Ironically, very little work has been done to comprehend the nature of the epidemic in Asia, especially in India which harbors the third highest HIV-affected population in the world. Although the government of India conducts HIV Sentinel Survey annually to monitor outcomes and impacts of national efforts and monitor trends in HIV prevalence amongst the major population groups [11
], not much information has been gathered about the adolescent population specifically. Through this retrospective study we have tried to bring to the foreground, the prevailing profile of adolescents living with HIV in India.
One of the major findings of our study was the appalling disparity between the sexes at different levels, their association with HIV and its impact on their daily lives. While most studies have focused on the late adolescents, our study also sheds light on the children aged between 10 and 14 years who often get blanketed under the pediatric population. This transient population is extremely important as not only do they constitute the new generation of infected individuals who are naïve and dependent on others for care, but also require specialized intervention strategies owing to the unique nature of the infection. Furthermore, we have tried to emphasize the role of a prejudiced patriarchal society in sustaining the epidemic.
In the course of our study, it was observed that the proportion of adolescent boys seeking the services of the ICTC was more as compared to that of girls. The low turnout of girls could be due to low status and restrictions imposed by backward societies upon women thus making them ignorant of sexually acquired diseases like HIV [12
]. In terms of HIV positivity, the proportion of males was more as compared to females. Also, males who test positive rarely divulge their HIV serostatus to their partners or spouses thereby making females oblivious to the transmission risk [16
Most of the participants who sought ICT did so voluntarily. The percentage of males was more than that of the females which again, as discussed earlier, is likely due to the neglected and backward state of females. A small proportion of adolescents were referred by the DOT centre suggesting the presence of a referral network. However, these findings are insufficient to substantiate the significance of this referral system. Although adolescents are a vulnerable population to HIV, surprisingly the ones between 10–14 years (group I) are more predisposed to HIV than the group II. A higher probability is seen in this case as many of the adolescents are HIV positive due to the lack of prophylactics during the delivery. Also, a strong association between the HIV seropositivity and the two age groups was obtained suggesting age to be an important risk factor for HIV.
While most of the adolescents were students, a considerable portion comprised of adolescents as salaried employees in different sectors. It was also seen that illiteracy was slightly higher in female adolescents. This could be due to the lack of educational opportunities for girls and the prevailing attitudes of the society during the study period.
Another important variable analyzed in our study was marital status. Our study revealed marital status to be significantly different for males and females. This could be attributed to the widespread social practice of marrying off females earlier than males [17
]. Also, marriage was found to be a potential risk factor for females. Similar findings were recorded in African studies on adolescent females [18
HTP was recorded as the most common risk behavior and varied significantly in males and females. Also, in case of HIV-positive adolescent boys, HTP was seen as the most common risk behavior. In addition to this, percentage of unmarried adolescents in this age segment exhibiting this risk behavior was worth noting. Furthermore, males in particular were observed to be the prominent population in this category. This could be ascribed to their more experimental and carefree nature. For females of the same category, 50% of these women was married and could have perhaps acquired the infection from their spouse as also seen by Vajpayee et al. [19
]. For adolescent females in Africa, the risk of HIV acquisition was noted to be directly related to risk profile of their partners [18
]. However, owing to the small sample size in this case, a generalized inference cannot be drawn from our analysis. A major portion of the study population, both males and females were aged between 15 years and 19 years which could imply early coital debut. This was also seen in some African nations where males are becoming infected at slightly higher ages than females but at lower rates. This is attributed to males having either younger or more similar aged female partners at coital debut [18
While, PTCT was the third highest risk behavior with adolescents acquiring infection which could be due to the absence or nonavailability of HIV preventive therapy during pregnancy, blood transfusion was the fourth most common risk behavior. The least common risk behavior seen was that of injected drug abuse. Our analysis also revealed that the there was a strong association between HIV seropositivity and the different types of risk behaviors among males and females. Additionally, patients classified into the heterosexual promiscuous group are 2.09 times more likely to be positive than patients whose risk group is not known. Similarly, adolescents with a potential history indicative of parent to child transmission are 3.57 times more prone to HIV than others. These results were in accordance with the NACO's data which highlighted unprotected sex (87.4% heterosexual) as the major route of HIV transmission, followed by transmission from parent to child (5.4%) and use of infected blood and blood products (1.0%) [5
The Posttest session is an important aspect of counseling wherein the test results were disclosed to the participants. The positive cases were first counseled individually and then referred to the ART clinic where they were registered and sent for CD4 count estimation free of charge. Participants both HIV seropositive and negative were counseled. Key issues that were discussed with positive patients mainly included awareness about HIV and AIDS, the necessary precautions that should be taken, importance of healthy lifestyle, and adherence to their drug regimen.
