|Year : 2014 | Volume
| Issue : 3 | Page : 134-139
Eleven year performance of an Integrated Counseling and Testing Center in a tertiary care hospital in Himachal Pradesh, India
Sunite A Ganju1, Suruchi Bhagra1, Anil K Kanga1, Dig V Singh1, Raman Chauhan2
1 Department of Microbiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Department of Social and Preventive Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||17-Aug-2014|
Sunite A Ganju
House No 214/B, Sector 3, New Shimla, Shimla - 171 009, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The integrated counseling and testing centre (ICTC) has proved to be an essential human immunodeficiency virus (HIV) infection prevention intervention, especially in nations where poverty, social inequality, and weak health infrastructure exist. Objectives : The study was conducted to (i) assess the performance of ICTC in a referral hospital over a period of 11 years (ii) understand the regional risk determinants of HIV-positive clients. Materials and Methods : In this record based hospital study, data from January 2000 to December 2010 of all ICTC attendees and HIV-positive clients (excluding pregnant women; surveillance in this group is being conducted routinely) was collected by reviewing the records, compiled, and analyzed. Results : A total of 19,234 clients were counseled, of which 17,411 were tested and 970 were detected positive for HIV. The HIV seropositivity amongst the total tested clients was 5.57%. The intake of clients attending ICTC consistently increased from 781 clients in 2000 to 5574 clients in 2010. Amongst the total 970 HIV positives the ratio between male and female positives was 3:2 (m = 584; f = 386). Of these, 42.1% were in the age group of 25-44 years and children (<15 years) accounted for 7.8%. The heterosexual route of transmission was documented in 77.4%. In 13.6% (n = 132) HIV-positive clients, the route of transmission was not identified. The provider initiated client visits increased significantly from 4.85% in 2006 to 82.05% in 2010 than the direct walk-in clients (P < 0.0000001). However, the HIV-positive clients were three times more in the direct walk-in clients than in the provider initiated clients (P < 0. 0000001). Conclusion : Increased utilization of ICTC reflects the overall attitudinal changes in behavior and heterosexual high risk behavior continues to be the major route of HIV transmission.
Keywords: Integrated counseling and testing centre, national AIDS control program, people living with HIV/AIDS
|How to cite this article:|
Ganju SA, Bhagra S, Kanga AK, Singh DV, Chauhan R. Eleven year performance of an Integrated Counseling and Testing Center in a tertiary care hospital in Himachal Pradesh, India. CHRISMED J Health Res 2014;1:134-9
|How to cite this URL:|
Ganju SA, Bhagra S, Kanga AK, Singh DV, Chauhan R. Eleven year performance of an Integrated Counseling and Testing Center in a tertiary care hospital in Himachal Pradesh, India. CHRISMED J Health Res [serial online] 2014 [cited 2019 Sep 19];1:134-9. Available from: http://www.cjhr.org/text.asp?2014/1/3/134/138880
| Introduction|| |
The number of people living with HIV/AIDS (PLHA) in India has been estimated to be 23.9 lakh with an adult HIV prevalence of 0.31% in 2009.  This accounted for 10% and 65% of the HIV burden in the world and South-East Asia, respectively.  Though the new annual HIV infections have declined by 50%, from 2.7 lakh in 2000 to 1.2 lakh in 2009,  but in some low prevalent states a slight increase in new infections has been documented.  The estimated prevalence of HIV infection in Himachal Pradesh is reported to be 0.19% with 4498 PLHA in 2010. 
The integrated counseling and testing centers (ICTCs) provide the first interface between the client and the public health system to know their HIV status confidentially.  Though ICTC services have been expanding, only 10-20% of the infected people know their HIV status.  Thus, systematic analysis of data will enable to understand the regional risk determinants and evolve an evidence based regional strategy.
