Backgrounds: Recognized as an emerging disease only in the early 1980s, AIDS has rapidly established itself throughout the world, and is likely to endure and persist well into the 21 st century. India has the highest number of HIV-positive persons in the world. The geographical location of Assam adjoining high prevalence states like Manipur and Nagaland will probably make it a high-risk zone in the coming years if appropriate intervention measures are not taken adequately beforehand. Objective: To assess the impact of Information, Education, and Communication (IEC) on Knowledge, Attitude, and Practice on HIV/AIDS among the slum dwellers of Dhubri town of Assam. Materials and Methods: A total of 492 slum dwellers aged 15-60 years were selected from all the slums of Dhubri by probability proportional to size (PPS) sampling method. The study was conducted in three stages. First, a baseline KAP survey on HIV/AIDS was done followed by IEC intervention. Then, just after the intervention, another survey was conducted, and after six months period, the final survey was conducted. Results: Eighty-seven percent of the study subjects were found to have heard about HIV/AIDS. Baseline knowledge regarding prevention of transmission of HIV/AIDS by having one faithful sex partner was there among 65% of the respondents, which increased amongst 82.2% of the respondents just after the intervention and amongst 68.5% of the respondents after six months period; similarly, knowledge of prevention by using condom increased from 70.7% to 80.3% and 76.3% of the respondents; using safe blood increased from 57.7% to 75.4% and 62.9% of the respondents. Conclusions: From the above findings, it can be suggested that, intervention programs were useful in enhancing the awareness regarding HIV/AIDS among the underprivileged population.
Keywords: HIV/AIDS, intervention, KAP
HIV/AIDS was first identified among the homosexual community of developed nations in North America and Europe in late 1970s.  AIDS has evolved from a mysterious illness to a global pandemic, which has infected tens of millions in less than 20 years. There was no treatment and apparently no way to stop the spread of HIV infection, except by engaging in dubious efforts to change people’s behavior.
Since the detection of the first case in India in 1986 in Chennai (Tamilnadu), 22.7 lakh confirmed cases of AIDS have been reported in India as per the HIV estimate of 2008-9.  Due to the absence of a potent vaccine or/and effective treatment, the only weapon we have at our hand is prevention aimed at increasing awareness of HIV/AIDS.
Assam is still among the low prevalence states of India, with 863 confirmed cases of AIDS reported as per the HIV estimate of 2008-9.  The geographical location of Assam adjoining high prevalence states like Manipur and Nagaland will probably make it a high-risk zone in the coming years if appropriate intervention measures are not taken adequately beforehand.
Till now, no interventional studies have been done in Assam, except one study done in upper Assam to find the effectiveness and impact of intervention regarding HIV/AIDS. Prompted by this above fact, the present study was undertaken among the slum dwellers of Dhubri town, which is a underprivileged district of lower Assam bordering Bangladesh.
The study area selected included 14 registered slums of Dhubri town.
It was a quasi experimental study of an intervention without control group. The study was carried out from March 2009 to Feb 2010. The study conformed to the Helsinki declaration, and Institution ethical committee (IEC) approved the study. All the participants were motivated, explained, ensured strict confidentiality, and then informed consent was taken from each participant.
Sampling Procedure: Probability proportional to size (PPS) sampling method was used for selecting the sample. Considering the different population size of each of the slum, the sample size which was calculated to be 492 was allocated proportionally to each of these slums.
The selection of the houses in those slums was done by picking up a random starting number, and then every nth house was visited. The eligible samples from those selected houses were then interviewed by the investigator himself, and given intervention till the required sample size in each slum area was obtained. In case of refusal, it was not replaced and the next nth house was visited. If any house was found to be locked or if no one was available, then the next house was taken as replacement, continuing with the original sampling units (every nth house) after that.
The study was conducted in three stages. First, a baseline KAP survey on HIV/AIDS was done among the sample population. In the second stage, an intensive IEC intervention was carried out through interpersonal communication technique (one to one counseling in a single session). The IEC tool used was the standard IEC package for urban slums formulated by NACO.  Just after the IEC intervention, another survey was done using the same set of schedules with some added questions. In the third and final stage, another survey was done after 6 months using the same set of schedules with some added questions among the same sample population.
The results were expressed in percentages represented by tables and statistically analyzed using chi-square test. P value less than 0.05 was taken as the level of significance.
Out of the total sample size of 492 persons, 18 were found to be non-respondents, of which 216 (45.6%) were males and the remaining 258 (54.4%) were females. In total, 312 study subjects (65.8%) were married. Total follow-up loss (six months after Intervention) was 34 (7.4%), among which 18 were females and 16 were males. Most of the male study subjects (29.6%) were engaged in unskilled work.
87.7% of the study subjects have heard of HIV/AIDS. Maximum number of study subjects (57.7%) had cited TV as their source of knowledge regarding HIV/AIDS [Table 1].
Before Intervention, 65.8% of the study subjects knew at least two modes of prevention of HIV/AIDS. Just after intervention and six months after intervention, the knowledge of at least two modes of prevention of HIV/AIDS was found among 78.4% and 68.5% of the study subjects. The difference of values among both males and females before intervention and six months after intervention was statistically insignificant (P > 0.05).
Before intervention, 76% of the study subjects had at least one misconception about the modes of prevention of HIV/AIDS. Just after intervention and six months after intervention, this misconception was there amongst 24% and 48.4% of the study subjects, respectively. This difference of values among the study subjects before intervention and just after intervention and before intervention and six months after intervention was statistically significant (P < 0.05).
