Literature Review

ORG Centre for Social Research (2003) examined awareness and behaviours related to reproductive health and HIV/AIDS among truckers and their cleaners/helpers in the cities of Ranchi, Bokaro and Jamshedpur in the State of Jharkhand, India. The baseline survey showed that the level of awareness regardingHIV/AIDS was quite high. However, the level of awareness regarding the prevention of HIV/AIDS was not so high. More than 40 percent of truckers and cleaners/helpers had misconceptions on the mode of HIV/AIDS transmission. Awareness of sexually transmitted diseases (STDs) and their common symptoms was particularly low among truckers and cleaners/helpers. Overall, condom awareness among the truckers and cleaners/helpers was high. Truckers and cleaners/helpers were sexually active at a young age and were at risk of HIV transmission, since they had multiple partners.

KABP study among truckers in India G K S Ganesan PONDYCHERRY AIDS CONTROL SOCIETY, Pondy, India Background: Since AIDS was found in india in 1981,the information spreads about HIV/AIDS almost in every part of place done by governement , NGOs and mass media.But knowledge and attitude of the truckers toward HIV/AIDS epedimic is still very low.To know how far the truckers attitude especially their own sexual health.A research study has been designed and conducted among 200 truckers in the state of Tamil Nadu. Methods: One to One interaction and Focus group discussion ( FGD ). Results: From 200 truckers who participated in the research study, 99% of them admitted that they heard of STDs/HIV/AIDS,A few of them admitted that condom reduces sexual pleasure and STDs leads AIDS. Conclusion: The KABP study reveals that the truckers needs to be given accurate and correct information about AIDS through a multple channels.The people who are currently working in the field of AIDS prevention and care programmes need a special training programme to impart RISK PERCEPTION among the high risk population.

The XIV International AIDS Conference Abstract no. G12640

Male sexual behavior has received considerable attention in the past decade because of the major role that men play in the HIV epidemic. Current global statistics show that there are more men who are afflicted with the disease. Of the 33 million adults who have been living with HIV/AIDS as of December 1999, men comprised 17.3 million while women constituted 15.7 million. In the coming years, however, HIV infections in women are expected to surpass those in men. Men continue to contribute to the rapid spread of HIV because in many societies their dominant position often gives them the power to decide when and with whom to have sex, and whether or not protection against HIV will

be utilized. Thus, men, particularly those who are engaged in risky sexual and drugtaking behavior, are most likely to infect women as well as other men. Currently, men direct the course of the HIV pandemic and in order to reduce the rate of rapid spread, prevention programs should address men.s risky sexual and drug-taking behavior (Foreman, 1999). The spread of HIV, however, is uneven among the world.s regions. As of December 1999, UNAIDS reported that the African continent exhibited the highest rates of infection particularly in countries of Sub-Sahara with a total estimate of 24.5 million adults and children who were living with HIV/AIDS. South and Southeast Asia ranked second with a total number of 5.6 million reported HIV/AIDS cases. Cambodia, Thailand, Myanmar, and India exhibited the highest HIV/AIDS prevalence rates among adults in this region (4.04, 2.15, 1.99, and 0.70, respectively). Despite the high rates of infection in many parts of Asia, several countries continue to exhibit low prevalence rates (below 1%). One of these countries is the Philippines with an HIV prevalence rate of 0.07 percent (UNAIDS, 2000). Jharkhand Epidemic Scenario (2009 Estimates) Total Male Female Adult HIV Prevalence (%) 0.13 0.16 0.10

RATIONALE FOR TARGETED INTERVENTIONS TO TRUCKERS A central strategy of Indias National AIDS Control Programme III (NACP III) is to reduce sexual transmission of HIV within high-risk sexual networks, and from these high-risk networks into the general population. Accordingly, NACP III prioritizes HIV prevention among truckers as a key programme component. Reaching truckers with effective HIV prevention programmes and services is important for a number of reasons: Evidence in India and elsewhere shows that the community of truckers is vulnerable to HIV due to a higher prevalence of risky sexual behaviour, which results from a variety of social and economic factors as well as their work patterns. Reportedly, close to 36%1 of truckers are clients of sex workers and 15-20%2 of clients appear to be truckers. Therefore, truckers represent a key sub-segment of the total male client population. Because long-distance truckers move throughout the country, those who are at higher risk of HIV can form transmission bridges from areas of higher prevalence to those of lower prevalence. India has about 3.3 million km of road network, making it one of the largest networks in the world. This figure includes expressways, National Highways, State highways and major district roads and rural roads. It is estimated that 65%-70% of the nations cargo handling is done by road, with the remaining 35% by rail. National Highways are the prime arterial route, covering about 65,559 km. Although National Highways constitute only 2% of the total road network, they bear approximately 40% of the total traffic. The Ministry of Road Transport and Highways states that as of 31 March 2003, the total number of registered motor vehicles in India was 6,735,291, of which 2,159,824 were multi-axle/articulated vehicles (i.e. trucks and lorries). The Asian Institute of Transport Development (AITD) gives a figure of around 5 million truck drivers in India. This estimate is based on the assumption that there are about 2.5 million trucks in the country and that each truck has two drivers. Similarly, the report of a study by the Indian Institute of Health Management Research quotes a figure of about 5-6 million truckers (i.e. truck drivers and other crew

