‘Gender’ based ban on blood donation – Food for thought on World Blood Donors Day

 An 18 year old young girl or a boy who is fully eligible to donate blood in India may technically be denied if self-identified as a transgender.

According to the Census 2011, 4.88 Lakh transgender were enumerated in India for the first time along with their literacy, employment, and caste. Here, the data was clubbed inside “males” in the primary data and for research and policy purpose, a separate data-set was curved out. It is logical to understand that only a miniscule number of transgender have been classified while large number of those who could not open up their status remain hidden and so are their issues. Sex of an individual is assigned at birth in most cases except in rare intersex category and as the child grows up, gender gets determined and is a social construct. A gender focused discussion and data collection is what is required as stated in a report by the International Development Research Centre (2020). As per the report, nearly two third of the surveyed persons were school drop-outs due to severe gender related bad experiences. Another report by Sangama, a human rights organization found that only 12% of the transgender were employed. In Kerala too, the ground reality is bleak where acceptance of a transgender by family and society is poor. Youth who already had a poor scholastic performance due to negative environmental factors and stressors during their crucial years are left un-employable and without adequate social support. The multiple jeopardy that a transgender has to go through in their early life result in indulgence in high risk behaviors and being noted as the “not-so-good-people” in the society. It is a vicious cycle that persistently pull down the social position of the transgender community where parents, family, teachers, societal norms and Govt. policies all play a significant role. Regardless, they get excluded and marginalized in every walks of life due to the stigma, to the extent that they are banned from contributing to social service or altruistic activities such as voluntary blood donation.

The Guideline on Blood Donor Selection and Blood Donor Referral (2017) by the National Aids Control Organization and the National Blood Transfusion Council, classifies transgender persons as a “high-risk category” vulnerable to HIV/AIDS and a reason for the ban. Taking gender identity and sexual orientation as a criterion for risk classification and permanently excluding from blood donation is un-scientific, discriminatory, unreasonable and violative of their right to equality to other blood donors. Though it is evidence based that the guideline excludes men having sex with men (MSM), female sex workers, injecting drug users and people with multiple sex partners from donating blood, there is no base that a particular gender to be labelled as high-risk. Just as men and women with high risk practices are excluded, a transgender has to be excluded if they are found to be high-risk in their behavior. Labelling transgender community as “high-risk-sex practicing individuals” will further bring down the social position of transgender community and hinder the development of future generation.

It is ludicrous that eligibility to donate blood is based on how a person identifies himself and to whom they are attracted to. In the US, based on research, the FDA clarified their related guidelines by adding a deferral for a 12 months from last MSM activity lifting the total ban on transgender and gays. During the COVID19 pandemic, FDA relaxed the period to three months owing to increased demand of blood and blood products. A similar clarification on who among gays and transgender to be excluded has to be made clear in the guidelines we have. In reality, it is the skill and genuineness of the blood bank medical officer or the counsellor to evaluate and accept safe-blood. It should be understood that behavior is what that puts someone in a high-risk category. Ensuring voluntary blood donation and abolishing the practice of replacement blood donation could be one major policy that can ensure safe-blood than maintaining discriminatory and stigmatizing ones though un-intentional. 

 Impaired Renal Function in HIV infected Persons treated

with Dolutegravir

 

Dr. Praveen G Pai, Technical Expert, Care Support and Treatment, Technical Support Unit, Kerala State AIDS Control Society.

 

Introduction

Dolutegravir, an Integrase inhibitor, a class of ARVs with a high barrier to drug resistance and also with very little side effects have led it to be put on the World Health Organization's guidelines for the use of ARVs [1]. Dolutegravir in combination with Tenofovir and Lamivudine, has been listed as part of the existing NACO guidelines as a favoured first-line regimen. Dolutegravir is a well-tolerated Integrase strand transfer inhibitor (INSTI), the newest class of anti-retrovirals (ARVs), and showing powerful anti-HIV activity via inhibition of the enzyme responsible for integrating viral DNA into the host genome [2]. Phase III clinical trials have actually analysed the antiviral activity of Dolutegravir compared to Efavirenz as well as Raltegravir in antiretroviral (ARV)-naïve patients. The clinical trial also discovered Dolutegravir to attain much faster and sustained virologic suppression in both instances. Additionally, researches on Dolutegravir activity in patients with known INSTI-resistant mutations have also shown benefits, indicating that Dolutegravir preserves activity in a variety of INSTI resistant phenotypes too. Just like currently marketed INSTIs, Dolutegravir is extremely well tolerated. Because Dolutegravir prevents the kidney transporter, Organic Cation Transporter (OCT) 2, a reduced tubular secretion of creatinine results in non-progressive increases in serum creatinine. These serum creatinine rises have actually not been associated with lowered glomerular filtration rate or progressive kidney impairment.

