i.e. 17.06% were positive. The sero-positivity was 17.76% among males and 14.53% among the females. The distribution of the attendees by their age, sex and HIV serostatus (Table IA) shows that among the males, the majority of the sero-positives, 65 out of 76 i.e. 85.53%, belonged to the age bracket of 20 – 39 years. The same pattern of distribution was observed amongst the females as well, 13 out of 17 i.e. 76.47% seropositives belonged to the same age group of 20 – 39 years. Amongst all, about 84% of the seropositives belonged to the age group 20 – 39 years. The distribution of the attendees by their marital status (Table I- shows that among the males, 39 out of 76 i.e. 51.32% of the seropositives were married, and the rest of the seropositives i.e. 48.68% were unmarried. The same pattern was observed among the females; 15 out of 17 i.e. 88.23% of the seropositives being married and the rest 11.77% unmarried.

The educational level and the HIV serostatus of the attendees (Table I-C) shows that for the male seropositives 28.95% were among the illiterates and another 63.15% were among those who were educated below or up to class X standard. Whereas, for the female seropositives, 52.94% were from the illiterates.

The HIV serostatus of the attendees by their occupations (Table I-D) shows that among the males, the majority of the HIV positives i.e. 31.59% were from that group of persons who were involved in business as their occupations; closely followed by 30.27% positives from the group of unskilled workers. In case of the female attendees, most of the seropositives (88.23%) were among the housewives and the rest 11.77% were from those who were occupied in some services. Only 22 drivers attended the VCTC and among them as high as 10 were sero-positives, that is 13.15% of the male seropositives were driver by occupation.

Table I: Socio-demographic profi les and HIV serostatus of the VCTC attendees (n=545)

Male Attendees:No. attended: Positives

Female AttendeesNo. attended: Positives

(n=428)No.

(n=76)No. (%)

(n=117)No.

(n=17)No. (%)

HIV Serostatus By Age And Sex:

<10 .

10

2(2.63)

: 5

-0 (0)

10 – 19:

33

0(0)

: 23

2(11.7)

20-29:

198

35(46.0)

: 46

7(41.1)

30-39:

136

30(39.4)

: 26

6(35.3)

40-49:

40

7(9.2)

: 11

1(5.8)

50 And Above

11

2(2.6)

: G

1(5.8)

HIV Serostatus By Marital Status

Unmarried

205

37(48.6)

: 25

2(11.7)

Married

221

39(51.3)

: 83 -15

(88.2)

Separated / Divorced / Widow(er)

2

0(0)

: 9

0(0)

HIV Serostutus By Level of Education:

Illiterate

130

22(28.9)

: 51

9(52.9)

Class I – IV

128

18(23.6)

: 37

4(23.5)

Class V – X

122

30(39.4)

: 22

3(17.6)

Class XI & above

48

6(7.9)

: 7

1(5.8)

HIV seroslatus By Occupation:

Unskilled Worker

145

23(30.27)

: 11

0(0)

Skilled Worker

21

5(6.56)

: 0

0(0)

Business

82

24(31.59)

: 3

0(0)

Service

52

5(6.58)

: 7

2(11.7)

Agricultural Works

33

1(1.32)

: 0

0(())

Driving

22

10(13.15)

: 0

0(0)

Others (Students,Unemployed, NotApplicable)

73

8(10.53)

: 16

0(0)

Housewives

-

-

: 80

-15(88.2)

HIV serostautus By Place Of Residence:

Rural Attendees

Urban Attendees

No. Attended: Positives

No. Attended: Positives

(n=400):

(n=66)

(n=145):

(n=27)

No.

No. (%)

No.

No. (%)

Darjeeling District:

219

37(56.0)

: 109

25(92.6)

Jalpaiguri District

52

7(10.6)

: 14

1(3.7)

Kooch Behar District

39

8(12.1)

: 2

0(0)

Other Districts

90

14(21.2)

: 20

1(3.7)

Table II: Pattern of Risk Behaviour and HIV Serostatus of the VCTC Attendees (n=545)

Male attendees No. attended: Positives

Female attendeesNo. attended: Positives

(n=428)

(n=76)No. %

(n=117)*No.

