Out of step? Promise to end AIDS warrants stronger action!

Shobha Shukla, CNS (Citizen News Service)
Dr Ishwar Gilada, President, AIDS Society of India
The promise to end AIDS by 2030 needs to be matched by a stronger response for preventing, diagnosing, treating and caring for people living with HIV (PLHIV) as well. The passage of the HIV/AIDS Act 2017 and National Health Policy (NHP 2017) are two major policy measures of the Government of India this year. "We appreciate the government of India for this potentially game-changing law but a lot more action is needed to deliver on the promises to end AIDS" said Dr Ishwar Gilada, President of AIDS Society of India (ASI).

India was among the countries that committed to the UN Sustainable Development Goals (SDGs) in UN General Assembly in September 2015, one of which is to end AIDS by 2030. This promise to end AIDS was also enshrined in the National Health Policy 2017 (NHP 2017) goals.

Are we out of step to end AIDS?

Current data, trends and experiences of HIV experts pose serious concerns on if we are on track to end AIDS by 2030. “Since India diagnosed its first case in 1986, we have enough scientific evidence to know what are the proven approaches for preventing HIV transmission and caring for people living with HIV (PLHIV),so that they can live normal lives. But is this a reality on the ground?” questions Dr Ishwar Gilada who has been at the forefront of HIV response when the first case got diagnosed in the country.

"We need unprecedented action to meet NHP-2017 goals. As of 2016, 67% of PLHIV (2.1 million/ 21 lakhs) know their status; 1.4 million (14 lakh) are diagnosed with HIV and 10,05,000 PLHIV were on life-saving anti-retroviral therapy (ART). Not only have we not yet reached out to 33% of PLHIV, but barely 50% of PLHIV are on ART, despite WHO and NACO guidelines to 'test and treat all'. As of now, only 65% of PLHIV who know their status, are receiving ART. We cannot be complacent in our efforts, because failing to reach out to each PLHIV and not putting on ART threatens to reverse the progress made in fighting AIDS" said Dr Gilada.

Baby steps will fail us on the '3rd 90' target

The National Health Policy 2017 of Indian government promises to “achieve the global target of 90:90:90, for HIV/AIDS by 2020, that is, 90% of all people living with HIV will know their HIV status, 90% of all people diagnosed with HIV infection will receive sustained ART, and 90% of all people receiving ART will have viral load suppression" (Source: of National Health Policy 2017 of Government of India). These NHP-2017 goals are in line with UNAIDS commitments too. Despite progress there is a long way ahead of us, if we are to meet these goals.

Scientific evidence has shown that if every PLHIV is on ART with viral load suppression, the risk of HIV transmission is negligible, and the person can lead a normal healthy life. "India needs to be commended for scaling up to 600 ART centres across the country with over one million people are receiving free ART. But we have only 10 Viral Load Testing laboratories. If every PLHIV needs a viral load test twice a year, then we need to scale up viral load testing capacity to conduct over 4 million (40 lakh) tests every year. Currently we do a few thousand viral load tests only. With such a small capacity to do viral load testing, it is not known how many of the documented 10,05,000 people on ART are virally suppressed. How would India meet the goal of achieving viral load suppression for 90% of those PLHIV who are receiving ART by 2020 if business as usual continues?" asks Dr Ishwar Gilada.

“In India today, almost 80-90% of PLHIV on ART are being managed, not treated, at 600 ART centres of NACO, and the remaining PLHIV access private healthcare. Retaining PLHIV on ART at public sector ART centres is extremely crucial for managing HIV in India, as they cater to the majority of PLHIV. Clinical studies tell us about efficacy of drugs in a controlled environment, but long-term effectiveness studies are important to corroborate clinical studies' findings” added Dr Ishwar Gilada.

Ending AIDS and TB both go in tandem

TB continues to be the lead killer of PLHIV.  According to the latest WHO Global Tuberculosis Report 2017, over 374,000 TB related deaths were among PLHIV in 2016 worldwide. Of the almost half a million reported cases of HIV-associated TB, 15% were not on ARTdespite WHO recommendation that all HIV-TB co-infected people to be put on ART. TB preventive treatment is not accessible for most of the eligible PLHIV. According to the WHO, the risk of developing TB is estimated to be between 16-27 times greater in PLHIV than among those without HIV infection. “TB and HIV/AIDS both are neglected.We must accelerate implementation of TB- HIV collaborative activities so that every person with HIV stays healthy and productive and TB free! Also, we should not neglect extra-pulmonary TB especially among PLHIVs. Research agenda too must get more thrust so that we have better TB diagnostics, shorter and less toxic TB treatments and an effective TB vaccine soon” said Dr Gilada.

“We have really come a long way and contained HIV in a good manner. But we still need to find those who either do not know their HIV status, or despite knowing their status have not reached ART centres. They should be enrolled for ART. Drug management has to be streamlined. Many patients are still receiving Nevirapine and Ziduvadine based regimens, even when they should not be getting them, especially those who maybe on anti-TB treatment or are highly anaemic. HIV medicines given at ART centres should be according to guidelines. Bulk buying of medicines for 5-7 years should stop as it interferes with introducing new optimum treatment regimens. Supply chain management of drugs should improve so that ART centres are not plagued with any uncertainty regarding future drug supplies.Also we need to ensure that viral load testing capacity of India is stepped up in a major way so that it matches government’s promise to ensure viral load suppression for every PLHIV on ART.”

On the pharmaceutical side, India remains to be a great saviour globally, and nearly 92% of PLHIV all over the world are accessing Indian ART; which is affordable and efficacious. Indian pharma companies have launched one new molecule (Dolutegravir); which is the latest and most robust among anti-retrovirals and two new combinations – namely Darunavir 800+Ritonavir 100 and Tenofovir+Lamivudine+Efavirenz 400 (TLE400) - which reduces pill burden/ pill size and eventually reduces cost and adverse effects.

Dr Gilada shared that to mark 2017 World AIDS Day, ASI is launching two initiatives: (i) The NACO-ASI inter-phase to strengthen the partnership efforts of these two organizations, and (ii) ASI Youth Forum to focus on young people. 

With 13 years left to deliver on the promise to end AIDS by 2030, undoubtedly the efforts to prevent, test and treat HIV need a major boost to get back on track to meet these ambitious targets.

Shobha Shukla, CNS (Citizen News Service)
1 December 2017
(Shobha Shukla is the Managing Editor of CNS (Citizen News Service) and has written consistently on health and gender justice for several years. Follow her on Twitter @Shobha1Shukla or visit www.citizen-news.org)