HIV in India - Interview with Dr. Ravikant Porwal
Dr. Ravikant Porwal is one of the few qualified infectious disease specialist in India with special interest in HIV management. He is currently Consultant in Internal Medicine & Infectious Diseases and Chair of Infection control at Manipal Hospitals, Jaipur, Rajasthan. His other interests include Infection control in healthcare facilities, Post-transplant infections and Multi drug resistant tuberculosis.
India has the third largest population of HIV infected people in the world. The notable anti-AIDS campaign over the last decade has reduced the prevalence of HIV infection from previous higher levels. Below is a brief interview with HIV specialist Dr. Ravikant Porwal regarding the current status of HIV infection in India
1. What are the incidence and prevalence of HIV infection in India? Is the HIV transmission coming down in India?
Current prevalence at the national level is 0.27%, which is declining (as per latest NACO 2013 report), while incidence is heterogeneous which means that now we are seeing more number of new cases from low prevalence states, for example in NACO report 2013 (which has data till 2011) nearly 1.2 lakh new cases were there and only 31% were from 6 high prevalence states, 57 % were from low prevalence states. So I feel it is premature to say that incidence of HIV transmission is coming down.
2. The prevalence of HIV infection has been found have regional variation with some states having high prevalence? What is the reason behind this variation?
There is a regional variation in prevalence of HIV. Highest is Manipur ( 1.4% ) > AP ( 0.9%) > Mizoram (0.8%) > TN (0.3%). Following are the reason for this -Manipur and Mizoram (Northeast states) -- Higher prevalence of IV drug usage and Tatto making habit. In AP, TN , MH there is a strong movement of truckers due to industrialization with lots of migrant population, Increase in alcohol consumption , also increased awareness among doctors to test for HIV in these states.
3. What could be a reasonable estimate of undiagnosed HIV infected persons in the Indian population? Should we implement some sort of mandatory screening at some point to identify this group to treat them early and reduce the risk of transmission?
It is difficult to estimate the number , but I would say this must be phenomenal as in a country like USA with ample of resources and robust testing policy, only 80 % of Americans know their HIV status while 20% don't know their status .(As per Gardeners cascade from CDC).
Second part of your question regarding testing policy , I believe that we need to encourage systematic testing policy once in life time for all apart from high risk groups and also opt out policy like WHO in hospitalized patients as consent is a barrier to testing.
There is a study published in plos one from brown university comparing various testing strategies found "testing every Indian once in every 5 years” is the cost effective strategy. I know this is not possible in Indian health care system as public health program, but this highlights the need of robust testing for Indian population, so I feel once in life time for general population is a reasonable strategy.
4.Part of the reason for the discrimination of people living with HIV infection is the perceived risk of transmission. Let me bring out a particular scenario. If a HIV positive patient with high viral titre coughs and a droplet from it falls on the surface of the eye of another person, will this lead to transmission?
There is no risk of transmission of HIV merely by living in same environment or in same house. Coming to the given scenario, there is negligible risk as HIV virion are mainly found in cells especially dendritic cells like genital secretions or lymphoid cells, so practically speaking there is virtually no risk of infection in such setting neither is reported in literature.
5. It is not uncommon to see health care workers especially in India, not following the universal precautions while handling blood from patients with unknown HIV serostatus. Do we have studies regarding HIV transmission to health care workers in India?
There are no Indian studies for such exposures, while there are data from CDC regarding HIV transmission in health care setting which is mainly related due to sharps or needle stick injuries. But this is a very important point to be taken care in Indian system as we still do not have that kind of support system in majority of health care facilities after such an exposure. So I take the opportunity to re impressed the fact of ABSOLUTE adherence to standard precautions while on patient care.
5. What are the lacunae in India’s current public health policy towards containment of spread of HIV infection? What can be done to improve the existing policy framework?
I feel following are the problems
Testing policy - intense community and health care based testing policy is required.
ART - needs up gradation of regimen as first line : as still ZLN or SLN on board.
Follow up - should include viral load in algorithm to detect early treatment failure.
Frequent stock out - Need efficient full proof support system to avoid stock out.
PMTCT - we need to change the regimen in tune of WHO, as still NVP monotherapy and limited duration in NACO program.
Preventive measures - needs strengthening for example-- increasing circumcision rates, Robust STD screen, promoting condom use in high risk groups, include NAAT based testing on blood donation programs.
6. What is the status of the vaccine development to prevent HIV infection?
It is still in very early phase to achieve any break thru. There have been total of 5 major trial that have been conducted so far, but only one Thai study showed nearly 25 % efficacy in intention to treat group but was not sufficient enough for population to offer. Currently A major trial is ongoing in USA by US Army on Prime & Boost strategy in phase II in HIV negative MSM population, results are expected in 2017 end. In view of major immunological problem in vaccine making esp with HIV , I don't see any good news in recent future , but we keep our finger crossed.
Dr Ravikant Porwal MBBS MD DNB FNB FIDSA
Consultant Infectious Disease
Manipal Hospitals , Jaipur, Rajasthan.
Thursday, February 12, 2015