The ART of India’s HIV/AIDS response

HIV stands for Human Immunodeficiency Virus. It attacks the body's immune system, gradually weakening its ability to fight infections and diseases. If left untreated, HIV can progress to AIDS (Acquired Immunodeficiency Syndrome), the most advanced stage of HIV infection. During the emergence of HIV/AIDS in the early 1980s, the disease was viewed as a death sentence, leading to widespread fear, stigma, and discrimination. Although the first antiretroviral drug, AZT (zidovudine), received approval from the US Food and Drug Administration (US FDA) in March 1987, subsequent drugs were approved in 1988, and a new class of antiretroviral drugs called protease inhibitors was introduced in 1995. However, access to these medications remained restricted for a large portion of the global population, particularly in low- and middle-income countries.

HIV Transmission

HIV is primarily transmitted through bodily fluids, including, Blood, Semen (including pre-seminal fluid), Vaginal and rectal fluids and Breast milk. 

Transmission can occur through

• Unprotected sexual intercourse (vaginal, anal, or oral)
• Sharing needles or syringes used for injecting drugs
• Mother-to-child transmission during pregnancy, childbirth, or breastfeeding

The Symptoms of HIV

• In the early stages, HIV infection may not cause any noticeable symptoms. However, some people experience flu-like symptoms within a few weeks of exposure, including, Fever, Headache, Fatigue and Swollen lymph nodes. 
• As HIV progresses, symptoms can become more severe and may include, Weight loss, Repeated or persistent infections (including yeast infections, tuberculosis), Shortness of breath and Night sweats. 

Living with HIV/AIDS

• With proper medical care, people living with HIV can lead long and healthy lives.
• Antiretroviral therapy (ART) is a combination of medications that can suppress HIV, preventing it from replicating and keeping the viral load undetectable in the blood.
• This significantly reduces the risk of transmission to others and helps prevent the development of AIDS.

HIV Prevention

There is no cure for HIV, but there are effective ways to prevent its spread

• Always use condoms (male or female) and dental dams during sexual activity.
• Regular testing allows for early diagnosis and access to treatment.
• Do not share needles or syringes and Use sterile equipment for injections.
• Pregnant women living with HIV can receive treatment to significantly reduce the risk of transmitting the virus to their babies.

2. Evolution to Free Antiretroviral Therapy (ART)

Global Efforts in Response to HIV/AIDS

In the year 2000, during the UN General Assembly’s Millennium Summit, global leaders established a specific goal to halt and reverse the spread of HIV/AIDS. This initiative led to the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2002. The Global Fund advocated for universal access to HIV prevention, treatment, care, and support services, emphasizing the need for comprehensive approaches to combat these diseases.

Challenges Faced in India

By 2004, India was grappling with an estimated 5.1 million Persons living with HIV (PLHIV), with a prevalence rate of 0.4%. However, only a small fraction of PLHIV had access to antiretroviral therapy (ART). The primary barriers were the high cost of ART medications and limited geographical access to treatment facilities. The introduction of highly active antiretroviral therapy (HAART) in 1996, though a breakthrough, remained financially out of reach for most individuals, priced at $10,000 annually.

Path-Breaking Decision: Free ART

Recognizing the urgent need to address these challenges, the Indian government took a significant step in making ART free for all adults living with HIV. This decision, initiated in 2004 and extended to children from November 2006, marked a transformative shift in HIV/AIDS healthcare in India. Over the years, the number of ART centres expanded significantly, from fewer than 10 to approximately 700, with an additional 1,264 Link ART centres providing free ART drugs to around 1.8 million PLHIV.

Impact of Free ART

The provision of free ART not only started individuals on treatment but also focused on maintaining suppressed viral loads to prevent disease transmission. By 2023, the prevalence of HIV among individuals aged 15-49 had decreased to 0.20%, and the burden of estimated PLHIV reduced to 2.4 million. India's global share of PLHIV dropped to 6.3% from around 10% two decades ago, showcasing significant progress. Notably, a large percentage of PLHIV knew their HIV status, were on ART, and achieved viral suppression, contributing to a decline in new HIV infections and AIDS-related mortalities in India, surpassing global averages. These achievements underscore the success and impact of India's free ART initiative in combating HIV/AIDS on a national scale.

