HIV Epidemic in India

Transcription

1 HIV Epidemic in India Dr.R.R.Gangakhedkar Head, Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research New Delhi

2 Waves in Spread of HIV Epidemic Core Group Bridge Populationmostly males Women & Children

3 HIV Epidemic in Pune, 1997 Sex workers have the highest HIV prevalence as well as HIV incidence in Pune Emerging HIV epidemic in Pune.

4 The trend today

5 Overall trend among HRGs

6 What does it suggest? Rapid decline in HIV prevalence among key sub-populations Sex workers Injecting drug users Does it mean major success? May but could also be due to low coverage of free ART programming

7 ANC

8 What is happening in the mainstream population..

9 ANC is the proxy for mainstream.. A major decline.. Suggest reduction in HIV incidence in mainstream population

10 Differing Drivers of HIV Epidemic in different regions ANC HIV Prevalence Rising trends due to IDU High Prevalence States IDU Vulnerability due to Migration High Prevalence States FSW;MSM

11 Evidences for the Programme (4): Epidemic is dynamic with emergence of new locations of high prevalence IDU

12 Evidences for the Programme (5): Every state has its own driver of epidemic Andhra Pradesh ANC FSW MSM IDU Punjab ANC FSW MSM IDU 29 Manipur ANC FSW MSM IDU Gujarat ANC FSW MSM IDU Migrants

13 New Infections (By Age, in Lakhs) 3.00 New HIV Infections Over Years New HIV Infections in Lakhs % Decline since Adults (15+ yrs) Children (0-14 yrs) Total

14 AIDS Related Deaths (By Age, In Lakhs) AIDS Related Deaths (ARD) Over Years 54% Decline since ARD in Lakhs Adults (15+ yrs) Children (0-14 yrs) Total

15 From where will the threat of reversal come?

16 Geographic areas Low prevalence states & Northeast Low coverage; poor health infrastructure; needs saturation with a comprehensive program

17 States with high volume of estimated annual new HIV infections, 2015 Ranking of state by estimated annual new HIV infections (high-low) 16% 12 47% % highest volume states 8 high volume states Remaining states 7

18 Risk groups MSM & TGs Sex workers IDUs

19 Evidences for the Programme (6): Migrants are a potential contributor to the epidemic in a diverse group of states ANC HSS ANC HSS Migrant Spouse Non-Migrant Spouse Migrant Spouse Non-Migrant Spouse

20 Current HIV programing achievements & its coverage Persons on ART ~ >1.25 million/2.1 million Over 250 million HIV tests every year Focussed Intervention Sex workers ~ 0.8/ 0.87 million = 80.1% MSM ~ 0.244/0.412 million = 68.1% TGs~ 18000/70000 =25% IDUs ~ 0.132/0.18 million = 74.6%

21 Harmonisation of ART regimen.. A debatable issue simplification but risky High PDR is being reported from Africa If and whenever reversal will occur, it may occur in all population groups..

22 National Cascade Courtsey: Dr. Rewari HIV diagnosis at ICTC to ART Registration : 82 % Registration to assessment of Immunological status (baseline CD4 testing): 93 % Medical Eligibility as per National Guidelines: 73% Initiation on ART : 86 % Retention at end on Financial Year: 86 %

23 With the adoption of Test & Treat The program data suggests 14% could not be initiated on ART & 14% could not be retained at Year 1 (LFU) The current ART regimen is TLE. With asymptomatic HIV infected coming in treatment net, strategies to reduce LFU will be required to be strengthened.

24 We conducted a large Indian study looking at viral suppression at 1 year of ART Over 12% have PVL >1000 copies/ml If we classically take tertiary care ART centres failure rate is around 14% GART revealed even at one year the prevalence NRTI & NNRTI mutations is high suggesting late detection of failure Low adherence and inadequate time spent on counselling

25 Adult Cohort for EWI (n=9468)

26 Adolescent Cohort (n=716)

27 Paediatric Cohort (n=1665)

28 Children <12 months age. N=79

29 Proportions of ART centres by EWI EWI Indicators EWI 1 Adults EWI 1 Paediatrics EWI 2 Adults EWI 2 Paediatrics EWI 3 Adults EWI 3 Paediatrics EWI 4 Adults EWI 4 Paediatrics Performance targets < 80% 16(26%) 80 90% 23(37%) >90% 23 (37%) < 80% 28(51%) 80 90% 19(35%) >90% 8(15%) <75% 37(60%) 75 85% 22(35%) >85% 3(5%) <75% 11(20%) 75 85% 20(36%) >85% 24(44%) <100% 42 (68%) 100% 20 (32%) <100% 36 (62%) 100% 22 (38%) > 0% 0 0% 62 (100%) > 0% 0 0% 58 (100%)

30 The reality of linkage with secondline ART is

31 Characteristics & Outcomes of Second-line ART Patients (n=411) Rewari et al % Immunologic failure, 13% Immunologic and/or Clinical Failure

32 Has PDR & TDR increased? Isolated small studies do not show increase. First National HIV Drug Resistance Survey will begin in couple of month.

33 HIV-TB Screening for HIV is improving in DOTS centres. ~80% Screening for TB in ART centre is high over 90% MDR TB among HIV infected individuals very small proportion

34 CBNAAT linkages with ART centre District ART centre 39 yes No CBNAA T 207 No Yes 86 No No 306 Yes Yes

35 But from despair of no medicines in AIDS, we have moved to a hope of near normal survival with ART From early days lipodystrophy to a normal body image From OIs causing death to fears of uncovered chronic morbidities High sigma leading to a tendency to be hidden in community to a better degree of empowered living in mainstream population

36 Prevention From condom, double condoms to PrEP ( but needs to be provided to some) From abortions due to fear of transmission to safer delivery & negative babies Microbicides high hopes to lack of interest Vaccine from hope to despair

37 From premature death to near normal survival but; from hopes of cure to simplified maintenance doses Future of HIV+ children still uncertain Empowerment of socially challenged populations to uneven marginalisation From health priority to also a health problem with TB, Malaria leading the list

38 Fast track response vs Constant response Stover et al 2016

39 India misses the new infection targets

40 Trend of HIV Prevalence among ANCs in Mumbai. MDACS

41 Trend: HIV Prevalence in Key sub-populations in Mumbai. MDACS

42 Trend HIV reactivity in ICTCs in Mumbai. MDACS

43 Mapping of HIV Positive Clients in Mumbai Based on their residence (2015)

44 Conclusion Effective comprehensive programming has led to decline in HIV incidence in India Despair has been transformed to hopes in every sphere The concerns of reversal will continue as intensified focus gets reduced due to low numbers A focussed attention makes HIV, a major success story in chronic infections.