Introduction
Human Immunodeficiency Virus / Acquired immunodeficiency syndrome (HIV/AIDS) is a life-threatening, secondary immunodeficiency disease and remains an immune threat to all over the world. HIV/AIDS has emerged as a serious public health emergency in Manipur, Northeast, India. The first HIV positive case in Manipur was reported in 1989 from the blood sample of an intravenous drug user (IDU). Since then Manipur with a population of 3 million has an area of 22.327 km square is reported as the second highest (1.43%) adult HIV prevalent state in the country, according to HIV estimation 2017 by the National AIDs Control Society (NACO). Manipur with hardly 0.2% of India’s population contributes 8% of India’s total positive case. The Strategic Information and Management SYSTEM is created at the State level to integrate from the grass-root level to the topmost level decision-maker for periodical tracking of the epidemic situation in Manipur. According to SIMS report 2016-17 by Manipur AIDS Control Society (MACS) the proportion of the male clients with HIV positive cases was found to be 56% followed by 43% of female clients with HIV positive case whereas Transgender / Transsexual with HIV positive case was found to be only 1% . The majority of the HIV positive clients were between the age group 35-49 years (41%) followed by age group 25 to 34 years (26%). One of the main causes of the high HIV prevalence in the state is the easy availability of heroin through illegal drug trafficking from the Golden Triangle area. To Limit the expansion of HIV, the various program has been initiated. NACO initiated Anti-Retroviral Therapy (ART) program countrywide on 1st April 2004 and to intensify the program, the second line ART program was started in January 2008. There are presently 11 ART centres providing free ART in Manipur. In addition, there is two private ART centres.
In this review, the authors focus on the current statistics of HIV of Manipur and its improvement data, major causes, and steps taken up by the Government of Manipur(SIMS), NGO, researchers and policymakers against the prevalence of HIV in Manipur.
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Methods
The data for this study was collected from the SIMS Annual report by Manipur AIDs control society (MACS) https://manipursacs.nic.in/, HIV Sentinel Surveillance Report of Manipur, Annual Report NACO http://naco.gov.in/. In 10 April 2020, based on keywords search ‘Manipur’ and ‘HIV’ an advanced bioinformatics’ search for published literature in English in last decade (since 2010) was performed using PubMed https://www.ncbi.nlm.nih.gov/pubmed/, PubMed delivers a publicly available search interface for MEDLINE as well as other NLM resources, making it the premier source for biomedical literature and one of the most widely accessible resources in the world. The selected articles are further accessed in ISI web of science database to maintain the standard of this review article. Finally, the steps involved in our article involves plotting data and information from published literature and extraction of related data and analysis of the findings.
Results
From the database PubMed, many articles were found to be published, 17 articles were considered for this study. The collection of accurate data, facts and figures from different sections of the community as well as from various units of sub-divisions will present near-accurate data of emerging HIV/AIDS epidemic situation in the state Manipur, which can then be observed. SIMS may assist MACS & DAPCU in monitoring, evaluation and surveillance for taking appropriate preventive measures, analysis, identifying, alerting program management and providing way for corrective measures.
Targeted Intervention(TI) program TI-IDU:
The main High-Risk Groups (HRGs) are IDU, Female Sex Workers (FSW), Men who have sex with men(MSM), Transgender(TG) and besides HRGs, other population groups, Migrant workers and Long-distance Truckers, known as bridge populations. The prevention programmes focused among (HRGs) and Bridge population supported by NACP are termed as Targeted Interventions(TI). Manipur State AIDS Control Society is implementing 63 Targeted Intervention Projects covering IDUs, FSWs, FIDUs, MSM and Migrant workers. They are highly vulnerable to HIV infection. Prevention efforts have been targeted towards HRGs and Bridge populations to reduce new HIV infections and prevent transmission to low-risk populations.