members) in India. Among them, about 40%-50% (or about 2-2.5 million) ply on long-distance routes. Given the rise in the number of trucks operated for goods transportation, the total number of truck drivers in the country is expected to double in the next ten years. 1Healthy Highways Behavior Surveillance Survey, First Round, 2000 2 National Behaviour Surveillance Surveys among Clients of Sex workers 1.2 HIV RISK AMONG LONG-DISTANCE TRUCKERS Long-distance truck drivers and their helpers spend months at a stretch on the highways and thus are away from their home family members for extended periods of time. These truckers are more likely to engage in high-risk sexual behaviour than short-distance truckers. They may have multiple sexual partners, including female sex workers (FSWs) on the highways, or have other fixed partners en route or at places where they stop for rest or food. This results in a higher prevalence of sexually transmitted infections among truckers than among the general population. Truckers are also reported to have sex with male sexual partners. For truckers, immediate sexual needs appear to take precedence over the possible longterm consequences of unprotected sex. The national BSS of 1999 indicates high-risk sexual contacts during transit (87%) and poor condom usage (11%) among truckers, making them vulnerable to STIs and HIV/AIDS. Surveillance studies indicate that the prevalence of HIV among truckers in general may be more than 10 times higher than in the general population (7.4% among truckers as compared to 0.7% with the general population). Given an estimated HIV prevalence of 11.16% among long-distance truckers in India, there could be an estimated 0.6-0.7 million HIV positive truckers by 2005 figures. 1.3 FACTORS WHICH MAKE TRUCKERS VULNERABLE TO HIV The factors affecting truckers risk-taking behaviour are varied, but are important in understanding the overall vulnerability of truckers to HIV. The harsh working conditions of truckers, including the risk of injuries, robbery, attacks and destruction of their vehicles, clearly contribute to their low perceptions of the seriousness of HIV infection. While the level of knowledge among truckers related to STIs and HIV/AIDS is relatively high, this knowledge is rarely converted into action. Lack of concern for self and a false sense of security due to improper understanding or interpretation of information about HIV/AIDS lead to risky behaviour. Other factors which affect truckers vulnerability to HIV include: Truckers are of an age to be sexually active but are separated from regular partners for extended periods of time Poor road conditions, long work hours and the urgency to reach their destination in the stipulated time cause stress In the absence of entertainment, consumption of alcohol leads to vulnerability Highly active and easily accessible sex networks operate along the highways and at halt points Truckers carry significant sums of cash to meet their travel needs, making them attractive customers to the sex work industry Limited sexual health services are available on the highways. Even if a trucker wishes to have himself treated for an STI or wants to collect condoms, he must wait until reaching his final destination or home. While the truck driver has money to access services of the sex networks, the cleaner/assistant is deprived of such privileges. But he may nevertheless take the opportunity to have sex when it arises.

This can leave him or his partner vulnerable to infection if his information about sexual health is minimal. Senior truckers may use younger ones, especially cleaners, for sex. Power dynamics within the community are such that the cleaner or younger trucker is largely helpless, and ignorance about the risks of sex between men can lead to infection with STIs (including possibly HIV). 1.3.1 Related Groups at Risk for HIV A large number of FSWs operating on the highways are from villages nearby and offer sex to increase their income. Lack of information for self-protection among these women is a concern. With NHAI constructing new highways or upgrading the present highways, many migrant labourers have become involved in road construction, and female road workers often also sell sex to truckers. Mapping data on these two groups should be shared with the concerned TI agencies (FSW and migrants) to enable enhanced coverage of these populations 00000-----------------------------------------------------------------------------------------------------------National Response to HIV/AIDS in India Introduction Available evidence on HIV epidemic in India shows a stable trend at a national level. The provisionally estimated number of people living with HIV in India is 2,390,000, with an estimated adult HIV prevalence of 0.31% in 2009( HIV/AIDS is concentrated among high-risk group populations and is heterogeneous in its spread. The primary drivers of HIV epidemic in India are unprotected paid sex, unprotected sex between men and injecting drug use. Heterosexual route of transmission accounts for 87% of the HIV cases detected.( The following popper user interface control may not be accessible..In the north-eastern part of the country, however, injecting drug use is the major cause for the epidemic spread; sexual transmission comes next. Over the years, the HIV/AIDS epidemic has moved from urban to rural India and from highrisk to general population, largely affecting youth.

