Re: Are we underestimating HIV prevalence?

[Guest guest]

Dear friends,

Greetings!

Re: /message/9445

First of all, I thank Lt Col (Dr) Paranjape for bringing up this important issue

for discussion. It is certain that better understanding of relationship between

HIV and fertility is essential not only for estimating HIV prevalence but also

for better counseling and case management of HIV positive women. Unfortunately

there are hardly any studies on this issue from India.

However, there are some important points I would like to raise for discussion.

1) The results of previous studies are inconsistent- The article mentioned by

Dr. Paranjape is obviously not the only study that has looked at the association

of HIV and fertility. However, there is still ambiguity about the causal effect

of HIV infection on fertility of infected women.

While most studies suggest that women with HIV infection have lower fertility [

for example Zaba & Gregson and Ross and others ] and higher incidence of adverse

pregnancy outcomes than HIV negative women, a few studies reported no

association of HIV infection with fertility in women and pregnancy loss or even

higher rates of pregnancy among HIV positive women [for example Sedgh et al

2006].

Nonetheless, the associated reduction in fertility among HIV positive women is

attributed to several factors including reduced ability of HIV positive women to

conceive [ Desgrees du Lou et al 1999]

2) There are considerable methodological differences in estimating fertility-

Fertility in demographic literature is referred to the actual reproduction- that

is number of life births. However, in previous studies various measures of

fertility have been used such as birth rate, pregnancy rate or even analysis of

inter-birth interval or waiting time to conception.

Though these methods might be appropriate for the given research questions, it

poses limitations on comparing the findings of different studies.

3) Effect of other confounding factors- ‘Unprotected sex’ is the common

determinant of HIV as well as pregnancy and it is know that the prevalence of

STI is higher among HIV positive people. Therefore, it is often difficult to

estimate the fertility reducing effect of HIV in presence of other sexually

transmitted infections (particularly syphilis and gonorrhea) which certainly is

the case in some of the African countries.

There are many other factors that can affect estimation of fertility such as age

at marriage, age at sterilization, total fertility rate of the region (which is

considerably high in Africa and is almost close to replacement level in most of

the high prevalent states in India) etc, etc.

In summary, it will not be appropriate to directly extrapolate the findings of

the studies done in Sub-Saharan Africa to Indian situation as there are

considerable differences in the epidemiological pattern and the social, cultural

and economic factors that affect the proximate determinants of fertility.

There is need for good data from India before we conclude that we are

underestimating HIV prevalence.

Kind regards,

Dr. Shirish Darak

PhD researcher,

University of Groningen, The Netherlands

e-mail: <shirishdarak@...>

[Guest guest]

Dear All,

Re: /message/9445

I agree with Dr. Darak on the point that there is " need for good data from

India " . The Family Health Survey III which was responsible for reducing the

estimate from 5.2 Million (NACO) or 5.7 Million (UNAIDS) to 2.5 Million approx

was a definite step in the right direction.

However how consistent is our data gathering in India?

We do not have a comprehensive mechanism in place for gathering data in India.

This might be unpopular to admit to, but its true. Many PLHIV are falling

through the gaps, and while there is a sizable NGO net to help overcome these

gaps, it doesn't always do so.

This is not because there are not enough NGOs working in the field of HIV/AIDS.

There are almost 70 agencies in Pune alone that are registered with the Pune

City AIDS Control Society.

But there there is little or no monitoring of these efforts

or even accurate reports on how many PLHIV NGOs are working with. Last year we

(Deep Griha Society) received a *telephone call* from PCACS inquiring as to how

many PLHIV we have on our project.

In addition the focus on Targeted Interventions have blinded many to the reality

that there are PLHIV who are not sex workers, IDUs, MSM, TG, truck drivers or

from those other marginalised 'uneducated' communities.

Targeted Interventions are crucial in the fight against HIV/AIDS in India and we

cannot be successful without them. We at Deep Griha and Wake Up Pune also agree

that India will not have a generalised epidemic on the proportions of Sub

Saharan Africa.

However, focus on ONLY TIs will only give us skewed look at India's epidemic,

and the data will reflect that.

PLHIV among the middle classes exist. Knowledge of HIV transmission here is

generally good. Yet, the stereotypes of people living with HIV is strong.

Stereotypes fuel myths about HIV, and of course fuel stigma and

discrimination that are major obstacles to gathering the data we require to have

a more accurate picture of India's epidemic.

In our experience through Wake Up Pune the middle class (and above) PLHIV we

have encountered have a fear of being alligned with their more marginalised

bretheren.

Coming forward for information and help is rare. Family doctors

are far more discreet. None of this data is reflected. Currently we know of only

a handful. So do we then assume it must be ok.?

Most of the PLHIV we have encountered in urban slum contexts also prefer the

discretion of their community doctor and come to us only if there is a need that

cannot be met.

Similarly they will only attend the Sassoon ART clinic if they need

ART. How many middle class people do we see at Govt ART centres? In Pune. Hardly

any. Maybe we need to know how much ART is being bought over the counter. but

then again this will reflect only those who require it.

The need for data is vital. Misconceptions, stereotypes, stigma and

discrimination needs to be broken down if this need is to be met.

Hans Billimoria

Deep Griha Society

e-mail: <deepgriha@...>

--

www.deepgriha.org

www.wakeuppune.org