Context:

• Twenty years ago, on April 1, 2004, the Indian government had launched Free Antiretroviral Therapy (ART), for Persons living with HIV (PLHIV), a decision which has proven one of the successful and a key intervention in the fight against HIV/AIDS.
• At present, with changed goals and priorities, it becomes necessary to look into the journey of AIDS control and to make it better.

What is HIV?

• HIV (human immunodeficiency virus) is a virus that attacks the body’s immune system. 
• It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected intercourse , from mother to foetus during pregnancy, or through sharing injection /drug equipment.
• If HIV is not treated, it can lead to AIDS (acquired immunodeficiency syndrome). There is currently no effective cure. But with proper medical care, HIV can be controlled.

What is AIDS?

• AIDS is the late stage of HIV infection that occurs when the body’s immune system is badly damaged because of the virus.
• People with AIDS can get an increasing number of opportunistic infections.
  • Opportunistic infections are illnesses that occur more frequently and are more severe in people with HIV. This is because they have damaged immune systems.

Evolution of the AIDS Control Journey:

• In the early 1980s, HIV/AIDS emerged as a global health crisis, marked by fear, stigma, and discrimination. The initial response was limited due to the lack of effective treatment options.
• Development of Antiretroviral Therapy (ART): The first antiretroviral drug, AZT (zidovudine), was approved by the US FDA in 1987. Subsequent developments led to the introduction of combination therapies like HAART (highly active antiretroviral therapy) in 1996, but access remained limited, especially in low-income countries like India.
• Global Initiatives: In 2000, at the UN Millennium Summit, world leaders set specific goals to combat HIV/AIDS, leading to the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2002. These initiatives aimed for universal access to HIV prevention, treatment, care, and support services.
• Introduction of Free ART in India: In 2004, the Indian government launched Free Antiretroviral Therapy (ART) for Persons Living with HIV (PLHIV). Initially, access to ART was limited due to high costs and geographical barriers.
• Expansion and Modification of ART Program: Over the years, India’s ART program evolved to include children, relax eligibility criteria, and adopt a “Treat All” approach irrespective of CD4 count. This expansion aimed to increase access and adherence to treatment.
  • CD4 count is the number of CD4 cells(CD4 T lymphocytes or “helper T cells) in the blood. 
  • These cells help fight infection by triggering your immune system to destroy viruses, bacteria, and other germs that may make you sick.
  • HIV attacks and destroys CD4 cells. Without treatment, HIV may destroy so many CD4 cells that the immune system will have trouble fighting off infections.
• Complementary Initiatives: In addition to free ART, India implemented complementary initiatives such as free diagnostic facilities, prevention of parent-to-child transmission of HIV (PPTCT) services, and management of opportunistic infections like tuberculosis.
• 95-95-95 Strategy: The National AIDS Control Programme (NACP) phase 5 calls for the attainment of ambitious targets of 95-95-95 by 2025, where 95% of all people living with HIV know their HIV status; 95% of all people diagnosed with HIV infection receive sustained antiretroviral therapy (ART), and 95% of all people receiving antiretroviral therapy achieve viral suppression by 2025. These targets are aligned with global targets agreed by the UN.

Current Status: 

• India’s share in PLHIV globally had come down to 6.3% (from around 10% two decades ago). 
• As of the end of 2023, of all PLHIV, an estimated 82% knew their HIV status, 72% were on ART and 68% were virally suppressed. 
• The annual new HIV infections in India have declined by 48% against the global average of 31% (the baseline year of 2010). 
• The annual AIDS-related mortalities have declined by 82% against the global average of 47% (the baseline year of 2010). 
• These are significant achievements considering that many of the other government-run public health programmes in India have failed to achieve or sustain good coverage.

Reasons for this Success:

• Free and Treat All approaches: ART services has been given free to certain patients from 2004 and was gradually widened to cover all types of patients with HIV infection.
• Patient-Centric Approach: The program adopted a patient-centric approach by providing free ART, reducing patient visits through longer medication supplies, and offering free viral load testing.
• Continuous Expansion and Adaptation: The program continuously expanded services and adapted to changing circumstances, such as introducing new, more potent drugs and relaxing eligibility criteria. 
  • In two decades of free ART initiative, the facilities offering ART have expanded from less than 10 to around 700 ART centres. 1,264 Link ART centres have provided, and are providing, free ART drugs to approximately 1.8 million PLHIV on treatment.
• Community Engagement: The program engaged communities and stakeholders, ensuring their participation and support.
• Political Will and Government Support: Successive governments showed political will and provided sustained funding for the HIV/AIDS control program in India.

Measures to streamline the process:

• Addressing Delayed Enrollment: Efforts should focus on addressing delayed enrollment to ART facilities, perhaps through increased awareness campaigns and improved accessibility.
• Enhancing Adherence: Patients stop or become irregular once they see small relief from the symptoms. This results in the development of resistance as well. This ‘loss to follow up’ needs to be addressed. 
  • Strategies should be devised to enhance adherence to treatment, including counselling services, support groups, and reminders for medication.
• Ensuring Supply Chain Management: Ensuring sustained supply and availability of ART across all regions of the country, particularly in remote areas, is crucial.
• Private Sector Engagement: Encouraging private sector engagement in care provision for PLHIV could expand service coverage and options.
• Integration with Other Health Programs: Strengthening integration with other health programs, such as those addressing hepatitis and non-communicable diseases, could improve overall health outcomes for PLHIV.
• Focus on Preventable Mortality: Adopting a focused approach to reduce preventable mortality, including systematic death reviews and advanced diagnostics, can improve survival rates among PLHIV.
• Continuous Training and Capacity Building: Continuous training and capacity building for healthcare staff are essential to keep up with evolving scientific knowledge and maintain service quality.

The success of the AIDS control program is a testament to the point that if there is a will, the government-run public health programme can deliver quality health services free, and available and accessible to everyone. The 20 years of free ART and subsequent steps under the NACP have the potential to guide other public health programmes in the country.