(n=17)No. %

Exposed to CSW (male) /acted or acting as CSW (female):

253

62(81.58)

18

6(35.3)

Multiple sex partners /

Pre or extra-marital sex:

3

1(1.32):

1

1 (5.88)

Injecting Drug Use (IDU):

8

2(2.64)

:—

—

Received blood transfusion:

20

3(3.94)

: 16

4(23.53)

Parents HIV positive:

10

2(2.64)

: 7

0(0)

Spouse HIV positive:

6

3(3.94)

: 11

5(29.41)

Risk nil or not known:

128

3(3.94)

: 63

1 (5.88) * A female nursing personnel had positive history of needle-stick injury in her workplace (hospital setting) and tested negative for HIV. The total number of female attendees includes her. However, she was not entered in the table.

With regards to place of residence and HIV serostatus of the attendees (Table I-E), it was observed that 219 out of 400 rural attendees (i.e. 54.75%) and 109 out of 145 urban attendees (i.e. 75.17%) were from Darjeeling district itself. As far as HIV seropositivity is concerned, as a whole, most of the positives that are 66 out of 93 (70.97%) were from the rural areas; 56.07% of the rural sero positives, and 92.60% of the urban positives came from the Darjeeling district only. A rural preponderance of the HIV seropositivity was observed among the attendees from the other neighbouring districts as well.

The pattern of risk behaviour and HIV serostatus of the attendees (Table II) shows that 253 out of 428 i.e. 59.11% of the male attendees gave history of visiting Commercial Sex Workers (CSWs) and 62 out of 76 i.e. 81.58% of HIV positives among the males were from that group. For the females, 18 out of 117 i.e. 15.38% attendees were working as CSW and 6 out of 17 i.e. 35.30% of the female seropositives were from that group. Although 128 out of 428 i.e. 29.91% of the male attendees and 63 out of 117 i.e. 53.85% of the female attendees did not have or did not disclose any type of risk behaviour related to HIV / AIDS, 3.94% of the male and 5.88% of the female seropositives respectively were from the group having no risk behaviour. The husbands of 11 out of 117 i.e. 9.40% of the female attendees and the wives of 6 out of 428 i.e. 1.40% of the male attendees were already HIV positive. Among them, 5 out of 11 wives and 3 out of 6 husbands were found HIV positive. Out of 545 total attendees, the number of injecting drug users was only 8 i.e. 1.47% of the attendees.

Discussion

The findings in the present study on age distribution of HIV positives corroborates with our National fi gure, where it is observed that most of the cases (about 89%) occurred among sexually active persons aged 20 – 49 years5,1,7. For the male attendees, the HIV positives were almost equally distributed among married and unmarried groups. Those unmarried males will soon enter their reproductive lives and infect their wives and ultimately the risk of parent to child transmission will increase.

With regard to level of education of the attendees this type of observation may be due to less number of attendees in the higher education groups; or it may be inferred that higher educational level offer some protection against HIV. Sex education is not included in our secondary school curriculum and anybody who is illiterate or educated below or up to secondary level may not have adequate knowledge for protecting himself or herself from STDs including HIV/AIDS. In general, it is observed that awareness and knowledge of HIV/AIDS remains weak in rural areas and among women5.

It was observed in 2001 that only 47% of the people in India were aware that HIV/AIDS could be prevented by consistent condom use and having one faithful uninfected partner. In the state of West Bengal, only 14% and 19% of the people respectively were aware about these two means7.

With regard to occupation, it may happen that the attendees having some businesses as occupation may get easy money and indulge in some risk behaviour that favours HIV transmission. High number of seropositives among the housewives is a matter of great concern and it might be an indication of increased HIV transmission in the area. Commercial sex and substance abuse are fi rmly entrenched in the socio-cultural milieu of the trucking industry in India and are a part of their daily life. A study in Indore (1995) observed that 94% of the truck drivers were ignorant about AIDS; and 82.9% of the senior and 43.8% of the junior drivers had history of extra-marital sex. The long distance truck drivers are a highly mobile group in whom multiple sex partners is quite common8. So it may be presumed that the population in the study area is vulnerable for a rapid spread of the infection due to its geographical location for regional, inter-state and international trade with a very high number of truck drivers moving through the area.

