Tough to end AIDS in India without promoting condoms
HIV PREVALENCE AT THE NATIONAL LEVEL HAS DECLINED FROM AN ESTIMATED PEAK OF 0.38% IN 2001-03 THROUGH 0.34% IN 2007, 0.28% IN 2012 AND 0.26% IN 2015 TO 0.22% IN 2017
Through the ’80s and ’90s after it was first detected in India in Chennai in 1986, HIV diagnosis meant certain death, sooner than later. Once people were infected with HIV, it steadily whittled away their body’s defence against opportunistic infections such as tuberculosis and pneumonia, making them sicker and weaker till it killed them.
A few got diagnosed, which helped protect their partners, family and caregivers from HIV infection, but fewer still got treated because the medicines were very expensive, highly toxic and not easily available.
It all changed on April 1, 2004, when the then health minister Sushma Swaraj announced the Indian government will offer free antiretroviral therapy (ART) used to treat HIV at eight centres in the six high-prevalence states — Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu.
Today, India’s “test and treat” policy provides free ART across the country to everyone who tests positive for HIV. As a result, 1.35 million of India’s 2.14 million people living with HIV and AIDS (PLHAS) get free treatment, which has led to Aidsrelated deaths reducing from 160,000 to 69,110 between 2010 and 2017, according to data from the NACO India HIV Estimation 2017 report.
ART suppresses the HIV viral load to lower symptoms and keep people living with HIV disease-free for decades. It also lowers their chances of infecting their partners. While there is no study for India, using ART to treat HIV can add 10 years to life and gives a 20-year-old who starts treatment a “near-normal” life expectancy of 67 years in Europe and north America, found an analysis of 18 studies of over 88,500 people that was reported in The Lancet HIV in August 2017.
With 2.1 million people living with HIV, India has the second largest HIV epidemic in the world after south Africa and Nigeria, but HIV prevalence in adults aged 15-49 years remains 0.22%, compared to 20.4% in South Africa, which has 7.1 million PLHAS.
In India, HIV prevalence at the national level has steadily declined from an estimated peak of 0.38% in 2001-03 through 0.34% in 2007, 0.28% in 2012 and 0.26% in 2015 to 0.22% in 2017.
The endgame for India is to meet the UNAIDS “90–90–90” targets to diagnose 90% of all Hiv-positive persons, provide ART to 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020.
Getting people on treatment is easy, and the hard part is ensuring there are no gaps in the availability and access to medicines and ensuring PLHAS stay on it to keep the viral load suppressed.
Stopping treatment midway leads to drug-resistance, which has to be treated with stronger and more expensive drugs that cause toxic side effects.
With most of National AIDS Control Organisation’s ₹2,500 crore-budget used for testing and treatment, there is little left for prevention and promotion of safe behaviours and practices, such as safe sex needle exchange programmes for drug users.
New infections have been stubbornly hovering around 80,000 for the past five years, with infections rising in Assam, Mizoram, Meghalaya and Uttarakhand, and declines in infection being lower than the national average in Bihar, West Bengal, Telangana, Delhi, Jharkhand and Haryana.
Just eight states accounted for two-thirds of the 87,580 annual new HIV infections in India. Telangana led with 11% of the new infections pan India, Bihar and West Bengal accounted for 10% each, followed by West Bengal (10%), Uttar Pradesh (8%), Andhra Pradesh and Maharashtra (7% each), Karnataka (6%) and Gujarat (5%). Aids-related deaths are also rising in Bihar, Jharkhand, Haryana, Delhi and Uttarakhand.
Given heterogeneity of infection between states, data-driven differential prevention and care services must be pushed with active community engagement. For example, among high-risk groups, HIV incidence is the highest among injecting drug users compared to other highrisk groups such as female sex workers, gays, lesbians, bisexuals and transgenders.
The NACO needs to pull out all the stops to end AIDS as a public health threat by 2030. To do that, it must reduce new infections by 75% by 2020 against the 2010 baseline.
Apart from testing and treating people living with HIV, prevention and protection campaigns for the general population cannot be abandoned as it also helps lower stigma and encourages community participation in seeking prevention services and treatment.
Outreach programmes must also include promoting safe sex and safe injecting practices in the high riskgroups and bridge populations (such as sexual partners, migrants and truckers), who unwittingly spread infection to the general population.
India cannot end AIDS without condom promotion and community participation.