| Materials and Methods|| |
This record-based study was conducted at Indira Gandhi Medical College (IGMC), Shimla, a tertiary care hospital in North India. The data of all ICTC attendees from January 2000 to December 2010 either attending voluntarily or by referral was collected. Pregnant women were excluded as surveillance in this group is being conducted routinely, and the prevention of parent to child transmission (PPTCT) center is located in a separate mother and child hospital. The HIV testing center at IGMC was established as voluntary counseling and testing center (VCTC) in 1999 and remodeled under National AIDS control program III (NACP III) to ICTC in 2007. The data from 2000-2006 (VCTC) and 2007-2010 (ICTC) was compiled and analyzed. The protocol for HIV testing was completely in accordance to National AIDS Control Organization (NACO) guidelines, which include pretest counseling, consent, HIV testing and post test counseling, and maintaining confidentiality. For the diagnosis of HIV, rapid diagnostic kits provided by NACO from time to time were used. All serum samples reactive in the first rapid test were reconfirmed by two other rapid tests based on different principles. The services at ICTC were provided by a trained counselor and a technician. ICTC has been participating in national external quality assurance program. The centre is funded by State AIDS Control Society and under the administrative control of Department of Microbiology, IGMC, Shimla.
The analysis of patient profile with respect to modes of HIV transmission was done by using SPSS 17.0. A P < 0.05 was considered to be statistically significant. The client versus provider referrals were analyzed in the EPI info version 3.5.1. The outcomes of both significant and non significant variables have been reported.
The study has been conducted in a referral hospital and has certain limitations. The external validity is decreased and results are based on the data recorded by the counselor and the technician employed in ICTC. Some additional variables like, previous HIV status, acceptance after disclosure by the family, alcohol abuse, and household income, which could have added to the behavior pattern of the clients, were not available. However, being the first study in the first centre established in our state and located in an apex hospital, with maximum client load, the data provides valuable information to assess the impact of implementation of NACP III and to design appropriate HIV/AIDS control measures.
| Results|| |
0Performance of ICTC
There was a gradual increase in the utilization of ICTC from 2000 to 2006 and a four-fold increase from 2007 to 2010 [Figure 1]. Of the total 19,234 attendees, 17,411 (90.52%) were tested. [Figure 2] shows the number of clients counseled and tested from 2000 to 2010. From 2005, almost all the clients counseled underwent testing. The ratio between male and female attendees was 1.8:1 (m = 12564 including one transgender: f = 6670). Majority of the clients, 82.68% who attended ICTC were in the age group of 25-44 years, of which males accounted for 42.12%. Most of the clients at that time were living with their families. The services availed by the clients at ICTC are depicted in [Figure 3]. There was a significant difference in the utilization of ICTC by direct versus provider initiated clients in 2010 as compared to 2006. From 2006 to 2010, a total of 4241 direct walk-in clients availed services at ICTC, twice as many, 10,053, were referred by providers showing statistical significance. (Chi square value 70.35, P < 0.0000001). The provider initiated client visits increased from 4.85% in 2006 to 82.05% in 2010. However, in the direct walk in clients the HIV seropositivity was 8.01% while in the provider initiated it was only 2.76% being statistically significant (Chi square value = 178.8, P < 0.000000.1) The most common reason for availing ICTC services by direct walk-in clients was high risk behavior (HRB) seen in 78.13%. All HIV-negative clients with history of HRB were followed up at ICTC, and all PLHA were registered with the antiretroviral center. Other services provided at ICTC included condom demonstration and promotion, referrals to directly observed treatment centre for detection and treatment of tuberculosis, and referrals to Suraksha clinic for complaints of sexually transmitted infections.
|Figure 1: Clients tested at the integrated counseling testing center for HIV from 2000 to 2010 with linear trend line|
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|Figure 3: Client initiated versus provider initiated attendees from 2006 to 2010.|
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Profile of HIV seropositive clients
During this 11-year period 970 clients were detected HIV positive. The overall seropositivity among ICTC attendees was found to be 5.0% while amongst the clients who got tested for HIV it was 5.57%. The year-wise HIV seropositivity is shown in [Table 1]. The HIV seropositivity has shown a remarkable decline from 13.1% in 2007 to 1.6% in 2010 [Figure 4]. Amongst PLHA, the male to female ratio was 3:2 (m = 584 including one transgender; f = 386). Based on self-reporting, the heterosexual route of transmission was documented in 77.42% (n = 751; m = 439, f = 312). In both male and females, history of HRB has been documented to be the major mode of HIV transmission [Figure 5]. The routes of HIV transmission in different age groups are shown in [Table 2]. Bivariate analysis demonstrated that a higher HIV seroprevalence was significantly associated with clients with heterosexual route of transmission aged 25-44 years (P < 0.0001). Three men (0.3%) having sex with men and six injection drug users (0.6%) were recorded. Of the total 970 HIV-positives in the age group <15 years, 7.83% (n = 76) were detected HIV positive. Mother to child transmission (perinatal transmission) was recorded in 90.78% (n = 69) in which 65.21% (n = 45) were males and 34.78% (n = 24) were females. The natives accounted for 95.46% (n = 926) of all HIV positives. The rest HIV positives had migrated from neighboring states and eight had migrated from Nepal.
