Shobha Shukla, CNS (Citizen News Service)
Globally, there are an estimated 36.7 million people living with HIV (PLHIV), with over 1.8 million new infections and more than 1 million deaths in 2016. However, only 65% of these PLHIV are aware of their status and 53% (19.5 million) of all PLHIV are on treatment.
SDG Goal 3.3 commits to end AIDS by 2030. Moreover, UNAIDS fast track targets as well as the targets enshrined in National Health Policy (Source: 2.4.1.3. of NHP 2017) of government of India, hope to achieve by 2020 the 90-90-90 target, that is, 90% of all PLHIV will know their HIV status; 90% of the people diagnosed with HIV infection will receive sustained antiretroviral therapy (ART); and 90% of all people receiving ART will have viral suppression.
As per UNAIDS data, with an HIV prevalence rate of less than 0.3%, India is currently home to an estimated 21.17 lakhs (2.12 million) PLHIV. Out of these 16.36 lakhs (77%) know their status (have been diagnosed), and 63% of them (10.24 lakh) are on ART. So overall, only 49% of the estimated number of PLHIV are on ART. The year 2016 saw 80,000 new HIV infections and 68000 AIDS related deaths in the country. And yet only 25.7% of the young people (15-24 years) have any knowledge of HIV.
Given that 80,000 new HIV infections are added every year, India will have to diagnose over 7 lakh more PLHIV, put an additional 13 lakh PLHIV on ART and ensure that 90% of all of them are virally suppressed, in order to meet the 90-90-90 targets. And it has barely 36 months to do so. A tall order indeed! But perhaps, it is good to aim high, else complacency might set in.
Dr Raman R Gangakhedkar, Director-in-Charge, National AIDS Research Institute (NARI) of Indian Council of Medical Research (ICMR), recently spoke with CNS (Citizen News Service) on the key challenges that lie ahead in the path of achieving the ambitious, but doable, 90-90-90 targets by 2020. According to him the key challenge for India lies in achieving the 90-90-90 target in key populations and in low HIV prevalence states, where the rural epidemic will be higher due to migration as a driver.
Diagnosing 90% of the estimated existing PLHIV
“Challenge would be to reach the invisible key subpopulations. The hidden population of those female sex workers, who seek clients through mobile or internet technology to ensure anonymity, will have to be reached through social media and internet based tools to bring them into the net of testing. The only way to access MSMs (who have gone into hiding after the Supreme Court ruling) is through enhanced outreach from peers. Then again, with injecting drug use no longer restricted to the North East region, the key challenge is to first identify the hitherto unknown hotspots of injecting drug users (IDUs), and then reach them through peers”, he said.
But Dr Gangakhedkar fears that even after being reached, these sub populations might not like to visit a health facility for testing. Hence community based testing will have to be provided - do an HIV test on the spot, and, if found positive, do confirmatory diagnosis subsequently through ICTC. But as per Indian law, only an authorized person (a doctor) can sign and give out a test report. So, we need a regulatory change to permit community based HIV testing. Also as community based approaches involve services of peers, we do not know how good these community based leaders would be in ensuring that a potentially HIV positive person who is linked to a clinic would go there for the confirmatory test, he feared.
In case of migrants, testing their partners would remain a challenge on two accounts - tracing them, (as they could be staying several km away) and approaching them without breach of confidentiality.
Putting 90% of those diagnosed with HIV on treatment
Counselling would play a major role in achieving this target, feels Dr Gangakhedkar: “Even if we are able to link the diagnosed PLHIV to an ART centre, the likelihood of their opting out and not remaining linked to that cascade is very strong. One can imagine the plight of those individuals, who were hitherto unaware of their HIV status, being tested today and told within the next 2-3 days that a lifelong treatment for HIV is to begin. How ready would they be to continue treatment? Their first reaction would mostly likely be to discontinue treatment, more so if there are no apparent symptoms of any sickness. A lot would depend upon proper counselling and on treatment readiness of the patient. From a public health point of view, we do not want to lose any PLHIV, but from the human angle, it might not be good to initiate ART when they are not ready for it, as it would be more damaging if they stop treatment midway”.
