Two years after the World Health Organisation (WHO) recommended that antiretroviral therapy (ART) be initiated in people living with HIV irrespective of the CD4 (a type of white-blood cell) counts, India has aligned its policy with the guideline. In a major shift, 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 CD count or clinical stage”. Nearly 4.5 lakh deaths can be averted through this move.
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, it changed its guidelines and, in 2013
increased the threshold to CD4 count less than 500 cells per cu. mm.
Change in WHO guidelines
The recommendation was based on the evidence that an earlier initiation of ART will help people with HIV live longer, remain healthier and “substantially reduce” the risk of them 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 the WHO’s decision. Earlier initiation could avert an “additional three million deaths and prevent 3.5 million more new HIV infections between 2013 and 2025,” noted the WHO in 2013.
In 2015, the WHO once again changed its guidelines. Based on evidence from clinical trials and observational studies since 2013, it became clear that an earlier use of ART, irrespective of the CD4 count, results in better clinical outcomes. Accordingly, it recommended that ART be initiated in HIV-positive people at any CD4 cell count.
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 over half a million people are not even aware of their HIV status.
With the government changing its treatment guidelines, the 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 0.35 million who have been diagnosed but not on treatment and the 0.5 million who have been infected but have not been diagnosed. Also, nearly 80,000 people get 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 it closer to those in need, and target special groups that are more vulnerable to infection such as partners of people who are HIV-positive.