(Focus - India)
As November draws to a close, our attention turns to the upcoming World AIDS Day on 1st December - aimed at raising awareness about the AIDS pandemic caused by the spread of HIV infection.
HIV/AIDS, a global health challenge, has seen remarkable strides in understanding and managing the condition. The development of antiretroviral therapies has transformed HIV from a once-debilitating illness to a manageable chronic condition for many individuals. However, misconceptions and stigma still cast a shadow over HIV/AIDS discourse.
To learn more about the misconceptions associated with HIV/AIDS, we have interviewed Dr. Laxman Jessani, a board-certified Infectious Diseases Specialist from India who has been awarded the prestigious “International Infectious Diseases Fellow” grant at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), San Diego, 2015.
Dr. Jessani says despite rising education levels, the acceptance and understanding of HIV lag, many perceive it as a dreaded disease, unaware that with regular medications individuals with HIV can lead normal lives much like managing diabetes. This misconception hinders widespread acceptance and perpetuates the stigma surrounding the condition.
Dr. Laxman Jessani is an Infectious Diseases Specialist currently serving at Apollo Hospital, India.
Home test kits use saliva and other tests, which are still not FDA-approved, and we still have not implemented them widely. The gold standard for HIV testing is the antibody test, done from the blood.
In 2019, India ranked as the world's second-largest HIV/AIDS epidemic, with an estimated 2.35 million People Living with HIV (PLHIV) and an adult prevalence of 0.22%.[1] Despite significant awareness efforts and a considerable percentage of the population having attained primary education, what underlying factors contribute to India's ongoing challenge of being the second-largest HIV/AIDS epidemic globally?
Dr. Jessani - In India, HIV is still considered a bigger stigma, and it is not openly discussed. People still feel that if you have HIV, you have a dreaded disease and have contracted it in the wrong way. HIV is now like diabetes because people who live with HIV can take their medicines regularly and have a normal life, but people are unwilling to accept this truth, which is an issue with HIV.
I think if there is more education, awareness programs, and a better level of education amongst people, HIV will be considered an acceptable disease. However, as of now, I still feel that patients who come to me believe HIV is a dreaded disease and are unwilling to accept that they have HIV. So, I think this is the main reason why awareness of HIV has not reached the masses, and people have not accepted it.
Are there any specific regions or states that exhibit a greater burden of HIV/AIDS?
Dr. Jessani - Yes, states like Tamil Nadu and Maharashtra, and to some extent Karnataka, all have a high incidence of HIV. The problem is the exact incidence of HIV is still not diagnosed, and the cases, although it is not increasing as rapidly as it was earlier, are still coming up. The incidence of HIV is still present, but we must test more people so that we can detect it earlier.
The challenge of motivating individuals to seek HIV testing in healthcare institutions can be overcome by the availability of in-home HIV test kits.[2],[3] How accurate are in-home HIV test kits as an alternative to testing in healthcare institutions, and what are the key factors to consider when evaluating their reliability and effectiveness?
Dr. Jessani - Unfortunately, these home test kits are unreliable because the methods they use for testing HIV are not accurate. Home test kits use saliva and other tests, which are still not FDA-approved, and we still have not implemented them widely. The gold standard for HIV testing is the antibody test, done from the blood. It cannot be done at home. It has to be done in a laboratory. I suggest that you should not advocate the home-based test unless and until we have FDA approval, and those kits are very well validated.
Under the Indian National Guideline, patients with viral load >1,000 copies /mL failing two lines of therapy are referred to a hospital or specialty clinic for third-line treatment.
To what extent are physicians in India adhering to this Indian National Guideline?
Dr. Jessani - More and more physicians are becoming aware of this HIV incidence because earlier, HIV could have been treated with three drugs, which are part of first-line regimen. But now, we are seeing people living longer with HIV and developing resistance to the first-line agents. The physician needs to be aware that when the first-line agent fails, the viral load will be more than 1000 copies. That is when you must switch the patient to the second-line or third-line. In that case, you may also need to do the resistance testing. This awareness is gradually building up among physicians, and we see patients referred to us by other primary healthcare physicians who are failing first-line therapy.
