HIV-AIDS and Anti-Retroviral Therapy: Awareness, Benefits and Challenges – Dr. Sagar Koli, Dr. Varsha Narayanan

By
The Indian Practitioner
-

Abstract
World AIDS Day observed on 1st December 2024 aims for the right to health by addressing the inequalities that hinder progress in ending AIDS. India has a large number of people living with HIV and factors like socioeconomic strata, stigma and lack of awareness, are till hurdles to cross even though the National AIDS Control Organisation (NACO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) organisation have made significant strides. Here we discuss the HIV prevalence and burden, evolving anti-retroviral therapies, and improvement in life expectancy over the last decade.

Keywords: HIV, AIDS, ART, PLHIV, CD4, viral load, DTG

Introduction

AIDS (acquired immunodeficiency syndrome) is caused by infection with HIV (Human Immunodeficiency Virus). World AIDS Day was first observed on 1st December 1988, to bring greater awareness to HIV. It is also regarded by some as the longest-running disease awareness initiative of its kind in the history of public health. Under the theme for 2024 “Take the rights path: My health, my right!”, WHO is calling on global leaders and citizens to champion the right to health by addressing the inequalities that hinder progress in ending AIDS.

India has the world’s second-largest number 2.47 million people living with HIV (PLHIV) and adult prevalence of 0.20% in 2023.1 The prevalence of HIV in India is more among the destitute or sections of society shrouded by years of social stigma such as prostitutes, truck drivers, transsexuals and people who inject drugs (PWID). One of the major hurdles is the lack of data on key HIV positive populations and on certain key indicators such as viral suppression rates.
National AIDS Control Organisation (NACO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) organisation have many several efforts over the years to set up counselling and testing centres all over the country and spread awareness about HIV among the masses. The Joint United Nations Programme on HIV/AIDS (UNAIDS) is leading the global effort to eliminate HIV/AIDS as a public health issue by 2030 as part of the Sustainable Development Goals. The 2021, UNAIDS goal to achieve 95:95:95, was 95% of PLHIV should be aware of their HIV status, 95% of people who know their HIV status are on antiretroviral medication (ART) immediately, and 95% of those on ART should be virally suppressed by 2025.2 Despite the efforts of the NACO, only 79% of the PLHIV know their status, and only 86% of them are under ART.3

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On a positive note, between 2010 and 2019, the number of new HIV infections and AIDS-related deaths have declined by 23% and 39% respectively globally.1 India’s HIV epidemic is also slowing down, as between 2010 and 2019 new infections came down by 37% and AIDS-related mortality more than 66%. But still issues like HIV-related discrimination, low levels of status awareness among PLHIV, and poor links between diagnosis and treatment leave a lot of room for work.

Imparting the Right Awareness and Knowledge

  • ART criteria

All persons diagnosed with HIV infection are eligible for Anti-retroviral therapy -ART initiation regardless of CD4 count or WHO Clinical Staging, age (Adults-Adolescents-Children), or population (Pregnant/Migrant/others). Criteria for ART initiation has evolved significantly over the years, and based on current WHO recommendations, India has adopted the treat all policy in 2016-17 regardless of clinical stage or CD4 count as evidence suggests that early ART initiation versus waiting for the CD4 count to decline to certain levels was associated with reduced morbidity, mortality, and HIV transmission.4

  • Life expectancy

For people living with HIV (PLHIV) receiving proper care and ART, life expectancy has increased significantly (for a 20-year-old person with HIV from: 39 years to 70 years). With the right treatment and care, people who have a good response to HIV treatment have excellent long-term prospects with similar life expectancy to HIV-negative peers.

  • ART regimens

As per WHO guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) + dolutegravir (DTG) known as the TLD regimen, is the preferred first-line antiretroviral therapy for adults and adolescents.4 These include drugs from 3 different classes – nucleotide reverse transcriptase inhibitors (NTRTI – tenofovir), nucleoside reverse transcriptase inhibitors (NRTI – lamivudine), and protease inhibitor (PI-dolutegravir).
Scientific evidence and programmatic experience have accumulated on the use of dolutegravir (DTG) in both first- and second-line ART (TLD regimen), including during pregnancy and tuberculosis co-treatment, and for children.5,6

The TLD regimen tenofovir disoproxil fumarate (TDF) 300mg + lamivudine (3TC) 300mg + dolutegravir (DTG) 50mg as a fixed-dose combination offers harmonization of treatment for all adults, adolescents (age >10 years and weight > 30kg), pregnant women and those with HIV-TB and HIV-Hepatitis B co-infections.7 It also offers the advantage of decentralized service delivery and monitoring. It is a simple, potent, and well-tolerated regimen.

