Urgent and accelerated HIV service delivery with equity and rights is critical to end AIDS

Bobby Ramakant *

No one needs to get newly infected with HIV or die of AIDS-related illnesses because we have scientific evidence-based tools and proven approaches to prevent any further spread of infection or avert any untimely death due to AIDS. But despite this, over 1.3 million new people were diagnosed with HIV and 630,000 died of AIDS-related illnesses in 2023 globally.

“Despite commendable progress in India’s AIDS response, almost 200 new people got diagnosed with HIV every day and almost 100 died of AIDS-related illnesses every day in 2023. If HIV is a chronic manageable disease, then why 169,000 people living with HIV were lost to follow up by March 2024 (as per government’s latest 6th Sankalak Report),” said Dr Dilip Mathai, President of AIDS Society of India (ASI), a pan India network of HIV medical experts and researchers. Dr Mathai is a distinguished medical expert and researcher, former Professor and Head of Medicine Department, CMC Vellore, and former Dean of Apollo Institute of Medical Sciences and Research.

“HIV is now becoming a concern for primary healthcare workers, which implies that we have to ensure that the people who get educated and trained to serve at the primary healthcare level, must get adequately trained to help provide HIV care services. People who train them also need to be optimally trained on HIV care. If we do not address these issues, we will not be able to end AIDS,” said Dr Mathai in lead up to largest conference of HIV medical experts that would be held later this week in Ahmedabad, Gujarat state of India (16th National Conference of AIDS Society of India or ASICON 2025). Gujarat Chief Minister Bhupendra Patel would inaugurate the scientific meet which will be held in Gujarat for the first time.

Only 70 months left to keep the promise of #endAIDS by 2030

“All governments have promised to end AIDS by 2030. But we have the evidence-based tools to do so now! We can prevent all transmission of HIV, diagnose all those with HIV, provide lifesaving antiretroviral therapy and keep them virally suppressed – so that all those with HIV can lead healthy and fulfilling lives and no one gets newly infected with HIV. The World Health Organization (WHO) evidence strongly shows that if people living with HIV are virally suppressed then there is zero risk of any further HIV transmission from them. We need to do better to prevent HIV as well as care for those living with HIV,” said Dr Ishwar Gilada, President Emeritus of AIDS Society of India (ASI) and Governing Council member of International AIDS Society (IAS) and its regional Chair for Asia and the Pacific. He is the first medical doctor to begin HIV care in India when first case was diagnosed in 1986 and credited to establish country’s first HIV clinic in government’s JJ Hospital, Mumbai.

“Preventing HIV transmission means that we do 100% in ensuring access of everyone (especially those who are more at risk) to the full range of HIV combination prevention options. For example, India needs to rollout PrEP options in its public programmes without any further delay (PrEP was first approved by US FDA in 2012 and is only available in private sector in India. Pre-Exposure Prophylaxis is a medicine for people who are HIV negative to protect them from HIV acquisition). We need to do a lot more to find all those with HIV so rolling out proven approaches such as HIV self-testing is important. Regular treatment monitoring to ensure adherence and prevent advanced HIV disease, HIV related co-infections and co-morbidities, and address ageing related issues like non-communicable diseases, is also important,” added Dr Gilada.

Agrees Dr N Kumarasamy, Chief and Director of VHS Infectious Diseases Medical Centre, Chennai and Co-Chairperson of ASICON 2025: "HIV treatment is also prevention – when we treat people living with HIV their virus level comes down and they become less infectious to others. When people with HIV stay virally suppressed then the risk of HIV transmission is zero as per the WHO. Also, when it comes to HIV prevention, we need to ensure that all HIV combination prevention options are available and accessible to everyone, especially to the key populations (among which HIV risk and rate is very high). PrEP should become a part of our national programme."

Where are we on 95-95-95 targets for 2025?

The 95-95-95 targets to be achieved by 2025 mean that 95% of all people living with HIV should know their status, 95% of those who know their status should receive lifesaving antiretroviral therapy, and 95% of those on the treatment should be virally suppressed.

In India, as of March 2024 (according to government’s 6th Sankalak Report 2024), 81% of people living with HIV in India knew their HIV status. Out of these, 88% were receiving antiretroviral therapy, and out of those receiving the treatment, 97% were virally suppressed. Globally, 86% people living with HIV knew their status, 89% were on antiretroviral therapy, and 93% of those on antiretroviral therapy were virally suppressed.

“We need to ensure 100% of those who know their HIV positive status must be on antiretroviral therapy and virally suppressed,” said Dr Mathai.

Out of those who were newly diagnosed with HIV in India, around 93% were initiated on lifesaving antiretroviral therapy. But in several states, the number of those on free treatment was lower (such as, Assam, Chandigarh, Delhi, Himachal Pradesh, Puducherry, and Sikkim). For example, initiation of antiretroviral therapy among newly diagnosed people, ranged between around 47% in Puducherry and 76% in Assam.

