Confronting inequalities to tackle AIDS during COVID-19 pandemic. Lessons from World Bank investment in India

After nearly four decades of tremendous efforts and advancements, new HIV infections have been driven down to the lowest level ever. However, recent data show that the pace of progress has slowed down and HIV remains a major global health threat. To date, HIV has claimed nearly 37 million lives and another 38 million people are currently living with HIV (PLHIV). (2021 Global AIDS update)

While landmark biomedical and scientific research advances have led to many successful HIV treatment and prevention strategies, not everyone is benefiting equally from them, with new infections highly concentrated among key and vulnerable groups.

Of the 1.5 million new HIV infections in 2020, a majority (67%) were among key populations (men who have sex with men, sex workers, and people who inject drugs) and their sexual partners (2021 Global AIDS update). Key populations continue to be marginalized and are largely not reached by HIV services in most countries.

To end HIV and AIDS as a public health threat by 2030 and reach the global 95–95–95 targets set by UNAIDS (95% of PLHIV will know their HIV status; 95% of those diagnosed will receive antiretroviral therapy (ART); 95% of those on ART will have viral suppression), tackling social and structural factors contributing to HIV disparities, and ensuring everyone has equal access to HIV prevention, care and treatment services are critical. It is also the theme of 2021 World AIDS Day: “End inequalities. End AIDS. End pandemics”.

Impact of COVID-19

The pandemic has not only disrupted HIV services, but has also widened social and economic inequalities, making marginalized groups more susceptible to HIV infection and less likely to access HIV services.

• First, PLHIV are more vulnerable to COVID-19 – their risk of dying from COVID-19 was two times that of the general population.
• Second, PLHIV are less likely to have access to health services, including COVID-19 vaccines. To date, fewer than 5% of PLHIV in sub-Saharan Africa have received at least one dose of a COVID-19 vaccine.
• Third, COVID-19 related lockdowns have severely disrupted HIV services in many countries, especially developing countries.

A study by the Global Fund found that over 40% of HIV testing services were disrupted globally, which has led to steep drops in HIV diagnoses, referrals to care and HIV treatment initiations. A UNAIDS modeling analysis showed that a six-month 50% disruption in HIV treatment could bring us back to 2011 AIDS-related mortality levels. Furthermore, a collapse in revenues caused by the economic downturn has constrained abilities of many poor countries to sufficiently finance essential health services, including HIV. To maintain HIV response during the COVID-19 pandemic, the world needs to substantially increase investments in the responses to both HIV and COVID-19 while ensuring they are inclusive, equitable, accessible, and rights-based. This is critical for reaching the marginalized populations that are still left out in the global response to HIV and AIDS.

Lessons learned from two decades of World Bank’s HIV investment in India

Despite a low HIV prevalence in the general population (0.22%), India has the world’s third largest HIV epidemic (after South Africa and Nigeria) with some 2.4 million Indians living with HIV. The Indian HIV epidemic is concentrated among the key populations and marginalized groups. The World Bank has invested and supported India’s national program for over two decades with IDA credits of USD 807 million (NACP I, II, III and IV) focusing on targeted preventions (TIs) among these groups. The World Bank brought global experience to the program and helped showcase the best practices of the India program to other countries across the globe. During the implementation of the phased NACP, a vast amount of data, some released in July 2020, showed that new HIV infections declined by 37% from 2010 levels and by 86% from the peak of the epidemic in 1997. Also, AIDS-related deaths have declined steadily by 66% from 2004 to 2019. Evaluations of the World Bank supported National AIDS Control Support Project showed the targeted interventions (TIs) were cost-effective and the unit costs to reach the project’s targeted populations were about three times lower than global reference prices.

Innovative service models pioneered by the HIV response in India are critical in ending inequalities and HIV disparities, especially during COVID-19 pandemic.

India’s HIV program was one of the largest in the world and considered a success story. Notable lessons learned include:

1. Putting the marginalized at the center of the response. The core principle of the program – “health and human rights”, protects and empowers the marginalized communities. The key populations were involved in implementation planning, mapping, peer-based outreach and advocacy around targeted interventions. This has empowered them to take on issues beyond HIV and AIDS, including COVID-19. Key populations were brought onboard in many State AIDS Control Units, strategy meetings, and the implementation review and consultation process. These models help penetrate services to the underserved communities, tailor to their needs, and courageously and consistently advocate for the removal of legal and policy barriers, such as punitive laws.
2. Expanding home and community-based delivery of HIV prevention, testing and treatment services and promoting differentiated models of care.  These models help deliver services to the underserved communities and tailor them to their needs. Approaches like these are used in all strategies that aim to end inequalities by reaching those that are left furthest behind and have been vital to maintain essential health services during the COVID-19 lockdowns. For instance, the National AIDS Control Organization (NACO) took advantage of the community-based ART centers created during NACP-IV and revised its policy expanding multi-month dosing prescriptions. PLHIV can receive ARV drugs at these centers or at home for up to 3 months.
3. Accelerating the use of digital technologies such as major social medial platforms (WhatsApp, online messengers, chatbot, text messaging, etc.) to reach the hidden, underserved communities with COVID-19, HIV, and other health services. PLHIV who missed appointments can receive a text message with a reminder and a helpline number to call if they need services. Additionally, the national phone helpline established under NACP-IV served millions of Indians during the COVID-19 pandemic.

The theme of this year’s World AIDS Day is extremely timely. Forty years of fighting against HIV have taught us that we cannot defeat the pandemic, especially in the midst of another global pandemic, unless we bring down inequalities and promote people-centered, rights-based approaches while continuously innovating.