Workshop Conducted on 02 and 03/12/2003

Session 3 - Methodological Issues in estimating Socioeconomic Impact of 

Dr. George, Director, invited the Chief Guest, Shri. Kodela Siva Prasada Rao, the Honourable Minister for Health, Medical & Family Welfare, Government of Andhra Pradesh. He briefed that this workshop is basically to outline the study design methodology to estimate the reliable Burden of Disease and Socioeconomic impact of HIV/AIDS in six highly prevalent states in India.

Dr. P. Hrishikesh, Chairman, IHS, invited the guests, the delegates, the participants, and members of the press.

Dr. P.L Joshi, Addl. Director, NACO, addressing the gathering told that this the first time a study is being launched to assess the Burden of Disease as well as the impact of HIV/AIDS on social and economic variables.

Dr. Maxine Olson, UN Resident Representative, India, stated that the current study will throw light on what we do not know much about, and also about what we need to know, so as to make our interventions more evidence based and hence more effective.

Dr. Suman K Bery, DG, National Council of Applied Economic Research, told that the NCAER has rich experience in household surveys, household modeling, health care delivery, macro economics etc.

Dr.M.D Gupte, Director NIE maintained that estimation of BoD is a very challenging task, and hope that this workshop will lead to a better estimation of the burden & impact of HIV/AIDS.

Ms. Damayanthi, Project Director, APSACS felt that arriving at some projections for HIV disease is the need of the hour.

Dr. Hrishikesh, Chairman, IHS was of the opinion that HIV /AIDS is not a medical problem only and that it has got multiple etiological factors. This is the fist time that a workshop on BoD & SEI studies is being conducted, and that this would aid the policy makers in decision making.

Dr. Kodela Siva Prasada Rao, Minister for Health & Family Welfare in his inaugural address said that the impact of HIV/AIDS on the society in the past one and half decades is alarming. For a disease which was almost unknown in 1986, there were only 10 million cases in 1990 and now in 2002, there are more than 42 millions cases worldwide. Unfortunately, India stands second in incidence by having around 4 million cases of HIV/AIDS. He was sorry to note that AP, which is a leader in many progressive development programs is also plagued by HIV/AIDS problem. This study will give the Government of India reliable figures of HIV/AIDS prevalence cases.

First session of workshop, HIV/AIDS Scenario in India was chaired by Prof. M.D.Gupte, Director, National Institute of Epidemiology. Dr C.K. George, Director, IHS invited him to chair the session.

First speaker of the session was Dr. P.L.Joshi, Addl. Project Director, NACO, who discussed the natural history of HIV/AIDS . Area of presentation included modes of HIV infection, types of HIV and mechanism of its advances and immunological parameters in different stages. Important suggestion made in this session included that survival period of HIV patients should be estimated carefully. Next suggestion was that though HIV type 1 is more common we should not exclude or neglect HIV type 2 and should try to work out the natural history of both type 1 and type 2 viruses. Dr. Joshi noted that most of the information on the natural history was available from various other countries. Information from India was incomplete.

Next speaker was Dr. M. Bhattacharya, Head, Dept of Community Health Administration. Topic of her presentation was Analysis of HIV/AIDS Surveillance Data among Six High Prevalence States in India. She presented Andhra Pradesh, Tamilnadu, Maharashtra, Karnataka, Nagaland and Manipur where reported prevalence of HIV was high. The available data was classified for prevalence according to different socioeconomic groups viz. age, sex, locality, occupation, educational status etc. It was recommended that we should have standard classification framework for socioeconomic/occupation divisions. Dr Abhay Indrayan recommended that we should try to present data from all the states. Dr Shaukat suggested that data from each state should be analyzed individually and conclusions should not be drawn from cumulative data for all the six states so that we can know the distribution differentials of disease which will help in arriving at some policy to combat the problem. Prof. Gupte mentioned that data should be presented using appropriate denominators.

Third speaker of the session was Dr. TLN Prasad, Dy. Director(STD) , APSACS. His topic was HIV/AIDS Scenario in Guntur, a High prevalence district in Andhra Pradesh. He highlighted the trend of HIV/AIDS by age, sex, educational status, marital status and occupation in Guntur. He emphasized that capacity building of health care system to meet the coming onslaught of HIV related morbidity and further said that innocent rural wives are falling preys to the infection and there was urgent need to address the issue. Suggestions made included that mapping for HIV high risk groups data should be done. Dr Prasad also provided information on behavioral aspects.