|Figure 5: Proportion of HIV positive clients according to the route of transmission|
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| Discussion|| |
ICTC serves as an ideal interface to a range of HIV prevention intervention, care and support services.  The clients who walk into ICTC may or may not know their HIV status. The skilful counselor provides informed choices to the client to volunteer for HIV testing and enables HIV positive clients to adopt a healthy life style, referral to ART and other support services. Significant increase in the client uptake from 781 in 2000 to 5574 in 2010 reflects to the effective confidential interaction between the counselor and the client. Vyas et al. has also reported the increase in ICTC attendees from 2,402 in the year 2002 to 10,133 in the year 2007.  At the national level 20, 00,000 clients have been tested in various VCTCs in India in 2001 and has shown an increasing utilization year after year. From April 2010 till December 2010, the number of clients attending the various ICTCs in India were 1, 11, 58, 869 Number of months = 9.  This can also be attributed to awareness among people having comprehensive knowledge of HIV/AIDS as reported in National Family Health Survey - 3 (NFHS-3).  Other factors include decrease in stigma and availability of antiretroviral therapy.  Of the total clients who underwent counseling, 90.52% were tested. From 2007, almost 100% were tested after precounseling indicating the effectiveness of counseling services similar to reported by other authors. , The provider initiated clients sharply increased from 4.85% in 2006 to 82.05% in 2010 [Figure 3]. During provider-initiated HIV testing and counseling, as a standard part of medical care, a healthcare provider offers HIV testing to all patients if they have not been tested recently unless the patient opts out. These include patients attending outpatient, inpatient, antenatal, sexually transmitted infection, tuberculosis, and emergency clinical settings.  However, the client-provider interactions needs to be explored in detail as we note that the HIV-positive detection rate is only 2.76% as compared to 8.01% in client initiated during the five-year period from 2006 to 2010. According to the age distribution, 82.68% were HIV positive in the age group of 25-44 years, which is similar the national average of about 89%.  In a study on the prevalence of HIV/AIDS and prediction of future trends in north-west region of India, HIV positivity was reported to be highest amongst sexually active persons aged 30-49 years and showed an increase in the age-group of 20-29 years. 
The male to female ratio of clients attending ICTC has shown male preponderance in several studies being around 64%. ,, The national average for female ICTC attendees is 38.4%.  In the present study, the males to female ratio was 3:2 (m = 12564 including one transgender: f = 6670). The males in our study were in higher proportion being 65%. The antenatal group has not been included in this study, being routinely monitored during sentinel surveillance. The females who attended ICTC were mostly the spouses of HIV-positive clients or provider initiated. This has serious implications in resource-poor countries where HIV pandemic in women has shown a rising trend due to heterosexual transmission.  This was quite evident by the fact that, though only 6,670 females were screened for HIV infection in contrast to 12,563 males, the HIV positivity was higher in females 5.78% (n = 386) than in males 4.64% (n = 584) being statistically significant (Chi-square value 11.79, P < 0.001). HIV/AIDS spreading to females both in the HRB and married monogamous relationship could be attributed to the inability of the female sex to negotiate safer sex and early age of marriage.  In order to prevent infections spreading to females, focused programs on information and education need to be implemented apart from PPTCT. Mother to child transmission or perinatal transmission is a significant route of transmission of HIV infection in children below the age of 15 years, which occurs during pregnancy, child birth, or during breast-feeding. It accounts for 15-25% of all new infection and more than 90% of HIV infections in children are acquired by transmission from mothers to their infants.  Several authors report the rate of perinatal transmission ranging from 2.63%  up to 12%.  In our study, 7.5% (n = 69) children <15 years of age were infected with HIV and 90.78% children were recorded to be HIV positive due to mother to child transmission. This has to be strongly addressed as it leads to proportionate increase in the children being infected and has already doubled infant mortality in the worst-affected countries. 