Before intervention, 70.7% of the study subjects knew that HIV/AIDS can be prevented by using condom consistently with non-regular sexual partner. Just after intervention and six months after intervention, this observation increased up to 80.3% and 76.3% of the study subjects, respectively [Table 2].
10.2% males and 2.3% females reported sexual intercourse with a non-regular partner/CSW during the past 12 months. 50% of the study subjects reported the use of condom in the last sexual act with a non-regular partner. Six months after intervention, 28.6% of the study subjects made changes in their high-risk behavior to avoid HIV/AIDS [Table 3].
Target-specific intervention programs are important strategies of the National AIDS Control Program in India. The present study was conducted in Assam to find out the effectiveness and impact of intervention regarding HIV/AIDS. Its results reflect the effect of the intervention carried out through interpersonal communication technique.
In the present study, it was observed that 87.7% of the study subjects had heard of HIV/AIDS. This finding was comparable with the finding observed in the Behavioral Surveillance Survey conducted by NACO in 2001.  In a similar study, 68% of the persons were aware of HIV/AIDS in 1999 as against 49% in 1996. 
In Kargil, a community-based survey in the reproductive age group population reported that only one-fifth were aware of AIDS; this was probably due to reasons like the orthodox population, low female literacy, low sex ratio, and issues related to sexuality being taboo. 
Many studies and IEC interventions have been reported in India in different age groups and settings with a wide range of AIDS awareness levels, e.g. 13.5% school students and 16.2% teachers had knowledge about AIDS in Calcutta,  83.3% – 100% students were aware in Maharashtra,  and 83% of child development project officers (ICDS) in Delhi knew about AIDS.  Significant improvement was seen in the areas of sex and AIDS knowledge during the post-training phase in students in Pune. 
In the present study, maximum number of study subjects (57.7%) had cited TV as their source of knowledge regarding HIV/AIDS. This observation was comparable to that observed in the Rapid Household Survey done under RCH in 1998. 
Bhatia V et al. (2004) in Chandigarh also observed a similar finding. In both the studies, the main source of knowledge was from the electronic and print media. 
This study revealed that the IEC intervention has significantly increased the knowledge and positive attitude of the study population, but the sad part of the findings is that this increase in knowledge could not be sustained to the same extent after 6 months as it was just after the intervention. The Sonagachi Intervention Project increased the proportion that had an optimistic attitude and increased prevention and treatment-seeking behavior.  A model has suggested that a successful sex worker intervention in India would drive the HIV/AIDS epidemic to extinction. 
Bhatia V et al. (2004) in an interventional study to enhance AIDS awareness among the underprivileged population in slum areas of Chandigarh observed that awareness about AIDS increased from 58.2% to 70% (P < 0.01). Knowledge regarding prevention of AIDS by using condom increased from 42% to 61.2%; having a single partner, from 59% to 72.3%; and using safe blood, from 14.9% to 29%. 
The findings of the present study were almost similar with the observations made in the Rapid Household Survey of RCH where it was found that a substantial number of males and females (Male-72%; Female-74.5%) had misconception about the different transmission modes of HIV/AIDS. 
In a similar study, it was observed that with intervention, there was an improvement in the knowledge; however, the proportion of students with misconceptions did not come down. Correct knowledge about two methods of prevention also did not reach the WHO recommendation of 90%. 
A study conducted by Raizada N et al. (2004) among the school-going teenagers in Jamnagar city of Gujarat observed that HIV-related stigma was highly prevalent among adolescents. In the same study, it was observed that inter-personal communication emerged as the most effective IEC in reducing negative attitude towards HIV-positive persons and increasing knowledge regarding HIV/AIDS. 
Prabhakaran. B (2003) in a Behavioral Surveillance Survey (BSS) in Maharashtra found that fewer than 3% of 15-19 years old male youth from slum areas reported sexual contact with a commercial partner in the previous 12 months. Only two-third of them reported consistent use of condom with commercial partners.  The difference of findings about reported sexual contact with non-regular partner in a 12 month recall period in the present study and some other studies like the BSS survey of 2001 by NACO  may be because of the fact that correct assessment of sexual behavior of the people was solely dependent on the information given by the study subjects, which may not be always true.
Agha S and Van Rossem R. (2004) in a School-Based Youth Targeted Program observed that students reported significant reduction in multiple sexual partnerships during the second follow-up after six months. 
The recent National AIDS Control Policy of the Government of India aims at preventing the spread of AIDS by making people aware of its implications and providing them with the necessary tools for protecting themselves. A large section of society is poor and still lacks basic knowledge about AIDS, its spread, and prevention. While a onetime activity such as done in this study has enhanced the knowledge, activities such as awareness campaign, IEC activities, camps, mass media, and involvement of community leaders must be consistently implemented and their achievements be assessed by regular evaluation.
Repeated periodical interventions on HIV/AIDS should be done, which will be more useful in achieving the desired positive outcome on prevention of HIV/AIDS. More intensive awareness-creating program should be developed by the Government to raise the level of awareness about STD amongst the general population. Condom promotion efforts should be more vigorous.
IEC intervention can only marginally improve awareness about HIV/AIDS. Moreover, how much this favorable improvement about awareness and attitudes is going to be permanent and translate into behavior could not be ascertained from the study. Ongoing behavior change communication and repeated studies to assess the impact of such measures may resolve these issues.
Assessment of sexual behavior of the people was solely dependent on the information given by the study subjects, which may not be always true. Other than verbal recording, there are no other ways of correctly assessing sexual behavior where respondents may hide his actual behavior.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]