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Recent Advances in HIV Therapy

May 25 | 1:30 PM

The care of the human immunodeficiency virus (HIV)-infected patient has changed dramatically in the last few years. Potent new antiretroviral drugs combined with updated treatment strategies have now achieved efficient inhibition of HIV replication in most patients. Classes of drugs include both nucleoside and non-nucleoside inhibitors of the viral enzyme reverse transcriptase (RT) and inhibitors of the viral protease and integrase enzymes. As yet immune-based therapies have had little, if any, impact. However, it is clear that the eradication of HIV is not achievable with existing anti-HIV drugs and in spite of the major advances there remains many challenges in the clinical management of HIV-infected individuals. Join us live with Dr. Gilada to understand some important advances in HIV therapy.

[Music] uh good evening everyone and my name is dr tanvi and i welcome you all on the behalf of midfield today we are gathered here for a very interesting session on recent advances in hiv therapy and to talk about it uh we have uh dr ishwar garada with us he is currently the consultant in hiv stds in the unison medicare and research center the first person to release the alarm against aids in india in 1985 dr ishwar is a globally acclaimed hiv expert get it credited with bringing india on the aids control map of the world he is the president of aid society of india secretary general of people's health organization india which is a premier ngo that spearheaded india's hiv awareness campaign since 1985 and was also elected as the governing council member of the international aid society in 2018 and has been re-elected on 12 may 2022 he is the third indian historically to be elected to the governing council of international aid society among the innumerable awards and recognitions he has received a few remarkable ones are the outstanding young young person of the world award conferred on him by the junior chamber international usa and the coveted and mary madison international award in munich where he was labeled the indian machine gun against aids in 1999. being a very added teacher he has trained thousands of students doctors nurses social workers and counselors in hiv i welcome you dr ish ishwar and without further ado i would uh hand over the stage to you ah thank you thank you mad fix for inviting me here for this very important topic and very important audience i would do not want to have a rift between audience and me i am one of you i am trying to learn day by day and that's the reason that we are able to have recent advances and what we would like to see in this advantage advances is basically people with hiv if you look back about 30 years back 35 years back 20 years back 10 years back are there any changes yes there are many changes and every time we look forward for fewer medicine three in one or two in one combination we look at the smaller pill size we look at the medicine without side effects for adverse effects and we look at the medicine can work for longer period maybe 10 years 20 years 30 years etcetera also we look at if there can be any shortcut like for example now there are even injectable arvs where you can stop all medications and take once uh to one injection so that kind of advances advancement has been done in the field of hiv when we started working in the field of hiv around 85 86 i never knew that my whole life will go in the field of hiv i thought it would be like any other pandemic coming for year two year three year it will go away but it did not it be it became a big problem not globally but also for india but uh nevertheless india played a great role now globally currently eighty to five percent of the uh people with hiv in the globe they are taking indian medicine so or this i would like to start with my first slide so in the outline what i would like to say is would like to see what is the natural course of hiv natural course means you don't interfere as a doctor you don't provide any medicine let the person with hiv and let leave on his or her own how big is the problem then who who to test what to test uh how to evaluate when and what to uh what is to start what is the latest for india what are the challenges what are the preventive strategies and uh are there any laws to prevent discrimination so i think doctors must be aware about this law because sometimes doctors do discriminate patients with hiv probably out of misunderstanding or little bit less knowledge than others and then they land up themselves in trouble so we would like to understand that also so let us start with the natural course if you look at the virus which is a rna type of virus but also has rna and dna and this is there therefore called reverse transcriptase means rna can change to dna dna can change to rna and there are different markers by which uh the virus has some kind of affinity to our white blood cell and therefore our cd4 type of white blood cell that provides entry to hiv positive hiv virus when the virus enters through either sexual transmission or blood transfusion or rarely through breast feeding or from other to child transmission so if you look at this natural course what happens in hiv that after the exposure within two to three weeks the person gets some kind of fever and that fever is like a blue fever comes chills come a little bit malaysia is there sometimes they can see also overall thrash but it is very transitory for few days at that time the virus is very high and then it goes down at that time cd4 also little bit goes down but it picks up cd4 cells are our immunity if you try to understand the cd4 and cd8 mechanism if you have been driving a vehicle the vehicle has accelerator and also brake if there is no brake to the vehicle the vehicle will run and may run so therefore cd4 is our accelerator and cd8 is our brake so whenever there is any attack from any organism the cd4 mechanism makes antibody against that virus bacteria parasite etc and suppose x attack is there our cd4 may make 2x3x but after that the cd8 will tell cr74 that here just slap you once don't kill that person so your response should be enough to what whatever has been a response from that side so stop it because tomorrow you may have another infection you may need to produce again antibodies so this cd4 cd8 works in tandem so initial period cd4 goes down little bit again picks up and remains there then what happens is uh when the person is overcoming that primary infection period for four years five years seven years sometimes ten years nothing happens to that person because all of us have double double immunity like we have two nostrils we have two eyes we have two kidneys we have two oris but we have only one sex organ and one uh one mouth so we always said the though java and therefore when our immunity is double then whatever attacks are there till half the immunity is depleted nothing would happen again out of the remaining humidity suppose we have 200 percent immunity 100 is depleted even 100 can manage to for many years then again it start depleting when it goes below 50 percent that means 75 percent minus immunity then you start getting problems and that time the virus viral load goes up cd4 count goes down there's a point of intersection and from there the decline of that person's health starts and they start getting up newer and newer infection so you can see here in natural course acute infection then the clinical latency and during this period person may get just a lymph gland enlargement at the most uh what you call the rp zoster but beyond that there's nothing and then the person start getting some symptoms maybe fever cough loose motion weight loss uh oral thrush tuberculosis other secondary infections and then when there are internal infections happening tuberculosis pcp pneumonia brain involvement abdominal environment cryptosporid diarrhea at that time it is called aids initially it was a one-way traffic a person with hiv positive becomes clinical disease we used to call them and we still call them hiv disease then goes to aids and then die but now with the advent of antiviral treatment there is a bilateral traffic a person can