In both males and females, the heterosexual route remains the most common route of transmission of HIV infection. A study from eastern India reports 80.4%.  Vyas et al., in their study report heterosexual transmission up to 81.6%, and Lal et al., reports 84%, while in the present study transmission through heterosexual route has been noted to be 77.42%.
Other routes of transmission also need to be focused on so as to achieve zero new infections. Transmission through blood transfusion has shown a declining trend due to mandatory screening of donated blood before transfusion. At the national level, it is estimated to be 1% in 120,000 new HIV infections due to transfusing blood or blood products.  In the present study, 0.2% (n = 2) have been reported from our state. Similarly, two cases (5.1%) have been reported in ICTC attendees.  The prevalence of HIV among IDUs according to the HIV sentinel surveillance report 2008 is about 18%.  During the 11-year period, 0.6% (n = 6) cases of HIV transmission have been documented in IDUs. Thirteen cases have been reported over a six-year period by Vyas et al.,  and as none have been reported due to IDU needle sharing in ICTC attendees from Ahmedabad.  In India, Manipur is the most affected state by IDU-related HIV epidemic and has the highest HIV prevalence. , In 13.60%, (n = 132) the mode of HIV transmission was not specified which implies that either the clients were unwilling to identify the route of transmission due to fear of discrimination; stigma or improved counseling skills were needed. Non response regarding the pattern of risk behavior to a large extent has been also noted (42.8% males, 90.8% females) in a study conducted amongst clients attending a district hospital VCTC in Udupi.  At the time of testing, though all the clients were residing with their families but to comment on the acceptance by the family after disclosure especially in case of females cannot be commented upon.
The HIV seroprevalence in the general population has been shown to be 0.34% from a community-based household survey.  Based on national HIV sentinel surveillance in 2008-2009, the adult prevalence of HIV was 0.31% and in our state, HIV prevalence among antenatal and STD clinic attendees was 0.00%.  In the present study, HIV seroprevalence of 5.0% in ICTC clinic attendees was found similar to the HIV seropositivity rate of 5% amongst ICTC attendees in the country. HIV seroprevalence was reported to be 4.8%, in ICTC attendees in Ahmedabad.  Higher HIV seroprevalence has been reported by other authors being 9.6% in Udupi and 17.1% in West Bengal in 2003.  The adult HIV prevalence at the national level has declined from 0.41% in 2000 to 0.31% in 2009 with 23.9 lakh people infected with HIV based on the sentinel surveillance 2008-2009.  In 2010, the HIV prevalence in our state was 1.6%, which corroborates with the epidemic projections by NACO. 
Young adults on account of their occupation stay away from their families and are at high risk of acquiring infection  and do not have access to information, condoms, or support services to enable them to have safe sex. Lack of knowledge, financial resources, and poor health and life skills increases their vulnerability to HIV infection. The findings of NFHS-3 depict highest HIV seroprevalence of 0.77% in the lowest wealth standards as against 0.18% with higher wealth standards. , Adverse attitude toward condom use coupled with poverty, illiteracy, and promiscuous behavior has increased India's vulnerability to the AIDS epidemic.  Increased utilization of ICTC services has enabled patients to know their HIV status. Thus, counseling and testing services need to be expanded to enable more and more people avail free services at ICTC and know their HIV status and is an important marker for allocation of resources by planners and policy makers.
| Conclusion|| |
ICTC have proved to be a critical interface between the client and the public health system where any client can know about his or her HIV status in resource limited nations. Being the oldest ICTC in the state and catering to a large population, the results can be utilized to assess the impact of NACP-III and to evolve evidence based strategy to meet millennium development goals.
| Acknowledgment|| |
The authors thank the in-charge ICTC IGMC, Shimla for providing permission and acknowledge the assistance and co-operation of the Himachal Pradesh AIDS control Society and ICTC staff of IGMC, Shimla.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]