N. Kumarasamy
Since the first diagnosed case of HIV in 1981, it is estimated that globally 39 million persons are now living with HIV. In India the figure is 2.4 million. What is being done to stop the spread of this virus? There were 1.3 million new HIV infections in 2022 globally and 63,000 in India. Most transmissions occur in the key population include female sex workers, men having sex with men, transgender community and injecting drug users. Prevention interventions using behavioural change never stopped HIV spread significantly. There are no vaccines for HIV despite extensive research. Involving the communities and making them the focus will prevent infections.
Persons who acquire HIV end up with compromised immune systems which lead to opportunistic infections like tuberculosis, fungal meningitis, pneumonia, diarrheal diseases, variety of skin lesions and certain cancers. These co-morbid conditions result in advanced HIV disease and progression to death. In 2022, 650,000 persons died due to these conditions globally. In India AIDS caused 42,000 deaths. Many of these opportunistic infections are preventable and treatable.
The World Health Organization has developed guidelines for Advanced HIV to prevent and diagnose these opportunistic infections. These guidelines are still not widely implemented across the world. Health care programs should implement these in-expensive guidelines and tools to prevent advanced HIV. Tuberculosis was a leading killer among those with HIV in 2022. Newer short course TB preventive treatments with Isoniazid and Rifapentine have proven effective in clinical trials. Still TB programs in many countries are struggling to implement these treatments.
Today we have effective antiretroviral medications available to prevent multiplication of HIV. People with HIV who are on these antiretroviral medications can lead a normal, healthy lifestyle without developing opportunistic infections. Results from clinical trials recommend starting Antiretroviral Therapy (ART) soon after diagnosis. The Voluntary Health Services Infectious Diseases Medical Centre in Chennai participated in the landmark global START clinical trial and based on the results, WHO Guidelines recommend rapid ART initiation for maximum benefit. Several lower and middle income countries haven’t implemented this guidance effectively. Analysis shows initiating early Antiretroviral therapy soon after diagnosis is cost effective and cost saving. Health care program managers need appropriate training on such scientific evidence to facilitate the implementation at an appropriate time without delay.
Almost 21 million lives have been saved with antiretroviral therapy globally. India’s capacity to produce generic HIV medicines and supply them worldwide led to major successes in the global AIDS fight. Over 90% of antiretrovirals consumed globally were from India. 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?
Persons with HIV who are on uninterrupted antiretroviral therapy lead a normal life and modelling studies have shown, their life expectancy is almost similar to persons who don’t have HIV. Several new antiretrovirals are in advanced clinical research, but we don’t have a cure yet. Long acting antiretrovirals have been recently approved for treatment and this is a boon for individuals who have issues with oral medication adherence. With all these newer antiretroviral therapies, HIV disease is yet another chronic manageable condition. New complications in people with HIV are non communicable diseases (NCDs) like diabetes, hypertension, stroke and kidney disease. NCD care will be key for persons with HIV for longevity.
Guidelines in the developed world recommend that everyone living with HIV aged 40 and over should take a statin to reduce their risk of heart disease, even if they do not have raised cholesterol or a high risk of heart disease. The new guidance is based on the results of the REPRIVE study conducted globally to test whether statin reduced cardiovascular risk in people with HIV. It was presented at the International AIDS Society Conference on HIV Science in July 2023. As study investigator, I was able to demonstrate results that showed taking pitavastatin daily reduced the risk of a major cardiovascular event such as heart attack, stroke or a clinical intervention to treat a serious heart disorder by 35% in people with HIV.
We have robust Antiretroviral Therapy (ART), that can result in undetectable viral load for those PLHIV on treatment within just a couple of months and by now it is amply clear that ‘Undetectable is Untransmittable’ or U=U based on other research led by my team. Thus, each new HIV case is a ‘missed opportunity’ where a range of combination prevention options could have helped prevent the person from getting infected. Likewise, every AIDS- related death is a grim reminder that it could have been averted because we have proven science-backed tools to make ‘AIDS death’ history.
We have effective biomedical prevention tools in preexposure prophylaxis (PrEP) medications. These oral medications are very effective in preventing HIV acquisition if a person with high risk of HIV takes them correctly without fail. Adherence is very important which might be an issue, as these medication have to be taken every day. To deal with this, a long acting injectable PrEP medication called Cabotegravir has been developed. Cabotrgravir injections can be taken every 2 months instead of the daily oral pill and studies have shown higher efficacy in HIV prevention with long acting injectable PrEP. Many African countries have initiated implementation of this innovative prevention tool. The Indian National HIV program should hurry to implement such interventions to stop AIDS in India.
Two decades ago, the global AIDS pandemic seemed unstoppable. More than 2.5 million people were acquiring HIV each year, and AIDS was claiming two million lives a year. The estimated 1.3 million new HIV infections in 2022 were the fewest in decades, with the declines especially strong in regions with the highest HIV burdens . These effects were due to the combination of effective antiretroviral therapy which resulted in community viral suppression and the introduction of PrEP to prevent HIV acquisition. Despite advocacy programs, the national program in India has not yet introduced PrEP in India. These delays in implementation will lead to an unstoppable spread of HIV.
By 2025, 95% of all people living with HIV (PLHIV) should have a diagnosis, 95% of those should be taking lifesaving antiretroviral treatment (ART) and 95% of PLHIV on treatment should achieve a suppressed viral load to improve health and reduce onward HIV transmission. In 2022, these percentages were 86%, 89% and 93% respectively.
Today we have science-backed robust tools to prevent HIV, diagnose HIV, treat, care and support PLHIV. Let us use these tools to end AIDS.
(Dr. N. Kumaraswamy is chief and director, VHS Infectious Diseases Medical Centre, Voluntary Health Services, Chennai. Kumarasamy@cartcrs.org)
