India’s HIV fight has changed: Why ageing, diabetes and new hotspots are the next big challenge

Dr Sanjay Pujari, Director and Chief Consultant at the Institute of Infectious Diseases, Pune, will be speaking on clinical strategies for integrating HIV, tuberculosis (TB) and non-communicable diseases at the International AIDS Conference being held in Rio de Janeiro. He spoke to The Indian Express about India’s changing HIV landscape, the country’s role in the global response and the priorities for ending AIDS as a public health threat by 2030.

What is the current burden of HIV in the country, and what concerns you the most?

India’s HIV response has come a long way. By the end of 2023, an estimated 2.54 million people were living with HIV, with an adult prevalence of 0.20%. Over the past decade, we’ve seen encouraging progress; new HIV infections have fallen by 44.2% since 2010, while AIDS-related deaths have dropped by 79.2%. Today, around 1.8 million people receive free antiretroviral therapy (ART) through the national programme, with 94% treatment retention and 97% viral suppression, which is a significant public health achievement.

But success brings a new set of challenges. Because people with HIV are living longer, we’re now seeing more of them develop age-related conditions such as diabetes, hypertension and cardiovascular disease. The proportion of people living with HIV, who are over 50, has risen from 17% in 2000 to 37% in 2023, and is expected to cross 50% by 2030. This means our focus must shift from treating HIV alone to managing HIV alongside other chronic illnesses. Another area of concern is the emergence of HIV transmission hotspots in states such as Assam, Arunachal Pradesh, Tripura and Punjab, where infections are being driven largely by needle sharing among people who inject drugs.

What unique perspective does India bring to this year’s global HIV agenda?

India’s experience shows that a nationally owned and predominantly domestically-funded HIV programme can be both sustainable and resilient. At a time when many countries are grappling with shrinking international support, that is an important lesson for the global HIV community.

The second major contribution is India’s role as the pharmacy of the world for HIV medicines. Nearly 80% of the antiretroviral drugs used globally are manufactured by Indian pharmaceutical companies. As discussions increasingly turn to equitable access to treatment and newer prevention tools, India’s manufacturing capacity becomes even more critical. The same is likely to hold true for innovations such as long-acting injectable prevention medicines like lenacapavir.

How is India incorporating newer HIV prevention strategies, such as long-acting PrEP (pre-exposure prophylaxis) into its public health programme?

India already has national guidelines for pre-exposure prophylaxis (PrEP) but access to these medicines has not yet been expanded as part of a large-scale public health programme.

One of the most exciting developments in HIV prevention is lenacapavir, a long-acting injectable that offers protection with just one injection every six months. It has not yet been approved by Indian regulators because additional country-specific safety and efficacy data are needed. However, Gilead Sciences has already signed voluntary, royalty-free licensing agreements with four Indian generic manufacturers. Once regulatory approval is granted, lenacapavir could become a valuable addition to India’s HIV prevention strategy.

Does stigma and discrimination continue to affect people living with HIV?

The situation has improved considerably over the years, but stigma has certainly not disappeared. Many people living with HIV continue to struggle with internalised stigma, which calls for sustained counselling and psychosocial support. At the same time, discrimination still exists within families, communities and, unfortunately, even in some healthcare settings.

Health insurance is one area where significant gaps remain. People living with HIV are often denied adequate insurance coverage despite advances in treatment that allow them to lead long and productive lives.

India has an important legal safeguard in the HIV and AIDS (Prevention and Control) Act, 2017, which prohibits discrimination in employment, healthcare, education and other areas. The challenge now is ensuring that these protections translate into meaningful change on the ground.

Looking ahead to 2030, what do you see as the biggest opportunity—and the biggest challenge—in ending HIV as a public health threat in India?

As people living with HIV age, healthcare must evolve with their needs. We need models that integrate HIV care with the management of diabetes, cardiovascular disease and other chronic conditions. While there have been examples of programme-level integration, the next step is to develop standardised clinical pathways so that care is organised around the individual rather than around separate diseases.

The biggest opportunity lies in India’s generic pharmaceutical industry, which is well placed to shape the future of the global HIV response by making both affordable treatment and long-acting preventive medicines more widely available. At the same time, if India is to achieve its goal of ending AIDS as a public health threat by 2030, it will need to sharpen its focus on prevention and treatment in the geographic hotspots where HIV prevalence remains higher than the national average.

As international HIV funding becomes more constrained, how should India adapt its HIV response?

Fortunately, India is less vulnerable to international funding cuts than many other countries. According to UNAIDS, we have relatively low dependence on PEPFAR funding and are grouped with countries such as South Africa, Thailand and Brazil.

That doesn’t mean funding reductions will have no impact. Community-based organisations and research projects supported by the US government and the National Institutes of Health (NIH) could face disruptions, which may affect some services and ongoing research. However, the national HIV programme itself is built largely on domestic funding, making it far more resilient to these global financial shifts.