Next speaker was Dr. Sheela Godbole,Research Officer, NARI, Pune. Her topic of presentation was Estimation of Disease Burden of HIV/AIDS in Pune: Methodological perspective. Objective of this presentation was to document networking and collaboration with the State Govt. and private institutions for continious data collection .She reported that the reporting of HIV related mortality was very poor and good cause of death studies were required for better anchoring of mortality estimates. She suggested that mandatory reporting from all sectors of health care would be ideal. Her presentation brought out several methodological issues and resulted in, in depth discussions.

Last speaker of the session was Dr K. Venu. Topic of presentation was Assessment of severity of disease in estimation of economic burden due to HIV/AIDS. Dr Venu emphasized the need to assess the severity and to reduce the economic burden of disease by proper inceptions such as understanding of the grades and severity of disease measure like specialised hospital care, social and psychological support, legal support etc which could revert the stage iii/iv to stage ii/i. He also emphasized that a mandatory disclosure was required for HIV infection. Some of the speakers pointed out that they expected information on socioeconomic impact at individual and family level. The group did not consent with Dr Venu on the issue of mandatory disclosure. 

Prof. Gupte summarized on salient features of various presentations and discussions and declared the session closed. 

Dr. Raman Kutty began the Session with a presentation on "Research design issues in estimating prevalence of HIV infection". He talked about the main challenges faced by the epidemiologists in estimating prevalence of HIV and the infected persons.

He discussed about the main sources of data available in India. He dwelt upon the crucial assumptions in calculation of community prevalence, and the assumptions used in NACO estimates. Dr. Raman Kutty defined prevalence and gave justification for urban-rural and male-female gradients. He finally discussed about the other considerations and the qualitative component to be included in the focus of inquiry and sensitivity analysis.

The second presenter in this session was Dr. Prasanta Mahapatra, who commented that his session would not be a conventional presentation, but a brainstorming exercise. He put forth two proposals before the participants:

1. Sample size for estimation of HIV prevalence in pregnant women.
2. Sample size for estimation of HIV prevalence in adult population.

He further added that ethical considerations require provision of support care & management to prevent transmission of disease to the child, if a woman is tested HIV positive during the study. Dr. Mahapatra opined that we are generally shy of spending money on descriptive epidemiological studies. The two issues to be considered before deciding whether a proposal is worthwhile or not are:

1. Is the study design statistically sound.
2. Is the HIV testing cost feasible.

Dr Shalini Bharat, Professor & Head, Unit of Family Studies, Tata Institute of Social Sciences, Mumabi, chaired the Socio-Economic Impact of HIV/AIDS session. She introduced Dr. Abusaleh Shariff and Dr. B.K.Pradhan the two speakers in this session.

The first speaker, Dr. Abusaleh Shariff, Chief Economist, NCAER, New Delhi made a presentation on "Socioeconomic Impact of HIV/AIDS: Methodological Issues". He discussed different issues of improvement of the human development parameters to assess the quality of life, in terms of life expectancy, education, knowledge, skills etc.

Dr. Shariff described the HIV/AIDS issue as not only a health issue but also a developmental issue because it affects health, income level, education level, as well as the productivity and the development of a nation. The rate, at which it is expanding, its cumulative effect will impact the regional economy, local economy, as well as the national economy.

He suggested addressing the equity issues from the point of HIV/AIDS. He mentioned that HIV/AIDS is a dynamic issue, as it is a part of health economics, sociology, psychology and development economics etc. He preferred the evidence-based approach to calculate the net impact of HIV/AIDS on the economy, as well as on the society. He proposed the household survey method to eliminate selective bias and stated that the study has 3 components: qualitative, quantitative and modeling.

He described HIV as a major gender issue in the current economy. He described the adverse impact of HIV/AIDS on the National Income or GDP. He pointed out that national accounts would be useful in the conduct of this study.

The technical part of the session was dealt by Dr. B K Pradhan, Chief Economist, NCAER, NewDelhi, who was the second speaker in the session and presented the topic titled "Socioeconomic Impact Study of HIV/AIDS:A Study of Six States".

Dr. Pradhan started his presentation by mentioning about the statistics of HIV/AIDS in India and neighboring countries. He discussed the social and fiscal impact of HIV/AIDS. He explained the proposed study design starting from objectives. He discussed the economic impact of HIV/AIDS on households, net impact of HIV/AIDS on state and national level of economic performance. He proposed to use CGE (Computerized General Equilibrium) model to assess the net impact of HIV/AIDS at national level. He discussed the methodology to be adopted by NCAER in detail and said that the economic indicators and social indicators to be used in the survey should be decided carefully.

Dr. Prashant Mahapatra (IHS) suggested the partial equilibrium model or demographic model as an alternative to the CGE model for the study. The consensus arrived at the end of the session was that enough care should be taken during analysis and it was suggested to differentiate HIV infected households from other households for study purpose.