HIV/AIDS
This class was so interesting!! Learning about this epidemic, from the history to the social implications to the biological nature of the virus, was incredible. The disease necessitates talking about both the social aspect and the biological aspect, as the response and efforts to combat this disease were heavily intertwined with politics and other societal issues. I really enjoyed the guest lecture portion of this class as well, especially one who spoke about the syringe services program in Seattle, and a doctor from Africa who spoke of his particular struggle with AIDS patients.
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Final Paper:
The HIV/AIDS Epidemic in India Neva Crnković Hahn University of Washington History of the HIV Epidemic In India, 1986 marked the earliest detected HIV infections—this initial recognition of HIV among female sex workers indicated the beginning of the Indian HIV epidemic [1]. That same year, India became the first country in the world to initiate a systematic national HIV sero-surveillance among individuals in high risk groups. From the earliest available data in 1987, the populations most affected by HIV in India were sex workers and STI patients. These populations were found to have the greatest number of infections throughout India, with 0.89% median prevalence within sex workers in major urban areas (and 0.49% outside major urban areas) and a median prevalence of 0.52% for STI patients in major urban areas (and 0.16% prevalence outside of major urban areas). The Indian population in 1987 consisted of 819.7 million individuals. There is no available data, however, for pregnant women and injection drug users in major urban areas, or any men who have sex with men. This lack of data may have skewed initial information surrounding HIV in India [2]. Indian STI patients may have initially been recorded as most highly affected by HIV as the main mode of transmission of both STIs and HIV is through sexual intercourse. Furthermore, STIs can assist HIV transmission by increasing HIV susceptibility and infectiousness. Sex workers were also initially the most affected, likely due to not being able to demand safe sex (e.g., requesting condoms). In 1992, India launched its own brand of AZT from a Bombay-based company. This novel AZT cost about 30 cents a dose, a fraction of what Retrovir cost, but still too expensive for most Indians. In 1996, the first successful ART regimen in India was declared, and in 2004 the Indian government started a free ART implementation program at eight centers in six high-prevalence states within the country. In 1997, the Delhi State government introduced the Delhi Quackery Prohibition Bill, as nearly 30,000 “quacks” (fraudulent doctors prescribing untested drugs to HIV patients) were operational in Delhi. As the interaction between ARV’s and drugs dispensed by quacks cannot be fully understood, this bill was aimed to increase treatment efficacy [2]. Numerous national governmental approaches were implemented after the first cases of HIV were diagnosed. In 1986, the Government of India started the National AIDS Committee, which implemented heightened surveillance, blood screening and educational efforts. In 1992, the Indian government started both the National AIDS Control Organization (NACO) and the National AIDS Control Program (NACP). By 1991, NACP was targeting prevention among high-risk populations, increasing blood safety (including implementing mandatory screening of blood donations), raising awareness and increasing surveillance efforts. NACO was established as a semi-autonomous organization under the Ministry of Health and Family Welfare to implement the NACP. The second phase of the NACP (from 1999-2006) was tasked to expand it’s goals at the state level, with an even greater emphasis on interventions for at-risk populations, preventative efforts, and the integration of NGOs (such as educational efforts). Currently, the NACP is in its fourth phase, aiming to increase prevention interventions within target populations. Another governmental effort introduced in 2014 was the HIV/AIDS (Prevention and Control) Bill, which sought to end discrimination and stigma against HIV positive individuals throughout Indian society. This was passed in 2017 [3]. Current State of the Epidemic Today, the state of the HIV/AIDS epidemic in India is concerning, yet exhibits potential hope for the future. The most recent available data about HIV/AIDS in India is all from 2017 [4], thus, these numbers may be different than those in 2022. In 2017, 2.1 million people were living with HIV in India; the overall prevalence of adult (ages 15-49) HIV in India was 0.2%. The incidence describes 88,000 new HIV infections in 2017 [4]. To contextualize, the population of India in 2017 was 1.399 billion, and has grown—the current 2022 population of India is 1.401 billion people! Populations which are currently most affected by this epidemic include sex workers, men who have sex with men, transgendered individuals and injection drug users. The three geographical states with the highest HIV prevalence are Manipur, Mizoram and Nagaland, showing that there are clear HIV infection disparities by ethnicity. Indian people who inject drugs and transgender people are the two populations with the highest HIV prevalence and incidence of all the key populations [4]. Around 2.7% of men who have sex with men in India are living with HIV; HIV prevalence is also generally higher among men than women in India, with 0.25% of men and 0.19% of women living with HIV as of 2017. This high HIV prevalence of men who have sex with men displays clear disparities by sexual orientation. Before 2018, when India’s Supreme Court decriminalized homosexuality, many HIV services for MSM were out of reach. The stigma and stereotyping of men who have sex with men led to homophobia and discrimination, making these men more vulnerable to acquiring HIV. There are also clear disparities in gender identity, as HIV prevalence among Indian transgendered people was the second highest prevalence among all key populations in the country in 2017 (the first being those who inject drugs) [4]. HIV prevalence differs for key populations. In 2017, an estimated 1.6% of female sex workers in India were living with HIV, a figure which varies between states. There is no recent data concerning male sex workers in India. 