 

Pharmacokinetics

The Dolutegravir pharmacokinetic profile under single dose and also constant state conditions ranging from 2 to 100 mg per day has actually been analyzed in healthy and balanced as well as HIV infected adults [3,4] Dolutegravir shows fast absorption, with a median time to optimum focus (tmax) ranging from 0.5 to 2 hrs. While not believed to be clinically significant, Dolutegravir absorption is modestly impacted by fat material of a meal. Song et. al. observed a rise of 133 to 242% in AUC ∞, Cmax, and also tmax following a single 50 mg dose under fasted conditions compared to a reduced, moderate, as well as high fat meal [5] Only a small percentage of Dolutegravir dosage (< 1%) is eliminated unchanged in the urine; and also as a result, Dolutegravir is not anticipated to call for dose adjustments with kidney problems [3] Currently no dosage changes are suggested for Dolutegravir in patients with kidney impairment.

Hepatic dysfunctions can also contribute to renal dysfunction. Dolutegravir is extensively metabolized in the liver by UGT1A1 [3] Preliminary study of a single 50 mg Dolutegravir dosage in a cohort of subjects with moderate hepatic impairment (Child-Pugh score 7-- 9) disclosed that, overall, Dolutegravir plasma exposure is the same and also well tolerated in mild to moderate hepatic problems. [6] Nonetheless, it has to be kept in mind that the unbound fraction of Dolutegravir in plasma is greater in hepatically impaired subjects than in healthy volunteers (0.41% vs 0.23%).

The frequency of graded research laboratory abnormalities reported for the SPRING-1, -2, and SINGLE were comparable between all Dolutegravir treatment as well as comparator arms. Laboratory abnormalities reported in 1 to 5% of subjects included raised cholesterol, lipase, bilirubin, AST/ALT, CPK and prothrombin time as well as lowered phosphorous and also neutrophil count [7,8,9]. Early investigations exposed a modest, non-progressive rise in serum creatinine connected with all Dolutegravir application groups and cohorts which appeared after roughly one week of treatment and remained steady with 24 weeks [7,8,10]. Following iohexol plasma clearance investigations exposed that glomerular filtration rate (GFR) is not affected by Dolutegravir [11]. Thus, this observation is likely due to the above mentioned Dolutegravir-mediated inhibition of renal OCT2 transporter activity, with minimized tubular secretion of creatinine [12]. Dolutegravir usage over 48 weeks of treatment does not show up to influence renal feature [7,8] although the lasting impacts of Dolutegravir on renal function are still unidentified.

 

Clinical studies in India:

Multi-centric studies in ART centers under NACO is in progress and there are no indications of statistically or otherwise significant severe adverse events that has been reported. Dolutegravir has been in use in high resourse setting globally since 2013 and post marketing phase-IV studies and pharmaco-vigilence is continuing with no significant reported adverse events that outweighs the documented benefits. Studies conducted by YRG Care, Chennai, evaluating 564 patients initiated on DTG-containing ART is one of the few initial studies conducted in India where low resource settings were considered [13]. Of the patients who underwent ART substitution, 75% had first line as TDF plus 3TC plus Efavirenz (EFV) while 28.1% were on TDF plus 3TC plus ritonavir-boosted Atazanavir and 25% on Darunavir plus Raltegravir plus ritonavir. It was observed that the overall renal function remained stable at 6 months follow-up and no patients had an increase in liver enzymes as per the National Institutes of Health/Division of Acquired Immuno Deficiency Syndrome grading scale. Frequency of opportunistic infections (OIs) were also found to be in a decreasing trend from 7.4% to 3.3% 6 months later. There were no discontinuation, treatment failure or death attributable to Dolutagravir reported in the study. As a first-line in treatment-naive patients, an excellent viral load suppression was observed from 48.9% at the time of initiation to 82.9% after 4 months. There has been independent studies that has been conducted by Medical Colleges in Kerala such as the Kozhikode Medical College where patients treated in ART Centre were followed up while they were receiving drugs as per the NACO protocol. The results of such studies are yet to be published.

 

Chronic Kidney Disease among People living with HIV/AIDS in an ageing population

With the newer treatment protocols and standard of care, life expectancy of PLHIVs are almost similar to the general population [14]. Hence, chronic kidney disease (CKD) is also becoming increasingly important as a critical comorbidity. It has to be also noted that more patients are in a viral suppressed status with combined antiretroviral (ARV) treatment and the population is also ageing. In this scenario of ageing, PLHIVs are increasingly exposed to, and often more affected by morbidities such as cardiovascular disease and CKD along with risk factors such as smoking and dyslipidaemia [15,16]. Growing evidence of an ageing phenotype is often explained by a pro-inflammatory state in people living with HIV, and an accelerated ‘immunosenescence’, both can contribute and complement each other to cause significant renal morbidity.