Services provide under Targeted Intervention:
Behaviour change communication, condom promotion and distribution( except for bridge population) free as well as through social marketing, STI detection & treatment and Partner Management, Linkage with Integrated Counselling and Testing Centres(ICTC), Linkage with Care/Support/Treatment services for HIV positive Clients, Community mobilization and ownership building, Creating an enabling environment with community involvement and participation, Specific intervention for IDU: Distribution of clean needle and syringes, Abscess prevention and management, Opioid Substitution Therapy(OST), Linkage with Detoxification and Rehabilitation services, Specific Intervention for MSM/TG: Provision of Condom/Lubes.
Achievement of TI-IDU:
Table 1: The above shows the coverage of IDus during the year 2016-17.The total target of the IDU during the year 2016-17 is 16,500 and observed that average monthly coverage is more than 100%. The majority of the new IDUs covered during the year 2016-17 were Non-daily injectors.
Fig 1: As per the above graph, the majority of the TI-IDUs covered more than 100% out of the target given by SACS except for three IDU-TIs namely: WESDEV, IFORD and RVS Khongjom.
A major component of HIV intervention among the HRGs is Condom promotion. They are encouraged to use condoms and provided free as there is a chance of transmission of HIV through unprotected sex. As per data, it is observed that the estimated number of sexual acts was 1624860 among the male clients and 353764 among the female clients, an average Condom distribution was more than 100% out of the estimated sexual acts.
Fig 2: Condom services provided by MSM Tis, 2016-17
Migrant TIs:
Manipur State AIDS Control Society is providing a comprehensive package of services like Outreach services, Counselling services, Condom distribution, Health camps, IEC activities etc. for migrant workers through two TI-NGOs. A total number of new individuals registered during 2016-17 was 8,705 however the actual coverage of Migrants including Old could not be extracted due to inadequate data. Counselling services provided were 6,139. The total number of Migrants covered through outreach sessions during the 4807 IPC programs conducted and the number health camps organized was 126
Needle Syringe exchange program:
It is one of the most important components of TIs covering IDUs. Under this, TIs are distributed with new needles and Syringes to the IDUs and taken back from them after use it. As per the above table, more than half (71%) of the total number of estimated injecting acts are daily injectors and only 29% are non-daily injectors. The number of syringes distributed is about 95% of the estimated injecting acts. TIs need to distribute syringes as per the requirement to reduce the chances of sharing syringes. Further, the return rate of syringes was 77% only, TIs may focus to increase the return rate of syringes.
Integrated Counselling and Testing Centre (ICTC)
An Integrated Counselling and testing centre (ICTC) is a place where a person is counselled and tested for HIV, on his own free will or as commanded by a medical provider. The main functions of an ICTC are - Early detection of HIV, Provision of Basic information on modes of transmission and prevention of HIV/AIDS for promoting behavioural change and reducing vulnerability, Link people with other HIV prevention, care and treatment services, Provision of Early Infant Diagnosis.
Overall 1,013 clients were found HIV positive out of 78187 clients were tested at the ICTCs. About 4% of children were found HIV positive out of 1516 were tested. It is also observed that the HIV positive among the spouses is 43%, out of 407 were tested, so high. As such, the program needs to focus on HIV testing of spouses of HIV positive clients.
Fig 3: it is found that the majority of the clients detected HIV positive is male clients i.e,60% followed by 40% female clients and 1% among the TS/TG. Presently 42 FICTCs are functional in Manipur and SIMS.
Blood Safety:
Manipur-SACS is trying to make available enough safe blood in all the Hospitals of Manipur. Various activities like sensitization cum VBD camps are taken up by the blood safety division of MACS for ensuring access to safe Blood and Blood Products . Blood Transfusion services play a vital role in a health care delivery system. Under SBTC/MACS Manipur always try to address issues of Blood collection, access and quality management practices. As a part of the mobilization of blood donors, National Voluntary Blood Donation Day 2016 was observed on 1st October 2016.
