25 years of HIV in India

The first case of HIV/AIDS in India was detected in Chennai sex workers in 1986, triggering shocked disbelief among health professionals which ultimately transformed into panic and then hopeless resignation.

"We never thought that HIV would ever visit India and take us on,” said Dr Ramesh Paranjape, Director of the National AIDS Research Institute, Indian Council of Medical Research. “At that time HIV was considered to be a disease of the western world and we had nothing to do with it. But slowly with more and more cases testing positive for the virus, it became a grave concern for us too."

Today, with an estimated 2.39 million HIV infections (of which 39 percent are female and 4.4 percent are children) India is home to the second largest population of people living with HIV - an epidemic which is concentrated in high-risk populations such as sex workers and their clients, gay men, transgenders and injecting drug users.

The 20 years from 1986 to 2006 saw the development of safe and effective therapeutic agents which could block each known stage in HIV replication in the human lymphocyte. By 2000 the triple drug cocktail had been developed which was the most exciting thing that happened for HIV treatment. Combinations of anti-retrovirals create multiple obstacles to HIV replication to keep the number of viral offspring low and reduce the possibility of a superior mutation. If a mutation that conveys resistance to one of the drugs being taken arises, the other drugs continue to suppress reproduction of that mutation.

India has played a significant role in combating the disease by way of manufacturing generic drugs used in treatment, bringing down the cost of medicines to affordable levels. Today it supplies 85 percent of low-cost HIV drugs to the developing world. Also, over the past few years we have seen a lot of advocacy for HIV control programs at different levels - NGOs, government and networks of people living with the disease themselves. In 1992 the National AIDS Control Organization was created.

This has helped to improve the understanding of the complex epidemic in India, with the focus shifting from raising awareness to behavior changes; from a nationalized response to a more decentralized one. The estimated number of new annual HIV infections has declined by more than 50 percent over the past decade. India had approximately 120,000 new HIV infections in 2009 against 270,000 in 2008. The trend of annual AIDS deaths has declined steadily since the rollout of free anti-retro viral therapy program in India in 2004.

Dr Paranjape feels that there are three major impediments in controlling the disease today:

(i) not having right strategies to reach the most at-risk populations, like unorganized female sex workers, injecting drug users, and gay men. Although homosexuality has been decriminalized and is gradually being accepted, they have not been reached fully. Also those who are married are potential threats for transmitting the virus to their wives. Reaching this population is still a major challenge.

(ii) The second challenge is to get everybody under the umbrella of medical care. There are lots of missed opportunities between the time the patient goes to integrated counseling and testing centers to the time they go for anti retroviral therapy.

(iii) Despite the huge investment in research, prevention methods remain based on behavioral change aspects. Vaccines, microbicides, or other clinical preventive measures remain out of reach. We only have condom use and behavior change. A close watch has to be kept on drug resistance too which could pose a great danger, more so as the number of patients on anti-retrovirals goes on increasing. Today more than 400,000 people are on anti-retroviral therapy and the number is likely to go up. Surveillance for drug resistance and surveillance for recombinant virus is the need of today.

"There are many issues we still need to understand as to how HIV can infect,” said Dr Atmaram Bandivdekar, Scientist at the National Institute for Research in Reproductive Health, Mumbai. New receptor cells in spermatozoa or vaginal epithelial cells have been identified, but the mechanism of HIV binding to these new receptors is different, and so there is a revised need for prevention technology, he says.

“We are getting some encouraging results in the field of microbicides. But it is too early to say as to when we will have one. The HIV virus is continuously mutating, and in the same person there could be a mixture of different isolates – in blood, semen or in other body fluids also. Hence it is difficult to control the virus and prevention is not easy. As clinical prevention strategies right now are not very effective, we can only socially educate the people to prevent unprotected sex. Multiple sex partners increase the risk of exposure to multiple viruses, and live in relationships can also be a problem area."

Unprotected sex (87.4 percent heterosexual and 1.3 percent homosexual) is the major route of transmission of the virus in India, followed by parent to child transmission (5.4 percent), infected needles/syringes (1.7 percent) and use of infected blood and blood products (1 percent).

"I do not believe that anyone should die of HIV any longer. The only two deterrents can be - not taking medicines and not knowing their HIV positive status,” said Dr Dilip Mathai, Professor and Head of the Department of Medicine, Christian Medical College in Vellore. “The problem is that people do not want to be tested, even though treatment is available and lifelong management of the disease is possible. In India we still have a big social problem of stigma/discrimination. This is earth shattering for me. In 2006 I had one ART testing center and 3,010 patients voluntarily tested. I put three in more centers and now I find only 1,060 people tested. Is it because of poor counseling?"

So proper counseling is imperative to ensure treatment adherence and compliance. Doctors can diagnose and treat, but it is the counselors who are in constant personal touch with the patient. Counseling should not be for the patient alone but stigma and other societal issues need to be addressed too. Very often, due to social stigma people do not come forward to avail of the free government treatment. Adolescent education on this issue is very important. This is the critical age where people need to be well informed about the perils of unsafe sex. As of now, India has a dearth of qualified counselors.

All said and done, the country has indeed come a long way from those days when the disease was nothing short of a death sentence. The HIV epidemic is coming under control, though eradication is still a long dream with about 172,000 people dying of AIDS-related causes in 2009 in India. Yet, one can now think of HIV just as a chronic disease, like diabetes, heart disease, hypertension, which can be controlled by taking medicines lifelong. Quality as well as longevity of life has increased. The scores of people living with HIV are more lively, healthy and cheerful than their negative counterparts.

But a lot more needs to be achieved. All eligible patients have to be put on anti-retroviral therapy and parent-to-child transmission has to be brought down to zero. There should be no relaxation on funding by national and international agencies. If we become complacent now we are likely to lose the gains made in the past few years.

(Shobha Shukla – is the Managing Editor of Citizen News Service (CNS). Email: shobha@citizen-news.org, website: http://www.citizen-news.org)