Statistics on HIV/AIDS patients in India

3. Complementary Initiatives in HIV/AIDS Care

Expanded Services

In addition to free Antiretroviral Therapy (ART), various complementary initiatives have played a crucial role in combating the HIV epidemic in India. These initiatives encompassed providing free diagnostic facilities, focusing on preventing parent-to-child transmission of HIV (PPTCT) and managing opportunistic infections, including tuberculosis (TB).

Evolution of Treatment Policies

Over the years, India's HIV/AIDS program exhibited adaptability and underwent dynamic modifications. Initiatives such as early initiation of ART and the "Treat All" policy, introduced in 2017, allowed for universal access to ART regardless of CD4 count. This approach significantly reduced virus transmission on both individual and community levels. Additionally, free viral load testing for all PLHIV on treatment was implemented to monitor treatment efficacy.

Patient-Centric Approach

The program adopted a patient-centric approach by providing stable PLHIV with two to three months' worth of medicines, reducing the frequency of visits to ART centres. This approach enhances treatment adherence, reduces travel time and costs for patients, and alleviates congestion at ART centres, allowing healthcare workers to attend to other patients effectively.

Continuous Improvement

India continued to enhance its HIV/AIDS program by incorporating newer and more potent drugs, such as Dolutegravir (DTG), which was introduced in 2020. Furthermore, the policy of rapid ART initiation, where individuals are started on ART within seven days of HIV diagnosis, was implemented in 2021, further improving treatment outcomes.

Ongoing Challenges and Future Goals

Despite significant progress, the fight against HIV/AIDS is ongoing. India's National AIDS Control Programme (NACP) phase 5 aims to achieve ambitious targets by 2025, including an 80% reduction in annual new HIV infections and AIDS-related mortalities. Additionally, the program aims to eliminate vertical transmission of HIV and syphilis. These targets align with global goals set by UNAIDS and emphasise the importance of achieving high levels of HIV testing, treatment, and viral suppression by 2025.

4. Challenges and Hurdles

• Delayed enrollment in ART facilities remains a significant challenge, with patients presenting with CD4 count <200 constituting a substantial portion of total visits. Moreover, patients may become non-adherent to treatment once they start feeling better, leading to missed doses or dropping out entirely, which can result in the development of drug resistance.
• Sustained supply and availability of ART medications need to be ensured across all regions, particularly in remote and difficult-to-access areas.
• There is a need to engage the private sector in the care of PLHIV to broaden the reach of services and support.
• Continuous training and capacity building of healthcare staff are essential to keep pace with evolving scientific advancements, emphasising practical, hands-on training.
• Strengthening integration with other health programs, such as hepatitis, non-communicable diseases (diabetes and hypertension), and mental health, is crucial as PLHIV often have additional health conditions that require attention.
• A focused approach is required to reduce preventable mortality, including systematic death reviews and the availability of advanced diagnostics.

5. Factors Contributing to Success

• The success of the free ART initiative can be attributed to the unwavering political will and support of successive governments.
• Adequate funding, regular program reviews, and field-based monitoring have been crucial in sustaining the initiative's success.
• A series of complementary initiatives, along with community and stakeholder engagement, have played a significant role in supporting the initiative's objectives.
• Modifying service delivery approaches to be more people-centric has enhanced the accessibility and utilisation of ART services.
• Efforts to bridge the gap between policy intentions and implementation have ensured the effective delivery of quality health services.
• Continuous Expansion of Services has enabled broader coverage of PLHIV over the years.

6. Conclusion

The success of the free ART initiative underscores the potential for guiding other public health programs in the country. Learnings from the initiative could be applied to launch nationwide initiatives, such as free hepatitis C treatment, and accelerate progress toward disease elimination goals.