Studies show ART could help eliminate transmission.
A new Lancet study should make India rethink how it extends anti-retroviral therapy (ART) support to those infected with HIV. Results from its PARTNER studies show that viral suppression brought about treatment with ART (plasma HIV-1 RNA <200 copies per ml) in the HIV-positive partner in a serodifferent couple (one partner HIV-positive, the other uninfected) translates into a zero risk of transmission in the case of unprotected sex between the couple—that is, the study backs a wider dissemination of the ‘Undetectable equals Untransmittable (U = U)’ message. While the message works to remove stigma and discrimination surrounding the disease, another inference from the study is that extending ART outreach with early testing and support for treatment could help eradicate the disease.
The Lancet study was conducted in two phases across 75 sites in 14 European nations. PARTNER 1 involved both heterosexual and gay couples and PARTNER 2 recruited only gay couples. The findings from both phases show condomless sex between serodifferent couples in which the HIV-positive partner was receiving virally suppressive ART didn’t result in HIV transmission from seropositive partner to the seronegative one—some of the seronegative partners reported having condomless sex with others outside the pairing being studied, and, in the 15 cases of new infection, none of these could be phylogenetically linked to the seropositive partner. ART intervention at an early stage, when the viral load in a seropositive person is likely to be much lower than in an advanced stage of the infection or where the infection has led to AIDS, could help stop transmission, and thus, preventing new infections altogether could become easier.
Of India’s 2.1 million people living with HIV/AIDS (PLHA), only 79% are aware of their HIV status—and just 56% receive ART. To qualify for ART from the government hospitals, earlier, a seropositive person had to have a CD4 count less than/equal to 500 cells/mm3. In 2017, India moved to the ‘test and treat’ protocol prescribed by the WHO, which meant every HIV-positive individual within the country was to be put on ART treatment, regardless of her/his CD4 count. India had adopted the UNAIDS 90-90-90 goal, under which, by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression. Clearly, India is far from realising these targets. Despite a marked rise in ART coverage, many PLHA are unable to access the clinics. NACO’s Link Workers Scheme under which volunteers from at-risk groups were trained to link their communities with HIV information, commodities and services. This has had some success, with 80% of those testing positive in these at-risk groups getting linked to ART centres. Adherence level, while at an encouraging 71% amongst adults receiving ART and 77% of among children, needs to be brought up to 100%. Centreing the HIV/AIDS strategy on ART will thus also need to tackle lack of adherence, which could be due to fear of disclosure and social stigma, low social support, inadequate communication and education, and depression amongst PLHA. Given how drug-resistant HIV is being flagged by experts as the emerging threat, India needs to make the most of ART by ensuring a 100% outreach, and adherence.