How International Patients can get Antiretroviral Therapy Services in India

Antiretroviral therapy

ART is the current therapy program of HIV (Human Immunodeficiency Virus) infection. It consists of a combination of medicines to control the virus and reduce illness and prevent transmission.

Important Points regarding ART

• Objective: Reduce the viral load of HIV so it is invisible and enhance the immune system (CD4 count) and improve the quality of life.
• Start time: All people living with HIV should consider initiated on a case-by-case basis.
• Effectiveness: ART may render HIV undetectable, that is, it is no longer sexually transmissible (Undetectable = Untransmittable, U=U).
• Life Long Treatment: HIV does not get cured by ART but it is kept in check.

Categories of Antiretroviral drugs:

NRTIs (Nucleotide reverse transcriptase Inhibitors):

• Tenofovir, Zidovudine, Lamivudine
• Mechanism of action: Block reverse transcriptase inhibition: destruction of viral DNA synthesis.

NNRTIs (Non-Nucleoside Reverse Transcriptase Inhibitors):

• Efavirenz, Nevirapine
• Nature: Directly binds to reverse transcriptase and inhibits it.

PIs (Protease Inhibitors):

• Atazanavir, Lopinavir, Ritonavir
• Use: Eliminate the ability of viral proteins to be cleaved into functional components.

INSTIs (Integrase Strand Transfer Inhibitors):

• Dolutegravir, Raltegravir
• Function: Block integrase, which is an enzyme, HIV uses to insert the DNA into the human cells.

Entry/Fusion Inhibitors

• Enfuvirtide, Maraviroc
• Active: Antiviral

Antiretroviral therapy services in India

This is a brief description of Antiretroviral Therapy (ART) in India including those provided by governments and outreaches as well as community based services:

Nationwide ART Care

These services entail diagnosis, counselling, provision of drugs, CD4 and viral load testings and provision of support to prevent infection in opportunistic infections.

The network comprises:

• Centres (in hospitals predominantly in district medical colleges)
• Increase in Link ART Centres(LACs) (nearer to patients, minimizing travel burdens)
• Plus Centres (increased services with second-line ART)
• Centres of Excellence (training, mentorship, second-line treatment, and knowledge centres)

In India, as of 2023 there were:

• ~700 ART Centres
• ~1,264 Link ART Centres

Treatment outcomes:

• Boosted by Accelerated CGI: Information and update: 82 percent of the PLHIV are aware of their status.
• 72 per cent of them are on ART
• Over Since 68% are able to reach viral suppression
• In the current version of NACP-V (20212026), India aims at the consequential 95-9 in-9 in-years by targeting 2025:
• 95% diagnosed
• Conversion to ART: 95 percent of the diagnosed patients in the process of ART sustainability
• 95 percent of the virally suppressed

Some of the State-level implementations have been highlighted as follows:

• Also includes FI-ART Centres-combined facilities that allow easier access to care

NGO-supported and community-based ART services

• Opened a community-based integrated ART clinic designed with the specifics of LGBTQ+ in mind, including diagnosis, counselling and treatment services, in a single location.
• Allows users to gain anonymous access to HIV testing and refers them to ART centres through online and WhatsApp-based virtual support.

Best hospitals for antiretroviral therapy in India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Factors Affecting Affordable antiretroviral therapy in India

In the following, there is a systematic analysis of the determinants influencing low priced Antiretroviral Therapy (ART) in India:

Generic Production & Drug Manufacturing

• India serves as an international centre of generic antiretrovirals (ARVs) medicines. 
• The flexibility of the TRIPS (WTO) in terms of generic licensing and letting patents expire also keeps the cost lower than standard medicines.
• Nonetheless, more recent ARVs (e.g. Dolutegravir-based regimens) can initially be more expensive before local production can reach volume.

Accessibility and Infrastructure Healthcare

• ART centres at the district level will ensure that patients access drugs at no cost, but travelling expenses may create a bottleneck to patients in their remote/rural locations.
• The limited number of ART centres close to each other makes patients to incur the extra cost of seeking alternative sources of ART treatment, especially in the cases where private care has to be used.
• Expansion of Link ART Centres (LACs) lowers down indirect cost of patients.

Treatment in the Private and Public Sector

• Free medicines, counselling, diagnostics, centres in the public interest.
• Private hospitals/clinics: expedited treatment and confidentiality, but out-of-pocket expenditure (consultation, medicines under brands, Laboratory services).
• There are patients who value discreteness at the expense of free government services

Drug resistance 

• Initial ART (TDF + 3TC + DTG), is inexpensive and multinational.
• The use of ART (in second-line treatment and third-line treatment with protease inhibitors or new integrase inhibitors) is more costly as there are not enough generic alternatives of the medicines.
• Resistive patients also incur more expenditure in treatment.

Therapeutic & Diagnostic & Monitoring Costs

• Frequent tests of CD4 cells and viral load are necessary.

Top doctors for HIV treatment in India

• Dr. Ashish Kumar Mittal
• Dr. Vikas Deswal
• Dr. Akanksha Rastogi

Advanced antiretroviral treatment in India

Advanced Antiretroviral Therapy (ART) -traditionally defined as second-line, third-line and other newer type of HIV drugs beyond the common first-line regimen.