Machine models are improving gradually, and artificial intelligence gives good results. If it is a simple case of HIV with no comorbidities or not many complications, the machine model can predict which medicines you should provide and monitor the side effects of the medicines. That will be much more useful in a government setup where many people are there, and you cannot give individualized attention to each patient.
What specific obstacles or hurdles exist for individuals seeking HIV treatment in India, hindering their access to necessary care and services?
Dr. Jessani - The biggest challenge for the treatment of HIV is the cost. For us, in the government setting, they are giving very good medications that are at par with the private setup. The combination of the first-line regimen is dolutegravir, emtricitabine, and tenofovir. The government has given us this combination, which we use in a private setup. I think that is a very good improvement that we are seeing in the HIV treatment program.
The people who cannot reach the government centers or do not want to be referred to the government setup because of the logistic issues or associated stigma come to the private sector. In the private sector, the biggest challenge is the cost. The second challenge is adherence. Because of the cost, people don't take medicines, which is why they suffer. Many who take medications do not adhere to medications regularly. So, they also go on to develop resistance. Cost and adherence are the two main challenges.
There are many NGOs in India that are actively involved in implementing specialized tests or diagnostic procedures and providing reimbursement for these tests as part of their initiatives to support individuals affected by HIV. Are you connected with any such NGOs, or do you refer your patients to such NGOs?
Dr. Jessani - Yes, for those patients who cannot afford it, we refer them to the NGOs, and they are taken care of by the NGOs. We treat patients in a private setting, and for those who can not afford it, we refer them to NGOs or the government sector.
A study which aimed to develop and validate machine learning models in predicting HIV infection among Men Who Have Sex with Men (MSM) were conducted in Zhejiang province, China from 2018 to 2020 and found that machine learning models are substantially better than conventional LR model.[4],[5]. How are Artificial Intelligence and Machine Learning being utilized to develop innovative approaches in HIV prevention, and what potential do these emerging technologies hold in effectively combating and ultimately eradicating the HIV-AIDS epidemic?
Dr. Jessani - Machine models are improving gradually, and artificial intelligence gives good results. If it is a simple case of HIV with no comorbidities or not many complications, the machine model can predict which medicines you should provide and monitor the side effects of the medicines. That will be much more useful in a government setup where many people are there, and you cannot give individualized attention to each patient. In those cases, artificial intelligence can help segregate the patients who require new treatment and differentiate them from treatment-experienced patients. It will reduce the burden of manpower and the number of doctors needed in the government setting.
Apart from this doctor, are there any other interesting or trends that you see in the treatment and management of HIV-AIDS?
Dr. Jessani - The treatment of HIV-AIDS is mainly the consumption of tablets and pills, but soon, we will come with injectable medications. Injectable medications must be given only once in three or once in six months. That is an attractive option because the adherence problem will be resolved. The patient must come to a clinic, take the injection, and come back again after six months directly. The pain of popping the pill every day will be gone. Adherence will be much better when these injectable agents are on the market.
What key message or information would you consider most essential when engaging with patients or addressing the public regarding HIV-AIDS?
Dr. Jessani - Suppose you have any undiagnosed illness, unexplained weight loss, loss of appetite, not doing well, getting repeated infections, and if your immunity is constantly low. In those cases, you should always consult a doctor and get tested for HIV. HIV tested earlier and diagnosed earlier is manageable with medications that are available now. The concept of HIV is very much like diabetes. In diabetes, a patient takes the medicine lifelong and lives a normal life, and it is the same with HIV. If you diagnose early, you can start treatment, and the patient can live a normal life. The message should be to detect early HIV, take the medicines, and have good adherence that can lead to a completely normal life.
Thank you so much for your time!
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