India wants to tackle AIDS by screening high-risk people at their doorsteps

Three out of every ten people infected with the Human Immunodeficiency Virus in India are not aware of their HIV positive status, according to an estimate by the National Aids Control Organisation, India’s HIV control body. In order to detect such hidden HIV cases, NACO has decided to roll out community HIV screening interventions, by which people who are at high risk of contracting HIV will be tested in their own homes or any location suitable to them.

“There is too much stigma associated with the disease and people don’t want to come to the ICTC [government HIV testing facility],” said Dr KS Sachdeva from NACO’s basic service division referring to the Integrated Counseling & Testing Centre that is the government’s HIV testing facility. “So, we have decided to go in the field.”

Sachdeva describes community HIV screening as India’s “game changer” intervention to end Acquired Immune Deficiency Syndrome by 2030. Union Health Minister JP Nadda claims that India is prepared to end the epidemic by 2030 on World Aids Day observed on December 1.

The problem of undetected HIV cases is not restricted to India. The World Health Organisation’s progress report says that 40% of the more than 14 million people with HIV worldwide are unaware of their status. Global HIV experts have, therefore, recommended increased and improved access to HIV testing. In fact, the World Health Organisation for the first time issued guidance of self-testing for HIV on December 1. Self-testing means that an individual can take a whole blood finger prick test that reveals if the person’s blood is reactive or non-reactive to HIV antibodies. A person whose report is reactive should go to a testing facility to confirm the HIV diagnosis with a more sophisticated test.

“By offering HIV self-testing, we can empower people to find out their own HIV status and also to notify their partners and encourage them to get tested as well,” Dr Gottfried Hirnschall, director of WHO’s department of HIV said in a statement.

The results generated by World Health Organisation’s approved kits for whole blood finger prick test have an accuracy about 99.7%. These kits are available online in developed countries but are not easily available in India.

India’s community testing program is going to use the same whole blood finger prick test but the test will be performed by NACO staff and not by the person getting tested. NACO officials feel that Indian society is not mature enough for adopting self-testing for HIV. “We are worried about self-harm,” said Sachdeva. “Pre- and post-testing counselling is integral to India’s HIV control programme.”

Self-testing versus community- testing

Sachdeva’s worries are echoed by state level officers who are busy readying a plan to implement the community testing initiative. “This is not a pregnancy test,” said Dr Vijay Hugar, joint director, of the Karnataka State Aids Control Society. “The result of such tests are far complicated and life-changing. Who will be responsible if people commit suicide after doing the self-test at home?”

Community testing will be offered to individuals who are classified as high-risk groups . State aids control societies along with non-profit partners will offer the finger-prick test to female sex workers, men having sex with men, transgender people and injection drug users. NACO guidelines suggest that these populations should be tested for HIV every six months.

However, Hugar said it is difficult to bring these high-risk people to government testing facilities regularly. “Now, we can just offer the test at any events organised by these communities,” he said. “So regular testing can be achieved. We just have to be cautious that unnecessary tests are not performed to achieve targets.”

According to Akhila Sivadas, executive director of the Centre for Advocacy and Research, the AIDS control programme will have to revitalise peer educators in the field for successful implementation of community testing. “These peer educators over the years have developed skills but 2011 onwards we are seeing a loss of momentum,” she said. “Only if this cadre is harnessed again, we can test those hidden cases. We very well know that there are many who will not walk into a center and say test me.”

Budget cuts in India’s aids control programme have led to the loss of many of these skilled workers. To implement community testing grassroot level workers need to identify and convince individuals from high risk groups to take the finger-prick test, officials from several states told Scroll.in.

“It is not about going to a brothel and testing,” said Sachdeva. “We are aiming at testing the female sex worker who is just like any other housewife. [Peer educators] have their own ways of finding individuals with high risk behavior and counseling them for testing.”

Dr Ajit Kumar Mishra, project director of the Odisha State Aids Control Society, said that community-testing is not an easy proposition. “Let me be honest and realistic, there is a lot of stigma around HIV irrespective of where you do the testing,” he said.

Breaking the HIV transmission cycle

Undetected HIV infections in the community enable the transmission of HIV in the community and the only way to reduce the number of new cases is to detect individuals who are unknowingly spreading the disease.

However, NACO is still not prepared to put all HIV-infected individuals on antiretroviral therapy as recommended by the World Health Organisation. Currently HIV-infected people with a CD4 T lynphocyte count of less than 500 units are started on the therapy. Apart from these cases, only pregnant women and children detected with HIV are put on treatment immediately after diagnosis. “We have still not reached a stage where we can provide treatment to everyone but that is on our agenda,” said a senior NACO official.

Screening of pregnant women and suspected TB patients

Less than 40% of pregnant women, who, if infected, are likely to pass the virus on to their unborn children, are tested for HIV infection. NACO officials said that under community testing the health worker in the village responsible for antenatal care could possibly perform the finger-prick test. “This will reasonably reduce the mother to child transmission of HIV,” said Sachdeva. “We are at a stage where we have to identify other modes of transmission which are contributing to new cases.”

Community screening will be extended to people suspected to have tuberculosis and those suffering from immunity compromising diseases like kala azar. “If a person has persistent cough, he will be screened for HIV,” said Sachdeva.

Besides finding hidden HIV cases, doctors are looking for improving testing, treatment and adherence to treatment and say policy makers should focus on these measures to if they really want avoid a resurgence of AIDS and end the disease in India by 2030.