2.7% of men who have sex with men in India are living with HIV. Injecting drug use is the major cause of HIV transmission in the north-eastern states, which mainly causes high HIV prevalence for PWID. In 2017, 6.3% of people who inject drugs had HIV. HIV prevalence among transgendered people in India was 3.1% in 2017 [4]. Despite these concerning data, there is hope in India’s struggle with the HIV/AIDS epidemic. Between 2010 and 2017 HIV incidence declined by 27% and AIDS-related deaths fell by 56%. In the key populations, described above, HIV incidence has decreased also. Specifically, populations of both sex workers and men who have sex with men have experienced a recorded recent decline in HIV prevalence and incidence. Improving information gathering is necessary to understand exact rates of decline in these key populations [4]. Current Challenges The most recent available 90-90-90 target data from 2017 shows that 78% of Indian individuals living with HIV know their status, and 71% of those individuals are on HIV treatment. There are no recent data about how many of those are virally suppressed [5]; a study from 2019, however, has calculated the viral suppression rates of HIV (in infected ART-taking individuals) in MSM and PWID in India, which they found to be 66.2% and 33.2% respectively [6]. All of these data display that India still has a long way to go in terms of meeting the 90-90-90 targets. Some challenges India has faced in relation to HIV testing are related to stigma and discrimination, in addition to unawareness and inaccessibility surrounding testing. Individuals who are not aware of testing sights, or who have faced discrimination, are less likely to get HIV tested. India has attempted to increase testing opportunities with the integration of increased HIV counseling and testing (HCT) facilities, a great success in HIV testing. HCTs provide education surrounding HIV/AIDS while also offering HIV testing. Scaling up HCTs could bring India closer to achieving the first 90; currently, there are more than 19,800 HCTs in India, which marks an 88% increase from 2011-12 [7]. The HIV tests themselves have presented separate issues—tests such as NAT (nucleic acid testing) are prohibitively expensive in India at 1,000 rupees per test, which can pose challenges to individuals who require more rapid results than provided by ELISA HIV tests [8]. Lack of key data (including viral suppression rates), in tandem with HIV-related stigma, have slowed HIV care and treatment in India, exemplified by their inability to reach the 90-90-90 targets. However, there have been multiple successes related to HIV care and treatment, including the HCTs, which 30 million individuals have utilized between April 2018 and April 2019. Additionally, recent studies have reviewed HIV TB co-infection in India, and have highlighted the necessity of psycho-social and financial support (including efforts to decrease poverty and unhoused individuals) to achieve TB elimination. This understanding is vital to begin eliminating HIV TB co-infections through interdisciplinary approaches [9]. As for co-morbidities, regular nurse-delivered phone counseling for Indian women with HIV has been shown to have successful outcomes with mental health surveys. This could promote prevention and treatment of women with HIV and mental health (e.g., depression) co-morbidities. A downfall of the study surrounding the implementation of phone counseling services is that it only recruited Indian women participants, therefore the results are not completely generalizable [10]. HIV prevention interventions available in India include efforts by NACP IV, focusing on building NGO resources, expanding Opioid Substitution Therapy and other treatments, and bettering past phase goals. Targeted interventions have also been crucial, as they provide services to high risk groups through NGO and CBO outreach efforts. Recent targeted interventions (TIs) have included implementing trainings on condom and needle usage, distributing condoms, and increasing ART centers in communities around India. TIs have increased through the NACP phases, marking a great success in HIV prevention interventions. A key challenge India has faced related to HIV prevention interventions has been the recent increase across key populations of using virtual spaces. These virtual spaces have been increasingly used to negotiate high-risk behaviors (such as dating apps, online messaging, etc.); locations of interactions are now increasing in numbers, whereas operations in brothels and other usual “high-risk” locations is decreasing. NACO is challenged to effectively measure these virtual populations, as many individuals have differing online and offline identities, and to promote safe sex behavior to a virtual population. Another challenge is aiding key populations who are not explicitly covered by the TIs necessitating outreach efforts [11]. Recent HIV Research A key area of research recently conducted about HIV in India surrounds the connection between young people who inject drugs (PWID) and HIV “risk behaviors” and incidence. Research in this area is limited, but a recent research study completed in 2019 funded by the National Institute