Study: With obstacles to services for men who have sex with men and people who inject drugs, diagnosis is first pitfall to HIV care in India

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Consider the gains India, home to the third largest number of people living with HIV in the world, has made against HIV in the last 10 years. With rates of HIV among women getting prenatal care dropping by 50 percent in that time, the UNAIDS 90-90-90 goal  for 2020 — 90 percent of people with HIV to know they have the virus, 90 percent of those to receive sustained antiretroviral treatment, and treatment suppressing the virus to undetectable levels in 90 percent of those in the next five years — could seem attainable.

Then consider recent findings from a study across 26 Indian cities that nearly one out of 10 men who have sex with men surveyed was living with HIV, just about 30 percent had been diagnosed, 16 percent were receiving antiretroviral treatment, and 10 percent had suppressed viral loads. The same study found that nearly one of five people who inject drugs surveyed had the virus that leads to AIDS, that just 41 percent were diagnosed, 20 percent were receiving antiretroviral treatment, and 15 percent had suppressed viral loads.

The major first obstacle to HIV care, the study found, was the lack of access those surveyed had to basic services that could link them to being tested for the virus. Both populations are criminalized in India, which, researchers noted, drives them into hiding, and discourages them from seeking routine health care. Nearly half of the men who have sex with men, and nearly two thirds of the people who inject drugs who were undiagnosed had never been tested for HIV, mainly because they did not perceive that they were at high risk for infection, and because they didn’t know where to go. At the same time, researchers noted, of those diagnosed and receiving antiretroviral treatment, 78 percent of men who have sex with men and 83 percent of people who inject drugs in the study had suppressed viral loads, numbers comparable to those found in India’s general population, and in high income settings. That indicates, the authors of the study write, that with improved access to diagnosis, men who have sex with men and people who inject drugs could remain in treatment in sufficient numbers to edge much closer to the levels UNAIDS has asserted, if reached by 2020, could end HIV as a global health threat in the next 15 years.

In 2009 a high court in India ended the country’s criminalization of same-sex relationships, but in 2013 the nation’s Supreme Court reinstated the ban. India’s National AIDS Control Organization has called the law a “serious impediment” to the nation’s efforts to fight HIV, and leadership of the International AIDS Society wrote to India’s president in the aftermath of the reinstatement, citing extensive evidence that anti-gay laws and practices hinder HIV responses, and urging him to lead an effort to eliminate the law.

The study surveyed more than 12,000 men who have sex with men and more than 14,000 people who inject drugs between 2012 and 2013. The findings recently published in Clinical Infectious Diseases provide one of the first looks across multiple sites of the continuum of HIV care for these marginalized populations in any resource limited setting, according to the report.

The study was led by Shruti Mehta of Johns Hopkins University’s Bloomberg School of Public Health and carried out by researchers from India’s National AIDS Control Organization in New Delhi, the Y.R. Gaitonde Centre for AIDS Research and Education in Chennai, India, and from Johns Hopkins University’s Bloomberg School of Public Health and School of Medicine.

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