30 years of HIV in India: Long way to go still?
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It is almost 30 years since the first case of HIV infection was detected in India in Chennai in 1986. In a recent webinar organized by Citizen News Service (CNS), Dr R R Gangakhedkar, Director-in-charge, National AIDS Research Institute, Pune (Indian Council of Medical Research), presented a vivid picture of India's tumultuous journey in its fight against this dreaded disease.
Going down memory lane, Dr Gangakhedkar recalled that India took almost 6 years (after the 1st HIV patient was diagnosed) to finally wake up to the realization of the imminent threat of HIV/AIDS, and thus was born the National AIDS Control Programme in 1991-92. Initially it offered treatment only for sexually transmitted infections (STIs) and opportunistic infections (OIs) arising out of HIV. The developed world was, at that time, already providing sequential mono therapy for the disease. 1994 proved to be another landmark year for the West, when prevention of mother to child transmission (PMTCT) became possible with AZT (generic name zidovudine, Retrovir). Also, protease inhibitors led to the evolution of the 3 drugs combination anti retroviral therapy (ART).
From despondency to action
The first anti-HIV drug, zidovudine was marketed in India in 1995 but the cost was prohibitively high. It was only in 2000 that generic pharmaceutical companies started manufacturing the drug and prices came down drastically. At that time the feasibility studies for PMTCT, that began in 1998-99, were already over. The government's PMTCT programme started in 2001--with a private pharmaceutical company CIPLA providing single dose Nevirapine free of cost to as many women and children as possible across the country. Then free ART was rolled out in 2004.
Today, government programme uses the CD4 cell count cut-off 210, and this is much better than that in many other countries, says Gangakhedkar.
The new WHO guideline
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