Greater action is warranted if we are to walk the talk to #endAIDS and #endTB

(Left to right) Dr Surya Kant, Dr Ishwar Gilada, Dr MLB Bhatt
India has promised to end AIDS by 2030 at the UN General Assembly in 2015 by adopting the UN Sustainable Development Goals (SDGs). Not just internationally, the government of India has also reinforced in National Health Policy (NHP) to end TB by 2025 and AIDS by 2030. "But these promises to end TB and end AIDS must be matched by a stronger response for preventing, diagnosing, treating and caring for people living with HIV (PLHIV) and those affected by TB 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 last year. We appreciate the government of India for these potentially game-changing policies and promises, but a lot more action is needed to deliver on the promises to end AIDS and end TB" said Dr Ishwar Gilada, President of AIDS Society of India (ASI). Dr Gilada was a guest speaker at the Department of Respiratory Medicine, King George's Medical University (KGMU). He also delivered a guest lecture at the Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGIMS).
The session in KGMU was inaugurated by Dr Madan Lal Brahma Bhatt, Vice Chancellor of KGMU; and chaired by Professor (Dr) Surya Kant, Head of Respiratory Medicine Department of KGMU and President of Indian Medical Association (IMA) Lucknow. Prof Surya Kant is also the President of National College of Chest Physicians (NCCP) and past President of Indian Chest Society.

The guest lecture in SGPGIMS was chaired by Professor (Dr) Tapan N Dhole, head of the department of Microbiology at SGPGIMS.

(Left to right) Dr Ishwar Gilada, Dr Tapan N Dhole,
Pat Ramsarup, Ashok Ramsarup in SGPGIMS
South African award-winning journalist Ashok Ramsarup and former senior nursing administrator Pat Ramsarup also shared their insights on health communications in both these talks. Ashok Ramsarup was also conferred the Health Justice Lifetime Achievement Award in 2016 by South Africa’s Gandhi Development Trust led by Mahatma Gandhi’s granddaughter Ela Gandhi, AIDS Society of India and CNS. He is also a recipient of ACHA International Peace Award for his editorials and reporting promoting peace in south Asian subcontinent.

Ending AIDS and TB both go in tandem

Dr Surya Kant, Professor and Head, Department of
Respiratory Medicine, KGMU and President, IMA Lko
Professor (Dr) Surya Kant said that if India is to end TB by 2025, it is important to ensure that we accurately diagnose every TB patient without delay, and ensure that the patient receives treatment with effective drugs (and not drugs he or she is resistant to), and completes cure. Prof Surya Kant also called for accelerating research and development of new tools so that we can empty the large pool of people with latent (or dormant) TB - estimated to be one-third of our population.We have to cut the transmission chain so that the rate of new HIV as well as new TB infections can be zero. The current rate of TB decline is too low, WHO estimates at this rate we will eliminate TB by 2184, not 2025. We need to ensure that TB decline rate is atleast 10 times more to get us back on track to end TB as promised.

Prof Surya Kant said that 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 ART despite 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 Prof Surya Kant.

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. “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."

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.

With less than 8 years remaining to end TB in India by 2025, and 13 years left to end AIDS by 2030, undoubtedly the efforts to prevent, test and treat TB and HIV both must get a major boost to get back on track to meet these ambitious targets.

Bobby Ramakant, CNS (Citizen News Service)
7 January 2018