Proteinuria is also a commonly found condition among people living with HIV in the absence of any known kidney disease. This has been described more than two decades, and though exact figures in India on this are not available, European studies show that the prevalence of CKD are between 2.4 and 17% [17-19]. Apart from the traditional risk factors for CKD, high HIV viral load and low CD4 counts may result in acute kidney injury (AKI), CKD and progression to end-stage renal failure [20]. This is a possible situation in India and in the State of Kerala where adherence to treatment and viral suppression targets are yet to be achieved. Good adherence to treatment protocols can control viral infection and associated HIV associated nephropathy. Chances for renal failures resulting from opportunistic infection or immune complex glomerular damage also has to be kept in mind while treating HIV. Risk for renal calculi has been observed for Protease inhibitors such as Indinavir, Lopinavir and Atazanavir while Tenofovir Disoproxil Fumarate (TDF) and Atazanavir have been documented to cause acute tubular injury and tubulo-interstitial nephritis [21]. Though TDF can be associated with mild proximal tubulopathy to a fulminant Fanconi syndrome, the molecule may be associated with a progressive renal decline through unclear mechanisms. Also, many ARV drugs interfere with the creatinine handling of the kidney through reducing the tubular secretion. This may lead to misdiagnosis of renal dysfunction as clinicians depend on estimated glomerular filtration rate (eGFR) alone that is calculated from Serum Creatinine values [22,23].

 

Need for further research in Kerala Scenerio

Kerala, compared to other states in India has an ageing population with high prevalence of non-communicable disease which can potentially add to the burden of illness for PLHIVs affecting their quality of life and dependency which may be further complicated with prevailing stigma. Medical Officers of various Antiretroviral Treatment centers have raised concerns on safety and probable adverse events with switching over to Dolutegravir base regime in previously well controlled patients. Such case reports has to be evaluated individually for significance, so as to formulate appropriate management protocols. Hence a robust research in ART is required to plan forward to improve care, support and treatment of PLHIVs.

 

Summary

Overall, observations and studies have documented Dolutegravir as inducing a noticeable increase in serum creatinine levels following initiation of therapy. This has been found to be due to tubular blockade of creatinine secretion as a result of inhibition of OCT2 which is non-pathologic. There has been no true renal adverse actions of Dolutegravir that has been reported. However, with higher prevalence of CKD in patients, a robust prospective study and follow-up of patients are required. Given the risk factors for chronic morbidity among PLHIV, an augmented effort and linkage to healthcare services to early detect and manage chronic non-communicable diseases too is required.

 

 References

1.     WHO recommends Dolutegravir as preferred HIV treatment option in all populations; Available online on https://www.who.int/news/item/22-07-2019-who-recommends-dolutegravir-as-preferred-hiv-treatment-option-in-all-populations; Accessed on 24/03/2022

2.     Adams JL, Greener BN, Kashuba AD. Pharmacology of HIV integrase inhibitors. Curr Opin HIV AIDS. 2012 Sep;7(5):390–400. [PMC free article] [PubMed] [Google Scholar]

3.     Min S, Song I, Borland J, et al. Pharmacokinetics and safety of S/GSK1349572, a next-generation HIV integrase inhibitor, in healthy volunteers. Antimicrob Agents Chemother. 2010 Jan;54(1):254–258. [PMC free article] [PubMed] [Google Scholar]

4.     Min S, Sloan L, DeJesus E, et al. Antiviral activity, safety, and pharmacokinetics/pharmacodynamics of dolutegravir as 10-day monotherapy in HIV-1-infected adults. AIDS. 2011 Sep 10;25(14):1737–1745. [PubMed] [Google Scholar]

5.     Song I, Borland J, Chen S, et al. Effect of food on the pharmacokinetics of the integrase inhibitor dolutegravir. Antimicrob Agents Chemother. 2012 Mar;56(3):1627–1629. [PMC free article] [PubMed] [Google Scholar]

6.     Song I, Borland J, Savina PM, et al. Pharmacokinetics of dolutegravir in subjects with moderate hepatic impairment. [abstract no. N-121 plus poster]. 19th Conference on Retrovirus and Opportunistic Infections; 2012 Mar 5–8; Seattle (WA). [Google Scholar]

7.     van Lunzen J, Maggiolo F, Arribas JR, et al. Once daily dolutegravir (S/GSK1349572) in combination therapy in antiretroviral-naive adults with HIV: planned interim 48 week results from SPRING-1, a dose-ranging, randomised, phase 2b trial. Lancet Infect Dis. 2012 Feb;12(2):111–118. [PubMed] [Google Scholar]