Ensuring viral suppression for 90% of those on treatment
The biggest challenge here would be non-adherence and loss to follow up. From Dr Gangakhedkar’s personal experience people are generally lost to follow up in the first 6-12 months - the main reason being drugs’ toxicity. So, once again the role of counsellors becomes crucial. He shared that, “In my clinic at NARI, I give my phone number to my patients at the time of initiating them on ART and request them to call me any time if they ever feel like discontinuing treatment. Moreover, within the first 15 days after start of ART, I personally call each of my patients to enquire about their well-being. This has always had a very positive effect on them. The very act of getting a call from the doctor gives them tremendous courage and hope and strengthens patient-doctor bond. They think that 'if the doctor is concerned about my health, I too should follow his advice.' Also, if in the first six months the patient has had no problems, I tell them to visit me not more than once a year. I prescribe my patients drugs from certain known pharmacies and I tell the pharmacists to report to me if any patient does not turn up to get the medicines. These are some simple ways by which one can keep track of one’s patients and know who is continuing treatment and who is not, and take immediate remedial action. Keeping the patients virologically suppressed requires a strategy that would impact their treatment adherence as well as facilitate distant monitoring."
Do we have enough resources?
In the best scenario of putting all efforts in place for the public health programme to achieve 90-90-90, paucity of human and financial resources would be an overriding problem. But the solution does not lie in bringing in more resources, it is more about moving towards proper utilization and better integration, believes Dr Gangakhedkar. Mainstreaming and doing away with vertical programmes is the need of the hour. Underutilized GeneXpert machines in TB clinics could be used for viral load testing.
Convergence of core health programmes can lead to cost cutting on human resource expenditure. Most Medical Colleges should be able to handle PLHIV alongside other patients in their Medicine OPDs. There should be no need of providing separate manpower for this. PLHIV would not have to go to a separate ART centre, but sit with other patients in the same OPD. This would also go a long way in removing stigma and discrimination, he said.
Empowerment of key populations is integral to achieving the targets and it is best to let the community run the targeted interventions programmes. Dr Gangakhedkar suggests that rather than asking PLHIV to come to a health facility, some ART centre staff could come to the community to supervise when all new patients are being put on ART and then let the community take over. We have to test the right kind of people; strengthen community based approaches and partner testing; focus on personalized counselling, improve supply chain management, and have effective public private partnerships.
Shobha Shukla, CNS (Citizen News Service)
1 December 2017
(Shobha Shukla is the Managing Editor of CNS (Citizen News Service) and has written consistently on health and gender justice for several years. Follow her on Twitter @Shobha1Shukla or visit www.citizen-news.org)
Globally, there are an estimated 36.7 million people living with HIV (PLHIV), with over 1.8 million new infections and more than 1 million deaths in 2016. However, only 65% of these PLHIV are aware of their status and 53% (19.5 million) of all PLHIV are on treatment.SDG Goal 3.3 commits to end AIDS by 2030. Moreover, UNAIDS fast track targets as well as the targets enshrined in National Health Policy (Source: 2.4.1.3. of NHP 2017) of government of India, hope to achieve by 2020 the 90-90-90 target, that is, 90% of all PLHIV will know their HIV status; 90% of the people diagnosed with HIV infection will receive sustained antiretroviral therapy (ART); and 90% of all people receiving ART will have viral suppression.
As per UNAIDS data, with an HIV prevalence rate of less than 0.3%, India is currently home to an estimated 21.17 lakhs (2.12 million) PLHIV. Out of these 16.36 lakhs (77%) know their status (have been diagnosed), and 63% of them (10.24 lakh) are on ART. So overall, only 49% of the estimated number of PLHIV are on ART. The year 2016 saw 80,000 new HIV infections and 68000 AIDS related deaths in the country. And yet only 25.7% of the young people (15-24 years) have any knowledge of HIV.
Given that 80,000 new HIV infections are added every year, India will have to diagnose over 7 lakh more PLHIV, put an additional 13 lakh PLHIV on ART and ensure that 90% of all of them are virally suppressed, in order to meet the 90-90-90 targets. And it has barely 36 months to do so. A tall order indeed! But perhaps, it is good to aim high, else complacency might set in.
Dr Raman R Gangakhedkar, Director-in-Charge, National AIDS Research Institute (NARI) of Indian Council of Medical Research (ICMR), recently spoke with CNS (Citizen News Service) on the key challenges that lie ahead in the path of achieving the ambitious, but doable, 90-90-90 targets by 2020. According to him the key challenge for India lies in achieving the 90-90-90 target in key populations and in low HIV prevalence states, where the rural epidemic will be higher due to migration as a driver.