Anti-Retroviral Therapy (ART):
There are presently 11 ART centres providing free ART. One Regional Paediatric Centre at JN Hospital has been implemented to treat complicated paediatric AIDS cases referred from different ART Centres of Manipur and the other the North East States. In addition, there is two private ART Centres, one at Churachandpur and another one at Moreh run by a bilateral donor Medicines Sans Frontiers. The state has at present a total of 9 LACS under MACS and orders MSF-Churachandpur to supplement the ART centres.
To render effective counselling to PLHA who are on ARV drugs about drug adherence and track down the lost to follow up patients of both Pre and on –ART patients, there are 9 Care Support centres under Vihan Project linked to all the ART centres. All the data of patients and children on ART are now computerised for proper monitoring in terms of drug adherence, loss to follow-up. Fixed-Dose Combination (FDC) paediatric formulations of ARV drugs are available at all ART Centres for better treatment and CLHAs. To render maximum treatment of PLHAs with ARV drugs, the maximum number of PLHAs have to be referred from different HIV service centres to ART Centres.
The number of PLHAs accessing ART have almost reached 15,336 as on 31st March 2016. The discovery of ARV and its accessibility have entirely changed the scenario of HIV/AIDS. It has improved the quality of life for many PLHAs which had literally made thousands of other PLHAs more open to coming out in the public and this has led to a substantial reduction in the level of stigma and discrimination.
Antiretroviral resistance and genotypic characterization of HIV in Manipur:
A publication related to resistance to HIV drugs suggests that the drug resistance mutation (DRMs) , genetic variance and origin of transmitted drug resistance of HIV-1 among the HIV-1 infected wives of IDUs in Manipur. HIV pol gene sequences were considered from blood samples by viral gene amplification method and sequencing. Sequences were then observed for origin and drug resistance genetic variants. The result indicates that among the treatment-naive cases, around 35% had transmitted drug resistance mutations(TDRMs) while among treatment cases, 50% had Acquired drug resistance mutation (ADRMs). TDRMs and ADRMs both shows resistance to nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors( NNRTIS),and protease inhibitors (PIs). Most of the isolated HIV 1 sequences (77%) were subtype C which is the highest prevalence among all HIV-1 subtypes and is predominant in our country India. While 9.1% was discordant subtype, 6% was subtype B ,and around 4% was CRF_01AE and about 2% was URF_BC. TDRM strains were found to be arise from Vietnam, Myanmar and mainland India. It also reveals the appearance of CRF_01AE for the first time in Manipur. The result of this case indicates high prevalence of drug-resistant mutation and complex molecular epidemiology in state Manipur.
Discussion:
This review article provided an opportunity to study and update the HIV/AIDS epidemic and prevalence. State Manipur lies adjacent to the Golden Triangle where the borders of Myanmar, Laos and Thailand meet, most of its eastern boundary is formed by the Myanmar which is the second largest opium producer in the world. Manipur is on a major drug-trafficking route from the Golden Triangle, thus drugs are variably available. Heroin, locally known as “number four” among IDUs, it is a major injecting drug in Manipur, and a powder form of dextropropoxyphene is also used by IDUs for drug Injection.
Fig 4: Map of the focus site and possible route of origin of transmitted drug-resistant strain of Manipur. Red star suggest the focus site. Arrows suggest the possible way of HIV origin according to viral subtype and pink triangle shows the golden triangle area.