8.     Raffi F, Rachlis A, Stellbrink HJ, et al. Once-daily dolutegravir versus raltegravir in antiretroviral-naive adults with HIV-1 infection: 48 week results from the randomised, double-blind, non-inferiority SPRING-2 study. Lancet. 2013 Mar;381(9868):735–743. [PubMed] [Google Scholar]

9.     Walmsley SL, Antela A, Clumeck N, et al. Dolutegravir (DTG; S/GSK1349572) + abacavir/lamivudine once daily statistically superior to tenofovir/emtricitabine/efavirenz: 48-week results - SINGLE (ING114467) [abstract no. H556b and oral presentaation]. 52nd Interscience Conference on Antimicrobial Agents and Chemotherapy; 2012 Sep 9–12; San Francisco (CA). [Google Scholar]

10.  Eron JJ, Clotet B, Durant J, et al. Safety and Efficacy of Dolutegravir in Treatment-Experienced Subjects With Raltegravir-Resistant HIV Type 1 Infection: 24-Week Results of the VIKING Study. J Infect Dis. 2013 Mar;207:740–8. [PMC free article] [PubMed] [Google Scholar]

11.  Koteff J, Borland J, Chen S, et al. A phase 1 study to evaluate dolutegravir’s effect on renal function via measurement of iohexol and para-aminohippurate clearance in healthy subjects. Br J Clin Pharmacol. 2013 Apr;75(4):990–996. [PMC free article] [PubMed] [Google Scholar]

12.  Reese MJ, Savina PM, Generaux GT, et al. In Vitro Investigations into the Roles of Drug Transporters and Metabolizing Enzymes in the Disposition and Drug Interactions of Dolutegravir, a HIV Integrase Inhibitor. Drug Metab Dispos. 2013 Feb;41(2):353–361. [PubMed] [Google Scholar]

13.  Kumarasamy, N., Prabhu, S., Chandrasekaran, E., Poongulali, S., Pradeep, A., Chitra, D., Balakrishnan, R., & Benson, C. A. (2019). Safety, Tolerability, and Efficacy of Generic Dolutegravir-containing Antiretroviral Therapy Regimens Among South Indian Human Immunodeficiency Virus-infected Patients. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 68(6), 1048–1051. https://doi.org/10.1093/cid/ciy763

14.   May MT, Gompels M, Delpech V et al. Impact of life expectancy of HIV-1 positive individuals of CD4þ cell count and viral load response to antiretroviral therapy. AIDS 2014; 28: 1193–1202

15.   Mdodo R, Frazier EL, Dube SR et al. Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys. Ann Intern Med 2015; 162: 335–344

16.   Pedersen KK, Pedersen M, Trøseid M et al. Microbial translocation in HIV infection is associated with dyslipidemia, insulin resistance, and risk of myocardial infarction. J Acquir Immune Defic Syndr 2013; 64: 425–433

17.   Ryom L, Kirk O, Lundgren JD et al. Advanced chronic kidney disease, endstage renal disease and renal death among HIV-positive individuals in Europe. HIV Med 2013; 14: 503–508

18.   Cambell LJ, Ibrahim F, Fisher M et al. Spectrum of chronic kidney disease in HIV-infected patients. HIV Med 2009; 10: 329–336

19.   Yombi JC, Pozniak A, Boffito M et al. Antiretrovirals and the kidney in current clinical practice: renal pharmacokinetics, alterations of renal function and renal toxicity. AIDS 2014; 28: 621–632

20.   Jotwani V, Li Y, Grunfeld C, Choi AI, Shilpak MG. Risk factors for ESRD in HIV-infected individuals: traditional and HIV-related risk factors. Am J Kidney Dis 2012; 59: 628–635

21.   Post F. Adverse events: ART and the kidney: alterations in renal function and renal toxicity. J Int AIDS Soc 2014; 17: 19513

22.   Arya V, Florian J, Marcus KA et al. Does an increase in serum creatinine always reflect renal injury? The case of Stribild. J Clin Pharmacol 2014; 54: 279–281

23.   Maggi P, Montinaro V, Mussini C et al. Novel antiretroviral drugs and renal function monitoring of HIV patients. AIDS Rev 2014; 16: 144–151

 

 

Preventive Health, Care and Support for People Living in Prison with HIV/AIDS

– Building evidence

 

Introduction

Like all individuals, prisoners are entitled to enjoy the highest attainable standard of health – a right assured under international law in Article 25 of the United Nations Universal Declaration of Human Rights and also Article 12 of the International Agreement on Economic, Social, and Cultural Rights. Furthermore, the international community has actually typically accepted that prisoners maintain all rights that are not eliminated as a result of incarceration, including the right to the highest obtainable standard of physical as well as psychological health and wellness. Loss of freedom alone is the punishment, not the deprival of basic human rights. States as a result have an obligation to carry out regulations, plans, as well as programs constant with international human rights standards, and also to guarantee that prisoners are provided with a standard of healthcare equivalent to that offered in the outside community.