go from here to there and there to here we often have seen a patient which has come on a wheelchair or even on a stitcher or on a bed that person who stand up and walk within 8 10 days 15 days 20 days mostly one month so that kind of and that person remains like that for many many years and that we have seen in our own practice and many years so as i was telling you the same graph of uh when the cd4 count call the wire load goes up and the newer and your infection comes in so there is another diagram to show you at what level which infections come but by and large 200 cd4 count is a marker where immunity starts falling about 200 cd4 count you can get tuberculosis because tuberculosis in india is very much prevalent whether you are hiv positive or hiv negative whether you are having cd4 below 200 or about 200 or about 500 you can still get tuberculosis but all other infections come only after 200 at 200 usually you start seeing oral thrush or oral candidiasis and it can be oral vaginal it can be melanophostatis also sometimes it can be severe oropharyngeal thrush so that is a sign of decline and then you start getting other infections so what we looked at that out of the patients with hiv how many are dying of aids and aids related illnesses and we noticed that only 29 percent die of aids related illnesses and other 71 percent die of other illnesses some of them are unknown illnesses some of them are non-aids cancer so there are cardiovascular diseases so they are liver related because of alcohol and uh non uh non alcoholic hypothetis so there are other infections there are other lifestyle diseases which kill that person other than its virus itself so what has happened with the advent of art uh we used to say that earlier we used to tell people when you are diagnosed with hiv you make a fire national like a fire national plant you make your fire personal plan and people used to say that i would like to save something for my children i would like to send my parents to madina or i never spoken nicely to one to my wife i would like to be nice with her so i said do it and plan five years after five years person start started coming again surpass other next make another five-year plan so they kept on making fire plan like our national fire plan and they are surviving for 25 years 30 years 35 years so when the lifespan was cut in africa particularly to 32 years it has now gone back to around 70 years uh in india average lifespan is 70 years 69 for male and 74 one for female so would we can now say that a person with hiv even if the person comes to us around 25 or 30 years of age that person can reach the average lifespan of 70 years and that's what we have seen and they can keep on celebrating their birthdays after about this so initially we had a lot of hiv infection at that time we had very little uh treatment available those available treatments were not affordable to people so we lost a lot of people initially but later on now currently for last four five years we are at 2.1 million that is 21 lakh cases just recently they said that during the long term we added some more almost a lag case or 1.5 lakh cases in two years but we are around 22 lakh 23 lakh cases but we are not going beyond why because and the number can go a little bit beyond because we are diagnosing more cases but few few people are dying so death rate in hiv is very very low now uh the units with who they made a plan which is called 19 1990 by 2020. so a lot of people will understand or they may ask what is this 1990 there are 90 percent people who are having hiv they should know their status a lot of people do not know their status they do not consider themselves in any risk category they do not want to go for any testing and somebody would say that i slept with somebody who is known to me who is not a sex worker so i cannot get hiv from that person so by that way there are some people who will not be diagnosed so we want to create that kind of awareness that those who have taken even risk once in life they should get tested so that 90 percent of people with hiv they know their status second 90 is those people who there know their hiv status 90 of them should be on a rt antiretroviral treatment and the third 90 is 90 percent of people who are on a rt they should have viral suppression that means their viral load should be under control and this 1990 even if we achieve 19 1990 it becomes 90 percent of 90 that is uh 82 uh 81 percent 90 percent of 81 percent is 72 so despite achieving this 1990 we can be still around less than 75 and therefore we need to uh upscale the target we wanted to achieve this target by 2020 but lockdown came and some part of the target is just yet to be achieved i can show you what we are achieving so initially we had around uh 79 percent of those people who zero hiv they knew their status eighty two percent of them were on a rt and seventy four percent were virally suppressed but now that figure is changed to 76 because more people were added to that so therefore they do not know their status they took risk during the two years they did not take post exposure prophylaxis or pre-exposure prophylaxis but 84 percent of those people who know their status they are on a rt and that is a great achievement and 84 of those which are on art they have a viral suppression so i think we are closer to that target it may take another year or so to bridge that target now who so nowadays we can see even 15 year old having sex and 75 70 80 year old also having sex so we cannot say who but basically when we talk about public health we talk about percentage and higher the 20 to 40 age group or 20 to 50 age group they are highly sexually active intravenous drug users those which are using injection for injection model for the drug abuse people receiving blood blood products organ transplants injections in health care settings multiple times unborn child anyone who is exposed to infection young old and especially marginalized community group so we have to think hiv and test hiv so there are there could be clinically initiated testing where a patient coming to doctor having fever or weight loss or something and you suspect partner notification if one partner is positive the other partner is likely to be positive it is not hundred percent necessary those people in that uh conjugal relationship out of husband and wife one is positive five years ten together wife's chance to get hiv is fifty percent not hundred percent ten years time together chances are around seventy percent but not hundred percent uh then testing older children of hiv positive mothers earlier we used to think that children with javid they do not see their second or third birthday but now we started seeing and that time we did not suggest any kind of taste for older children so uh husband coming we tested wife wife coming we tested younger child but we never suggested older child but now we see that children which are born to hiv-positive mothers they survive 25-30 years without symptom and therefore when they fall sick around 25 30 and we have some history we ask them to get tested and they if they have no sexual history of their own they could have got it from their mothers of uh or father so that kind of that kind of scenario we are seeing pm pre-marriage health checkup so uh rather than a matching horoscope other than looking at uh other parameters of marriages we should also look at health parameters so health scope is better than horoscope horoscope we call horoscope we have seen people having breakup marriages despite matching horoscopes and we have to do counselling and testing at that level also now clinical initiated testing we need to have signs and symptoms suggestion of hiv aids signs and symptoms or sexual partners who have hiv babies born to hi positive mother untested children of these women all pregnant women and that is being done all over the country now victims of sexual assault because earlier the victims of sexual assault rape or incest etc they were look from only forensic angle they were never looked at from the std or hiv angle and we prevailed upon the government and now government has agreed that even victims of sexual assault should be checked for hiv a patient with tb or question