Pre pandemic efforts taken against HIV by India

National AIDS Control Organisation (NACO) is the body that manages HIV control in India. NACO aims to extend medical therapy to all PLHIV in India. They have been making consistent efforts to abolish the stigma around HIV patients and create awareness about the fundamental modes of spreading HIV. They envision building Integrated Counselling & Testing Centres (ICTCs) over the country (including remote areas). Hence, every HIV patient has access to quality care and an opportunity to live a safe and healthy life. India provides antiretroviral drugs free of cost [Reference Rao11]. Free distribution of condoms among vulnerable groups is another method to reduce HIV spread [Reference Rao11]. These centres are also essential in transparently calculating the prevalence of HIV in India. Pregnant women with HIV have been a significant target of ICTC to help bring HIV-free babies to the world. NACO forms partnerships with many non-governmental organisations, faith-based organisations and women's self-help organisations to make their vision a reality [Reference Rao11].

Challenges of COVID-19 to India's efforts against HIV

According to official figures, India has a staggering over 2.3 million PLHIV/acquired immune deficiency syndrome (AIDS), making it the world's third most heavily affected country by this dangerous sickness. The disease is centred mostly among disadvantaged communities, such as sex workers, who are disproportionately affected in India. In addition to men having sexual relations, those who use intravenous drugs are at risk [1], as are migratory labourers, truck drivers and transgender people (hijras). According to one study [1], a lack of sex education and safe sex behaviours can potentially raise the risk of HIV transmission.

India still fails to establish policies to manage its HIV population, and COVID-19 has only added fuel to the fire. COVID-19 has created a significant burden on this vulnerable HIV-positive population struggling with financial aid, obtaining medical care, and seeking help for their psychological problems like anxiety, depression and others. HIV-positive people are all more prone, just like the average population [Reference Kumar12]. The vulnerable populations like sex workers have no source of income during the lockdown, and they already have been subjected to stigma and are reluctant to seek medical therapy for HIV. Migrant workers and truck drivers are also facing unemployment due to the COVID-19 pandemic. Loss of jobs and layoffs significantly increased during the pandemic, and many HIV-positive patients faced severe economic crises [1].

AIDS-affected states Maharashtra and Andhra Pradesh are the most severe in India, and they were also the hardest hit by the COVID-19 pandemic, which occurred in the same year. By July 2020, there would have been 570 antiretroviral treatment centres and 1264 link antiretroviral treatment centres operating under NACO; however, due to COVID-19's state-wide lockdown, the vulnerable population would not have sufficient access to these services [13].

HIV/AIDS patients are more susceptible to COVID-19 infection, plus the lockdown creates trouble in accessing food, medicines, etc. All the resources and infrastructure initially devoted to managing HIV/AIDS have been deployed for battling COVID-19 [Reference Kumar12]. HIV/AIDS patients need access to treatment to ensure that their viral load remains undetectable and their CD4 count is high enough to protect them from HIV and COVID-19 [14]. HIV-positive people face many stigmas in society regardless of the pandemic, and many of them prefer to hide their HIV status; hence it is difficult for them to seek help and support during the tough times of the pandemic [15].

UNAIDS and their recommendations during COVID-19

The Joint United Nations Programme on HIV/AIDS (UNAIDS) is leading the global effort to eliminate HIV/AIDS as a public health issue by 2030 as part of the Sustainable Development Goals [15]. By 2020, the UNAIDS goal is to achieve 90:90:90. According to this, 90% of PLHIV should be aware of their HIV status, 90% of positive patients should begin antiretroviral medication (ART) immediately, and 90% of those on ART should be virally suppressed by 2020 [Reference Rao11]. COVID-19 infections are more likely to infect older PLHIV patients and those with heart or lung disease. During lockdowns, UNAIDS recommends that persons living with HIV contact local authorities as soon as possible to ensure that they receive multi-month renewals of ART prescriptions. Both PLHIV and individuals from underserved groups at risk of contracting HIV should continue to use condoms, sterile needles and syringes for at-risk populations, pre-exposure prophylaxis and HIV testing [16].

Despite the efforts of the NACO, only 76% of the PLHIV know their status, and only 56% of them are under ART. The HIV epidemic is mainly concentrated among the key population groups. HIV self-testing is an excellent approach where people with HIV collect their samples (blood or saliva), perform a test and interpret the results. HIV self-test can undoubtedly be helpful during the COVID-19 pandemic; however, awareness about it in India is still low [Reference Rao11].

Future recommendations

This is a watershed moment in the history of HIV/AIDS. This lethal disease is attracting unprecedented money, political will and media attention. The World Health Report 2004 states that the global community has a once-in-a-lifetime opportunity to change the course of history by augmenting existing prevention measures and upgrading health systems with HIV treatment programmes [17]. According to data, HIV treatment programmes were successful in 2020, with the number of people taking antiretroviral medication growing by 9% from 20.1 million in 2019 to 21.9 million in 2020. However, critical prevention and testing programmes fell short of expectations for the first time in the Global Fund's existence [18]. As the COVID-19 epidemic spreads, it is uncertain whether primary treatment and preventative programmes delays will cause countries like India to fall further behind. To avoid long-term devastation in the HIV/AIDS fight, we must rapidly increase adaptation and mitigation efforts to reclaim lost territory. Collecting reliable data on the volume, trends and distribution of HIV and AIDS illness is critical to effective control and prevention of the AIDS pandemic. These serve as the foundation for developing and implementing successful interventions. This is a crucial consideration that must constantly be taken into account while planning future policies and implementations. Because India is a heavily populated country, separating PLHIV into tiny clusters and pockets makes relief operations easier. In these clusters, rigorous and frequent testing should be performed, and if somebody is found as having HIV infection, their contacts should be tested to confirm the presence of the virus [Reference Sukaina19]. Safe and sanitised methods, particularly in the under-researched category of barbers and street-based tooth extractors, should be prioritised by requiring them to discard the blades after use. Strict standards requiring the use of safe and disposable syringes should be implemented. Weekly audits should be performed to ensure that these procedures are followed. Otherwise, only counselling will be ineffective in this demographic segment [Reference Sukaina19]. Early identification of the problem is required, followed by the development of comprehensive strategic frameworks for intervention. Mechanisms for coordinating a multi-sectorial collaborative plan must be an inherent element of the country's national HIV/AIDS strategy.