 

Objectives

·        Promoting an integrated healthcare approach within prisons to handle public health concerns through positive behaviour change, comprehensive health-checks and through appropriate changes in general prison conditions and management.

·        Provide prisoners with prevention, care, support and treatment for HIV/AIDS that is equivalent to that is available to general community.

·        Prevention of opportunistic infection, early detection and treatment in order to excess morbidity and mortality among these individuals.

·        Preventing transmission of HIV and other infections among prisoners, prison staff, and to the community on release.

·        Develop an evidence based prospective follow-up plan for PLHIVs getting involved in crime and being incarcerated.

 

PLHIV in a prison setting

Individuals remanded to jail live in a prison setting which are generally crowded and not designed to prevent opportunistic infections. High risk sexual practices may also be prevailing in jail setting which can add on to the problem. All the prisoners with HIV eventually return to the larger community and hence lowering the transmission of HIV and other sexually transmitted infections (STIs) in prisons is an integral part of decreasing the spread of infection in the broader society, as any illness contracted in prison, or any clinical problems made worse by poor conditions of prison, end up being concerns of public health for the bigger society when individuals are released. Access to healthcare and health seeking behaviour as well as adherence to treatment may be different while in a prison setting.

 

Correctional services as an opportunity

As Kerala State moves forward in elimination of HIV by 2025, good practices in prison settings can be an opportunity to prevent and control transmission of HIV and STIs through high risk practices. A prospective targeted follow-up of such people living with HIV will offer good results in preventing transmission of such infections of public health relevance. Incarceration can be a significant obstacle to positive health-seeking and access to preventive health, care and support, though they may be provided with medications and due doctor consultations. Thus, the criminal justice-based strategy to individuals at high risk for HIV/STI, particularly people that use illicit drugs, men having sex with men (MSM) and sex workers should consider sexual health concerns of prisoners in their comprehensive healthcare package.

 

Way forward

In view of the current design of prisons and the situations within, people who are incarcerated are exposed to an additional risk of Tuberculosis which is the leading opportunistic infection in PLHIVs which can result in higher morbidity and mortality. NACP-V prescribes at least two to three preparatory adherence counselling sessions for PLHIVs in prison. Isoniazid Preventive Therapy (IPT) that prevents new TB infection or prevent progression of latent TB to active TB is a standard of care which needs to be ensured in prison setting. A baseline profile of PLHIVs in prison and a prospective follow-up could bring in evidence that can guide intervention strategies and policies.

 

Health Profile of PLHIV

Current health profile of PLHIV in prison and follow-up in a life-course perspective will be beneficial for the AIDS Control Program as the people getting involved in crime and being incarcerated form a separate subset in the population who require additional effort to get integrated to general population. The chances for being marginalised when they contract multiple morbidities are very high compared to general population. Hence a life-course approach would be beneficial to provide care and support where maintaining a prospective targeted health data is essential.

Relevant data to understand the health profile may include (apart from demographic details) risk practices, Condom use/practice, serial investigation results, viral suppression status, adherence with medications and occurrence of other comorbidities, STIs and opportunistic infections. Serial data with an interval of 6 months could predict functional decline or declining health status where care-plan could be modified. Adherence counselling sessions could explore risk practices which has to be documented and intervened.   

 

“Food Handler with HIV infection” – Understanding HIV and the legal provisions related to the food industry

Dr. Praveen G Pai, TE-CST, TSU-KSACS; May 2022

 

Background:

Human Immunodeficiency Virus (HIV) is a group of virus that cause Acquired Immunodeficiency Syndrome (AIDS) in human beings. Recently, there has been rumours circulating in social media claiming packed food, juice and even contaminated food products from hotels have caused transmission of HIV. Four decades back when HIV was detected for the first time, it was linked with drug abusers and homosexuals and people were not sure of the route of transmission. The disease had huge stigma that people were discriminated and denied of basic human rights. Over the past two decades, advances in treatment options were tremendous and currently HIV infection has become a chronic manageable condition. However, though severe forms of sigma and discrimination are not found, stigma still persists. Recently, reports from positive networks and medical officers in ART centres suggest that food handlers who are tested positive for HIV are denied “Health Card” which is mandatory or them to work in any food handling centre including street vending to food processing units and hotels. Health card is made mandatory for all food handlers under the Food Safety and Standards Act of 2006 through the Food Safety and Standards Authority of India (FSSAI).

