India’s National AIDS Control Organization (NACO) provides free antiretroviral therapy (ART) to people living with HIV, including key populations, through public centres. Before COVID-19, all people living with HIV generally received 30 days of ART, and people considered “stable” on treatment were eligible for multi-month dispensing (MMD).
In response to COVID-19, NACO made three-month dispensing available for all people living with HIV, regardless of whether or not they were established on treatment. Other policy adaptions included expanding home- and community-based delivery of ART (rather than facility pick-up), allowing ART pick-up from any public ART centre (rather than only the centre where clients are registered), and issuing multi-day doses (5-7 days) of opioid agonist therapy (instead of daily doses).
We spoke with Subash Ghosh, the Project Lead for ACCELERATE, a PEPFAR- and USAID-supported programme at the Y.R. Gaitonde Center for AIDS Research and Education (YRG CARE), and Rose Pollard, a Program Officer at the Johns Hopkins University School of Medicine, to learn more about HIV service delivery for key populations in India and adaptations made due to COVID-19.
What do you want people to know about DSD for HIV treatment in India?
SG: NACO is currently considering the transition to dolutegravir across its treatment programme for adults, which may have an impact on the HIV treatment policy. MMD for all people living with HIV has been employed only in response to COVID-19, not necessarily as long-term policy. The national policy outlining DSD guidance for HIV treatment in India recommends MMD for “stable” clients only. These services are provided through the network of ART centres and referral sites called Link ART Centres.
Subash, from your experience at YRG CARE, what are the key lessons learned from COVID-19 adaptations to service delivery, such as MMD and community distribution?
SG: We saw that expanded MMD and community distribution of ART during COVID-19 supported people living with HIV to continue their treatment irrespective of their viral load status and access to virtual counselling. These adaptations especially helped those in COVID-19 containment zones where movement was severely restricted; special permissions from government authorities facilitated home delivery of ART. In some cases, people living with HIV were concerned about unintentional disclosure, so they preferred to pick up ART from a convenient location away from their home in coordination with outreach teams at YRG CARE. Many people living with HIV felt that it would be beneficial to maintain MMD and community distribution as these options reduce transportation costs, time taken off work and resulting loss of wages, and exposure to COVID-19 at hospitals. For children living with HIV, community distribution of ART and MMD also helped ensure ART adherence through the pandemic and supported favourable treatment outcomes.
Rose, based on your assessment of client experiences during COVID-19, presented at the 11th IAS Conference on HIV Science, which model did clients from key populations prefer and why?
RP: Key populations in our focus groups appreciated both MMD and home delivery of ART as it made medication accessible and treatment adherence possible without exposing themselves to SARS-CoV-2. However, there were different perspectives about both options. Some individuals had confidentiality concerns about storing more pills at home or having someone show up at home with medications, fearing suspicion from neighbours or family members. Others valued the ease of having refills delivered directly to them at home.
What are the next steps needed to better understand and adapt HIV service delivery to client needs and preferences?
RP: Participants’ varied perspectives necessitate further assessment to understand trends in service preferences among key population groups, including people who inject drugs (who were not represented in our discussions), and variations across Indian geographies. Our focus groups also highlighted how key populations want access to services beyond HIV care as the pandemic aggravated many challenges to socioeconomic stability. These include food and nutrition support, mental health counselling and services for other health concerns. Comprehensive models that address health holistically are urgently needed. We are in the process of developing frameworks and implementing comprehensive models that address physical, mental and social well-being for key populations in India.
Subash, which of the adaptations made to HIV treatment delivery due to COVID-19 are likely to be kept in place even after the pandemic?
SG: It is hard to comment now on what will remain as these strategies need extensive supply chain monitoring. During public health crises, the immediate focus is to ensure service continuity. However, it does seem likely that with the transition to dolutegravir, MMD for all people living with HIV might be maintained post-pandemic. Further, home- or community-based dispensation of ART and expansion of ART pick-up sites have been helpful during COVID-19, especially among key population members, and are likely to be kept in place. People living with HIV would benefit from continued expansion of ART pick-up sites to include more convenient locations with accessible hours.