mark tv basically hepatitis b but had to see an sti because if a person can get any sti or hepatitis b or dependency sexually that person is also exposed to hiv therefore we should check for hiv any other situation where healthcare provider feels that hiv test is essential so basically all of you can always do hiv test for anybody because the person coming to you fits in any of the criteria uh what innovations we are required for testing there is ongoing debate should we have a universal testing that person coming as a body profile you are doing body profile plus hiv or now they call executive body profile in that they included triple h pre marriage testing as i already told you blood bank screening followed by strong linkages because what happened is blood bank that bloods are screened person is found positive that person may not be told because you don't use that blood and you say that we are not double check therefore we did not inform that person so that person is not linked to the hiv care so this is a very weak mechanism where the blood banks are not linked to the care centers integration and we are relabeling ait centers in a non-hiv technology so on one hand we say we should not discriminate then we call art center now everybody is a smart enough they will go and go on google and say what is art anti-retroviral treatment what is retrovirus hiv so basically we label in such a way that anybody going there is seen with a suspicion and that discrimination start from there so we should label them as something differently and we need to decide what that name could be self-testing and home-based testing where people can order from uh some kind of portals get testing kit just at home and if they get you they don't have to go anywhere if positive then they can also find where to go for treatment so that reduces stigma also so basically there are different type of hiv tests first generation test used to have a lot of false positivity they used to look at only igg in second generation they started looking at igg but false positivity star they got integrated of hi1 and two first positivity is much less in uh third generation test they started looking at igg and igm both and the fourth generation they look at antigen and antibody both so they are combo test and therefore currently we can the earlier first generation is to say the window period is up to six months thereafter it reduced to three months then it uh with the fourth generation it is reduced to six weeks but by three months everybody who is infected are positive so if you are doing four generation tests at six weeks negative 99 percent chance that person will remain negative but after three months everybody either positive or negative has to be decided at that period so basically first generation second generation and third generation graphically uh described and we can just understand that the third generation and fourth generation anything about third generation they are better test because they can detect people very easily now p24 antigen p24 antigen is one of the first antigen to come in high positive person so if you are now western lot is almost redundant because it is expensive test it take more time but in western lot also firstly you will get p24 and p17 and then gp 120 gp 160 etc so p24 comes first and after some days it will vanish after some days maybe six months or eight months and some people took advantage of that they started doing western lot on western blot nine out of nine band were positive and then after some time giving some basmati children uh etc and some bands started vanishing and they said look my medicine is working now your p24 has gone p17 is gone this is gone so that is actually the person's immunity is going down and losing one by one antibodies but they make advantage of that for themselves so we need to look at both antigen and antibody and therefore this compute combo test they are looking at both and they are better than other tests so window period as i was telling you there are two kind of window period one individual is for test that when a person is exposed how fast that person could be found positive so for the sake of pcr within two weeks the person can be one positive there are pcs to check at three or seven days also but at three or seven days a person is negative we need to recheck at two weeks so therefore it's better to recheck at two weeks western blot three weeks uh integer antibody compound test six week and all other tests around three months so this is a window period for testing but there is also window period for clinical window period that after you're getting infection when do you get first symptom and that is real period for doctors because if you are not testing will not know but that window period can be as long as five to ten years and there are some cases which are we call them elite controller without art they control their virus in such a way that they do not progress at all for 10 years 15 years 20 years 25 years i have patient uh just now i just see that person 26 year positive husband is on treatment wife is not on treatment that is called elite controller or there are some vitamin controller where virus can be around thousand two thousand copies uh but it is not progressing so whether light controller or viralbit controller we don't treat them we just observe them ask them to come every six months now look at how to evaluate and when and what to start treatment so basically we have to evaluate by certain specific tests one is cd4 test one is hiv rna viral load and then there are other tests like serum creatinine liver function test because some of the drugs may cause liver toxicity some of the drug may cause kidney toxicity some of the drugs may cause bone toxicity so if we know the baseline and tomorrow a patient should not come and say that when i had come i was fine you don't know what i don't know what you have given me and you spoil my kidney you spoil my this so you should know you should understand what are the adverse effects and we should start doing this test secondly at the baseline we should also do hepatitis b beta dc syphilis and urine routine and by and large you also do exercise and sonography because tuberculosis is very common in the country and in hiv almost everybody gets tuberculosis at least once in their lifetime and sometimes they can go get extrapolates also so therefore we need to look at those issues since beginning number one number two why we need to look at because if you start art tuberculosis is like tears in the eyes tears in the eyes come in the good time and bad time and therefore tuberculosis can come in good time and bad time so you are treating a person there is some incubation incubating tuberculosis inside you did not diagnose that tuberculosis will explode and that will call that will be called iris eventually constitutional informal inflammatory syndrome but whether typologies is for a good time or bad time you need to treat that person sometimes people can die of iris so we therefore we should be able to diagnose at baseline what other conditions are there now why what do we interpret on cd4 count as i told you by and large all of us have suited for council around 500 so whether hi positive or negative uh positive people who are recently infected couple of month one back a year two year back around 500 but 400 450 is not bad what is the problem is when they it go below 200 and that is the time when the person start progressing so therefore below 200 we should be very careful 200 to find it we should wait and watch 500 onwards uh is okay nothing to be done but currently there is a test entry strategy which i'll explain to you so interpreting cd4 count is easier most private practitioners can interpret cd4 count that cd4 count is good or bad but when you are doing cd4 cd ratio the by and large the ratio of cd4 cd8 which is a break and accelerator should be around one and more than one so we should be able to check whether the break mechanism of the body is also intact or not and when the immunity goes down both goes down but sometimes disproportionately cd4 goes down uh very low and silly it may remain up and that time the ratio are very very poor then there are the conditions