IDUs who share needles are more likely to engage in unprotected sex with their regular partners. These results provide evidence regarding the debate around the increase in HIV transmission to spouses from high risk partners. A large proportion of HIV positive IDUs in Manipur have adopted safer injecting drug use behaviour and don’t share needles with others which is a major success of the MACS. This study adds literature suggesting a significant association between IDUs risky sexual practices with a casual partner and non-condom users. The data of this study indicate that the majority of the IDUs who have sex with female casual partners were not using condoms in their relationship, this finding is similar to those reported in studies elsewhere in India. Female sex workers are also in high risk for sexual transmission of HIV and Hepatitis virus. According to report, female drug users engage in sex work to support their drug use. As HIV/ AIDS is mainly associated with the behavioural nature of a person many people hesitate to disclose their HIV positivity. Various reports of HIV/ AIDS infected persons being bullied by their society. The ART drug distribution had been started since 1st April 2004 in Manipur, it remains inaccessible among the HIV/AIDS infected patients due to hesitation on being registered themselves in ART canters which results in serious public health issue for diagnosis and ART treatment. The easy availability of drugs(heroin) in Manipur, an important drug trafficking route, and ongoing political insurgency, have led many NGOs possibly focused on development to adopt drug use and prevention as their major goals, and to form alliances as anti-drug pressure groups. Moreover, drug trafficking is allegedly a source of funding for some of the insurgency groups; thus, combating the drug trade also serves political and military goals. From the perspectives of participants and key informants, the actions of many NGOs and anti-drug groups often serve to produce risk by fomenting criminalization and rigid abstinence-only approaches thereby targeting drug users themselves.
Most IDUs have low-wage jobs and are unemployed. Without the support from family members, some IDUs undergo crime activities in order to get or buy drugs for their eager needs, including stealing, which may lead them in prison sometimes from the direct report of family members. Moreover, injecting drugs may also be available in prisons, at higher prices, it is very difficult to get sterile needles in prisons. And many IDUs in prison, including those who are known to be HIV positive, may be forced to share needles with others. Drug use in Indian prisons has been caught by the Indian Government. But India does not have government-sponsored NSPs or opioid substitution treatment programmes in prisons, which increases the spread of HIV and negatively affects the health of HIV-positive IDUs inside the prisons.
Fig 5 : Flowchart of factors which influence high HIV/AIDS
The person-to-person spread of HIV is called HIV transmission. HIV is spread only in certain body fluids from a person who has HIV: Blood, Semen, Pre-seminal fluids, Rectal fluids, Vaginal fluid, Breast milk. HIV transmission is only possible if these fluids come in contact with a mucous membrane or damaged tissue or are directly injected into the bloodstream (from a needle or syringe). Mucous membranes are found inside the rectum, the vagina, the opening of the penis, and the mouth.
Manipur State AIDS Control Society has accorded the title of Brand Ambassador of HIV/AIDS to Mr. Khundrakpam Pradipkumar, recently crowned Mr. Manipur (60 kg wt), who has been living with HIV for over a decade now. He has also been selected among the six finalists in the Mr. India contest held in Meerut (UP) in last week of March. His mission as an Ambassador is to take a leading role in spreading HIV/AIDS messages to people, particularly the PLHAs to motivate them to ‘live and achieve’ even with HIV in them.
Conclusion :
Our study and finding shows that the IDUs who engage risk like unprotected sex with casual partners, unsafe needle-sharing drug injection habits are more likely to engage in unsafe sex with regular female partners so they must acquire specific knowledge by providing awareness programs. So the ongoing risk can be reduced for IDUs need to expand their main focus to add communication and idea about condom use in different relationships in addition to addressing IDUs unsafe injection practices in an effort to achieve the main goal of minimum or zero new infection. The study identified powerful social, economic legal, policy-level factors that lead to a context in which HIV positive IDUs in Manipur who might otherwise adopt safer injecting practices instead of sharing needles. Such high-level interventions hold the promise of effecting sustainable reduction of HIV infection among IDUs and improving the health of IDUs living with HIV in Manipur. Moreover, Manipur has the highest rate of HIV prevalence rate in the country so, any study related to HIV/AIDs in this region need to encourage, solve the health issue and encourage the development issue of the country as whole. The major cause of HIV pandemic in this International border area is the uses of the drug heroin which are transported and smuggled from the ‘South Asia Golden triangle’. The HIV pandemic in such border region is more complex than another region of this country due to the emergence of recombinant HIV forms and DR HIV-1. Further studies like emerging genetic variants in response to ART, the effect of coinfection with different viruses need to be inspired in all international borders to limit the expansions of more complex form of the virus and increase the rate of HIV testing coverage in Manipur.
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