World Health Organisation (WHO) gave 2 key recommendations in its 2015 guidelines for treating and preventing HIV infection:
- First, antiretroviral therapy (ART) should be initiated in everyone living with HIV at any CD4 (a type of white-blood cell) cell count.
- Second, the use of daily oral pre-exposure prophylaxis (PrEP) is recommended as a prevention choice for people at substantial risk of HIV infection as part of combination prevention approaches.
The first of these recommendations is based on evidence from clinical trials and observational studies released since 2013 showing that – ‘earlier use of ART results in better clinical outcomes for people living with HIV compared with delayed treatment’.
The second recommendation is based on clinical trial results confirming the ‘efficacy of the ARV drug tenofovir for use as PrEP’ to prevent people from acquiring HIV in a wide variety of settings and populations.
- It was in 2002 that the WHO first issued its ART guidelines. In the absence of AIDS-defining illnesses, the WHO set CD4 count less than 200 cells per cubic millimetre as the threshold to begin ART treatment.
- Over time, it changed its guidelines and, in 2013, increased the threshold to CD4 count less than 500 cells per cu. Mm.
- However in 2015, the WHO once again changed its guidelines. Based on evidence from clinical trials and observational studies since 2013, it became clear that an earlier use of ART, irrespective of the CD4 count, results in better clinical outcomes. Accordingly, it recommended that ART be initiated in HIV-positive people at any CD4 cell count.
India follows WHO’s recommendations
Two years after the WHO recommendations, India has aligned its policy with the above guideline.
- As per 2015 estimates, India has 2.1 million HIV-positive people, of which only 1.6 million have been diagnosed and about a million are on treatment. But over half a million people are not even aware of their HIV status.
- Health Ministry recently announced that any person who tests positive for HIV will be provided ART “as soon as possible and irrespective of the CD count or clinical stage”.
- With the government changing its treatment guidelines, the 0.6 million who have been diagnosed but not been on treatment are now eligible for treatment.
The above move is considered to be a welcome move as nearly 4.5 lakh deaths can be averted. Earlier initiation of ART will help people with HIV live longer, remain healthier and “substantially reduce” the risk of them transmitting the virus to others.
But the biggest challenge will be to identify the 0.35 million who have been diagnosed but not on treatment and the 0.5 million who have been infected but have not been diagnosed. Also, nearly 80,000 people get infected each year.
There should be greater focus now on identifying people with HIV and expanding treatment delivery sites. The government should start community-based testing to bring it closer to those in need, and target special groups that are more vulnerable to infection such as partners of people who are HIV-positive.
HIV/AIDS: first disease to be the subject of a UNSC resolution
In July 2000, the United Nations Security Council (UNSC) adopted Resolution 1308, calling for “urgent and exceptional actions” to mitigate the threats posed by HIV/AIDS.
These exceptional actions referred to the need to provide exclusive responses and resources to mitigate the threat posed by HIV/AIDS.
As the first disease to be the subject of a UNSC resolution, the exceptional status of HIV/AIDS had brought about unprecedented levels of international funding allocated primarily in developing countries where responses to the disease have historically been scarce or non-existent. With financial assistance from international institutions and bilateral governments, HIV/AIDS responses intensified in many developing countries.
Declining trend of HIV/AIDS international financial assistance
However, there has been a stagnating and even declining trend of HIV/AIDS international financial assistance in recent years.
- Data show that most European donor governments have reduced their HIV/AIDS financial commitments since 2012.
Moreover, in light of the continuous economic boom in countries such as India and China, international funding agencies now argue that these countries should be donors instead of recipients of international HIV/AIDS-specific grants and loans.
Without renewed and increased commitment from international donors and recipient governments, the sustainability of future national HIV/AIDS programmes is in doubt.
In response to the changing global health agenda, most of the countries are prioritising the integration of HIV/AIDS programmes into existing health-related systems.
Integration into health systems
An integration of HIV/AIDS interventions and primary health-care systems has taken place in India from 2010 onwards.
For instance, six components of the National AIDS Control Programme (NACP)-III merged with the National Rural Health Mission (NRHM) in 2010. These included –
- Integrated Counselling and Testing Centresers (ICTC);
- prevention of parent-to-child transmission (PPTCT);
- blood safety;
- sexually transmitted infections (STI) services;
- condom programming along with ;
- together with antiretroviral treatment (ART)
National AIDS Control Programme (NACP)-IV
The continued integration of HIV/AIDS responses under the umbrella health system is ongoing in the NACP-IV; where all the service delivery units except the targeted interventions (TIs) have been set up within the health-care system.
AIDS-free by 2030, India included
At the 2016 high-level meeting at the UN General Assembly, India pledged to follow targets to fast track the pace of progress towards ending HIV/AIDS as a public health threat in the next five years, and ending the epidemic by 2030.
- To fulfil the commitment, the Government of India is now playing a larger role in funding its HIV/AIDS programmes — this is evident from the fact that two-thirds of the budget for the NACP-IV is provided by the Government of India and comes from the domestic budget.
- Indian HIV/AIDS programmes have progressively become less dependent on foreign assistance considering that over 85% of the budgets in the first and second phases of the NACPs and 75% in the third phase were supported by international and bilateral funding mechanisms.
- Ongoing improvement in the funding levels shows an increased policy commitment and fiscal capacity to address HIV/AIDS locally.
But in order to ensure the sustainability of the HIV/AIDS interventions, continuous integration of HIV/AIDS programmes into a larger health system is required. However, health care has never been a priority in India per se.
Despite rapid economic development over the past two decades, public expenditure on health care in India as a proportion of GDP is among the world’s lowest. Health expenditure in India was merely 1.3% in 2015-16, while countries such as Norway, Canada, and Japan allocated over 9% of GDP to health. India’s health-care expenditure is also comparatively less than other BRICS countries. The highest expenditure is by Brazil composing of 4.7% of its GDP. India’s overall health budget has declined by 13%, i.e. from Rs.35,780 crore in 2014-15 to Rs.31,501 crore in 2015-16.
Connecting the dots:
- Elaborate on the Policy actions initiated by the government w.r.t. HIV AIDS and the necessary concerns associated. Highlight the provisions of the recent legislation.
- What is HIV and how is it a life threatening disease? How has India battled against HIV? Critically examine.