which are either described by cdc atlanta or who the n number of conditions but basically if we go by system then the what most commonly system affected islam the second most common is gastrointestinal tract third is a hemopartic system and fourth is brain these four systems are first affected but almost all systems are affected because hiv virus is there in the glial cells in the brain it is there in allele spaces in the lung it is there in chroma field cells in the intestine it is there in langerhans cells in the skin it is there in the lymph nodes so basically it is everywhere inside the body and therefore we can see lot of diseases which can occur but all of them are even dependent so immunity going down so below 200 i already told you when it goes below 100 then you start getting pcp pneumonia which is a pneumocity scary pneumonia you start also getting cryptococcal meningitis we need to go below 50 then cryptographical meningitis toxoplasmosis they they become more prevalent also microbacterium ibm intracellular mai or mac infection so these infections are there and we should be looking at that interpreting viral load sometimes untreated person who is wiring the viral load can be up to two crore per ml of blood to cross thick road we have seen and it can be as low as less than 50 or less than 200 less than thousand depending on what test you are using earlier the tests were little bit macro and that time we used to have a detection limit of 1000 2000 or 3000 thereafter 200 and 400k now we are having a micro ss where detection limit is 20 34 or 40 and therefore above 40 or about 24 about 20 you can count the 25 virus or 2 000 or 10 000 below 20 or below 34 whatever limit or test you are using it can be one or it can be 33 so therefore we should have that mechanism to see what is the undetectable water load what is detectable and low to moderate can be 50 000 to one lakh copies one lakh is also we call moderate now one lakh copies per ml of blood in the body we have six liter of blood we can multiply six thousand times to this one lakh and then the cells in the organs in everywhere it is there so there are millions and billions of viruses but when it is high as i have told you two crore per ml of blood you can imagine how many viruses could be there so who to treat basically what has happened initially every four or five years there used to be some guideline even we used to say when our people could not afford treatment we used to say 500 and above no treatment 200 to 500 wait and watch below 200 start treatment and we used to have even even a modulator between 150 to 200 to push people beyond 200 and that worked during that time but now after so many years of time the who has decided rather than having and wait and watch approach in 2016 they change guidelines three times what is the latest guideline test and treat if you test somebody if the person is positive you start treatment test entry doesn't mean that person has come you've done hiv test and you start a rt in just one hour you need to evaluate the way i told you but that is in concept you would convince the person that the person is positive you should be treated only caveat will be a light controller wire limit controller or having some other conditions where you should first treat those condition then art and what are the benefits because what ah all uh all of us believe in science and science gives a solution which is like bob the khao natirakar so in that cox postulate science shows the way and what is the way they are shown in immediate art versus delayed art and they found that what is the uh time also start getting sick [Music] what is the person when the person start getting sick so we realized that if you have started treatment early that person doesn't fall sick person doesn't fall sick at all and therefore uh the sickness has come down by almost 50 60 percent in those which are on immediate dirty but if you look at there are studies which are done in africa particularly what they are done they made four groups one is immediate treatment one is immediate treatment with art one is a delay treatment and one no one is immediate treatment immediate treatment with ipt that is chronic prophylaxis and one is only isolated prophylaxis and one is no treatment and they found that people with isolated prophylaxis even with treatment they fared much better and therefore isoniazid prophylaxis started as a practice that everybody every hiv-positive person on treatment or without treatment they should be given isolated prophylaxis at least for six months and then that can be repeated every two years now earlier is to say that prevention is the only treatment but with the advent of variety what has happened our focus is shifted and now it is called treatment that prevention so we treat for a couple setting if couple one is positive you treat that person the other person who is negative will remain negative forever and we have seen that in multi uh sexual partner setting with single sexual partner setting and therefore rather than campaigning and asking people to have prevention campaign using condom etc on one hand on the other hand treating hi positive person and putting everybody who is a high positive treatment that will automatically prevent other infections and that has been uh seen and proved so what has been seen that if you have treated hi positive people the infection rate which has 100 it has gone to only four so 96 percent prevention has occurred only by treating people with hiv and therefore what is the goal now it is called undetectable is untransmittable that you start treatment test and treat by treatment you are preventing the infection in other person but in that person who is hiv positive that person becomes undetectable that means within couple of months time three months to six month time that person's wire load becomes undetectable the viral load can be too crude two lag ten lakh etc but within two to three month period or maximum six month period that person become undetectable the simple logic is if the person is undetectable and as i told you the current uh scenario with the viral load we are able to test at 20 copies 34 copies or 40 copies if you cannot detect that person uh viral load in that person that means he's undetectable if his person is undetectable is untransportable so in a couple setting other partner could be safe in the hospital setting doctors are safe so therefore we would like to tell doctors that if a person who is hiv positive come for a surgery come for any procedure come for dialysis you don't worry just check the viral load if viral load is undetectable undetectable is untransmittable to you also as a health care setting and despite some time not using growth sometimes get turned on some accidental injury you will not be infected now undetectable becomes untransmittable and transmittable becomes also you can enjoy the whole life and that is the whole principle that you is equal to you and whole world is hovering around this thing for the hi-positive people what are game changers in india the game changes in india were all in financial year 2017 to 2018. the first one was being the hiv aids act hiv aids act 2017 this act has been in a process for many many years at least for 30 years we have been fighting that there should be some law to protect hiv-positive people from other people because if hiv-positive people are not protected with further human rights discrimination they will go underground and infection will spread faster and as a human being nobody has gone to get hiv they want to enjoy they want to whatever do what they wanted to do that they got hiv by mistake and therefore they have a right to live the normal life as much as hiv negative people so this act was passed in 2017. launch of test and trade the trusted trade was there by who in 2016 but india took one year time to decide can we test and treat and third one was launch of viral load testing so if you look at the uh 1990 third 90 was virally suppressed but till 2018 wire load was not done utility at all ert centers because the capacity of doing viral load was very limited it was not even 10 percent of the people could be tested for viral load till 2018. so 2018 they had