Figure 1 HIV Prevalence among adult population, India (2006-09) National AIDS Control Programme (NACP) aims to contain the spread of HIV in India by building allencompassing response reaching out to diverse populations. The overall goal of NACP-III (2007-2012)( The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version. Destroy user interface control2) is to halt and reverse the epidemic in India by 2012 by integrating programs for prevention, care and support and treatment. This will be achieved through a four-pronged strategy: a. Prevention of infections through saturation of coverage of high-risk groups with targeted interventions (TIs) and scaled up interventions in the general population; b. Provision of greater care, support and treatment to larger number of people living with HIV/AIDS (PLHA); c. Strengthening the infrastructure, systems and human resources in prevention, care, support and treatment programs at district, state and national levels and d. Strengthening the nationwide Strategic Information Management System (SIMS). Go to: Program Implementation

To meet the above objectives, various interventions were initiated with clearly defined technical and operational guidelines and monitoring indicators, which are constantly reviewed. The National AIDS Control Organisation (NACO)( The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version. Destroy user interface control3) under Department of AIDS Control of the Ministry of Health and Family Welfare is the overall body for framing policy, guidelines and strategies for program implementation. It also releases funds to various states and reviews the progress under various components of the program. State AIDS Control Societies (SACS) have been constituted throughout the country with the responsibility of program implementation. In high HIV prevalent districts, District AIDS Prevention Control Unit (DAPCU) has been set up for direct supervision at the ground level. Go to: Program Components Targeted interventions HIV epidemic in India is mainly concentrated in high-risk population like female sex workers (FSW), men having sex with men (MSM), injecting drug users (IDU) and clients of sex workers.Given their special vulnerabilities, prevention strategies include five elements behaviour change, treatment for sexually transmitted infections (STI), monitoring access to and utilization of condoms, ownership building and creating an enabling environment. Prevention strategy of NACP-III includes peer led interventions by Non-Governmental Organizations (NGOs)/Community Based Organizations (CBOs), both in the rural and urban areas. These are networked and linked to general healthcare facilities to ensure that HRG s' access them without stigma or discrimination; they are also linked to Community Care Centers (CCC), Counseling and Testing Centers and anti-retroviral treatment (ART) centers. TIs are aimed to effect behavior change for having protected sex through awareness rising among the high-risk groups and clients of sex workers or bridge populations, particularly single male migrants and long distance truckers. At present, 1375 TI projects are being implemented by SACS and about 220 projects are managed by partners. Of the estimated number of high-risk groups, the coverage has been 78.3% of FSW, 70.3% of IDU and 76.2% of MSM and transgender populations. Management of STI STI and Reproductive Tract Infections (RTI) are key determinants of HIV transmission. An estimated 6% of adult population suffers from STI/RTI annually, accounting for about 30 million episodes per year. Presence of STI increases the risk of acquisition and transmission of HIV infection five to ten times. Control of STI provides a window of opportunity for prevention of new HIV infection and is the most cost-effective means for preventing HIV transmission. Provision of standardized package of STI/RTI services through syndromic case management by public health facilities and preferred private practitioners is the cornerstone of the program. Pre-packaged, color-coded syndromic drug kits are being supplied through the program to ensure compliance to treatment. During the year 2009-2010, 8,240,000 STI episodes were managed. The target for NACP-III is to treat 15,000,000 STI/RTI episodes by the end of NACP-III. Condom promotion Condom promotion strategy aims to integrate the use for family planning as well as prevention of HIV and STI using various channels of supply, i.e. free, through social marketing and commercial outlets. In addition, various innovative approaches have been introduced including Condom Vending Machines (CVMs) at strategic sites, female condoms particularly for FSW and special condoms for MSM population.