According to Lal, the data of the HIV sentinel surveillance does not unfold the true picture of HIV prevalence in rural areas because almost all the participating sites in sentinel surveillance are located in urban areas and the attendees most probably are urban in most settings5. The present observation of rural preponderance of HIV sero-positives is believed to be an indication of spread of HIV from the urban to the vast rural areas. This type of distribution might be due to rural location of the VCTC facilitating, easier access by the rural people; or it might indicate real increase in the HIV prevalence in the rural areas of the district through which pass some very important National Highways and where many areas of important tourist interest are located. Unprotected heterosexual intercourse is the predominant mode of transmission of HIV in India (about 84%)5. It was observed that sex with non-regular partners in the last 12 months was prevalent to the extent of 7% in urban and 6.3% in rural areas; and condom use rate with such kind of risky sexual relationship was 62.4% in urban and 42.9% in rural areas5. This population with non-regular sex partners is the "bridge population" which connects high risk to the low risk population. The larger the size of the "bridge population" the greater the risk of transmission in to the general population5,9. The observation of the study also highlights that a large number of attendees are connecting the high-risk group (CSWs) with the low risk population (general population and housewives). And the fact remains that about two third of the male attendees are clients of the commercial sex workers and more than half of the male HIV positives were enjoying married lives.

As the present study was conducted in a clinic of a medical college hospital, the results observed are subject to bias arising from rate of reporting in the counselling and testing centre. As of now, the care seeking behaviour of our common people are infl uenced by so many factors; and it is observed that in case of sensitive issues linked with social stigma like Leprosy, STDs, HIV/AIDS there is under-reporting and underutilization of facilities. So, the probability of a different type of pictures in the community setting might not be impossible. A Community based study would have been better to avoid such type of bias.

Conclusion

The city of Siliguri and its surrounding vast rural areas with huge number of tea gardens and their workers are highly vulnerable to the rapid spread of HIV/AIDS for its geographic location, rapid urbanization, industrialization, huge population migration including cross border movements and low literacy level. Though it appears to be a Herculean task in view of the rising trend and unabated spread of HIV to the general population to achieve zero level of growth of HIV/AIDS by 20075, no time should be wasted to carry out Priority Targeted Interventions among the selected high risk groups in different areas and to carry out intense IEC activities to promote behavioural changes to the favourable direction. Epidemiological studies have to be conducted in various settings to understand the role and complex relations of innumerable behavioural, social and demographic factors, which will help to interrupt and control the transmission of HIV/AIDS.

Acknowledegment

The authors acknowledge the Principal, North Bengal Medical College, Sushrutanagar, Darjeeling, and the State AIDS Prevention and Control Society, Govt. of West Bengal for allowing to undertake the study and for utilizing the data.

References

Park K. Park's Text Book of Preventive and Social Medicine; M/s Banarasidas Bhanot, Jabalpur (India), 2002; 17th. Edition: 259 – 267 and 314 – 316. National AIDS Control Organization, Ministry of Health and Family Welfare, Govt. of India, New Delhi: HIV Testing Manual - Laboratory Diagnosis, Biosafety and Quality Control. An Overview of the Spread and Prevalence of HIV/AIDS in India. Available from website: www.naco.nic.in/nacp/bss1. pdf Surveillance for AIDS cases in India (Period of Report – from 1986 to 31st August, 2004). Available from website: www.naco. nic.in/nacp/bss1.pdf Lal S. Surveillance of HIV/AIDS in India (Editorial). Indian Journal of Community Medicine, 2003; XXVIII (1): 3 -9. National AIDS Control Organisation. Ministry of Health and Family Welfare, Govt. of India New Delhi: Voluntary Counseling and Testing: 01 – 08. Kumar S. Suresh, Project Director, West Bengal State AIDS Prevention and Control Society; Unpublished presentation in the Annual State Conference of IAPSM W.B. Chapter,on 26.06.2004 at North Bengal Medical College, Darjeeling. Bansal R. K. Truck Drivers and Risk of STDs including HIV. Indian Journal of Community Medicine, 1995, XX (1-4): 28 – 30. International Institute of Population Science (IIPS). India National Family Health Survey (NFHS 2) – Key Findings, Mumbai: IIPS, 1998 – 99.

(1.) Deptt. of Community Medicine,(2.) Deptt. of Microbiology, North Bengal Medical College.Received: 3.11.04