 

The Problem

Acquired lmmune Deficiency Syndrome (AIDS) is caused by a group of viruses called Human Immunodeficiency Virus (HIV). HIV harms the immune system making the patient more vulnerable to additional infections, especially diarrhoeal diseases, lung infections and also cancers. Millions of individuals all over the world are thought to be infected with the virus and the number is raising quickly. It is inescapable that several of these individuals will certainly be as food handlers.

The existing scientific evidence, the United States Centers for Disease Control and the World Health Organisation and National AIDS Control Organisation (NACO) verifies that there is no recognized threat of transmission of HIV/AIDS throughout the preparation or serving of food or beverages. It has been stated that a recognized danger of HIV transmission to co-workers, customers, or consumers from a person with HIV infection within industries such as food-service establishments is not documented ever. People living with HIV infection need not be excluded from work in food handling industry unless they have other infections or health problems (such as diarrhoea or hepatitis A) for which any kind of food-service worker, despite HIV infection condition, must be limited. The Food Safety and Standards Act of 2006 suggests that all food-handlers comply with suggested criteria and methods of good individual hygiene as well as food cleanliness where the employer has a big role to play. It is for that reason it is important that the food sector, the consuming public as well as the media all understand that transmission of HIV/AIDS by food as well as drinks is not a risk. However, individuals with HIV/AIDS are most likely than others to acquire one of those diarrhoeal illness that can be transmitted by food, and also other infections or lesions. In this occasion, the food handlers ought to be taken care of according to the standards provided by the Department of Health.

 

How the virus spreads

AIDS is caused by one or more of a group of retroviruses, which are been called Human Immunodeficiency Virus. Human beings are ought to be considered the single reservoir of the virus; neither food items, (including food animals), neither animals, nor pet dogs, nor pests are a source. HIV is spread by sexual contact with an infected individuals, sharing injection needles with an infected person, injection of infected blood or blood items and also by transmission from mother to child. HIV cannot be spread by touching, coughing, sneezing or by insect bite. The virus has a long incubation period of upto 5-8 years and therefore the development of the disease differs from one person to another; some individuals can unwittingly carry the virus without showing any kind of symptoms or signs. It appears possible that all HIV carriers will certainly develop into AIDS at some point if appropriate treatment and follow-up is not done.

Survival of the virus outside the body

The virus dies just gradually at room temperature while it will survive well when frozen. Nonetheless, it is really sensitive to warm and it is damaged at 55 degrees Celsius and above. It is conveniently inactivated at both reduced and high pH. The HIV virus is quickly destroyed by the generally used concentrations of all biocides, consisting of hypochlorite, ethyl alcohol and isopropyl alcohol. When accidents occur, the safety measures adopted to stop the spread of viral hepatitis as well as other blood borne infections will also prevent the spread of HIV. First aiders must cover any type of open cuts or abrasions by themselves using gloved hands and ideally to be wearing an apron. Spilling of blood and other body liquids must be flooded with a biocide as well as mopped up with paper towels. All these non-reusable products ought to be disposed off in plastic bags as well as securely taken care of, preferably by incineration.

Implications for the food dealers

Food handlers that carry HIV are not a risk to their workmates or to the items that they manage. They need to not be restricted from working with foods or beverages or be restricted from using telephones, equipment, office tools, and bathrooms, showers, eating facilities or drinking fountains. They may hence function usually, unless obviously they develop a second infection such as a diarrhoeal disease, which will prevent them from managing food. In that event, the employee as well as the employer must adhere to the guidelines released by the Department of Health: "Food Safety and Standards Act" (2006).

 Legal provisions related to food handlers and HIV

In the context of employment, especially with food-handling by people living with HIV, the following are of importance –

·       The Constitution of India, 1950, guarantees every citizen certain rights such as in Article 39 that asks the states to ensure an adequate means of livelihood for all the citizens including the HIV/AIDS patients; The Article 42 put forth the responsibility of states to make appropriate provisions for securing just and humane conditions of work.

·       National Policy on HIV/AIDS and the “World of Work” Policy: The Ministry of Labor & Employment has developed the "World of Work" and the "National Policy on HIV/AIDS" at the 43rd Session of the Standing Labor Committee. This Policy was established by the Ministry of Labor & Employment after consultations with ILO (International Labor Organization), NACO (National Aids Control Organization), and also Social partners. The policy focuses on creating understandings concerning AIDS along with working on encouraging actions in order to stop the spread of AIDS. It likewise intends to make the work environment supportive and encouraging for those people working while living with HIV. The goal of the policy is to curb the stigmas involved with this entire disease and also bring in an environment of equal treatment and opportunities at the work environment. It aims to create an open space devoid of these social stigmas and discriminations as well as protect against the spread of HIV amongst co-workers and also make individuals aware of the issues concerning the same. As per the policy, persons with HIV infection can function as long as they are fit. If there is a test performed, the person can wish to stay anonymous throughout the procedure.

