As yet another World AIDS Day dawns, and States move towards the “Zero new infections, and deaths” goal, the debate now centres around the possibility of early initiation of antiretroviral therapy for all people with HIV. New evidence has emerged to prompt early initiation of antiretroviral therapy (ART) for better outcomes among people with HIV infection.
While certain sections of the private sector in Tamil Nadu, a pioneering State for interventions in the sector, have absorbed this idea already, putting people on treatment immediately after they test positive, the government is yet to take a decision on this, but has relaxed the norms for starting someone on ARTs. Currently, anyone who has a CD4 cell count of 350, and consequently, a very high viral load, is eligible for free ARTs. In Tamil Nadu, as elsewhere, the present policy is to treat those below 350 CD4 count, which may be raised to below 500 CD4 count. WHO has recommended that even those with higher CD4 counts be treated. Recently, studies have shown initiating on ART irrespective of CD4 cell count have resulted in reduction in HIV transmission, and prevention of opportunistic infections like Tuberculosis and cancers, explains N. Kumarasamy, chief medical officer, YRG Care.
He was the primary investigator for India in the multi-centric Insight START study, which conclusively proved the benefits of early initiation of ART. YRG has begun to put all patients testing positive on ART.
A.S. Valan, former regional co-ordinator, of the body earlier known as the National AIDS Control Organisation, agrees. “Earlier, there was a fear that early or very late initiation of ART would lead to a condition called Immune Reconstitution Inflammatory Syndrome, but clinical trials have disproved this, and in fact, indicated better survival.
The fact also is that better drugs are now available at more affordable rates.
P. Kausalya of the Positive Women’s Network agrees that better drugs have entered the market, but for people like her, the issue is one of ensuring a steady supply of free drugs given by the State/Centre. Currently, Tamil Nadu provides 89,000 people with ART, of which 1,600 take second line drugs, and just over 4,000 are children. It is estimated that there are between 1.10 lakh and 1.61 lakh people with HIV in the State, according to a senior health official.
P. Kuganantham, former UNICEF-CDC consultant for the HIV/AIDS programme in Tamil Nadu, says issues of supply must be addressed before even contemplating the ‘Test and Treat’ model that the WHO has recommended.
“Counselling and testing programme has to be mainstreamed, as we did in Tamil Nadu in mid-2000s. The other thing is maintaining a pipeline supply of ARTs.”
