Dr Ishwar Gilada, president of AIDS Society of India since 2015, is among the most prominent names associated with AIDS prevention and control in India. During the past 30 years, he has served on several national and multi-country platforms such as the National AIDS Committee, the governing board of AIDS Society in Asia and Pacific (ASAP), AIDS Advisory Board for Goa and Uttar Pradesh and boards of Global AIDS Policy Coalition and AIDS and Reproductive Health Network under Dr Jonathan Mann. He was recently elected to the Governing Council of International AIDS Society for a four-year term to represent Asia and Oceania regions. He discusses the progress made in AIDS control in the country, and the gaps where the system has fallen short. Edited excerpts from his conversation with Dr Sumit Ghoshal.
There is still some disagreement about the number of people living with HIV infection in India. The official government data says it is about 2.1 million, while other sources put the figure at 1.4 to 1.6 million. Why this difference? Why do we not have an accurate figure for the whole country?
It will always be a guestimate, because the entire population has not been tested for HIV, and that will never be possible. Besides, HIV surveillance is now carried out only by the government of India. Surveillance by private organisations has almost stopped now. Hence, whatever figure the government puts out has to be taken as authentic. More importantly, HIV used to be most prevalent in the five southern states: Maharashtra, Karnataka, Tamil Nadu, Andhra Pradesh and Telangana, along with two northeastern states, Manipur and Nagaland. However, HIV is becoming more common in other states like Madhya Pradesh, Rajasthan and Gujarat because people from these places travel for work. This is more worrying.
What is the government doing about it?
Perhaps, not enough. Only an estimated 1.6 million people are aware that they have got the infection, which means five lakh people are spreading the infection unintentionally. The international standard is 90:90:90. That is: 90 percent of people who have the infection should be aware; of these, 90 percent should be on ART; and of the people on HIV treatment, 90 percent should have viral load suppression. This is the target for 2020, but India is falling short on all counts. The ‘third 90’, or the testing for viral load suppression, is definitely very weak. Until 2017, the government of India was doing viral load estimation for just 16,000 people each year, which is one percent of the requirement! This year, they have expanded this to 1.6 lakh through a Private-Public Partnership with Metropolis Health Services, but the requirement is 1.6 million.
In the global scenario, the Sustainable Development Goals of the UN have a target to end the AIDS epidemic by 2030. What exactly does that mean?
It means that there should be no new HIV infections. That is possible to achieve, but very difficult. It will happen when all 2.1 million HIV positive people in India are aware of their status and they are put on treatment. Then, HIV positive men will not pass on the infection to their spouses and pregnant women to their newborn infants. Besides, people who cannot avoid being exposed to HIV infection should take pre-exposure or post-exposure prophylaxis.
We have made a lot of changes in HIV treatment now. A person who knows he is going to get exposed to the infection can take treatment in advance and then go and get exposed. Or if the person has been already exposed; if he comes to us within 48 hours, we can treat that person by which he doesn’t get HIV infection.
Now you mentioned pre-exposure prophylaxis. One drug is being discussed from Gilead Life Sciences, known as Truvada. How effective is it? And does it serve the same purpose as an HIV vaccine?
Truvada is marketed in India as emtricitabine-tenofovir combination by Cipla under license from Gilead, to be used for post-exposure prophylaxis. For pre-exposure prophylaxis, it is not licensed to anyone, and is not part of the government of India’s programme. Elsewhere in the world, it is available and being used. It is 95 percent safe; no medicine is 100 percent safe (only abstinence from sex is 100 percent safe). The person needs to take four tablets for each sexual exposure – one tablet 8-10 hours before the act, two tablets at the time of sex and one tablet within 12 hours after the act. But if the person is going to be exposed again and again, like sex workers, or someone with multiple male sex partners, then they need to take the tablet every day. That is known as Daily PrEP, which offers protection of more than 95 percent. In episodic PrEP, it is about 90 percent.
HIV-AIDS today is closely linked with TB and malaria. In fact, The Global Fund covers all three diseases. But in India, there are separate programmes for HIV, TB and malaria. Is that appropriate?
First of all, the idea of clubbing the three diseases together is misleading. There are studies to show that HIV predisposes the patient to malaria, or even that malaria is more frequent in HIV positive people than in the general population. But TB and HIV are twin brothers, closely associated with each other. Hence, under the Revised National Tuberculosis Control Programme (RNTCP), the two programmes of HIV control and TB control have been merged. They are now managed by a single office, instead of two separate ones. Also, HIV testing is done at the TB clinics while TB medicines are supplied through HIV treatment centres.
Health insurance for HIV positive people is another issue of contention. What is your view on that? Most health insurance companies have got HIV under their exclusion criteria, although IRDA (Insurance Regulatory and Development Authority) has given clear directives that such discrimination is not permitted anymore. Now, a new law has been enacted under which such exclusion will attract a jail term. This is because HIV infection today is a chronic, manageable disease like diabetes or hypertension. It is no longer a death sentence.