·       The Indian Employers’ Statement of Commitment on HIV/AIDS: Facilitated by ILO and NACO, various employers’ associations of India signed a commitment for non-discrimination of HIV infected persons in workplace and that HIV testing shall not be a re-requisite for an employment that also include food-handling industry. The commitment was signed in 2005 by senior national leaders representing organisations such as All India Organisation of Employers (AIOE), The Associated Chambers of Commerce and Industry of India (ASSOCHAM), Confederation of Indian Industry (CII), Employers’ Federation of India (EFI), Federation of Indian Chambers of Commerce & Industry (FICCI), Laghu Udyog Bharati (LUB) and the Standing Conference of Public Enterprises (SCOPE).

·       The United Nations Declaration of Human Rights: The United Nations, with time, has created a great deal of action in order to provide equality as well as human rights to all people consisting of AIDS patients. The United Nations Declaration of Human Rights offers the right to equal rights to all humans including those with HIV infection. It additionally sets specific provisions taking care of equal opportunity of work, individual liberty, opportunity, and also protection. Numerous conventions focus on removing discrimination and also stigmas connected to patients' civil liberties, specifically AIDS. Everyone including those people living with HIV can work and take part in the cultural as well as social life in the community. The UN conventions time after time have stressed that all individuals including AIDS patients have to be dealt equally before the law and should be equally entitled to protection by the law. This sets the truth that it is not just in India, but globally people living with HIV find it tough to enjoy equality in legal rights and opportunities.

·       Legal provisions under Indian law- Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (Prevention and Control) Act, 2017: Section 3 of the Act deals with the rights of HIV infected persons against discrimination and right to employment. The act clearly states that no person shall discriminate against the protected person on any ground including denial of, or termination from employment or occupation, unless, in the case of termination, the person, who is otherwise qualified, is furnished with a written assessment of a qualified and independent healthcare provider competent to do so that such protected person poses a significant risk of transmission of HIV to another person in the workplace, or is unfit to perform the duties of the job. The act also directs that HIV testing should not be a pre-requisite for obtaining or continuing an employment or using any other service or facility. The Act also prescribes punitive actions against those who discriminate or stigmatise a person with HIV infection – that include heavy penalty/fine to be paid along with imprisonment. This means that, it is unlawful to deny “Health card” to a person with HIV infection that can result in denial of employment. While denying employment or Health-card, HIV status of the person will be disclosed in the process which again is unlawful.

·       Food Safety and Standards Act (2006): This is an Act “to consolidate the laws relating to food and to establish the Food Safety and Standards Authority of India (FSSAI) for laying down science based standards for articles of food and to regulate their manufacture, storage, distribution, sale and import, to ensure availability of safe and wholesome food for human consumption and for matters connected therewith or incidental thereto”. The Section 26 of the Act that deal with the responsibilities of the food business operator, in its clause (3) states that “No food business operator shall employ any person who is suffering from infectious, contagious or loathsome disease”. The Act came into force only after the National Policy on HIV/AIDS and the “World of Work” Policy was put into action; and hence the national policy on HIV/AIDS would stand valid and included. The Act restricts only those persons suffering from infectious or contagious disease that may be spread via food or beverages which is not the case with HIV. The term “loathsome disease” could be considered for diseases with an external appearance that can cause aversion or an unpleasant feeling of disgust or repulsion such as in a visible skin diseases, disfigurement, and mal-odour from wounds and lesions etc. It has to be noted that HIV infection per-se do not have any loathsome condition.

Conclusion

Health authorities around the world all agree that transmission of HIV/AIDS via food and beverages is not a recognized danger. This situation requires to be explained to all employers and also employees in all branches of the food/drink sector and to the consuming public. It requires to be emphasised to individuals with HIV/AIDS that they have to comply with the other health and safety demands appropriate to all food handlers. They are most likely than others to acquire among those diarrhoeal illness that can be transmitted by food, and also various other infections or sores.

For the question whether HIV/AIDS be transmitted by food, as per the World Health Organization (WHO) and current available scientific literature, HIV cannot be transmitted through food or water. In fact, the said virus cannot live long outside the human body. In a situation where small amounts of HIV-infected semen or blood get contaminated in food or water, cooking, exposure to the air, and the acid inside stomach would destroy the virus. Hence, based on available scientific evidence, food is not a source of HIV infection. In this occasion, it has to be understood that the food industries have to abide to the prescribed standards of FSSAI and the food handlers also need to be managed according to those standards without discriminating people living with HIV. The health authorities should not deny “health-card” to any person (a mandatory requirement to work in food-handling industry as per FSSAI) on the basis of his or her HIV status.