How HIV impacts women

"It is important to understand how HIV impacts women in order to tailor our HIV responses in a gender-sensitive manner. There is a difference in frequency of cardiovascular and cerebrovascular diseases among women living with HIV. The way HIV impacts their bone density or issues related to HIV and menopause also need to be taken into account," said Dr Glory Alexander, Scientific Committee Co-Chairperson of ASICON 2025 and Founder-Director of ASHA Foundation Bengaluru. She is also among the recipients of the prestigious Dr BC Roy National Award. Dr Cristina Mussini from Italy said that risk of cardiovascular diseases is double and risk of stroke is two-three times among women with HIV.

"Women living with HIV have a six-fold greater risk of developing cancer of cervix (cervical cancer) compared to women who are not positive in general population. About 85% of all cervical cancers are caused by human papilloma virus (HPV). There are vaccines to prevent it but India till recently was dependent on imported vaccines which were very expensive. Now, Pune-based Serum Institute of India is making the vaccine (Cervavac) since 2023. So now our goal is to provide this vaccine to eligible women living with HIV so that they can protect themselves from acquiring cancer of the cervix. Our government too is considering it seriously to include vaccination in the national public programme. I am part of "Cancer Cervix Elimination Consortium India" which is complementing the work of the government. In the private sector, many organisations are already providing the vaccine," said Dr Glory Alexander.

Antimicrobial resistance and HIV

When HIV virus becomes resistant to lifesaving antiretroviral medicines, then the person with HIV needs to be treated with a different set of medicines - and treatment options get limited. Antimicrobial resistance, which is fuelled by misuse and overuse of medicines, is among the top 10 global health threats today. Dr Kumarasamy said: "We have the latest antiretroviral regimen in our national programme as recommended by the WHO but antiviral resistance is also on an alarming rise. Drug resistance is also reported now against some of the newer antiretroviral medicines."

Progress made but challenges remain to end AIDS in India

New HIV infections surged by over 400% during 2010-2023 in few Indian states like Tripura and Arunachal Pradesh and doubled in Punjab and Meghalaya. Despite a lower national prevalence (0.20%), HIV rates in Mizoram (2.73%), Nagaland (1.37%), and Manipur (0.87%) significantly exceed the national average. In 2023-2024, injecting drug use was the main transmission route in some states (Assam, Arunachal Pradesh, Punjab, and Tripura) accounting for 61-77% of newly diagnosed people with HIV.

HIV prevalence remains very high among key populations such as migrants, truckers, female sex workers, prison inmates, men who have sex with men, transgender people and people who inject drugs. These groups experience HIV rates 9-43 times higher than the general adult population. According to a 2021 report by the National Centre for Disease Control (Directorate General of Health Services) based on HIV sentinel surveillance, Hepatitis B Virus (HBV) seroprevalence ranges from 0.95% in female sex workers to 3.09% in people who inject drugs, whereas Hepatitis C Virus (HCV) seroprevalence varies from 0.67% in migrants to 33.41% in people who inject drugs. HCV rates among people who inject drugs and are HIV positive is very high at 82.23%.

Co-infections management is a critical need to reduce morbidities and mortalities among people with HIV. The population is aging with around 37% of total people with HIV in India estimated to be aged 50 years or more. Around 4% of people with HIV were screened as those with presumptive TB, out of which 4-6% were diagnosed with active TB disease (and over 99% of them started TB treatment).

India has made significant stride towards the goal of eliminating vertical transmission of HIV and syphilis. In 2023-2024, about 19,100 HIV-positive pregnant women were identified, 63% increase from 2020-2021. The resultant increase in treatment coverage reduced the vertical transmission rate from over 25% in 2020 to around 11.75% in 2023. Additionally, treatment coverage for syphilis-infected pregnant women increased from 78% in 2021-2022 to around 90% in 2023-2024.

When compared to 2010, HIV rates have almost halved in India by 2023 (44.23% decline, which is more than the global decline in the same period 39%) and AIDS-related deaths have declined by 79.26% in India by 2023 (which is more than the global decline in the same period 51%). Compared to 2010, by 2023, decline of HIV incidence in Gujarat (state which is hosting ASICON 2025) was 56.86% (which is more than the national average decline of 44.23%), said ASICON 2025 Co-Chair Dr Harsh Toshniwal, President of Infectious Diseases Society of Gujarat.

Scientific partners of ASICON 2025 include the National AIDS Control Organisation (NACO) and National TB Elimination Programme of Ministry of Health and Family Welfare, Government of India; Gujarat Medical Council; Infectious Diseases Society of Gujarat; UNAIDS; CAPRISA (Centre for the AIDS Programme of Research in South Africa); among others.