Getting to zero: Possibility or propoganda?

The world is now in the fourth decade of a pandemic that united all the nations more than any other calamities or policies. The numbers with relation to HIV are falling consistently. Unfortunately the funding is also decreasing. In the current uncertain economic environment, the Joint United Nations Programme on HIV and AIDS (UNAIDS) has set a very ambitious target of reducing HIV to zero by 2015. There are strategies that are good and cost-effective and, if used appropriately, will give remarkable results. No new innovations have recently been discovered related to HIV. More molecular level studies are needed besides strengthening the existing strategies. We need money for all these activities and it should not stop coming. The paper reviews the success of HIV program in India and also foresees the challenges lying ahead of us in "getting to zero."

INTRODUCTION

As HIV/AIDS entered in its fourth decade of existence in 2011, there has been renewed interest amongst stakeholders to halt the epidemic that has killed millions of individuals in a short span of 30 years. There has been remarkable progress in the fight against this deadly disease due to unprecedented support by funding agencies, researchers, people living with HIV/AIDS, health activists, and civil society organizations. According to the estimates by UNAIDS, there were 34 million people living with HIV at the end of 2010. Nearly 2.7 million individuals, including 390,000 children, became newly infected with the virus in 2010. Despite a significant decline in the estimated number of AIDS-related deaths recently, there were still an estimated 1.8 million AIDS-related deaths in 2010. There is a fall of 21% in the annual incidence of HIV infection from 1997 to 2010.[1] Accessible treatment led to 22% decline in AIDS-related deaths in the last 5 years.[2] India accounts for the largest number of HIV-positive individuals from South and South East Asia and ranks third globally in terms of HIV positives living in a country. As per the estimates, there were an estimated 23.9 lakh people living with HIV/AIDS in India with an adult prevalence of 0.31% in 2009. New HIV infection fell by 56% in 2010 from its peak value in 1996 in the country.[3] Deaths due to AIDS have been steadily declining since the free antiretroviral therapy (ART) program was started in the country in 2004. Around 3.8 lakh HIV positives are currently on ART in 292 health centers.

No disease, in recent memory, has attained these milestones so rapidly. At this important juncture when the major world economies face an uncertain future, UNAIDS and other interested parties came out with a vision of a world with zero new HIV infections, zero discrimination, and zero AIDS-related deaths in 2011. With this vision in mind, the theme of World AIDS Day 2011 was “getting to zero.” This is an uphill task and there are formidable challenges before us. This paper reviews the current status of HIV/AIDS in India, critically sees the achievements made in the past and foresees the challenges lying ahead in achieving “getting to zero.”

The important reasons for the fall in number of new HIV infections are discussed below.

Behavior change particularly among young people

This appears to be the single most important reason for the dramatic fall in HIV number. Also, this is the preventive strategy at its purest form. Young generation, particularly sex workers and their clients, men who have sex with men, and transgenders, are indulging less frequently in risky sexual encounters. The beneficial behavior changes include reduction the in numbers of sexual partners, increased use of condoms, and delayed age of first sex. Studies based on modeling have shown that without behavior change, HIV incidence would have remained twice as high as the current levels in some countries.[4]

Preventing and managing sexually transmitted infections

Sexually transmitted infections (STI) increase the risk of getting HIV.[5] Interventions that have been found effective for controlling STI are syndromic management of genital ulcer disease and urethral discharge, syphilis testing of pregnant women and individuals diagnosed with other STI, treating the male partners, counseling about risk reduction related to HIV and STI, and human papillomavirus vaccination. These interventions have not only led to a decline in the number of STI cases but also contributed to the gradual decline in HIV prevalence in several low- and middle-income countries.[6]

Blood safety

The national policy concerning donation, screening, and transfusion of blood or its constituents, along with collecting blood from voluntary, unpaid donors; screening all donated blood for transfusion-transmissible infections such as HIV, and ensuring adequate training of clinicians on rational blood use helps in keeping the number of new HIV infections due to blood transfusion low.

Access to antiretroviral drug therapy

Behavioral changes help in the decline of new HIV infection, but only up to a certain level. Then, the curve plateaus off. Evidence has shown that this can further be brought down by bringing more and more HIV positives under the net of treatment.[7] It is estimated that nearly 7 million people in low- and middle-income countries, which is around 50% of the eligible HIV-positive individuals, are receiving antiretroviral drug treatment. The Government of India started distributing free ART to people living with HIV and AIDS (PLWHA) from April 2004. Though universal access to treatment (defined as 80%, or greater coverage) is a distant dream in the country, the number of new patients on ART has been gradually increasing since then. The United Nations General Assembly Special Session (UNGASS) India report of the year 2010 mentions that 19.6% of adults and 35.1% of children with advanced HIV infection were receiving ART by December 2007.[8] As of March 2012 in 342 ART centers located throughout India, 486,173 HIV patients are receiving antiretroviral drugs.[9] Globally about 2.5 million deaths since 1995 have been averted only by providing the quality ART services to eligible population. Again the study based on modeling has shown that the number of new HIV infections is 30%-50% lower now than it would have been in the absence of universal access to treatment for eligible people living with HIV.[1]