Way forward, there is a need for sensitisation and creating awareness among policy makers, government officials, political leadership, healthcare workers and enforcement agencies apart from civil society; without which, the discrimination and stigmatisation of people living with HIV will continue.  

 

Senior Living Solutions

“Your Sweet Home” – is it for you when you are old??

Living arrangement when old is still an uncertainty for many. As age advances and when you need assistance or help for activities of daily living, the place where you actually going to age and live the rest of life is a mystery. In many situations especially in urban areas and cities, older persons manage to stay alone as long as possible independently. Later, it is the time for children or the so called responsible relatives to take away their autonomy and execute their decision on where they will stay next. It can be an oldage home, another relative’s house or one of the children. Whatever it may be, they are going to stay in a totally new environment where they may not have any roots. Adding to the losses that comes along with ageing, independency and dignity needs to be given up; similarly, their life long emotional and sentimental investments needs to be sacrificed including their most cherished sweet homes.

In our culture, the biggest investment for a family or person during his productive age apart from an own house are their children. They have invested a major part of their financial, physical and emotional resources on children with the expectation that they will be along with and take care of their parents. It is true according to the statistics that still majority of older persons stay with their children and they are the sole care- providers. But as traditional joint families break down giving rise to nuclear families and increased migration of younger generation in search for a better job, older parents are often left alone at home. The most cherished sweet home starts haunting them along with the ‘empty-nest’ feeling. Taking the example of an older couple staying in the city, Mrs and Mr. Madhavan Nair, both were working in government service – long 30 years of service and now 18 years of retired life. Madhavan Nair was 35 when he started planning for an own house. It was a dream for the small family. With great difficulty and tremendous planning, an independent 2 bedroom house was completed. As children grew, Mr. Nair renovated his house expanding the space to a 4 bed room house where one room each were earmarked for children. But all his plans were shattered as his elder son opted to work in the United States after completing his Masters in Computer engineering. Parents initially were proud to announce the achievement of their son to obtain a high position. Later, his second son decided to stay with them working in a school as a teacher. However, soon after his marriage, adjustment problems of the new member with the family left no option for him but to move out of his parental house to build his own nuclear family. Again Mrs. and Mr. Nair consoled themselves that it was the best decision to save a family from breaking. Today, this old couple is alone to take care and support each other – uncertainties still remain about their future whether the most cherished own home where all fond memories lie will go with the wind. There is no much difference with many other older persons in the present society.

Oldage homes are an option for such elderly where at least a caregiver is assured and basic needs are met. Stigma attached to oldage homes and retirement centers are barriers for many. However, for those who wish to spend their retired life with people with common interests, a retirement home is the best solution. There are a variety of oldage homes ranging from the ones meant for destitute run by charitable organizations to the ones with 5 star facilities. A retirement community is an emerging concept in India where senior housing is provided with all care facilities. In a continuing Care Retirement Community (CCRC), residents can continue living in the same environment in all phases of ageing whether independent, needing assistance or fully dependent. This continuum of care is made available in such CCRCs on payment basis.

A new concept is been proposed as solution for senior living taking into account the merits and demerits of oldage homes and retirement communities – a ‘Lifecare Enabled Community’ (LEC). LEC is a normal community not intended only for older persons unlike a retirement community or oldage home. This is a normal mix of generations as any flat / villa complex or a residential layout. When present day’s flats and villas provide services such as swimming pool, health club, children’s park, drivers lobby, guest rooms etc, an additional unique service of ‘Senior Care’ is added in a LEC. As the population of older persons is rising and number of care givers for such elders is decreasing, this is an emerging need and demand of the society. Ageing in place is a fortune that is rarely experienced with dignity by older persons. Even though the younger generation wishes to take care of their elders, circumstances forbid them from giving their best. It is the duty of the policy makers and planners to create services and infrastructure that enables seniors to continue living in familiar environment for life. Services should also be targeted to encourage children or family to take care their elderly to preserve the great Indian tradition. As mentioned earlier, children and family are still the main care givers for elderly in India. Government may not be able to create such huge infrastructure or take the responsibility to take care of this huge population who are dependent. Further, the cost of hiring a formal caregiver is also high. If “Senior Care” is enabled in normal communities, it would help the elderly living in that community and also foster the losing tradition of ‘Family or children will look after their elderly family member’.

Bottom line is that, service providers should enter with such services in the community. Government should promote such services that would enable the younger generation to take care of their elderly and help older persons to age in place with dignity, safety and security.  More important is that, while planning new residential layouts or flat/villa projects, builders or Government can include this new service that is “Senior Lifecare” thereby creating a “Lifecare Enabled Community”.