India has a golden opportunity to end HIV-related discrimination by realistically implementing the HIV/AIDS (prevention and control) Act 2017.
Generally, deaths generate more news, but wellness a little. Ditto same with HIV/AIDS, that has changed its status from a ghastly deadly disease during the 1990s to a chronic manageable condition now that can be considered better than diabetes. This journey wasn’t easy for India that had topped globally in HIV/AIDS cases in 1996.Since then we have come a long way. Though the research in finding anti-retroviral therapy (ART) was done elsewhere, India realised the dreams of millions of people living with HIV (PLHIV) globally by making the fruits of such developments affordable and assessable. Today we are poised to set another dream and that is #endAIDS. That isn’t an easy goal either with the challenges around, fortified with collateral damages due to the protracted Covid pandemic.
When we know how to prevent HIV transmission, and how to keep every PLHIV healthy, then how can one fathom the deaths of at least 650,000 people due to AIDS-related illnesses,witharound 1.5 million new HIV infections occurring globally in 2021? In this era, every new HIV infection is a reality check and grim reminder that we are failing on prevention, that we could have done better. Every death due to AIDS-related illness is not only unfortunate but a deeply disturbing setback.No one has to die of AIDS—only if we can convert scientific gains, words and promises into public health actions on the ground—quickly and efficiently.
93 MONTHS LEFT TO END AIDS BY 2030
All nations globally have promised to end AIDS by 2030 as part of the UN Sustainable Development Goals (SDGs) and domestic commitments. But why should we wait till 2030 if we can make #endAIDS a reality in the lives of PLHIV, today? The entire cascade of HIV care and support with lifesaving ART and monitoring viral load suppression keeps them away from HIV-related illnesses. Similarly,we can break the chain of HIV transmission withtreatment as prevention (TasP) and other HIV combination prevention options. The price of inaction is heavy and unacceptable. Since most nations could not meet the 2020 AIDS targets, now eyes are set on the 2030 goalpost of 95-95-95 targets (95% of people living with HIV to know their status, 95% of them should be on ART, and 95% of these be virally suppressed).
In 2021, globally, 85% of all PLHIV knew their HIV status. Among those who knew their status, 88% were accessing treatment. And among people accessing treatment, 92% were virally suppressed, that translates to 75% were accessing treatment and 68% were virally suppressed. In India, as on March 2022, 77% of people living with HIV knew their status, 84% of them were on ART, and 85% of them had viral suppression. This translates into 55% of total PLHIV being virally suppressed.
India has made a commendable progress since the World Health Day of 7thApril 2004 when it began the rollout of lifesaving antiretroviral therapy (ART) for people living with HIV, but formidable challenges remain.
According to Government of India’s National AIDS Control Organization 2022 report, annual new HIV infections and AIDS-related deaths continue to decline nationally. Between 2010 and 2021, new infections declined by 46% and while AIDS-related mortality declined by 76%. The goal to reduce new HIV infections by 2025 is 80% and clearly, we need to do much more to turn the tide.
Also, while the overall adult prevalence remains low (0.21% in 2021), HIV prevalence among high-risk groups and the bridge population remains very high. HIV prevalence among migrants is 4 times, among truckers 5 times, among inmates in central jails and female sex workers 9 times, amongmen who have sex with men (MSM) 16 times, among hijra/transgender people 18 times and among people who use drugs 43 times of the overall adult HIV prevalence. This divide shows our indifference to vulnerable populations by depriving them of fruits of scientific developments. India missed meeting the target of “zero discrimination by 2020”, now shifted to 2030, albeit with a caveat, “less than 10% discrimination by 2030”. This proves, we are born discriminatory and will remain so.
India has a golden opportunity to end HIV-related discrimination by realistically implementing the HIV/AIDS (prevention and control) Act 2017. Even after almost six years, only 15 states have made some progress towards appointing ombudsman; which is a mandatory provision in the Act.We are yet to see a single prosecution under the provisions of this Act and it in no way connotes those violations have not happened. For example, PLHIV are denied “mediclaim” policies, as such policies still mention HIV in the exclusion criteria. Life insurances have still provision not to allow people living with HIV to take policies for an insured sum more than INR 10 lakhs and claims aren’t settled. Insurance Regulatory and Development Authority of India(IRDAI), after persuasion from the AIDS Society of India,recently warned insurance agencies against such discriminations.
MISSED OPPORTUNITIES PLAGUE HIV RESPONSE
Without affirmative steps against inequalities, India and other countries risk missing the targets to #endAIDS by 2030. An array of “missed opportunities”is plaguing the AIDS response worldwide, India is no exception. Lack of accountability, sub-optimal programme effectiveness, tokenism and complacency are factors that are differing the goal of an AIDS-free world.Unfortunately, the Covid-19 pandemic is used as an excuse towards non-achievement.
In the journey towards #endAIDS, one of the earlier milestones has to be elimination of mother to child transmission (MTCT) of HIV, as that doesn’t even need a change in behaviour. Indiais yet to achieve the goal. Coverage of pregnant women who receive medicines to prevent MTCT is 64%. Vertical transmission rate including during breastfeeding is 24.3%. This is another “missed opportunity” which we truly cannot afford to ignore if we are to #endAIDS by 2030. Rather we should immediately eliminate MTCTthat is now part of the WHO goal of triple elimination—elimination of mother-to-child transmission of HIV, syphilis and hepatitis-B.
Amidst calls to #endAIDS globally, let us remember that business as usual will fail us. If current trends continue, more than 1.2 million people will be newly infected with HIV in 2025, three times more than the pre-set target of 370,000.
92% OF HIV MEDICINES INDIAN
Global agencies like the UN, WHO, UNAIDS devise goals of “TasP”, “Test and Treat’, #endAIDS only on the strength of India’s contribution through its pharma that is responsible for treating 92% of PLHIV globally. India’s capacity to produce generic anti-retrovirals and supply them globally had resulted in major successes for AIDS fight worldwide. If we look back on HIV response in the past decades, it sends shivers down our spine to even imagine what would have happened if Indian generic manufacturers had not stepped inwith affordable lifesaving medicines, and if we had to depend on the mercy of Big Pharma of the Global North. Thankfully, this is not the situation due to the stellar leadership demonstrated by Indian pharma.
We have the time-tested and proven capacity to manufacture HIV diagnostics, medicines and robust supply chain mechanisms to deliver them worldwide sustainably.But are HIV programmes worldwide strong enough to ensure that HIV prevention, diagnostics, treatment, care and support services are reaching every person in need, without any further delay?
The next best opportunity to eliminate the difference between “what we know works” and “what we do” is now. We know how to prevent HIV, diagnose HIV, treat, care and support PLHIV. But the gap betweenwhere we are and where we need to be or what we can do and the ground reality is a chasm we cannot afford to have anymore.For unexplainable reasons, India is much behind even the countries of Africa. This is a call to energise, empathise and equalise to bridge the gap to #endAIDS.
DrIshwar Gilada is Consultant in HIV in Infectious Diseases, President of AIDS Society of India, Secretary General of Organised Medicine Academic Guild-OMAG and Governing Council Member of International AIDS Society, firstname.lastname@example.org, www.unisonmedicare.com,Twitter @DrGilada.