Dr Sunil Solomon, Associate Professor, Johns Hopkins University School of Medicine explains to Viveka Roychowdhury the importance of “virtual” outreach initiative SafeZindagi.com to screen, diagnose and treat segments with higher burden of HIV infection. He also predicts that with the pipeline of long-acting drugs, the future of HIV prevention and management could be as simple as one to two injections every 4-6 months, similar to getting a COVID booster
Dr Sunil Solomon, your mother Dr Suniti Solomon’s diagnosis of India’s first AIDS cases among sex workers in Chennai in 1986 was the first hard step, forcing the country to shed its denial about AIDS infection rates. Has the country managed to put the stigma of HIV infection into perspective, given that we see the same pushback in varying degrees to many disease conditions, ranging from cancer, TB, and even SARS-CoV2 infection in the early stages of the pandemic?
Stigma is something that does not change overnight. It takes generations to change and accept. But stigma towards HIV has definitely reduced over the years. I still remember my mom desperately trying to find any hospital that would be willing to deliver the child of a woman living with HIV in the 90’s. Today, I have a choice based on the patient’s preference.
But stigma against HIV disease alone is not enough. There are several vulnerable groups such as men who have sex with men, people who inject drugs, transwomen and female sex workers – we judge them without trying to understand them. Until, we really recognise that we are all people and we all make choices for a reason and can be accepting of the reason, there will continue to be HIV infections.
But the one thing that HIV has taught us is the power of communities and advocacy which is lacking for other diseases. Stigma exists for several of the conditions because of ignorance – treatment literacy around these other diseases can help alleviate stigma.
The one missing on the list is mental health – in my opinion, all of us have some mental health issue and are “crazy” in some particular way but mental health is something that is rarely talked about and COVID has really brought this to light. I would almost put mental health ahead of all these other conditions and plan campaigns to make it normative and not a taboo topic.
What have been the initiatives to increase screening and diagnosis rates in these past decades?
The government of India and National AIDS Control Organization (NACO) have done a remarkable job of increasing access to HIV diagnostics – there are over 5000 centres across India where people can get screened for HIV. Additionally, there is community-based screening for key populations as well via community-based organisation. The challenge is demand generation and treatment literacy around the benefits of early diagnosis and treatment.
So, I would say it is more of a demand issue as opposed to a supply issue. Modes of communication have changed and most health information today is via social media as opposed to print and the NACO is currently expanding to include social media in dissemination which I think will further improve screening.
How is the Safezindagi.in initiative, launched last World AIDS Day, different, and what are the gaps it tries to address?
SafeZindagi is something we are piloting in collaboration with the National AIDS programmes and is funded by PEPFAR/USAID. What has happened over the past decade is the penetration of internet and mobile dating/hook up sites across India. This has resulted in populations seeking sex partners online or buy drug online and these populations are not reached by the physical facilities.
The goal of SafeZindagi is to reach these populations and provide them with education, testing and linkage to care online using “virtual” outreach workers. The vision is to make it a wholly virtual clinic to cater to the health care needs of the “Swiggy” generation.
What has been the response and learnings so far from this initiative?
I must say I am surprised from what we have seen over the past year and half. We have provided HIV testing services to over 3000 and HIV self-testing services to over 2500 clients from these virtual places. What is surprising is most of them have very low HIV risk perception despite about one in 20 testing positive for HIV.
But what is more striking is the vast majority of them have never been screened for HIV before. Given the general population prevalence of HIV in India is about 0.2 per cent, the clients we are able to test through these online avenues have almost 25 times higher burden of HIV infection.
HIV infection comes along with co-infections of TB etc. How does this complicate the management of the disease condition?
As I mentioned earlier, the key is early diagnosis and treatment. If we are able to detect and treat them early, they lead normal lives by just taking one pill a day with almost no side effects and we do not need to worry about co-infections.
In fact, the TB is more challenging and medications more toxic than the HIV medications. It does complicate treatment due to drug interactions, but there are enough medications now available in both the public and private sectors to manage both conditions. But as I previously said, the easiest way to treat TB in HIV is to prevent it by early diagnosis and management.
What is the cost burden of HIV infection at the individual, community, and country-level?
At the individual and community-level, if you seek care in the public sector the cost is essentially your transport to the site and loss of wages for the day – so really minimal. The recent introduction of dolutegravir (a very potent and safe drug) in the public sector brings the public sector programme in India at par with any other country including the US and Europe.
At a country-level, the majority of people with HIV are in the economically productive age group of 20-50 years and so, in my opinion their productivity offsets the cost of medications. The number of annual new infections has also reduced and the key to making it even more cost-effective is to bring the number of new infections down and the most efficacious way of doing this to get as many people on treatment as possible. People who are on effective HIV treatment do not transmit HIV to others as the amount of virus in their blood is too low to effectively transmit.
What have been the recent innovations addressing HIV management in India? Are these innovations affordable and accessible to vulnerable populations in India and across the world?
As I mentioned earlier, the introduction of dolutegravir in the public sector is a game-changer in my opinion. And this is available free of charge to anyone via the public sector. The introduction of tele-health and multi-month dispensation (dispensing multiple months of medications at a time) are also both great enablers of treatment retention and accessible to all.
The biggest game changer in the HIV field globally is the introduction of long-acting drugs for HIV treatment and prevention. They were recently approved by the US FDA and we are just seeing the first generation of these drugs. Given the pipeline, I believe the future of HIV prevention and management could be as simple as one to two injections every 4-6 months. That is where the field is going. It will be sort of similar to getting a COVID booster.
You were awarded a $35 million grant from USAID to implement and evaluate innovative models of service delivery to improve the HIV care cascade in India with a focus on vulnerable populations. Can you give us an update on your work to improve HIV care in India?
A lot of our progress and plans were hampered by the COVID-19 pandemic. But still, despite the pandemic, we have been able to implement novel models and strategies that are currently under evaluations. As I have already mentioned, safezindagi.in the online platform has been a real eye opener to the risk that exists in the private sector. Via this platform, we were also able to provide HIV self-testing for the first-time in India as well as access to pre-risk exposure prophylaxis (PrEP) to these vulnerable virtual populations.
We are also piloting a self-sustainable HIV care model led by the HIV community – the TAAL+ clinic in Pune. We established one of the first trans community-led, comprehensive health care clinics for the transgender community in Hyderabad – “Mitr clinic”. We have also since established two more in Maharashtra. The goal is to provide the community with a space where they have access to their health care needs.
We have also established adolescent friendly health centres for children and adolescents living with HIV and their siblings with the objective to not only improve their HIV outcomes, but their lives in general.