Will #PutPeopleFirst Mantra Drive HIV Responses? – OpEd

Science has gifted us proven tools to stop the spread of HIV infection, as well as to ensure that all people living with HIV live healthy and fulfilling lives. But we failed to save 630,000 people with HIV who died in 2022.

Science has proven that if people with HIV are on lifesaving antiretroviral therapy and remain virally suppressed, then there is zero risk of any further transmission of HIV from them to anyone else. According to WHO, "people living with HIV who have an undetectable viral load using any WHO-approved test and continue taking medication as prescribed have 'zero risk' of transmitting HIV to their sexual partner(s)." That is why undetectable equals untransmittable.

"If we are to end AIDS, we have to ensure that along with 100-100-100 (100% of people with HIV know their status, 100% of people with HIV are on lifesaving antiretroviral therapy, and 100% of them are virally suppressed), we also have to ensure that no one suffers or dies of TB," said Dr Ishwar Gilada who is part of the upcoming world's largest AIDS conference in Munich, Germany (25th International AIDS Conference or AIDS 2024). Dr Gilada is also on the Governing Council of International AIDS Society (IAS).

As treatment is prevention, it is time for accountability now

Despite knowing #UndetectableEqualsUntransmittable or #UequalsU, 1.3 million people got newly infected with HIV in 2022. If we had ensured that all people with HIV are virally suppressed and everyone has access to the full range of HIV combination prevention options, then we could have averted new infections.

#PutPeopleFirst

AIDS 2024 is being organised by International AIDS Society (IAS) along with the government of Germany and partners. "Germany has a low rate of HIV prevalence. According to the Robert Koch Institute (RKI), as of 2022, an estimated 90,800 people in Germany are living with HIV infection. The number of new HIV infections has been declining, with an estimated 1,900 new HIV infections occurring in the year 2022- a slight increase from 1800 news cases in 2021," said Ministry of Health Germany in an exclusive interview (over email) with CNS. CNS is an official media partner of AIDS 2024.

In 2022, 90% of people with HIV in Germany knew their HIV positive status, 96% of them were on lifesaving antiretroviral therapy treatment, and 96% of those on therapy, were virally suppressed.

In India, "79% of the estimated number of people living with HIV knew their status, 86% of them were on the lifesaving therapy, and 93% of those on therapy have achieved viral suppression," said David Bridger, UNAIDS Country Director in India. But Indian data is not uniform across its 36 states and union territories.

"New HIV infections globally have declined over the last 10 years by 38% which is not enough but at least it is headed in the right direction," says Bridger. He points to the variations in HIV decline rates (or lack of) if we look at regional, sub-regional or national level data. In eastern and southern Africa, rate of new HIV infections has declined by around 60% over the last 10 years whereas this decline in Asia Pacific region is only 14%.

In India, the decline in new HIV infections over the last 10 years has been 42%. This is about half of what India aspires to achieve (80%) by 2026. AIDS related mortality in India has dropped by around 70% over the last 10 years. Indian government's National AIDS Control Programme phase-V aims to reduce annual new HIV infections and AIDS-related mortalities by 80% by 2025-2026 from the baseline value of 2010. "We are still well short of that target," said Bridger.

According to Indian government's Sankalak 2023 report, "while the overall adult prevalence of HIV in India remains low at 0.20%, it continues to be more than 1% in Mizoram and Nagaland states. The annual new infections between 2010 and 2022 have declined by 42% nationally. However, contrary to the national trend, select northeastern States have seen increases in annual HIV infections in 2022 vis-à-vis 2010. In Tripura, annual new HIV infections in 2022 increased by 300% times vis-à-vis 2010. Similarly, in Arunachal Pradesh, annual new HIV infections increased by around 200%, in Meghalaya by 150% and in Assam, by 75%."

Undoubtedly, there is an urgent need to step-up the responses in select locations and sub-populations to fast-track progress towards ending AIDS by 2030.

Investing in young people

Younger people are more at risk of getting newly infected with HIV infection. Access to the full range of HIV combination prevention options looks to be sketchy when it comes to the young.

"Since the last 18 months, we have been focusing to rebuild some momentum around investing in young people (in the context of strengthening HIV responses). India has the largest number of young people on the planet. We really need to be genuinely engaging young people if we are to sustain the HIV response and ensure that we have the energy and new ideas to sustain it to 2030 and beyond," shared Bridger.

Missing Key: Key populations are left behind

"When we look at the HIV service cascade, key populations are lagging behind compared to general population in India. For example, among people who use and inject drugs, coverage of HIV prevention interventions is only 46%. Treatment uptake among people who use and inject drugs is also low - around 54%. HIV prevention interventions must reach all of them as it is so critical. We have to reinvigorate, innovate and find new and varied ways of reaching those who are currently not accessing treatment and prevention services," said David Bridger to CNS.

At the same time, over one-third (36%) of people living with HIV in India are above the age of 50 years. "We have to adapt and ensure that the health system is prepared to look after people with HIV who are getting older (like all of us)," said Bridger.

Indian government's Sankalak report 2023 states that HIV prevalence in key populations is 9 to 43 times higher than that in general population: 1.85% among sex workers, 1.93% among inmates in prisons, 3.26% among gay men and other men who have sex with men, 3.78% among Hijra/ transgender persons and 9.03% among people who inject drugs. HIV prevalence among migrant workers and truckers is 4 times than the national average of 0.20%.

Germany's Ministry of Health told CNS that "HIV infections have remained largely confined to a few population groups, such as, gay men and other men who have sex with men, people who inject drugs, and heterosexual contacts (often among individuals from countries with high prevalence of HIV in the general population)."

"Among gay men and other men who have sex with men, the estimated number of new HIV infections in Germany has decreased from about 2,800 in 2007 to about 1,000 in 2022 (from approximately 72% to around 52% of all new HIV infections). However, among people who inject drugs, there has been a significant increase in new HIV infections - from 6% in 2010 to 20% in 2022 of all new HIV infections - with 370 new infections occurring in 2022. Infections through heterosexual contact have also shown an increasing trend in recent years, with 520 new infections in 2022 (28% of all new HIV infections in 2022)- an increase of 24% from the previous year," said German Ministry of Health to CNS.

TB HIV co-epidemics

Despite TB being preventable and curable, even one TB or AIDS death is a death too many - as we have the tools to avert it. If we deploy the tools in people-centred, community-led and science-backed ways, we can do so much more than we currently are in HIV and TB responses.

According to the WHO Global TB Report 2023, over 11,000 people with HIV died of TB in 2022 in India. Each of these deaths could have been averted. It is a grim reminder of our collective failure to provide integrated and colocated TB and HIV services to people in need over the years.

Gains made by lifesaving antiretroviral therapy and people-centred and rights-based HIV programmes are threatened with lack of action to prevent all, find all, and treat all TB. We have the tools that have proven to work. Failure to deploy them in a timely and socially just manner will wither away the gains made in the fight against AIDS. The possibility to end TB and AIDS depends on if we are successful in putting people first at all levels of the response - everywhere.

• About the authors: Shobha Shukla and Bobby Ramakant lead the editorial at CNS (Citizen News Service) and are on the board of Global Antimicrobial Resistance Media Alliance (GAMA). CNS is an official media partner of AIDS 2024. Follow them on twitter @Shobha1Shukla, @BobbyRamakant