a public private partnership roped in a private lab and samples were collected from art centers from all over the country some people went there and they are still going there and if they are found undetectable that means your treatment is working if they are not found undetectable you need to do address counseling you need to see whether the person is missing etc so pill count etc but somebody can throw the appeal and say that my package is empty that means i have taken the medicine so those were all raw things but now there are definitive things like viral load and therefore these three things india has done very well between 2017 to 18. now key issues are what to start management of adverse effects co-infections opportunistic infections hiv and aging and convincing patient to take medicine despite good health a person who has come for testing we are tested person is healthy not having fever cough etc and then you are asking that person to take medicine will that person take medicine so this is a very challenging thing and cost issues those who can go to government they're getting free but in private why should person spend and same thing was there for and they still there for many of the vaccines they don't want to take uh pneumonia vaccine they don't want to take flu vaccine they don't want to take typhoid vaccine they said we are healthy we don't need anything and a lot of people your boss that happened so all those issues are there and each art class they act at different level so there are different class of medicines which i'll explain to you at every level they act and basically at least if you choose two classes then you for example is a marriage setting husband and wife you vasectomize husband and tibetan's wife he cannot produce a child if you don't have a vasectomize the woman can have child from anybody else if you to veptimize to her this man can produce child anywhere so therefore in a hiv setting if you act at two different places the virus cannot multiply the virus cannot go out of cell secondly our cd4 cell just like all of us have a life of 60 70 80 90 years the cell also has a life of 70 days after that the cell will die its own death it is called apoptosis that is a self cell death so when the cell is dying the cell will die with whatever inside material is there including hi virus so what is our job to see that in the 70 days the virus doesn't if the cell is infected virus doesn't trickle out of that cell and go and inject new cell before the cell dies and therefore in this 70 days we try to kill uh not kill but basically don't allow the virus to multiply don't allow the virus to go out of there and you at every stage you stop it so currently we can see out of this almost 30 odd arvs there are some arvs which are in the dark they are in use those which are italics they are not available in india those which are strike they are striped up because better arvs are available and those are not required so they are already stacked back so there are five classes of medicine ah one is nrti that is a nucleoside reverse transcriptase nnrt is a non-nucleoside nuclear reverse transcriptase pi is a protease inhibitor uh hd is an integral inhibitor and entry limiter so at nt also you can stop and as i told you reverse transcriptase inhibitor means if the virus is rna virus cannot multiply without becoming dna so this reverse transcriptase wire will stop that virus from becoming rna into dna or dna to rna so virus cannot multiply so likewise protease inhibitor as i told you uh the virus comes out of body that burning is possible because of a chain called protease that enzyme called protease so if you block protease it cannot be body so if you look at between 99 to 2018 because first uh antiviral was found ajt in 1987. and there was a time magazine headline saying that a game changer found but thereafter we realized that with one drug the virus went down within six eight months they started going up in 92 we had another truck called three tc or lamy odin two truck was better than one drug but virus went down and after a year two years they started going up but when they found the third drug it was a protease inhibitor after 1995 then the combination treatment started and from that update on what they started calling highly active anterior medicine heart rather than only art and we can see that in major advances happened in 99 when there is a new drug came efforts with less side effect than the previous dog a less requirement of medicine than the previous done then the combination started then the thyroid analog analog came which is a tdf which is widely used in everywhere and then the other drug came tdf3tc fibers fdc came this fdc or fixed drug combination was a gift of india to the rest of the world and this is a gift of anti-tb program to hiv because in anti-tb program we knew that all four drugs r h e z can be combined in four four and can be taken together so we told the pharma companies here that if our tb patients are taking four in one combination why can't you make three in one and they were not convinced at that time i said if you make it it will run in everywhere in the world and they made it and i'm uh i told them that if i'm asking my patient to take three tablets together with the water why can't you make it three in one and they started making it the three in one was made in india and the gifted to the rest of the world rest of the world copied when we copy from the world they call us copycat but when they copy they never give us any credit and then you can see that from 2007 onwards there is another drug came raltegravir wonderful truck intricacies inhibitor then the other truck came which is uh diluted gravel elite agave is not in india and the big day gravel came here so every year one or two one or two drugs kept on getting added and some of the drug got uh subtracted so what are the challenges basically we have a challenge number one our goal of the therapy is keep the viral load low undetectable level and that's the primary goal that should always remain there our goal is to see that they do not interact with other medicine so therefore the medicine should be such that that can be used with any combination and without uh having any kind of uh interaction or drug drug interaction and one of them is the best one is a dtg autograve and that can be in green in all the guidelines with the who dhhs acs the european uh aids aids control society so what what do the patient expect when your patient comes to us they say sir sustainability we want low cost we want a single tablet we want less adverse drug reaction we want no food restriction because earlier medicines were don't take with oily food spicy food don't take with that take empty stomach take after food keep a two hour gap good survival everybody wants good survival smaller pill size so when the three in one combination came some people came around so we used to tell them okay take a tablet and eat banana it will go down but now they want smaller pill size no physiological pathological restriction so you don't say that don't take during pregnancy don't take during tuberculosis don't take during this thing so they don't want that kind of inhibition now what do physicians expect physicians also want to give better survival to patient because if patients survive then they will come to pressure doctors and doctor can earn if the patient's dying on one hand you lose business on the other hand your bad will so you want your patient to survive though emergency from patient management initially you are happy you want emergency but at a particular rate like my age i don't want emergency i don't want people to call me at midnight saying that my chakra less advanced drug effect so patient should have good effect but less adverse very fair ease of co medication so a person with hiv are surviving for 25 30 40 years and they are also having their own commodities because of aging hypertension diabetes they should be able to take medicine together and i should be able to prescribe them that okay you can take this with uh you know metformin you can take this with upload no problem fewer molecules and combo all the times your molecule so all of us want every year or every two years