on Drug Abuse by a consortium of Indian and American scientists, analyzed the connection between exposures of different demographic and geographic aspects (such as age and location) with the outcomes of sexual risk behaviors and HIV incidence between emerging adult (18-24), young-adult (25-30) and those older (above 30) PWID. This study examined cross-sectional data from 14,381 PWID of all age ranges from various cities in Northeast and North/Central India. Age-stratified cross-sectional HIV incidence was estimated using a validated multi-assay algorithm. The researchers evaluated three “risk behaviors” as outcomes: needle-sharing, having multiple sexual partners and unprotected (or condom-less) sex. The scientists also examined self-reported accounts on whether the participants had ever received HIV testing [12]. The scientists found that 18-24 year olds were significantly (p<0.01) more likely than older PWID to share needles (with an adjusted odds ratio of 1.82 for males and 2.29 for females), have multiple sexual partners (males’ aOR 1.56, females 3.75) and have condom-less sex (males aOR 2.29) in the Northeastern states. In North/Central Indian states, 25-30 year olds were significantly (p<0.05) more likely to needle-share, (aOR 1.23), while 18-24 year olds were significantly (p<0.05) more likely to have multiple sexual partners (aOR 1.74). In both Indian areas, 18-24 year olds had the lowest HIV testing rates, and annual HIV incidence was calculated as significantly higher in 18-30 year olds who inject drugs in the North/Central region (emerging adults 4.3%, young-adults 4.9%, older adults 2.1%), while similar results in the Northeast did not achieve significance [12]. These findings show that there is both higher HIV incidence and HIV “risk behaviors” among younger persons who inject drugs throughout India compared to older persons who inject drugs. These findings could inform HIV prevention as this study highlights a target population for HIV prevention— interventions focused on younger populations (especially surrounding PWID) in India may be required to slow the HIV epidemic in these specific populations [12]. The NACP in its fourth phase could target young populations of PWID in India by working together with educational and community efforts. I would emphasize increasing community interventions, in rehab centers and around high-saturation areas of PWID’s, with education surrounding safe needle habits. Also, integrating an increased number of SSPs throughout India could aid with the issue of HIV prevalence among PWIDs in India. Future Recommendations Significant progress has been made regarding the HIV epidemic in India. To continue this progress, I would focus on mitigating the stigma surrounding HIV/AIDS. A recent qualitative study done by researchers centralized in Bihar, India, found that perception of HIV is inaccurate and damaging. The “vast majority” of study participants associated HIV with immorality and dirty acts, and had misconceptions surrounding the modes of transmission of HIV—of the 71 participants interviewed, including 35 people who were HIV positive, 30 believed that sharing food and drink would transmit HIV/AIDS [13]. Due to educational shortcomings, I would recommend implementing pop-up centers in major cities where scientists and community members (including those who are HIV positive) could educate other community members. In these centers free HIV testing would be available as well, encouraging testing. I believe that education is the first step to prevent stigma, and must be integrated into an effort to decrease HIV prevalence by preventing new infections, and improve access to testing. I would also recommend advertising the pop-ups on different apps such as Grindr. This would hopefully reduce HIV-related disparities, and increase the education and testing efforts throughout India. A 2018 study described a novel care package in India to treat HIV-infected TB patients, which included a self-administered daily drug intake along with ART center visits for both ART and TB. This study resulted in more unsuccessful TB treatment outcomes compared to conventional care (30.5% vs. 23.4%, p<0.001, aRR 1.3). The challenges posed were deficiencies in training among providers, and increased work load for ART staff [14]. To mitigate these problems, and improve TB treatment outcomes with the new care package, I would implement operational changes. I would recommend increasing ART centers that offer both TB and HIV care in order to decrease individual work load, and to increase educational opportunities for staff members about HIV, TB, and the novel care package [14]. I would also start additional ART centers offering a combination of treatments of specific HIV co-infections and co-morbidities, to make treatment of all efficient. Another study screening for the co-infection of HBV and HCV in 272 HIV-positive PWIDs in Chennai found that HBV was found in 9.2%, and HCV in 86% [15]. Due to these high rates of co-infections among PWIDs, I would recommend increasing the amount of ART centers that offer treatment to HIV along with the aforementioned comorbidity and co-infections, in areas with large proportions of PWIDs such as the state of Uttar Pradesh (with the most PWIDs recorded in India in 2018) [16]. As of 2020, India had 1,270 link antiretroviral therapy centers, which focus on treating HIV and HIV TB co-infection, along with HBV and HCV [16]. I would recommend to aim to double the numbers of centers, and to increase the amount of centers in specific areas of high concentrations of at-risk individuals. With these recommendations, India could increase assistance to HIV patients, and could finally, successfully reach its 90-90-90 target. References
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