Thu Nov 28 2013, 05:25 hrs
Dr R S Paranjape
As World AIDS Day (December 1) draws near, Dr R S Paranjape, Director of National AIDS Research Institute, during an interaction with The Indian Express at an Idea Exchange programme, speaks on a range of issues — from the hunt for an HIV vaccine and containing fresh infections to new collaborations for better drugs.
Anuradha Mascarenhas: What is the reason for the decline in new HIV infections?
India has shown decline in new infections by more than 50 per cent in the last 10 years. The prominent reason is a largely successful targetted intervention programme by the Centre and a sustained information, education and communication campaign. The focus on promoting use of condom and providing interventions in high-risk groups like commercial sex workers and men having sex with men is also a reason that has led to the decline. The prevalence of HIV infection has been declining every year thanks to these efforts. A majority of the people are on anti-retroviral therapy (ART); they will continue to remain infected but will arrest the transmission of the virus.
Manoj More: How big was the epidemic ten years ago and who played a major role in bringing about this decline?
Ten years ago, 2.7 million people were estimated to have been infected with HIV. Over the years, the decline in new infections has been effected due to efforts made by the National AIDS Control Organisation. There is no vaccine or microbicide but sustained use of condoms and behavioural changes were among the key factors that led to the decline. NGOs also played a huge role.
Anuradha Mascarenhas: International agencies had funded the AIDS control programme. Now, with the decline in cases, have the funds dried up?
You will be surprised to know that in the 12th Five Year Plan, the Department of AIDS Control has provided tremendous funding for the programme. A majority of the HIV prevention programmes were funded by international agencies, but the government has now allocated a huge amount.
Geeta Nair: Has the change in funding pattern led to drug stock-outs?
India is a big country. With so many ART centres and different channels to procure funds, it is likely that there will be procedural issues. We may have an occasional stock-out but reaching out to 6.5 lakh to provide free ART is a huge task. Of course, stock-outs should not happen and a week ago we did fear one at our ART centre at Model Colony. But it just took a couple of calls and NACO immediately sent the supply.
Nisha Nambiar: What was the reason for calling off the trial on humans for developing a vaccine?
First of all, the trial was not called off. The recent HIV vaccine trial tested ADVAX — a DNA-based vaccine as the prime and a vector, Modified Vaccinia Ankara (MVA), as the boost. They were found to be safe but in spite of several efforts we were not able to ensure stability of the vaccine or in other words found that the vector was genetically unstable.
Anuradha Mascarenhas: A vaccine against HIV still remains elusive. Why?
HIV is a complicated virus. There is no clear-cut co-relate of protection. For instance, in any other medical condition, like say tetanus, once the vaccine is injected, it stimulates the body to make antibodies against the tetanus toxin and these protect one from illness. Again, there are ethical issues related to animal testing. The testing for HIV vaccine can be done only in monkeys and there are issues like availability that have to be dealt with. Also, the virus mutates or changes very fast. The vaccine has to be developed against a wide variety of HIV strains. However, there is progress made on identifying a portion of the HIV common to various strains. Neutralising antibodies have shown potential in the treatment of retroviral infections. This can neutralise the HIV strain. The second step is also to develop immunogens.
Manoj More: How much time will it take?
Hopefully, we will see a new generation of vaccines to be tested in the next two to three years. However, this is a complex virus and it will take long time from the time it is taken for testing vaccine candidates to obtaining licences and so on. We are hopeful, though.
Sushant Kulkarni: Truck drivers and commercial sex workers are known to be high-risk groups. Have you identified any more? And which are the specific areas in India where HIV prevalence is high?
Luckily, there are no new high-risk groups. Of concern is the migrant population that is always on the move. The prevalence of HIV is also not as high in truck drivers as it was earlier. Among the areas that have high HIV prevalence include Andhra Pradesh, Karnataka, Maharashtra and Manipur. Tamil Nadu is no longer among the high prevalence states. Injecting drug use has been the driver of the epidemic in Manipur while in the other states is it commercial sex that has driven the HIV epidemic. There are, however, increasing reports of injecting drug use in Punjab and parts of Maharashtra.
