Two years after the World Health Organisation recommended that antiretroviral therapy (ART) be initiated in people living with HIV irrespective of the CD4 cell (a type of white blood cell) count, India has aligned its policy with the guideline. In a major shift in the HIV treatment guidelines, Union Health Minister J.P. Nadda had recently said that any person who tests positive for HIV will be provided ART “as soon as possible and irrespective of the CD4 count or clinical stage”. By expanding the provision of ART, about 0.45 million deaths can be averted.
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, the WHO changed its guidelines and, in 2013, increased the threshold to CD4 count less than 500 cells per cubic millimetre. But for certain populations — HIV positive people who also have TB disease, pregnant and breastfeeding women, children below five years — ART was to be initiated regardless of the CD4 count.
The recommendation was based on the evidence that earlier initiation of ART will help people with HIV live longer, remain healthier and “substantially reduce” the risk of transmitting the virus to others. The availability of safer, affordable and easy-to-manage medicines that could help to lower the amount of virus in the blood played a key role in WHO’s decision to increase the threshold. Earlier initiation could avert an “additional three million deaths and prevent 3.5 million more new HIV infections between 2013 and 2025,” the WHO noted in 2013.
The biggest challenge will be to identify half a million who have been infected but have not been diagnosed.In 2015, the WHO once again changed its guidelines. Based on evidence from clinical trials and observational studies since 2013, it became clear that earlier use of ART, irrespective of the CD4 count, results in better clinical outcomes compared with delayed treatment. Accordingly, it recommended that ART be initiated in HIV positive people at any CD4 cell count. Early start of treatment has the potential to “signiﬁcantly reduce the number of people acquiring HIV infection and dying from HIV-related causes and signiﬁcantly impact global public health” it said.
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 half a million people are not even aware of their HIV status. With the government changing its treatment guidelines, 0.6 million who have been diagnosed but not been on treatment are now eligible for treatment. Of the 0.6 million, about 0.25 million have been enrolled for pre-ART care and can be started on treatment almost immediately. But the biggest challenge will be to identify the 0.5 million who have been infected but have not been diagnosed and about 80,000 people who become infected each year.
Even as efforts are on to expand the 1,600 treatment delivery sites that are currently operational, there should be greater focus now on identifying people with HIV. The government has plans to start community-based testing to bring HIV testing closer to those in need, and target special groups that are more vulnerable to infection such as partners of people who are HIV positive.
Despite the WHO releasing the guidelines for self-testing in December last year to improve access to testing, India has refused to approve it on the grounds that pre- and post-testing counselling will not be possible. Self-testing could have increased the number of people who would have got themselves tested. However, the OraQuick self-test is not highly sensitive and any positive test should be reconfirmed with conventional testing.