Has India won the war against HIV? At best, some skirmishes have been won, but the National AIDS Control Programme needs to pull out all the stops to end AIDS as a public health threat by 2030 by reducing new infections by 75% by 2020 against the 2010 baseline.
New infections have gone down, but not enough. Between 2010 and 2017, annual new infections fell from 120,000 to 87,580, AIDS-related deaths from 160,000 to 69,110, and people living with HIV from 2.3 million to 2.14 million despite the average 1.24% annual increase in the country’s population of 1.3 billion.
Annual new infections, which indicate whether an epidemic is growing or ebbing, have fallen by 27% during the period, compared to the global average decline of 16%, but have stubbornly hovered around 80,000 for the past five years.
Annual infections have increased in Assam, Mizoram, Meghalaya and Uttarakhand while Bihar, West Bengal, Telangana, Delhi, Jharkhand and Haryana have seen a decline in infection lower than the national average.
Just eight states accounted for two-thirds of the 87,580 annual new HIV infections in India. Telangana led with 11% of the new infections pan India, Bihar and West Bengal accounted for 10% each, followed by West Bengal (10%), Uttar Pradesh (8%), Andhra Pradesh and Maharashtra (7% each), Karnataka (6%) and Gujarat (5%).
Given the heterogeneity of infection between states, data-driven differential prevention and care services have to be adopted.
For example, among high-risk groups, HIV incidence is the highest among injecting drug users compared to female sex workers and lesbians, gays, bisexuals and transgenders, with the highly populated states of Uttar Pradesh Bihar recording the highest incidence. Apart from testing and treating people living with HIV, outreach programmes must include promoting safe injecting practices and safe sex among the high-risk groups and bridge populations (such as partners, migrants and truckers), who unwittingly spread infection to the general population.
India’s “test and treat” policy provides free anti-retroviral treatment (ART) used to treat HIV and AIDS free to everyone who tests positive. But with the National AIDS and STD Control Programme budget this year increasing fractionally to Rs 2,100 crore from ₹ 2,000 crore in 2017, the majority of funds are used for testing and treatment, with little left for prevention and the promotion of safe practices and behaviours.
The scale-up of the ART programme has led to a 71% decline in AIDS-related deaths in India, compared to 48% worldwide, but the coverage is a low 56% against the global target of putting 82% of people living with HIV on treatment by 2020. AIDS-related deaths are also rising in Bihar, Jharkhand, Haryana, Delhi and Uttrakhand.
ART suppresses HIV viral load to not just lower symptoms and keep people living with HIV disease-free, but also lowers their chances of infecting others. While there is no study for India, using ART to treat HIV can add 10 years to life and gives a 20-year-old who starts treatment a “near normal” life expectancy of 67 years in Europe and north America, found an analysis of 18 studies of over 88,500 people published in The Lancet HIV.
To persuade people to stay on treatment, Mission Sampark (contact) has been started to bring back on ART patients lost to follow-up. Integrating programmes, such testing for HIV and syphilis, HIV and tuberculosis, and HIV and Hepatitis C — will also help take comprehensive services to a wider population.
In India, unprotected sex with an infected person and injecting drug use are the leading causes of new infection.
Ending AIDS as a public health threat by 2030 is only possible only if services are offered to all, including high-risk groups, and everyone who tests positive gets treated. While decriminalising gay sex will help take services to lesbians, gays, bisexuals and transgender people, promotion of safe injection practices still needs a boost to ensure injecting drug users and their partners are protected from infection.