Evolved Antiviral Therapy

When Special ART is required?

• Virologic or Clinical treatment failure on 1st line ART
• A non-adherence to treatment that has resulted in the rising viral load (HIV RNA >1000 copies/mL by the end of 6 months of treatment).
• Rapid decline in- Questionnaire falls in CD4 count or clinical worsening
• Drug Resistance (mutations of HIV which makes the first line drugs worthless)
• Intolerability or Serious Adverse Effects of first line drugs

Second line ART Regimens:

• Usually used when initial regimen do not work.
• India (NACO guidelines) recommends:
• BoostedProtease Inhibitor (PI/r) + 2 NRTIs

Example:

• Atazanavir / Ritonavir (ATV/r) or Lopinavir / ritonavir (LPV/r)
• AZT+3TC OR TDF+3TC
• Two-line is costly as compared to one-line.

Third-Line ART Regimens:

• To patients who respond inadequately to a first- and second-line treatment.

They normally use newer generation drugs:

• Darunavir/ritonavir (DRV/r) has a high genetic barrier PI
• Dolutegravir (DTG) or Raltegravir (RAL) - integrase inhibitors
• Optimized NRTI backbone based on the resistance profile
• Becomes necessary prior to initiation of resistance testing: genotypic

Newer / advanced drug classes

• INSTIs (Integrage Strand Transfer inhibitors)
• Dolutegravir (DTG) - which is now a part of first-line therapy around the world
• Bictegravir (BIC) is currently marketed in single-tablet regimens abroad
• Cabotegravir (CAB) - also indication for prevention (PrEP)

Entry/fusion Inhibitors

• CCR5 (CCR5 antagonist): maraviroc
• Enfuvirtide (fusion inhibitor, injectable)
• New Advances of the Long-Acting Injectable ART (New Advances)
• Cabotegravir + Rilpivirine (CAB-LA/RPV-LA) - monthly or two-months injection (approved in the US/EU with trials/limited rollout in India)
• bNAbs- in research stage to resistant HIV

ART in India

Private Sector:

• Newer medications such as Darunavir, Bictegravir, Cabotegravir injections have a potential of being available but expensive.
• The regimen consisting of darunavir + ritonavir can.

Issues in Advanced ART

• Expensive third-line/novel drugs.
• Newer drug (cabotegravir, bictegravir) availability limited in the public sector.
• Increased necessities of adherence support- as advanced ART have fewer options in case of resistance building.

Side Effects:

• PIs → metabolic issues, GI disturbances
• INSTIs → insomnia, weight gain (esp. Dolutegravir, Bictegravir)

Factors Affecting Antiretroviral therapy cost in India

This is how the various influencing factors on the cost of Antiretroviral Therapy (ART) in India look in a tabular form:

Type of ART Regimen

• First-line: most affordable, as well as most accessible.
• Second-line ART: more expensive because of protease inhibitors.
• Third-line ART (Darunavir/r, Raltegravir, Dolutegravir combinations) → very costly, when purchased privately.
• The greater the sophistication of the treatment line, the greater the price.

Branded Drugs vs. Generic Drugs

• India is a large manufacturer of generic ARVs (Cipla, Hetero, Mylan, Emcure).
• Generics are 70-90% cheaper as compared with branded foreign versions.
• The image drugs (or imported drugs, such as Bictegravir-based regimens) are much more expensive in the private sector.

Private Sector

• Private hospitals/clinics: Patients pay to see a doctor, brand-name drugs and lab analyses. The expenses incurred can be in thousands per month
• This is determined by the affordability of patients on either a public or a privatized healthcare.

Drug Resistance & Line Switch

• Resistance to first-line drugs develops in patients, translating into expenditure on second/third-line ART that is significantly more expensive.
• Resistance testing (genotypic testing) is cost-adding by itself, unless done by a national health care system.

Diagnosis & Surveillance costs

• CD4 count/ viral loads testing is mandatory in CD4

In home lab:

• Frequent testing in addition to the treatment adds to costs to the treatment not integrated into the public programmes.

Medication accessibility & supply chains

• Rural/remote locations could have no access to ART centres making it more expensive to travel or have to purchase it privately.

New and Reduced Therapies

• Long-acting injections (Cabotegravir + Rilpivirine) and newer integrase inhibitor (Bictegravir) are used in some countries which are expensive imports in India.
• Low quantity leads to high prices being charged to those patients that require them.

Access and Healthcare Infrastructure

• The multiple ART centres make patients in metros access their treatment cheaply.
• Having to travel, pay accommodation, and loss of wages increases the cost of ART indirectly to the rural patients.

Antiretroviral therapy in India by GetWellGo

GetWellGo is regarded as a leading supplier of healthcare services. We help our foreign clients choose the best treatment locations that suit their needs both financially and medically.

We offer:

• Complete transparency
• Fair costs.
• 24 hour availability.
• Medical E-visas
• Online consultation from recognized Indian experts.
• Assistance in selecting India's top hospitals for Antiretroviral therapy.
• Expert doctor with a strong track record of success
• Assistance during and after the course of treatment.
• Language Support
• Travel and Accommodation Services
• Case manager assigned to every patient to provide seamless support in and out of the hospital like appointment booking
• Local SIM Cards
• Currency Exchange
• Arranging Patient’s local food