“With an estimated 21 lakh (2.1 million) people living with HIV (PLHIV), India has the third highest burden of HIV in the world, after South Africa and Nigeria. India is among 193 countries that are aiming to end AIDS by 2030 and achieve 90-90-90 targets by 2020; which are not just milestones set by UNAIDS but also enshrined in Government of India’s National Health Policy (NHP 2017). Despite formidable challenges, India has made commendable progress towards these ambitious goals, but there is a very long way ahead of us, if we are to deliver on these promises,” said Dr Ishwar Gilada, President of ASI and Governing Council Member of International AIDS Society, at a press conference at Bangalore.
What is 90-90-90 target?
The 90-90-90 targets include goals like 90% of all people living with HIV (PLHIV) will know their HIV status, 90% of all PLHIV will receive antiretroviral therapy- ART, and 90% of all people receiving ART will have suppressed viral load to minimize HIV transmission.
“Some partial success must not set in any complacency” warned Dr Ishwar Gilada who was among the first Indian doctors to begin HIV care. “India’s AIDS response is at a precarious point – new HIV infections which amounted to 87,580 (decline of just 27% between 2010-2017) – warrant us to reflect if we could have done better in preventing HIV transmission, diagnosing more PLHIV and putting more people on ART to inch closer towards 90-90-90 goals. We are almost the halfway point to reach the 90-90-90 targets by 2020, however the pace of progress in India has to be speeded up to match our national ambition to reach these goals”, he said.
He was speaking on the sidelines of the 11th National Conference of AIDS Society of India (ASICON 2018) which will be held from Nov 2-4 in Bengaluru. This year marks the 18th year of AIDS Society of India (ASI), a nationwide network of medical experts providing HIV care.
“The theme of ASICON 2018 is ‘Breaking barriers for health, hope and healing.’ And the clock is indeed ticking to break the barriers that stand in India’s way of achieving the 90-90-90 targets by 2020. After India adopted WHO’s Test and Treat strategy as a national policy, the entire machinery has been gearing up to achieve these targets. We are just about 26 months away from the deadline and a lot is yet to be achieved”, added Dr Gilada.
“As per NACO data of 2017, 77% of the estimated 21.40 lakh PLHIV in India knew their HIV status; 11.81 lakhs PLHIV (56%) were on life-saving ART. We haven’t yet reached out to 23% of PLHIV, and 44% of PLHIV have yet to get ART in India, despite WHO and NACO guidelines to ‘test and treat all’. We cannot slacken our efforts, because failing to reach out to each PLHIV, not putting them on ART and doing viral load testing (VLT), threatens to reverse the progress made in fighting AIDS and HIV prevention cannot take a backseat”, rues Dr Gilada.
The World Health Organization (WHO) guidelines 2016 as well as NACO India guidelines recommend routine viral load monitoring to be carried out at 6 months, at 12 months and then every 12 months thereafter if the patient is stable on ART. It is very important to scale up viral load testing in India to monitor the viral load suppression stressed the experts.
Scientific evidence has shown that if every PLHIV who is on ART has undetectable viral load – <20 copy/ml, his/her risk of transmitting HIV becomes negligible, and the person can lead a normal healthy life commensurate to the principle “Undetectable = Untransmittable”. VLT in India were done only at 10 national reference laboratories for suspected treatment failure cases. In 2016-17, only around 16,500 PLHIV who were on ART received VLT, but this capacity is escalated to 160,000 VLT in public-private partnership initiative. As per WHO and NACO guidelines, every PLHIV should have received the VLT. With such a small VLT capacity, it is not known how many of the documented 11.81 lakhs people on ART are virally suppressed.
“If every PLHIV needs a viral load test even once a year, then we need to scale up VLT capacity to conduct over 2 million (21.4 lakh) tests every year. How would India meet the goal of achieving viral load suppression for 90% of those PLHIV who are receiving ART by 2020 if business as usual continues?” asks Dr Ishwar Gilada. He said that efforts of National AIDS Control Programme (NACO) to move from targeted VLT to routine VLT for all patients on ART is a step in the right direction. This will help in earlier and more accurate detection of treatment failure. A viral load test will be conducted for all patients at 6 and 12 months after initiation of ART. All second/third line patients will be tested every 6 months and the first line patients will be tested annually after 12 months of ART initiation.
Dr GD Ravindran, co-chair of 11th ASICON said that in 2017, Karnataka had 2,47,413 PLHIV (1,23,821 women), among who 1,55,411 (62.8%) were receiving ART. AIDS related deaths have declined in Karnataka state by 68% between 2010-2017 to 8450. Despite a decline of 46% in new HIV infections in the state, we still saw 5008 new HIV infections in 2017.”
Dr Glory Alexandar, co-chair of 11th ASICON said that, “Regarding prevention of parent to child transmission of HIV (PPTCT), out of the estimated 22677 pregnant women living with HIV in India in 2017, only 13716 of them were receiving ARVs for PPTCT (60% coverage). In Karnataka however PPTCT coverage in 2017 was around 70% at 1421 against need of 1951. India aims to eliminate HIV transmission from parent to child. We need to accelerate progress towards these goals as well as maintain surveillance of HIV in pregnant women to ensure we do not risk reversing the progress made so far.”
ASICON 2018 will present the latest developments in diagnosis, prevention and management of HIV, and associated co-infections/ opportunistic infections. Recent advances in the vaccine, early treatment, cure research, diagnostics and future drugs will also be discussed. Academic partners of 11th ASICON include: government of India’s National AIDS Control Organization (NACO), United Nations joint programme on HIV/AIDS (UNAIDS), Medical Council of India, CAPRISA, Gilead Sciences Inc., PHO, Asha Foundation among others