Multi-month prescription, home delivery for uninterrupted AIDS drugs in times of Covid-19
Antiretroviral therapy (ART) given to people living with HIV (PLHIV) works in two critical ways -- it slows disease progression and helps PLHIVs lead productive lives, and reduces the viral load to lower disease transmission and prevent new infection.Updated: Aug 09, 2020 02:06 IST
Within days of China locking down Wuhan and other cities in coronavirus disease (Covid-19) -hit Hubei province on January 23, and India confirming its first case in Kerala on January 30, officials from UNAIDS and National AIDS Control Organisation (NACO) went into a huddle in New Delhi to ensure an uninterrupted supply of HIV services, which are offered free to everyone who needs them under the national Aids control programme.
Antiretroviral therapy (ART) given to people living with HIV (PLHIV) works in two critical ways -- it slows disease progression and helps PLHIVs lead productive lives, and reduces the viral load to lower disease transmission and prevent new infection.
“When Covid-19 was first reported in India, we put our heads together with NACO, civil society and PLHIVs to plan for contingencies such as the Wuhan lockdown , to mitigate the impact on critical HIV services, including ART delivery and harm reduction,” said Dr Bilali Camara, Unaids Country Director for India, who is a medical epidemiologist by training. Unaids is the Joint United Nations Programme on HIV and AIDS.
By March, monthly dispensation of ART drugs was replaced with a three to six months supply across states. “Instead of monthly, we began giving six months provisions to people so they didn’t have to come back to a facility and risk exposure to Covid-19, or spent money on transportation etc. This was introduced by state Aids control societies across India very quickly. With treatment saturation, we can achieve a lot in terms of keeping PLHIVs health and preventing new infection,” said Dr Camara.
What also helped was the introduction of a new antiretroviral drug with fewer side-effects called dolutegravir. “At the beginning of the pandemic, there was a very good policy change, when NACO introduced a much safer, less toxic drug on Unaids advice. That medication really helped people stay on treatment course, which will improve outcomes and lower their risk of developing drug resistance,” he said.
There are 2.1 million people living with HIV in India, with new infections rising in Assam, Mizoram, Meghalaya and Uttarakhand, and declining in Nagaland, Manipur, Delhi and Chhattisgarh. Just eight states accounted for two-thirds of the estimated 87,580 annual new HIV infections in India in 2018.
In absolute numbers, India has the third highest number of people living with HIV (PLHIV) in the world after South Africa and Mozambique, but cases have hovered around 2.1 million for the past decade despite people living longer with improved access to testing and ART. Since 2010, India has reduced new infection by 37%.
Delhi resident Saurabh, 41, who does not want to share his second name, is among those who benefited from the multi-month dispensation of ART drugs just before the lockdown. “I was surprised when I was given medicines for several months in March but within a week, the lockdown was announced, which meant I couldn’t step out. It was a big relief as I could continue treatment without a break,” said Saurabh, who was diagnosed with HIV in 2012.
“India has accomplished reductions in new HIV infections, important reduction in AIDS-related deaths, and an increase in the number of pregnant women living with HIV on treatment, with a 66% ART coverage in 2018. This has resulted in 79% people knowing their status, and 82% of them being on treatment,” said Camara. Testing and treatment is provided free in the public sector, and costs the government US$ 70-80 per patient per year.
The lockdown also invigorated the community-based dispensation drugs. “We have volunteers collect the ART drugs from the government and distribute them on motorbikes, bikes, carts, and on foot to ensure people get medicines at their doorsteps. I really have to thank all the networks of HIV and Aids in India, all of them have participated,” said Dr Camara.
Opportunities to fast track the AIDS response include focusing on high burden districts for the elimination of mother-to-child transmission of HIV based on the last ANC survey data which has shown a prevalence of 0.2%., and intensifying prevention programmes, including targeted interventions for key populations such as female sex workers, (1.56% HIV prevalence), the prison populations with 2.04%, transgender (3.14%), and people who inject drugs (6.26%), according to NACO data.
“Covid-19 has been a huge challenge but it has forced us to think differently. UNAIDS has worked with NACO and ministry of health to take oral substitution therapy to injecting drug users in prescribed doses for two to three months,” said Camara. Since this again was community- led, the oral substitution therapy using buprenorphine (opioid) reached injecting drug users at home as well as the homeless.
“The unexpected outcome was that more and more people moved from injecting drug use to oral drug use, which is preferred because HIV infections occur from injecting drug use. So we have an opportunity to reduce risk as injecting drug use is a serious problem is in the north eastern states, and some pockets in Punjab and Uttar Pradesh,” said Dr Camara.
At least 82 countries criminalise some form of HIV transmission, exposure or non-disclosure, sex work is criminalised in at least 103 countries and at least 108 countries criminalize the consumption or possession of drugs for personal use, according to UNAIDS.
“There are instances drug users being put in jail, NACO data collected for the first time from jails for 2019 shows 2.04% prevalence rate which is 10 times more than the general population. Jailing drug users like criminals is not addressing the problem of drug use and Covid-19 has helped establish that overcrowded jails are not practical. Jails should be an instrument to educate and rehabilitate people,” he said.
Working closely with the community for HIV service delivery and engaging them in the national AIDS response is key. “Community empowerment is essential to reduce stigma, deliver medicines and and tools for prevention, which has gone down. The increasing emphasis in treatment is needed, but not at the cost of prevention in vulnerable populations, who still account 62% of new infections in India,” said JVR Prasada Rao, former health secretary, and founder director of NACO, and special envoy at Unaids.