some numeracy income otherwise if there's a fixed drug then what is the difference between a doctor and a compounder that can be treated by comforter also and knowledge enhancement program which you are uh having today and these are thanks to medifix that we are getting this knowledge announced now pre-treatment hiv regressions in western countries where there is no dearth of funding they have a lot of facilities to do uh registered testing they do first restaurant testing to decide which drug will work but that is possible when you have a lot of money and if there is a lot of drug registers in around 13 it rate is around 5 to 10 percent and thailand and other countries around five percent or so the second option is either use non-in rti that is a dtg for initiation so dtg is being a new drug there is hardly anybody who is registered with that drug and that is a resistance profile of that drug is very good it's a robust drug so even if suppose the person forgets taking drug every alternate day takes only two or three pills a week nothing would happen to that drug it doesn't mean that you should ask people to do that but there's a robust there so either you should use a drug which is a robust so that you know that person is not registered and will respond or you do hiv uh good regression testing to the people when the prevalence is about ten percent now what are the factors to consider whether person is having hepatitis b or not because if person is having hepatitis b then the other two drugs which have to be used they should work on both so dilute agave or if a variance plus two drugs and which is uh dtg which is uh 3tc commonly used but in hepatitis b the drug which will be a preferred will be you know forward and fd stability rather than terraforming with uh lemonade concomitant medication for other commodities food requirement either unscalability toxicity known or suspected resistance because if you take a history of the person what medicine person has taken we know the registrar's profile of the person empirically may not be doing a test and opportunistic infection if there are any and iris so sometimes the person comes and says where is my kidney or my kidney is not functioning so we need to look at whether the person has been taking any uh ancient drugs whether the person is having diabetes whether the person is having little stone which are damaging the kidney and there are drugs like tdf or tinophobia they also can damage the kidney so first we have to uh safeguard the person from other things and then decide whether the drug which you are using is damaging kidney or not two of the drugs one which is called abacavir that damages heart to some extent and the drug which is turn off aware can damage bones and kidney so it is like a tarparki kasara you need to decide whether you should use this drug or that drug and that is can be tailor made from person to person similarly cardiovascular risk factors have to be assessed and therefore if they already have a cardiovascular risk factor we should not add another drug which will give you a problem of a serious cbd problem now just going with the uh as i was telling you pre-99 era 2000 2001 20036 and 2021 what has been there before 1998 people used to take almost 20 to 22 medicines at a time people with hiv taken 22 medicines every day then it became daily two plus two for medicine then became one plus one then it became compliance back all three medicine at a time you take at night and sleep and this we told our companies that can you make three in one in one tablet that came as a single tablet regimen after that in 15 years i can go on and on on that but what what i can say that in 2021 one drug is approved which is a capital gravity and will be varying where if the person is on a rt if viral load is controlled for more than two years you can stop art and the person can take that injection once in two months just come back six times a year make the injection go away that is approved in usa every approved drug but it is not available in india and even if it is made available in india it will not be cheaper till indian companies make it so before 95 we were like beggars and wish to say that yes very good drug has come but 102 people could afford another three percent could afford by borrowing money from somebody but how long you can borrow and after that medicines came we could afford so many medicines and now it is a single medicine so india has gone from beggary to being a donor and this is a quantum change in the country's profile is of hiv aids so the same thing can be shown in the uh more medicine and less and less is more powerful than more so it is not always that if you eat more medicine it will be better even a single medicine can be better which i'll explain to you so choosing a right art it depends on cost toxicity will burden creatine and clearance if the person is already middle ager also or having a diabetes or so baseline hiv rna viral load and cd4 test baseline hypothesis b test hbcg antigen a single pill and two pill so there are in single pill there are so many medicines available in two peeled again there are so many medicines available so we can either choose between single peel and double peel in private sector there are more medicines available in government sector there are only two three competitions available so private sector has more choice of using different trucks depending upon the usability or the other issues which i discussed so what is the latest and surprisingly less is more so less is better lesser those lesser pills lesser pill size lesser toxicity and drug drug interaction lesser susceptibility to resistance and lesser cost all these are better now so what we have seen efforts was 600 milligram a lot of people used to have depression suicidal tendency or well high headedness in the morning bad dreams and empirically we used to make that medicine half a lot of people were below 40 and we started using half medicine and it worked wonderfully but medicine was available as a 200 milligram or 600 milligram so you can give either 200 400 or 600 200 for 400 you need to give 2 but cost was high so we used to use 600 milligram half the tablet what one uh study has done that they've studied 600 if awareness versus 400. they found 400 is better than 600 you get same therapeutic effect and less side effects similarly didophobial diazoproxyl fumarate is a 300 milligram and that causes kidney damage that causes bone damage the same product can be used as a tap to the forward elephantamide and that is only 25 milligram so it is a one twelfth of the drug but giving the same therapeutic effect so tap is better than tdf similarly dharuna will with written aware combination it was to be originally said that you would give 600 100 competition warning and one and one one in evening so it was going 1200 plus 200 now there is one study which has been done which has found 800 plus 100 that it works better than 600 plus 100 twice a day once a day and similarly now there is another study to say that rather than three drug you can use two drugs so new oral fixed stock combination of two drug has come three drugs are bitter gravy duravarian and darwin taranaville in the true drug there is a delta cavity with relp variant and double travel with that three tc these competitions are available and these studies have done which shows that how these two drugs are better than three drugs so this is a game changer that you reduce the uh pill size you reduce the cost you reduce the adverse effect and what are the prone pros as i was telling you a person who has a heart problem you cannot give a bhaktavir the person who is having a kidney problem you cannot give time for tinnitus so pros were there that we don't need to give them that drug we are just giving dtg with three tc and no registers at failure at in trial so in trial there are no registers despite not adding the third drug cons is basically potential for hepatitis b registers if person is already impacted is b then person will have a only single drug which is working on impedance b that is 3 tc and that will person will become registered so for reduced activity with baseline 3tc resistance limited data in advanced hiv uh in under