Partha Sarathi Biswas: How is NARI collaborating with world class institutes on HIV-related research. What role does NARI play in HIV prevention programmes in Third World countries?
One of our major partners in the USA is National Institutes of Health and among other collaborations include Yale University, Duke University and Vanderbilt University. A neuro-AIDS programme with a California-based university was a huge success. Presently, we have tied up with Melbourne University and also plans are under way on an Indo-French project. With South Africa too, there is a programme to assess different responses to control HIV. We have not directly collaborated with Third World countries, but helped Bhutan set up a laboratory for HIV drug resistance, sent teams for training people in Sri Lanka and also helped in a project for proficiency drug resistance for CD 4 testing estimation in Thailand.
Ardhra Nair: When should treatment for HIV start?
I am proud to say that our study on HIV discordant couples (where one person is HIV positive while the partner is not infected) had a role to play in WHO recommending new guidelines for treatment in June this year. In our study, we initiated treatment when the person had a CD 4 count between 350 and 500 as against 250 and followed the participants for a specific period. We found that at least 96 per cent of the partners were protected who had received ART. If treatment is started early, there is an advantage in protecting people from transmitting the virus and arresting the progression of the disease. WHO has recommended that any HIV positive person with a CD 4 count of 500 or less should be immediately put on treatment. We are optimistic that the government will implement these recommendations.
Sushant Kulkarni: What is the co-relation of HIV prevalence in urban vis-a-vis rural areas?
There is not much data from rural areas. However, there is not much difference in the HIV-prevalence rates. As you know, there is more than 60 per cent urbanisation in Maharashtra and in general there is a lot of mobility between urban and rural areas.
Joyce William John: Have HIV/AIDS helplines helped? The stigma still persists.
I will not be able to comment on helplines as there has been no study to assess their impact. Stigma does persist but it has gone down. NARI has started a rural unit at Karad and the feedback we get is surprising. For instance, there is a provision of concessional travel for HIV positive persons and we were pleasantly surprised that they readily availed of the government facility.
Nisha Nambiar: What is the percentage of decline of HIV in mothers and babies?
A single dose of Nevirapine has led to a 50 per cent decline. This single drug regimen has now been replaced with a multi-drug one. The bigger challenge, however, is to reach out to pregnant women and bring them under the mother-to-child prevention of HIV transmission programme.
Geeta Nair: Has there been a major change in treatment protocol and how do you reach out to more pregnant women?
One major change was the phasing out of the drug, Stavudine, and introducing Tenofovir. Drug resistance has not gone up and these regimens are effective in treating HIV. We will have to focus on IEC campaigns and inter-sectoral coordination to include more pregnant women in the programme.
Anuradha Mascarenhas: Do HIV positive persons follow treatment properly?
By and large, yes. The government has set up several ART centres to ensure that issues like access to treatment is taken care of.
Nanda Kasbe Dabhole: How effective is alternative medicine like homoeopathy or Ayurveda in treating HIV?
There are unconfirmed reports, so it is difficult to comment. However, drugs that are used have been tested on humans and then marketed. Not many trials are undertaken with alternative medicine and there is need for more research.
Nisha Nambiar: What happens to volunteers who are part of any vaccine trial?
As per the protocol, the volunteers are looked after during the trial. Anyone who has participated in the trial is encouraged to come to NARI for follow-ups.
Anuradha Mascarenhas: Have there been any serious adverse events in the trials and what is the compensation given to participants?
Fortunately, there have been no major serious adverse events. Reports are sent to the Drug Controller General of India. We take care of the participants during the trial period. All projects are cleared by ethical committees and travel reimbursement is provided. After the SC ruling, we have been working out ways to develop a mechanism to pay compensation.
(Transcribed by Anuradha Mascarenhas)