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DTG is linked to a more rapid viral suppression and higher genetic resistance barrier when compared with NNRTIs, and compared with efavirenz, DTG-based regimens are better tolerated and tend to be protective against treatment discontinuation due to adverse events.8 Among stable, virologically suppressed patients on NNRTI or PI (protease inhibitors) group of drugs like ritonavir and atazanavir, substitution with a DTG-containing regimen was also well-tolerated and non-inferior in maintaining viral suppression, with high rates of satisfaction compared to those remaining on their existing regimen.
The availability of DTG 10mg (dispersible and scored tablet) under NACO and in line with the global recommendations, DTG 10 mg is recommended and the preferred regimen for children living with HIV (CLHIV) with body weight less than 20 kg.

  • Monitoring of PLHIV on ART

The World Health Organization’s (WHO) latest 2024 report highlights high levels of HIV viral load suppression (>90%) in populations receiving dolutegravir (DTG)-containing antiretroviral therapy (ART). However, among the surveys reported, levels of resistance to dolutegravir ranged from 3.9% to 8.6%, and reached 19.6% among people experienced with treatment and who transitioned to a DTG-containing ART while having high HIV viral loads.9 So, there is an urgent need for increased vigilance and surveillance of HIV drug resistance.

WHO recommends viral load as the preferred approach for monitoring HIV1 infected individuals on ART over immunological (CD4) and clinical monitoring.10 This is because viral load provides an early and more accurate indication of treatment failure and the need to switch to second-line therapy, and helps reduce the accumulation of drug-resistance mutations and improves clinical outcomes for PHLIV on ART. Measuring viral load can also help distinguish between treatment failure and non-adherence.

HIV-2 infected individuals should not be monitored by viral load (currently not available in the national program) but by assessing CD4 count. HIV-2 is less infective and virulent, shows less vertical (mother to child) and heterosexual spread, has lower genetic diversity and prevalence (mainly in West Africa), and a much longer time to development of AIDS (>20 years vs <10 years) as compared to HIV 1 that is globally more common.

Conclusion

India has a large number of PLHIV, many from marginalized socioeconomic strata, suffering the brunt of stigma and lack of awareness. While National AIDS Control Organisation (NACO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) organisation have made significant strides and brought down the percentage of new cases, and mortality, still issues like HIV-related discrimination, low awareness, and poor treatment initiation post diagnosis, are hurdles to cross. ART has improved life expectancy and is now the standard for all patients diagnosed with HIV. DTG based regimens are linked to a more rapid viral suppression and better tolerability. Monitoring with viral loads can detect early treatment failures and provide more effective care. Building knowledge and awareness at the level of general practitioners and family physicians can strengthen the foundation of AIDS management in a country like India.

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References

  1. Kumar P, Das C, Kumar A, Sahu D, Rai SK, Godbole S, Arumugam E, P V M L, Dutta S, Devi HS, Vardhana Rao Mendu V, Kant S, Pandey A, Reddy DCS, Mehendale S, Rajan S. Diversity in HIV epidemic transitions in India: An application of HIV epidemiological metrices and benchmarks. PLoS One. 2022 Jul 18;17(7):e0270886.
  2. Frescura L, Godfrey-Faussett P, Feizzadeh A A, El-Sadr W, Syarif O, Ghys PD; on and behalf of the 2025 testing treatment target Working Group. Achieving the 95 95 95 targets for all: A pathway to ending AIDS. PLoS One. 2022 Aug 4;17(8)
  3. NACO -SANKALAK (Status of National AIDS and STD Response) 2023; Fifth edition. Available from https://naco.gov.in/sites/default/files/Sankalak%20Booklet.pdf
  4. Rewari BB, Mediratta V. How ART Guidelines are Changing over the Years. JIACM 2020; 21(1-2): 66-70.
  5. WHO [Internet] Policy brief: update of recommendations on first- and second-line antiretroviral regimens 2019. World Health Organization. Available from https://iris.who.int/handle/10665/325892.
  6. Gandhi RT, Bedimo R, Hoy JF, et al. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society–USA Panel. 2023;329(1):63–84.
  7. Fantauzzi A, Mezzaroma I. Dolutegravir: clinical efficacy and role in HIV therapy. Ther Adv Chronic Dis. 2014 Jul;5(4):164-77.
  8. WHO [Internet]. WHO recommends dolutegravir as preferred HIV treatment option in all populations. Updated July 21, 2019. Available from https://www.who.int/news/item/22-07-2019-who-recommends-dolutegravir-as-preferred-hiv-treatment-option-in-all-populations
  9. WHO [Internet]. New report documents increase in HIV drug resistance to dolutegravir. March 5, 2024. Available from https://www.who.int/news/item/05-03-2024-new-report-documents-increase-in-hiv-drug-resistance-to-dolutegravir
  10. WHO [Internet]. What’s New in Treatment Monitoring: Viral Load and CD4 testing. Updated July, 17, 2017. Available from https://iris.who.int/bitstream/handle/10665/255891/WHO-HIV-2017.22-eng.pdf

1Technical Specialist and Expert-HIV, New Delhi
Corresponding Author: Varsha Narayanan, Chief Editor, The Indian Practitioner, and Medical Director, Dr Varsha’s Health Solutions, Mumbai, Email:info@drvarsha.com

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