Criminalisation of gays barrier to HIV response: Lewin
Ensuring long-term antiretroviral therapy for people living with HIV is a challenge that India's healthcare system needs to overcome, says American infectious diseases expert Sharon Lewin, co-chair of the International AIDS Conference to be held in Melbourne, Australia in July 2014.
doi:10.1038/nindia.2014.58 Published online 25 April 2014
Q. What makes you confident of a HIV cure in near future?
A. First, that cure is possible — the Berlin patient , the Mississippi baby and the VISCONTI patients — all tell us that cure is indeed possible. Second, the fact that latency can be reversed at least to a small extent, using drugs such as histone deacetylase inhibitors is encouraging that HIV latency is not a fixed and irreversible state. Finally, progress in ways to boost immunity, including molecules such as anti-PD1 and anti-PDL1, may all form part of a cure strategy.
Q. What are the key issues facing India in the fight against HIV?
A. Stigma and discrimination is a huge issue as it limits the capacity for affected communities to learn about prevention, testing and treatment. Criminalisation of men who have sex with men is also a major barrier to the HIV response. Finally getting testing, care and treatment to key affected populations who are often marginalised in India and Asia is a major issue.
Q. You interacted closely with the transgender community during a recent trip to India. What are your observations on their fight with HIV?
A. Transgender women have been part of the Indian society for centuries and live as separate tight knit communities. Although they are marginalised and few remain in contact with their biological families, they are believed to bring luck to newborns and newlyweds.
There are 5-6 large "clans" of transgender women in Mumbai and many are now sex workers. The prevalence of HIV in these communities is close to 40% which is extraordinarily high. Although there is widespread access to condoms in these brothels, ongoing infection continues.
Q. What is India's contribution towards the global search for a cure?
A. Few low income countries have become involved in this effort, other than Thailand so far but I believe India has a lot to offer. There are excellent institutes such as the National AIDS Research Institute (NARI) that are well placed to take a lead here. The cure research area is emerging and I am hopeful we will have strategies in place soon to engage countries such as India.
Q. Which are the "last reservoirs" of HIV?
A. We are still very focused on the major reservoirs currently, which are long lived infected T-cells. There may even be sub populations of T-cells that have additional challenges, particularly cells such as stem cells and naïve cell that undergo homeostatic proliferation. These T-cell reservoirs need to remain a high priority but we can't forget about other important reservoirs such as tissues and non T-cell reservoirs.
Q. Are antiretrovirals a good option for resource poor countries?
A. Long term antiretroviral therapy is highly effective and life expectancy is now normal in people who initiate antiretroviral therapy at the right time. In addition, antiretroviral therapy reduces a person's infectiousness. So it is central to the HIV response for every country.
With cheap generic drugs, low toxicity, simple regimens and very little drug resistance, ART is undoubtedly one of the most effective health investments. There are 10 million people on ART in low income countries. So I strongly believe this is feasible.
The big challenges are keeping people living with HIV in long term care with continuous access to ART for often over 40 years. This requires much more than just access to medicines and will require significant strengthening of the health system.
Q. How do you rate India's fight against HIV in the global context?
A. There are many successes in India including access to ART and testing. However only 50% of people who need treatment are on it and there are still 10,000 babies born each year with HIV. These are ongoing challenges for India and need to be addressed.
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- Persaud, D. et al. Absence of detectable HIV-1 viremia after treatment cessation in an infant. New Eng. J. Med. 369, 1828-1835 (2013)
- Sáez-Cirión, A. et al. Post-treatment HIV-1 controllers with a long-term virological remission after the interruption of early initiated antiretroviral therapy ANRS VISCONTI study. PloS Pathog. (2013) doi: 10.1371/journal.ppat.1003211