In an extensive essay (with a bibliography of 15 references) on how AIDS affects the family, ICMR provides guidelines on how doctors can tackle some difficult issues. We reproduce some sections of this essay.

Guidelines for hospitalisation

In the Indian context it is essential to evolve appropriate guidelines for hospital admission of persons with HIV/AIDS so as to ensure that health care services do not get overwhelmed while trying to provide care for HIV/AIDS cases and that persons with all other ailments do get due attention. AIDS patients require hospitalisation for treatment of acute pathogenic or opportunistic infections and treatment of acute life-threatening emergencies. Many will require emergency or elective surgical intervention. Malignancies occurring in AIDS patients would require appropriate management.

Care of chronic illnesses

During the chronic and terminal phases of their illness, AIDS patients require symptomatic and supportive treatment. The management of this phase of illness can be readily undertaken at home with the hospital outpatient visits providing the necessary monitoring and therapy. Patients are much more comfortable at home amidst the family; the family can provide them with the emotional and psychological support as well as physical comforts that are needed. There are, however, situations, where support from the family may not be available. Such patients have to be provided with care so that they can spend the last days of their lives in some comfort in hospice-like facilities. Special efforts may be made to explore feasibility of involving non-governmental/voluntary agencies for providing this type of care.

Screening for HIV infections

Testing for HIV infection has been a controversial issue. In developed countries counseling and informed consent of the individual prior to HIV testing is mandatory and confidentiality of results is strictly maintained. Under the existing conditions of illiteracy, social and other taboos, obtaining informed consent from the person undergoing HIV testing in India poses several problems. The Expert

Group of the ICMR discussed the issue and recommended that in the Indian context HIV infection should be considered as a sexually transmitted disease or transfusion transmitted disease. The clinician will decide on the basis of clinical assessment whether HIV testing is required for an individual patient, in exactly the same way as they would decide on any other laboratory investigation of patients under their care. All donors of semen and organs should be screened for HIV infection to prevent iatrogenic infection in the recipient. All donated blood should be screened for HIV antibodies; this is also mandatory for blood used for blood product manufacture. The testing facility should be made available for those who voluntarily seek tests. HIV tesing may be done for research purposes on approved research protocols after obtaining clearance from concerned institutions. Health service personnel need not be screened for HIV antibodies because patients are not at risk of acquiring HIV infection during their contacts with health personnel during the course of health care delivery. Health care seekers need not be screened for HIV infection because they are unlikely to infect health care persons or other health care seekers provided universal precautions for infection control are observed.

Care of seiopositive persons

All HIV infected individuals require counseling because of the social stigma attached to the disease and the invariably fatal outcome of the infection. They require health monitoring. This can be done on an outpatient basis. Health education to infected persons and their families is essential for reducing the risk of transmission of infection. All HIV seropositive persons should be taught simple precautions against common infectious diseases prevalent in the community because related morbidity due to infections may prolong the asymptomatic phase of the disease. During the asymptomatic period, seropositive persons may require health care for problems related or unrelated to HIV infection. All HIV infected persons should receive the prophylactic and therapeutic care required. Elective and emergency surgical procedures should provided as and when required. However, invasive palliative procedures such as renal dialysis for chronic renal failure may not be indicated in these individuals.

Screening for HIV in pregnancy

Screening for HIV during pregnancy along the lines of screening for syphilis during pregnancy has many ardent advocates. The major reason for screening for sexually transmitted disease (STD) like syphilis in pregnancy is to provide therapeutic intervention to prevent intrauterine infection. This justification does not exist for HIV. In many developed countries counseling women about STD and HIV and screening them for STD including HIV after obtaining informed consent has been included as a part of ‘routine’ antenatal care. In these situations there are adequate facilities for post-test counseling and care of women if any of them are found seropositive. In India such facilities are neither available nor affordable. Counseling for medical termination of pregnancy (MTP) in early pregnancy in parous seropositive pregnant women may provide the rationale for HIV screening… in our country…

Management of pregnancy in seropositive women

The fate of the unborn child is the major reason for concern regarding HIV infection in pregnancy. To prevent these potential calamities MTP may be done in the first trimester should the mother desire it…

Women who want to continue pregnancy should be provided with adequate, appropriate antenatal care… specific attempts being made to promptly diagnose and treat any opportunistic or pathogenic infections in these women.. .

During labour specific efforts may be made to reduce any invasive procedures, such as scalp vein sampling and use of scalp electrodes to monitor fetal heart rate, to reduce the risk of transmission of infection to the fetus during labour… Stringent precautions should be taken to prevent accidental spread of HIV infection while providing health care, especially during delivery.