BASED ON THE HINDU ARTICLE

HISTORY

• April 1, 2004 – Indian government had launched Free Antiretroviral Therapy (ART), for Persons living with HIV (PLHIV)
• AZT (zidovudine) was the first antiretroviral drug approved in 1987, followed by three more in 1988 and protease inhibitors in 1995. However, access to these drugs was limited, mostly available in high-income countries.

EVOLUTION OF FREE ART

• In 2000, at the UN Millennium Summit, world leaders set a goal to stop and reverse HIV spread.
• The Global Fund to Fight AIDS, Tuberculosis, and Malaria was established in 2002, advocating universal access to HIV services.
• In 2004, India had an estimated 5.1 million PLHIV, with a population prevalence of 0.4%, but few were on ART, with only 7,000 by year-end.
• Key barrier to ART: high cost, unaffordability, and limited geographical access
• Cocktail therapy/HAART (highly active antiretroviral therapy) available since 1996, but costs were prohibitively high ($10,000/year)
• Stigma and loss of life among HIV-infected individuals
• Healthcare providers felt helpless due to non-availability and affordability issues with ART

THE SUCCESS

• Free ART decision was path-breaking, available for adults since 2004 and children since November 2006.
• In two decades, ART facilities expanded from <10 to around 700 centers, including 1,264 Link ART centers.
• These centers have provided free ART drugs to approximately 1.8 million PLHIV on treatment.
• Comprehensive Approach – free diagnostic facilities, focused attention on preventing transmission to children, and managing opportunistic infections like tuberculosis
• Evolution of ART eligibility criteria: from CD4 <200 cells/mm3 (2004) to ‘Treat All’ approach in 2017 + The evolution of the ‘Treat All’ approach in 2017 demonstrates a willingness to adapt to evolving medical understanding and guidelines
• The integration of free viral load testing, providing 2-3 months of medication, and adopting a rapid ART initiation policy underscores a patient-centric approach. These initiatives aim to improve treatment adherence, reduce burdensome clinic visits, and optimize healthcare resources efficiently
• The introduction of newer and more potent drugs like Dolutegravir (DTG) reflects India’s commitment to incorporating advancements in medical science into its treatment protocols. This move enhances treatment efficacy while minimizing adverse effects, ultimately benefiting PLHIV
• As of 2023, HIV prevalence in India’s 15-49 age group reduced to 0.20% with around 2.4 million estimated PLHIV, down from 10% two decades ago.
• India’s global share in PLHIV decreased to 6.3%.
• 82% of PLHIV knew their status, 72% were on ART, and 68% achieved viral suppression by 2023.
• Annual new HIV infections in India declined by 48% (baseline 2010), higher than the global average of 31%.
• Annual AIDS-related mortalities in India declined by 82% (baseline 2010), surpassing the global average of 47%

PATIENT-CENTRIC APPROACH TO SERVICES

The success in combating HIV/AIDS has been a result of various initiatives, not just free ART. These include:

• Provision of free diagnostic facilities and PPTCT services
• Management of opportunistic infections and co-infections like tuberculosis
• Evolution of ART eligibility criteria towards a ‘Treat All’ approach
• Free viral load testing and a patient-centric approach with extended medication supply
• Integration of newer drugs like Dolutegravir (DTG) and rapid ART initiation policies

Looking forward, India’s National AIDS Control Programme (NACP) phase 5 aims to achieve ambitious targets by 2025, in alignment with global goals:

• 95% of PLHIV knowing their HIV status
• 95% of diagnosed individuals receiving sustained ART
• 95% of those on ART achieving viral suppression

These targets are crucial steps towards reducing new infections, AIDS-related deaths, and vertical transmission of HIV and syphilis.

CHALLENGES

• Delayed enrollment at ART facilities, with many patients presenting late with CD4 counts below 200.
• Loss to follow-up after starting ART, leading to resistance development due to missed doses or dropouts.
• Ensuring sustained supply and availability of ART across all geographical areas, including tough terrains and remote regions.
• Engaging the private sector in PLHIV care.
• Continuous training and capacity building for healthcare staff.
• Strengthening integration with other health programs for holistic care.
• Adopting a focused approach to reduce preventable mortality through systematic reviews and advanced diagnostics.

The success of India’s free ART initiative stemmed from political will, sustained funding, regular program reviews, community engagement, people-centric service delivery, bridging policy gaps, and expanding services to reach more PLHIV.

CONCLUSION

The free ART initiative arguably paved the path for bending the HIV/AIDS epidemic curve in India. It is a testament to the point that if there is a will, the government-run public health programme can deliver quality health services free, and available and accessible to everyone. The 20 years of free ART and subsequent steps under the NACP have the potential to guide other public health programmes in the country. As an example, the learnings can and should be used to launch a nationwide free hepatitis C treatment initiative in India and accelerate progress towards hepatitis C elimination.