Targeted interventions

According to an estimate by National AIDS Control Organisation (NACO), there are 1.8 million individuals belonging to high-risk group and another 11 million bridge population. Indian National AIDS Control Programme (NACP) aims to cover 80% of these with tested primary prevention services, like treatment for STI, condom provision, behavior change communication, creating and strengthening an enabling environment with community involvement and participation, linkages to care and support services, and community organization and ownership. A study published in BMC Public Health by Kumar et al. shows that the targeted interventions (TIs) on HIV prevalence have worked in the southern states with high HIV prevalence. Among the female sex workers (FSWs), consistent condom use with last paying clients increased from 58.6% to 83.7%, and among men of reproductive age, the condom use during sex with non-regular partner increased from 51.7% to 68.6%. A significant decline in prevalence of HIV and other sexually transmitted diseases (STDs) has occurred among FSWs and young antenatal women.[10]

CHALLENGES LYING AHEAD

Less number of people know their status

According to UNAIDS estimates, globally more than 60% of people living with HIV are unaware of their HIV status. This limits access to treatment and care services and hampers prevention efforts. Though HIV testing has been incorporated in routine health services in many countries and there are dedicated centers for voluntary HIV testing, the result has not been encouraging. New approaches to HIV testing need to be explored to increase knowledge of HIV status. Community-based HIV testing should be initiated after thorough research. A study published in The Lancet Infectious Diseases showed that use of community-based voluntary counseling and testing (CBVCT) improved the rates of initial and repeat HIV testing in remote communities, compared with standard clinic-based VCT (SVCT). CBVCT included mobile HIV testing, community mobilization, and post-test psychosocial support services. The researchers found that the proportion of people receiving their first HIV test from the study was higher in CBVCT communities than in SVCT communities in Tanzania (37% vs. 9%), Zimbabwe (51% vs. 5%), and Thailand (69% vs. 23%). HIV prevalence was higher among those tested for HIV in SVCT communities than in CBVCT communities, but due to the larger number of people tested, CBVCT detected almost four times more HIV cases than did SVCT across the three study sites (952 vs. 264). The authors concluded that communities can be mobilized to learn their HIV status despite little infrastructure available.[11] It is easier said than done. There are many barriers that have to be crossed before advocating the community-based HIV testing. Most important of them is the HIV-related stigma that occurs at individual, interpersonal, community, and institutional levels. Steps and resources are needed to address the stigma adequately.[12]

Dwindling funds for HIV programs

Current economic crises have reduced the financial resources made available for the HIV/AIDS programs globally. International assistance has declined from US$ 8.7 billion in 2009 to US$ 7.6 billion in 2010. It is declining every year and it may be one of the reasons of not achieving all the goals at the end of 2010, which were set in 2001. In June 2011, UNAIDS estimated that at least US$ 22-24 billion annually is required for reaching the future targets. Making this amount available every year till 2015 is a herculean task. The countries should invest wisely whatever money they have. The UNAIDS’ Investment Framework for HIV mentions rational allocation of resources to six basic program activities, namely focused interventions for key populations at higher risk; elimination of new HIV infections among children; behavior change programs; condom promotion and distribution; treatment, care, and support for people living with HIV; and voluntary medical male circumcision in countries with high HIV prevalence and low rates of circumcision.

Mother-to-child transmission of HIV

Mother-to-child transmission is the most important source of HIV infection in people below 15 years of age. Though much progress has been made in the prevention and treatment of HIV infection, awareness about the vertical mode of transmission of HIV is still lacking amongst the general population. In India, about 28 million births take place each year. Considering the national average of 0.3% prevalence amongst pregnant women, around 84,000 deliveries would occur in HIV-positive women. Without any intervention, about 30%-45% of these babies will become infected with HIV.[13] Round 3 of National Family Health Survey, a socio-demographic-health survey of India, shows that around 60% of births still take place at home.[14] Even if all the mothers delivered in health centers are screened for HIV, a substantial number who opt for delivery at home will be left undiagnosed.

Newer methods of preventing HIV

A number of clinical trials have shown that male circumcision reduces the risk of female-to-male HIV sexual transmission considerably.[1516] UNAIDS and WHO recommend it in areas of high HIV prevalence and low rates of male circumcision. A number of countries in southern and eastern Africa are scaling up the male circumcision. Vaginal microbicides are found to be effective in preventive HIV infections to those who are not infected with HIV.[17] A cost–benefit analysis indicates that the introduction of a microbicide in 73 lower-income countries, which reduced the risk of infection by 40%, at 30% coverage, would avert approximately 6 million HIV infections over 3 years in men, women, and children, besides reducing the health care costs by US$ 3.2 billion.[18] Microbicides, better known as topical pre-exposure prophylaxis (PrEP), should be safe, cost-effective, and culturally, socially, and ethically acceptable before they can be widely used.[19]

GETTING TO ZERO: 10 GOALS FOR 2015

India is not in a position to achieve all the 10 goals earmarked to be achieved by 2015 by the United Nations in a short time of 4 years.[20] The third phase of NACP (NACP III) finished in 2012 and finalization of NACP IV is going on. This transition period when more planning and less ground work activities take place would consume major time duration. The program should maintain the success achieved in the past and reorient its strategies according to the UNAIDS vision of getting to zero. Local community should be involved more and more in every step of HIV control right from getting the people to know their HIV status to bringing the eligible PLWHA to the free ART centers. The money should be spent judiciously as less of it would be available in the near future.