Should we celebrate success or gear up to end AIDS?

The fight against AIDS has definitely made considerable progress but formidable challenges confront the path to ending AIDS by 2030, as committed by the countries globally at 70th UN General Assembly in September 2015. The brutal irony is that despite knowing 'what works in helping us progress towards AIDS' the uptake of these evidence-based strategies is abysmally low, and some countries like India, have slashed health budgets by 20%.

Embarrassment of riches?

"It is almost an embarrassment of riches because we know how to end AIDS but we are failing to match the scale of response required to do so! Also ironically we save millions globally but loose thousands to HIV nationally" said Dr Ishwar Gilada, President of AIDS Society of India (ASI).

Eliminate mother to child transmission of HIV

"A small country such as Cuba can eliminate mother-to-child HIV transmission by using Indian medicines; but India is far from reaching that achievable goal though we export ART to 168 countries. In India, less than 30% of the pregnant HIV+ve women received PPTCT (Prevention of Parent To Child Transmission of HIV) therapy and that too only single-dose nevirapine, an outdated therapy. Admittedly, the National AIDS Control Organization (NACO) said India recorded 18,000 children getting HIV from 65,000 HIV+ve mothers in 2009, despite of proven strategies to prevent each of them. The world has achieved near-zero mother to child transmission but NACO aspired for merely 50% reduction. This gross negligence has created thousands of drug resistant HIV+ve mothers as well as children in India. Gladly, NACO has now rectified its strategy and decided to provide best available ART to pregnant women now" added Dr Gilada.

No ART for those who test HIV+ is clinical malpractice

Taking new WHO HIV Guidelines 2015 and latest (strong) scientific evidence into account, antiretroviral therapy (ART) must be provided to every PLHIV - this will not only help keep all PLHIV healthy and enable them to live normal lifespans, but also drastically reduce chances of any further HIV transmission. But 64% of PLHIV in India are yet to get life-saving ART. "Also it is important to note that 20% patients at free ART roll-out facilities were dead, 12.5% lost to follow-up or stopped ART in 3 years. Only half of HIV infections are recorded at NACO, as the other half infected people do not know their HIV status. This is indeed a formidable gap. Data shows that only 56% of sex workers are reached with HIV prevention program, 38% of them identify correct ways of prevention methods, yet most intervention programs are scrapped. ‘Test and Treat’, Treatment as Prevention (TasP) and Pre-exposure prophylaxis (PreP) for all, Post-Exposure Prophylaxis(PEP) also for the victims of sexual assaults are some of the evidence-backed approaches where we should not delay to maximize public health outcomes" said Dr Ishwar Gilada, who is also one of the first clinicians to come forward for HIV care when first case got diagnosed in India.

'Make in India' became a reality in fight against AIDS

"Fixed dose combination (FDC) of different ARVs, on the lines we did for anti-TB, invented in India had made ART cheaper, safer and easier. The west copied India! Ironically, the Multi National Companies (MNCs) made hue and cry, calling Indian Generics copy-cats! When the ‘West copies the East’, why apply different yardsticks? Indian pharma took lead and risk of inviting litigations, circumvented patents by using reverse engineering to produce generic copies and brought down the price to 1%, with 100% bio-equivalence. The yearly cost of three-in-one cheapest first-line FDC is down from US$ 11452/- per patient to $69 – the lowest quoted cost by an Indian Pharma. Similarly, even other combinations have been made affordable and accessible, with India meeting more than 80% of the global ART requirement. For this, the Indian Pharma must be lauded for saving millions" said Dr Gilada.

Dr Gilada shared a chart comparing how private and public sector acted in fight against AIDS in India:

ART Centres of NACO
ART in Private Sector
When did ART start?
1994, widely from 2000
CD4 testing facilities
start widely?
2004-5, more after 2007
1994, widely from 1998
When did PMTCT start?
~ 2000
1993, widely from 1996
What drug is used in
till Oct.2012 Nevirapine:
singledose, changed now
Triple drug combos,
some use Lopinavir/r,
Efficacy in saving unborn
child from HIV
Drugs available for 1st line
5, now changed, 7
ART combinations for 1st
~ 15
Drugs available for
2nd line ART
1 PI
Five Protease Inhibitors
One Integrase Inhibitor
One CCR5 Inhibitor
ART combinations for
2nd line
~ 15
Duration of ART experience
~10 years
~ 15-20 years
Consistency of ART
officer (doctor)
Retention in job Poor,
changes~ 6 monthly
ART Officer:
Good to Excellent

We are facing an extremely challenging situation with Multi-drug resistant and extremely drug resistant (MDR/XDR) Tuberculosis and HIV, Immune Reconstitution Inflammatory Syndrome (IRIS), Lipodystrophy- as most patients in public sector were on stavudine (d4T) based ART, HIV and aging, marriages/ alliances among HIV+ve people, several eligible bachelors among generation-next who are infected from failed PMTCT or were born before it was in place, generic CD4 and viral load kits on lines of generic ARVs – which can reduce follow-up costs.

"From disease of young population it is moving towards issues of aging with HIV. Many age-associated diseases are more common in HIV patients than in age-matched uninfected persons. They include cardiovascular diseases, cancers, bone fractures and osteopenia, Liver failure, Kidney failure, Frailty, illnesses of degrading immunity and neurological diseases" said Dr Gilada.

"We must critically evaluate the state-run and NGO programs, replicate best practices and shun the unsuccessful ones. We should provide three tiered (not free for all) ART with quality care and should move from ‘donor-dependence' to ‘self-reliance'. We should focus to reduce vulnerability of women and children and make PPTCT a national emergency with 100% coverage to achieve near 100% success so that no child gets HIV vertically. There should be a strong focus on youth and de-addiction as more than 50% new infections are among youth. Revised National Tuberculosis Control Programme(RNTCP) and National AIDS Control Programme (NACP) are orphaned and face resource crunch. It is time for their convergence and betterment. Later Hepatitis-B and C programmes can be combined" added Dr Gilada.

To end AIDS by 2030, the world surely needs more effective tools, but this is NO EXCUSE not to optimally utilize existing evidence-based proven strategies to progress faster towards ending AIDS.

Bobby Ramakant, CNS (Citizen News Service)
1 December 2015

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