performance at cd4 count less than 200 and however only 3 out of 20 were underperformed and similarly uh in the first line and uh which i will show you the gemini 1 and 72 studies were done to establish the supremacy of two drugs versus the three drug and maintenance was also tango that the two studies are different the study first is that when you want to start the medicine first time in a hiv-positive person but never use any kind of art then the first line can be given through drug the second study was to see if a person is already taking three drugs virally suppressed can you shift that person from three drug to true drug and both these studies show that that is possible so in the german study it was done in 192 centers in 21 countries and two studies were similar and they were divided into one into one population uh one one part was given three drug one part was equal to drug and they start with their two drug box better so how could dtg3tc affect the first option the advantage is that co-formulated single tablet is available no avocado no tradeoff aware no tap is required potentially lower cost because two versus three drug potentially lower side effect because two or sixty deducts so you are going to have if at all side effects of only two ducks not the three drug and the disadvantage cannot be given in hepatitis b or infected people need hiv resistance data of hiv viral load earlier which was done and not studied in patients which are having more than five lakh copies because the study population was only one lakh to file a copies reasons to change therapy they can be substitution or switch because of toxicity because of pregnancy because of treatment of active tuberculosis where you need to double the dilute agave uh part because of the interaction between dilutography and refurbishing non-adherence which is a single daily dosing treatment failure can be clinical it can be immunological it can be biological clinical failure takes longer time to establish because till person falls sick it may be two to three years immunological takes little bit longer time but less than illegal failure time so cd4 can't start falling but biological failure is detected immediately and that is a robust so when you are looking at ai toxicity they are different drug one of the first stock which was very toxic with zero burden which is almost phased out very few people are given that drug stagodin that could give you that could give you a lot of lipo dystrophy lipoentropy etcetera or lactic acidosis that is now phased out pedophile again question mark but currently being used and we can have other options effortless in five percent people they used to have suicidal tendency they are now being phased out european lot of skin dashes and lot of times the people developer class registers like if you are using european the person become registered to negotiate that person will be also registered to lp variant as well as difference so you can see lipo entropy where the muscle mass or fat mass goes down and lipo dystrophy the excess mass is there so this could be there because of the d40 and indian available in treatment failure as soon as the uh viral wire load starts going up more and more drug will start coming more and more this will start coming cd4 will keep going down so you can see that currently they looked at vedic medicine started while load went down but never touch undetectable and again start picking up this is not a good regimen in the second regiment the viral load went down it remained there for two three years you are observing every six months and you start going up so there is a biological failure and tuberculosis and hiv they are coexisting in many people and mortality in hiv and tb is twice as that of hiv negative people active case finding look beyond x-ray and smear sometimes we require ct scan to see that or sonography to see whether there is an abdominal tuberculosis integrated art within two to eight weeks of att initiation so you can wait for two weeks start a tt and then after that you can introduce art sometimes brain involvement is there then you have to wait maybe up to eight weeks higher is very common with lower cd4 count and steroid are mainstay which can control iris one these are lymph node tuberculosis and pgl we will need to make a distinction between two reserve only hiv but lymph node enlargement here is a tv lymph node no hiv here is the plural efficient and hierarchical load so is there good divinity is a good ability to close this where neural fusion is found now as i am telling you opportunistic infections start coming over the years when the cd4 counts goes down so at 500 nothing comes after 500 to 250 or 200 you get skin infections like shingles varicella zoster 200 thus will come below that pcb pneumonia will come tuberculosis can come at any age any sugar for count then extra permanent tuberculosis will come below 200 below 100 pcp pneumonia cryptocurrency that is toxoplasma herpes simplex infection which will be a fluorine histoplasmosis cytomegalovirus and mycobacterium ibm infracellular when cd4 goes below 50. prevention of opposite infection for tb we use isoniazid prophylaxis for pcp when cd4 count is below 200 we use cotramexicol one double uh strength tablet uh if percent is about 50 kg below 50 kg half tablet cryptococcal meaning that is not indicated back candidate assistant cv is not indicated because first say candidacies your five six days of course of uh fluconazole so if person gets we can treat but you don't need to give a weekly course or a monthly course of gluconasol which some physicians are giving treatment of why digital infection as i told you proconsul is the main state but uh also chlorothermal dissolve will work very conservatively will work interchangeable will work but focus always cheaper five to six days score seven day course is good enough cryptococcal meningitis amphotericin b either liposomal or non liposomal and fluorocyto uh fluconazole and it can be also given gluconation with a maintenance dose cryptosporidial diarrhea isosphere microspora everywhere core trimex is all works fantastically but nitrous oxide is another mainstay medicine there pcp pneumonia the best one is quater mexico but some people are raised uh are sensitive to control oxygen or to uh sulphur you can use daphzone you can use clendamycin and mycobacterium avm intracellularly refrigerating ironh ethambutol and clear the vitamin and cytomegalovirus you have gan cyclovir or bella cancer cyclovir or phosphate iris 11 to 45 percent of the people they get iris within 60 days of initiating grt so we need to watch person after starting ert predictors of iris are low baseline silly poor so if silicon count is very low then irish chances are very high because the drug which you are using a very potent viral load goes down immediately and cd4 is hampered line of treatment nsaid and steroid and timing of reality has to be decided so commodity as i told you they are in four main system which i already explained to you now who can uh what what can we help and prevent new infections so basically this is a major combination of combination prevention there's not only no sex or condom sex there's a female condom there are oral prep pre-exposure prophylaxis there are vaginal rings there is a non-uh non-surgical circumcision there are behavioral intervention so all these work together and therefore prevention can be very strong if you are using all combination out of which two of them are drug prevention one is the post exposure prophylaxis if the person is already exposed and comes to you within 48 hours maximum up to 17 hours you can provide a combination of you know forward and disturb it and you can prevent the infection in that person in 94 chances pre-exposure galaxies a person would like to have sex with the unknown person or a positive person that person can be given pre-exposure prophylaxis it can be either given daily dose or it can be given four dose per secs that is two dose 12 hours in advance one at the time of six and one two hours after that so prep and pp they are very important now they are drug uh which are being used in art but out of three two decks are used for pvp or prep so i would like to just show