Context

• It has been 20 years since the groundbreaking free Antiretroviral Therapy (ART) initiative began in India.

Emergence of Antiretroviral Therapy (ART) 

• Fear and Stigma: Emergence of HIV/AIDS in the early 1980s, the disease was considered a death sentence and was met with a lot of fear, stigma and discrimination
• First Antiretroviral Drug: The first antiretroviral drug, AZT (zidovudine), was approved by the US Food and Drug Administration (US FDA) in March 1987
• Introduction of new medicines: Three more drugs were approved soon after in 1988 and a new class of antiretroviral drugs, protease inhibitors were introduced in 1995. 
• Limited Access to drugs: Access to these medicines remained limited for most of the world’s population except in some high-income countries.

Evolution of Antiretroviral Therapy (ART) 

• The UN General Assembly’s Millennium Summit (2000): It published a declaration to halt and reverse the spread of HIV.
• The Global Fund: It was established to Fight AIDS, Tuberculosis, and Malaria, established in 2002, promotes universal access to HIV prevention, treatment, care, and support services.
• Prevalance of HIV: In 2004, the estimated number of people living with HIV in India was 5.1 million, with a population prevalence of 0.4%.
• Cocktail Therapy: The ‘cocktail therapy’ or HAART (highly active antiretroviral therapy) became available in 1996, but the expenses were excessively expensive.

• Free Access: Children were also given access to free ART beginning in 2006.
• Barriers to Access ART: Key barrier to ART was high cost and unaffordability for individuals, and geographical access to treatment.
• Non-Availability of ART’s: People infected with HIV were stigmatised and lost their lives while health-care providers felt helpless due to non-availability/non affordability of ARTs.

Impact of Antiretroviral Therapy (ART) 

• Increase in ART Centres: Antiretroviral Therapy (ART) centers have increased from less than 10 to around 700, with 1,264 Link ART centers offering free medications to approximately 1.8 million PLHIV on treatment.
• Decline in Prevalence of HIV: The prevalence of HIV in 15-49 years has dropped to 0.20 (confidence interval 0.17%-0.25%).
• Decrease in Burden of Disease: The burden of disease in terms of estimated PLHIV has been coming down to 2.4 million.
• Decline in PLHIV share: India’s share in PLHIV globally had come down to 6.3% (from around 10% two decades ago).
• Decrease in HIV infections: The annual new HIV infections in India have declined by 48% against the global average of 31% (the baseline year of 2010)
• Reduced Mortalities: The annual AIDS-related mortalities have declined by 82% against the global average of 47% (the baseline year of 2010).

Patient-Centric Approach to Services

• Complementary Programmes: 

  • The  combination of initiatives including free diagnostic services, prevention of mother-to-child transmission, management of opportunistic infections and co-infections, and a policy evolution towards early ART initiation.

• Treat All Approach (2017): 

  • It ensures that Antiretroviral Therapy (ART) is initiated, regardless of CD4 counts.
    • It has helped to minimize virus transmission on both the individual and community levels.
    • It is supported by free viral load testing for everyone PLHIV undergoing therapy.

• Stabilization of PLHIV: 

  • The programme adopted a patient-centric approach by providing two to three months of medicines to stable PLHIV
    • It minimizes the number of patient visits to the ART centers, reducing travel time and costs for the patients.

• Adherence to Treatment: 

  • It increases adherence to treatment besides decongesting ART centers by reducing the average daily OPD, giving health-care workers more time to attend to other patients.

• Introduction of New Potent Drugs: 

• • India continued to add newer and more potent drugs to the programme, as and when those became available. 
    • For example, Dolutegravir (DTG), a new drug with superior virological efficacy and minimal adverse effects was introduced in 2020. 

• National AIDS Control Programme (NACP): 

  • India’s National AIDS Control Programme (NACP) Phase 5 seeks to significantly reduce new HIV infections and AIDS-related mortality by 2025, as well as abolish vertical transmission of HIV and syphilis. It strives to accomplish the ambitious “95-95-95” targets set by UNAIDS.
    • 95% of PLHIV knowing their status, 95% of those diagnosed on ART, and 95% of those on ART achieving viral suppression.

Challenges in Antiretroviral Therapy (ART) 

• Delayed ART Enrolment: A significant issue is the late presentation of patients at Antiretroviral Therapy (ART) centres, with nearly a third having a CD4 count below 200, delaying effective treatment.
• Noncompliance with Treatment: Once patients begin to feel better, they frequently discontinue or follow their ART regimen inconsistently, putting their health at danger and fostering  drug resistance. 
  • Further, addressing ‘lost to follow-up’ is critical to the treatment program’s success.
• ART Supply and Accessibility: It is critical to ensure a consistent and accessible supply of ART drugs throughout all regions, particularly in remote and hard terrains.
• Private Sector Engagement: To increase access and support for HIV/AIDS patients, the private sector should be more involved in their care and treatment.
• Continuous Training for Healthcare Staff: To stay up with the advancing science and enhance treatment outcomes, medical workers must get ongoing, hands-on training.
• Integration with other Health Programmes: Integrating HIV/AIDS programmes with other health initiatives focusing on hepatitis, noncommunicable diseases, and mental health is crucial for providing complete care.
• Reducing Preventable Mortality: Focused efforts to reduce preventable fatalities through systematic reviews and sophisticated diagnostics are critical for increasing patient survival rates.

Conclusion

• The free Antiretroviral Therapy (ART) project in India success story serves as a model for establishing comparable programmes, such as a statewide free hepatitis C treatment programme.