Recent data from the National AIDS Control Organisation shows that the number of new HIV cases in India has fallen significantly since the peak of the epidemic in India in 2005. However, the pace of decline has also slowed in recent years.
New registrations of HIV cases in India have dropped from 1,30,000 in 2005 to 88,000 in 2017. There were 2,40,000 AIDS-related deaths in 2005 whereas there were 69,000 in 2017. But new HIV infections declined only 27% between 2010 and 2017 – or from 0.10 per 1,000 uninfected population in 2005 to 0.07 in 2017 – leaving a long way to go for NACO’s target, which is to achieve a 75% reduction by 2020 from 2010 levels.
A report by UNAIDS released at the 22nd International AIDS Conference in July this year highlighted that there was a “dangerous complacency” over treatment and prevention of HIV globally that could lead to a resurgence of the deadly disease. Even in India, public health workers and activists attribute the deceleration in the control of new HIV cases to waning interest in the programme, and shrinking funds.
“Today, the numbers of people with HIV are lesser than the high numbers came in 2001-’05 but not very low,” said Sonal Mehta, chief executive of Alliance India, an NGO that works on HIV/AIDS. “Suddenly India has gone in denial and our focus on prevention of HIV has gone down. We see more young people coming with HIV with almost no education and awareness campaigns.”
In addition, the risk of infection in high risk groups has gone up since the government’s focus on prevention has gone down. “There are stock outs of condoms, and due to lack of coordination between NHM and NACO, condoms of adequate quality are not supplied for sex workers, transgender people and gay and other men who have sex with men,” said Mehta. “Soon we might see increase in HIV infections as we already see in some states such as Gujarat, Andhra Pradesh, Manipur, Telangana, Maharashtra and newer states such as UP, Chhattisgarh and Mizoram.”
According to the latest NACO report, Mizoram had the highest adult HIV prevalence in the country, followed by Manipur and Nagaland. Other states with high adult HIV prevalence are Telangana, Andhra Pradesh, Karnataka, Goa, Maharashtra and Delhi.
Dr Samiran Panda, director of National AIDS Research Institute under the Indian Council of Medical Research, explained that NACO’s approach of targeted prevention and treatment has worked well so far but may not lead to a greater decline in incidence of new cases.
“The NACO strategies worked very well till 2015 after which, in 2016-’17, the results have reached a plateau,” he said.
The gains that NACO has made so far have largely been due to its targeted interventions, which are strategies tailored to prevent the spread of HIV infection in groups most at risk including female sex workers, men who have sex with men, transgender people and injecting drug users. For example, to prevent the spread of HIV among injecting drug users, NACO started a needle and syringe exchange programme to prevent them from sharing possibly-infected needles. It also provides oral-substitution therapy to shift drug addicts away from injection use.
One of the more progressive moves under the programme is the Test and Treat policy that was approved in June 2017. As per this policy all people living with HIV are given antiretroviral therapy regardless of their CD4 count, clinical stage or age. Before this policy, only people with CD4 counts higher than 500 were given medicines.
“This policy is really helping people gain access to therapy and better treatment,” said Mona Balani, programme officer with the India HIV/AIDS Alliance in Delhi, a non profit organisation that supports community action to prevent HIV infection. Balani was diagnosed with HIV in 2000. Both her husband and her younger son died of AIDS.
Antiretroviral therapy has made HIV a chronic manageable disease, like diabetes or high blood pressure and the life expectancy of someone living with HIV is almost as much as that of someone without HIV, Mehta pointed out. “Yes, antiretroviral therapy has actually stopped people from dying and improved their life expectancy,” she said. “[But] the government needs to do much more for better quality of life – sexual reproductive education for children born with HIV who are young adults today, ensure regular pap smear tests for all women living with HIV, optimum services for dialysis for people living with HIV etc.”
Dr Rajat Goyal, director of the International AIDS Vaccine Initiative or IAVI in New Delhi, feels that the success in saving lives of people infected with HIV has not been matched with equal success in reducing new HIV infections. “HIV prevention services are not being provided on an adequate scale and with sufficient intensity and are not reaching the people who need them the most.”
The drug resistance problem
Meanwhile, drug resistance is making treatment of HIV and AIDS more complicated. A person who does not strictly follow the antiretroviral treatment regimen can become resistant to the drugs. As a result, the HIV virus is not adequately suppressed in his or her body, once more leading to the immune system being compromised, leading to illness and possibly death due to opportunistic diseases associated with HIV. An article published in The Journal of Infectious Diseases in June 2017 states that, “High resistance rates in children and in communities with mature treatment programs, poorly documented rates in populations most at risk for both HIV infection and treatment failure, and delays in switching regimens after documented virological failure suggest that current strategies to minimise HIV drug resistance are suboptimal.”
When patients fail to respond to standard antiretroviral drugs, which are known as first-line drugs, they are put on stronger medication.
“When infected people on ART therapy do not adhere to their treatment, drug resistant strains of the virus may develop,” said Panda. “This needs a second line of treatment that is being rolled out by the National AIDS Control Programme. The National AIDS Research Institute is working on making second-line drugs, too. Awareness is needed about adhering to the treatment.”
According to NACO data from 2015, a total of 3,00,743 HIV patients were on first-line medication and NACO estimates that nearly 3,000 patients have become resistant to first-line therapy and have been put on second-line medication. For patients failing second-line therapy, treatment options are largely nonexistent, especially for countries that have financial constraints in adopting possible third-line treatments.
Panda advocates new interventions to bring about a further decline in new infections, especially to reach pockets of the population such as those who get sex partners online.
One new intervention that Panda thinks will help is a HIV self test kit that his institute is developing and may be released soon. The advantage of this kit, Panda said, is that it will be easy to use in the privacy of one’s home.
Meanwhile, Goyal feels that that AIDS research needs to look beyond control and towards a vaccine to prevent infection, “We need a vaccine and cure to put an end to this,” he said.
In more than 35 years of research, scientists have learnt that the HIV virus is particularly tricky to develop a vaccine for because of its ability to change slightly from generation to generation - just enough to evade detection by the human immune system. In recent years, some research groups have discovered leads and are even trying to begin clinical trials. But so far, an AIDS vaccine has been elusive.
“ IAVI remains committed to its mission of creating tools for prevention and cure,” said Goyal. “We work closely with scientists, researchers, HIV prevention and treatment advocates, policymakers and communities most affected by the pandemic to advance the research and development of effective, safe and accessible AIDS vaccines for the people most in need.”
Mitchell Warren, executive director of the international organisation AIDS Vaccine Advocacy Coalition, also feels the urgent need of an HIV vaccine. “This progress [in HIV incidence reduction] is not shared equally,” he said. “There are many countries and populations that have unequal treatment access, and, perhaps even more importantly, there has been little progress in preventing new infections. While the threat of drug resistance is real, the biggest issues to me are accelerated access to the prevention and treatment and the the urgency to develop additional options, most importantly an HIV vaccine.”