Adolescents often encounter difficulties of a more personal nature, such as, dealing with their sexuality and peer pressure [20
]. Thus, they are gullible and ready to experiment making them more vulnerable to HIV. Also, issues like sex and sexual behavior are still tabooed subjects for discussion between parents and children and even in a formal set-up between teachers and students in many parts of India. Hence, adolescents are likely to have more misconceptions and be misinformed, and in the long run, pose risk of HIV/AIDS [21
]. Therefore, topics, such as, safe sexual practices, premarital issues and test of spouse or partner were stressed upon when advising sexually active adolescents. Furthermore, since HIV is generally associated with unsafe sex practices and premarital sex in the Indian society; it is considered a taboo and thus the HIV-positive adolescents face discrimination at different levels: medically, professionally, academically, and even socially. Patients complained of discriminatory behavior meted out to them by their family members. Such cases needed Counseling for the family members as well. In case of adolescent IDUs, there is a double burden of stigma of addiction and HIV infection [17
]. Some of the patients were hesitant and unresponsive to certain questions possibly fearing discrimination due to their HIV serostatus which thereby rendered the ICTC ineffective in their cases. Also those who were among the high-risk behavior group but received a negative result were advised to adopt safe practices and a healthy lifestyle. This is important to avoid any further exposure to the infection. Its importance and effectiveness were validated in a study from Pune which showed that ongoing confidential Counseling and testing were positively associated with risk reduction behavior among men [22
Although various intervention and preventive strategies against HIV have been formulated for majority of the HIV seropositive population, a more ‘adolescent-centric' approach is necessary to combat such cases. Public health policy should recognize adolescents as a separate section, design and implement prevention strategies keeping in mind their vulnerability and sensibilities for greater effectiveness of these programs.
Also awareness regarding HIV must increase among them. This could be achieved through incorporation of information regarding HIV, its transmission, and prevention into their schools' curricula. This would help in transmission of accurate information at the grass root level and would thus aid us in reducing the misconceptions and myths surrounding HIV. Furthermore, in the case of adolescent girls, orientation regarding risk of teenage pregnancy must also be discussed.
Moreover, in some western countries, Protection Motivation Theory (PMT), a social cognitive theory, has been developed and widely used to guide intervention development regarding multiple health threats, including HIV/AIDS [23
]. Although its appropriateness has only been assessed in a limited number of oriental countries, such as, China, Vietnam, and the Bahamas, its applicability to the Indian scenario can be evaluated.
There were few limitations in our study. Information such as, the reason for visiting the ICTC, risk intentions, their awareness levels regarding HIV, if recorded, could have provided better insights for in-depth analysis. Additionally, owing to the small sample size, the current analysis could be considered as a pilot study that describes the profile of adolescents living with HIV in India. Therefore, the findings of this retrospective study must be followed by more elaborately designed prospective studies to provide conclusive comments on the current scenario of adolescents living with HIV in north India.
In conclusion, the present analysis has focused on the lesser known adolescent section of the population attending the ICTC in north India and draws attention to the association of HIV serostatus with variations in demographic and psychosocial responses. Not only do these findings highlight the pivotal role of ICTCs as intervention strategy, they also paint a picture representative of the current scenario of adolescents living with HIV, attending a tertiary health care centre.