During 2009-2010, 2,160,000,000 condom pieces were distributed which included 840,000,000 by social marketing, 600,000,000 by free distribution and 720,000,000 through commercial sale. More than 21,000 CVMs have been installed in various states, including metros and major cities, across the country. Blood safety Blood Safety program under NACP-III aims to ensure provision of safe and quality blood to the far-flung remote areas of the country in the shortest possible time through a well-coordinated National Blood Transfusion Service. This is sought to be achieved by the following: Strengthening infrastructural facilities and establishing blood storage centers in the primary health care system for availability of blood in far-flung remote areas; Ensuring that regular (repeat) voluntary non-remunerated blood donors constitute the main source of blood supply through phased increase in donor recruitment and retention; Vigorously promoting appropriate use of blood, blood components and blood products among the clinicians; Developing long-term policy for capacity building to achieve efficient and self-sufficient blood transfusion services; Mandatory testing of each unit of blood for HIV, Hepatitis B and C, Syphilis and Malaria and Voluntary blood donation for which camps are organized with the help of various organizations. Presently, the government is supporting 1124 blood banks in the country, including 10 Model Blood Banks and 137 blood component separation units, to promote appropriate clinical use of blood. It has also been planned to set up four Centres of Excellence in Transfusion Medicine (Metro Blood Banks) in New Delhi, Mumbai, Chennai and Kolkata. A Plasma Fractionation Centre will be established with a processing capacity of 150,000 l of plasma annually to meet the ever increasing demand of hemophilia patients and other clotting factor deficiency patients. NACO along with National Rural Health Mission (NRHM) has taken the initiative to establish blood storage centers in First referral Units (FRU) where a full-fledged blood bank is neither feasible nor required. Against an annual requirement of 8,500,000 units/year, the availability of blood in government supported blood banks is only 4,400,000 units/year. The remaining demand is met through blood banks in private hospital/private commercial blood banks. During 2009-2010, voluntary blood donation was increased to 76.1%, against our target of 75%. A total of 2,880,000 units of blood were collected by organizing more than 60,000 VBD camps in 2009-2010. Integrated counseling and testing services Counseling and HIV testing services are being provided through 5223 Integrated Counselling and Testing Centres (ICTC) mainly located in government hospitals. These services are also being expanded in PHC/CHC in the rural areas, private sector facilities and mobile clinics. The main functions of an ICTC include HIV diagnostic tests, counseling and promoting behavioral change and referral for care and treatment services. The ICTC services are accessed by voluntary clients (who visit the ICTC on their own), provider initiated client testing including patients with signs/symptoms of HIV infection, patients with STI/RTI/TB and pregnant women visiting antenatal clinics. During the year 2009-2010, more than 14,300,000 people availed counseling and testing services including 6,119,000 pregnant women. Nearly, 300,000 people were detected HIV positive during the year. A total of 12,282 mother-baby pairs were given prophylaxis dose of Nevirapine. In addition, 38,196 patients co-infected with HIV and TB were diagnosed and treated. Care, support and treatment The care, support and treatment needs of HIV positive people vary with the stage of the infection. The HIV infected person remains asymptomatic for 6-8 years. As immunity falls over time, the person becomes susceptible to various Opportunistic Infections (OIs). At this stage, medical treatment and psychosocial support are needed. ART and prompt diagnosis and treatment of OIs improve the survival and quality of life.

Care support and treatment services are provided through various facilities closely linked with each other, with a defined referral system as illustrated in Table 1. Selected ART centers are upgraded as Centers of Excellence (CoE) for tertiary care, training and operational research.

Table 1 Key functions of facilities for diagnosis and treatment of HIV/AIDS At present, nearly 1,000,000 people living with HIV/AIDS are registered for treatment and 350,000patients are being provided free ART, including 20,000 children. Information, education, communication and mainstreaming Information, Education and Communication (IEC) cuts across all program components of NACP-III.( The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version. Destroy user interface control2) There has been a strategic shift in IEC strategy during NACP-III, with the focus moving on to behavior change communication from just awareness creation during NACP-II. NACO has undertaken extensive campaigns to raise awareness and strengthen health seeking and safe preventive behavior among people toward HIV. Thematic campaigns are designed and undertaken using mass media, mid media, outdoor and interpersonal communication channels. Some innovative interventions initiated for mass awareness include Red Ribbon Express [Figure 2] during 2007-2008 and 2009-2010 and multimedia campaigns in Nagaland, Manipur and Mizoram during 2009-2010. The key interventions targeting the youth are Adolescence Education Programme (AEP) and Red Ribbon Clubs. Efforts are being made to mainstream HIV/AIDS with other sectors, notably with the departments of women and child development, rural development, labor, tribal development, railways, armed forces, etc for a multisectoral response.

Figure 2 Mass mobilisation and awareness through Red Ribbon Express Strategic information management system India's response to HIV epidemic is governed by the strategic information derived from HIV Sentinel Surveillance, routine program monitoring data, operational research and evaluation studies. A nationwide web-enabled Strategic Information Management System (SIMS) has been set up to empower program management at various levels with the information required for planning, management and monitoring purposes. This system also helps in evidence-based policy formulation and program planning. Beginning NACP-III, NACO has positioned itself as the promoter and coordinator of research on HIV/AIDS through partnership, networking and capacity building of institutions within the country. The objective is to identify knowledge gaps that are critical for effective program implementation. There is evidence that HIV epidemic is stabilizing(

The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version. in the country, particularly in southern states. However, there is also indication of emerging hot-spots in the northern states of the country, which require focus and attention. Conclusion National response to HIV/AIDS during the first three years of the NACP-III has been commendable in terms of infrastructure and system development, coverage of targeted population and monitoring systems. However, there are still challenges to achieve the goal of the reversal of the epidemic. Key areas which require special attention are TIs for MSM, IDU and migrants and services to HIV positive pregnant women and infants.