Diagnosing 90% of the estimated existing PLHIV
“Challenge would be to reach the invisible key subpopulations. The hidden population of those female sex workers, who seek clients through mobile or internet technology to ensure anonymity, will have to be reached through social media and internet based tools to bring them into the net of testing. The only way to access MSMs (who have gone into hiding after the Supreme Court ruling) is through enhanced outreach from peers. Then again, with injecting drug use no longer restricted to the North East region, the key challenge is to first identify the hitherto unknown hotspots of injecting drug users (IDUs), and then reach them through peers”, he said.
But Dr Gangakhedkar fears that even after being reached, these sub populations might not like to visit a health facility for testing. Hence community based testing will have to be provided - do an HIV test on the spot, and, if found positive, do confirmatory diagnosis subsequently through ICTC. But as per Indian law, only an authorized person (a doctor) can sign and give out a test report. So, we need a regulatory change to permit community based HIV testing. Also as community based approaches involve services of peers, we do not know how good these community based leaders would be in ensuring that a potentially HIV positive person who is linked to a clinic would go there for the confirmatory test, he feared.
In case of migrants, testing their partners would remain a challenge on two accounts - tracing them, (as they could be staying several km away) and approaching them without breach of confidentiality.
Putting 90% of those diagnosed with HIV on treatment
Counselling would play a major role in achieving this target, feels Dr Gangakhedkar: “Even if we are able to link the diagnosed PLHIV to an ART centre, the likelihood of their opting out and not remaining linked to that cascade is very strong. One can imagine the plight of those individuals, who were hitherto unaware of their HIV status, being tested today and told within the next 2-3 days that a lifelong treatment for HIV is to begin. How ready would they be to continue treatment? Their first reaction would mostly likely be to discontinue treatment, more so if there are no apparent symptoms of any sickness. A lot would depend upon proper counselling and on treatment readiness of the patient. From a public health point of view, we do not want to lose any PLHIV, but from the human angle, it might not be good to initiate ART when they are not ready for it, as it would be more damaging if they stop treatment midway”.
Ensuring viral suppression for 90% of those on treatment
The biggest challenge here would be non-adherence and loss to follow up. From Dr Gangakhedkar’s personal experience people are generally lost to follow up in the first 6-12 months - the main reason being drugs’ toxicity. So, once again the role of counsellors becomes crucial. He shared that, “In my clinic at NARI, I give my phone number to my patients at the time of initiating them on ART and request them to call me any time if they ever feel like discontinuing treatment. Moreover, within the first 15 days after start of ART, I personally call each of my patients to enquire about their well-being. This has always had a very positive effect on them. The very act of getting a call from the doctor gives them tremendous courage and hope and strengthens patient-doctor bond. They think that 'if the doctor is concerned about my health, I too should follow his advice.' Also, if in the first six months the patient has had no problems, I tell them to visit me not more than once a year. I prescribe my patients drugs from certain known pharmacies and I tell the pharmacists to report to me if any patient does not turn up to get the medicines. These are some simple ways by which one can keep track of one’s patients and know who is continuing treatment and who is not, and take immediate remedial action. Keeping the patients virologically suppressed requires a strategy that would impact their treatment adherence as well as facilitate distant monitoring."
Do we have enough resources?
In the best scenario of putting all efforts in place for the public health programme to achieve 90-90-90, paucity of human and financial resources would be an overriding problem. But the solution does not lie in bringing in more resources, it is more about moving towards proper utilization and better integration, believes Dr Gangakhedkar. Mainstreaming and doing away with vertical programmes is the need of the hour. Underutilized GeneXpert machines in TB clinics could be used for viral load testing.
Convergence of core health programmes can lead to cost cutting on human resource expenditure. Most Medical Colleges should be able to handle PLHIV alongside other patients in their Medicine OPDs. There should be no need of providing separate manpower for this. PLHIV would not have to go to a separate ART centre, but sit with other patients in the same OPD. This would also go a long way in removing stigma and discrimination, he said.
Empowerment of key populations is integral to achieving the targets and it is best to let the community run the targeted interventions programmes. Dr Gangakhedkar suggests that rather than asking PLHIV to come to a health facility, some ART centre staff could come to the community to supervise when all new patients are being put on ART and then let the community take over. We have to test the right kind of people; strengthen community based approaches and partner testing; focus on personalized counselling, improve supply chain management, and have effective public private partnerships.
Shobha Shukla, CNS (Citizen News Service)
1 December 2017
(Shobha Shukla is the Managing Editor of CNS (Citizen News Service) and has written consistently on health and gender justice for several years. Follow her on Twitter @Shobha1Shukla or visit www.citizen-news.org)
