Recent results of the START, TEMPRANO and HPTN 052 studies, as well as various pre exposure prophylaxis (PrEP) studies have led to new approaches for treatment and prevention. The latest WHO HIV guideline makes available two key recommendations that were developed during the revision process in 2015. Firstly, ART should be initiated in all PLHIV irrespective of their CD4 cell count. Secondly, the use of daily oral PrEP is recommended as a prevention choice for people at substantial risk of HIV infection as part of combination prevention approaches.
Can India implement these recommendations?
In India, estimated ART coverage among the 21 lakh people living with HIV (PLHIV) is 38%, with close to 8 lakhs PLHIV alive and on ART--768840 on 1st line and 8500 on 2nd line ART. Almost 50% of those who are infected never came in contact with the government programme. If India takes evidence into account and begins to provide ART to the remaining 62% PLHIV, regardless of CD4, then public health outcomes are likely to be enormous -- including, but not limited to, quality of life and care, and reducing the rate of new infections as well.
However, despite having a massive infrastructure for provision of free ART related services --516 ART centres, over 976 Link ART centres, 5100 integrated counselling & testing centres, 350 care & support centres--Gangakhedkar lists some of the key challenges that will have to be overcome to adopt the 'treat all' approach. These are:
Strengthening existing ART centres to ensure that the number of PLHIV per healthcare provider is manageably small in order to offer quality services
Enhancing coverage to key population groups of sex workers, men who have sex with men, and injecting drug users
Enhancing coverage by ensuring access to testing and treatment services in low prevalence states
Ensuring quality supply chain management for ART drugs and test kits
Enhancing timely targeted viral load test in order to offer 2nd line ART to all those who fail 1st line treatment
Enhancing treatment services to the mobile migrant population
He also cautioned on the need of having enough stock of medicines before embarking on the new strategy. This could take 6 months to1 year from the date India adopts the new guideline, in order to be able to buy additional stocks of drugs. Regarding roll out of daily oral PrEP as a prevention choice, a demonstration study is likely to begin soon among sex workers in Kolkata and Mysore, results of which might spur further action.