you this this was actually uh uh animation but uh because on uh while elimination is not possible i'm just showing you that day 0 the person is exposed to the virus the virus is only on the surface and it will not do much but day 0 to 2 that's 48 hours the virus gets attracted to the dendritic cells of our cd4 cell the virus is carried to the lymph node and by day 4 to day 11 the virus is replicated and sent into the blood blood system by 11 days it is in all parts of the body so therefore when you are looking at intervention with drug pp it will work best when zero to two below forty forty eight hours but it can work in three days because third day is not described here so up to 72 hours you can provide pvp so as i told you two one one that is a prep so definition of exposure basically again depends on blood exposure or semen or vaginal secretion but lot of people are exploiting people who are scared of hiv some of them have gone to massage parlor and touch vagina some of them had some uh semen somewhere in their hand and they think that they got hiv and there are scoundrels in our profession we have been taking thirty thousand to fifty thousand from such people saying that they are providing a post-transplant prophylaxis pep should not cost more than two thousand if you are giving two drug combination if you are giving third combination it cannot be more than five to six thousand a month seven thousand a month so basically decide uh what is required and when it is required and whether you required to give pep or not to give pp reducing this cup occupational exposure recapping needle properly because if you are working in a clinic giving injection recap properly transferring body fluid between containers rather than a bare hand container to container or on a tray uh failing to dispose of used needle properly in puncture resistant uh sharp containers so that is a risk for health care based management practices safe mother mother to child transfusion can be zero if you are treating the mother uh with this three drug combination even at the late stage of pregnancy seventh or eight months of pregnancy and even though she is breastfeeding continuity nothing would happen to the baby this is elimination of mother-to-child transmission and this is a good program and what is required currently is a b plus option that means you don't need any extra drug that what you are giving art to a pregnant one so pregnant one form positive start ert there is nothing additional required for preventing a mother to child transmission now there are vaccines which are autotypingization for the first time people understood the importance of adult definition only in kovaid but before that at least 10 vaccines existed and we are not even able to promote them properly so i think medical community should promote impedance b vaccination which is a much cheaper typhoid vaccination much cheaper other expensive accelerations are there like pneumococcal vaccine hpv vaccination depending on the class of the people you can extend that kind of advice to them so i'm at the last point now what are what are the laws we should know so this is the hiv aids act 2017 hiv-positive person cannot be discriminated because of his hiv status so as a doctor if you don't want to manage a patient you just say that i am inefficient but you can't say or you can't show in your action that you don't want to treat that person that person is hiv positive you don't don't want to do surgery because the person is hiv positive you don't want to do delivery because person is hijab positive if that person takes you to task file the complaint against you you can be jailed for six months to two years for not providing care to a child positive person because of his status so be careful there are very large very strong laws though till today now nobody has been prosecuted but there are doctors who are ill-treating hiv-positive people there are cases where they are facing discrimination and we have been advising people to go assertively to the doctor and tell you are undetectable if you require a certification we can provide solution to the person that that so person is under treatment for such a long time and is undetectable but don't ill treat them don't discriminate them don't do their human right violation so mandatory consent must take consent whether verbal or written pre-test and postage counselling though mandatory hiv testing should be imposed as a precondition to providing health care you don't say because otherwise patient will start demanding from doctors that you show whether you are positive or negative doctors should extend the same care and support to people living with hiv aids that that they offer to an uninfected person so if you are having both stay a stream of person your care your love your affection your management should be same for both you cannot be discriminated to hire positive person you cannot just your mass can close just as soon as you see hi positive report and there are hospitals and nursing home writing notes on your fine isolation or some kind of zero positive i i don't know what you are going to gain out of that at one hospital i have seen iv whatever was going on in a person and that on the ivy bottle return hi positive what are we going to get out of that so what was there 20 years back same thing persist our doctors don't change we need to change our medical profession we need to change their attitude and this dominic dysusa who was jailed because of hi positive i went all the way from here to goa we filed cases i'm talking about 1988-89 and the film was made of that my brother killed and we goa is back to square one so we have this campaign stop a discrimination and i'm appealing to you all of you people and you can put a poster in your clinic my passion with it's still my passion my friend with it's still my friend and if you don't discriminate then people will never leave you so other emerging issues are multiple infections in the family who should be prioritized children with hiv aids and aids are fun vanishing pediatric areas there are no pediatric areas available now exploitation at the hands of cracks as well as doctors and police just because they are found positive the income tax person from one of my patients extracted one crore rupees just because he found a high positive status in that person's uh locker so i think there are people who can do all such kind of things we should be very careful discrimination for delivery surgery dialysis and procedures migrants homeless provision of treatment and follow-up airways disconnect use and emerging registers gives us no clear policy for whether we should provide clean needles because we say if you are providing clean little that means you are supporting drug addiction msm male sex with male section 377 of ipc and decriminalization and insurance and medicare so take-home message is basically what can we assure once wireless suppress hiv is now a chronic manageable disease even better than diabetes and i can debate for hours how hiv this is better than diabetes undetectable is untransmittable full life and life expectancy is at birth can be appointed to every hiv-positive person though hiv-related hospitalizations are required once the person is well-managed though hiv transmission occurs from that person to other person can marry both positive positive and positive negative can have baby and that to hiv uninfected baby can lead a perfectly healthy life as good as or even better than non-infected people because non-infected people do not go through any periodic checkup hi positive people go through periodic checkup during the equivalent we have seen that so many non-uh hiv people in the family they died hi positive people survived because they were well looked after so finally we would like to have 100 percent people should know their status by 20 30 100 people should be on a rt if they know their status and 100 should be widely suppressed so zero new infection that is our target thank you very much and if there are any questions i am happy to answer i am sorry i go little bit overboard but with the 35 years of experience or 37 years of experience it was uh impossible to encapsulate that in 60 minutes time thank you yeah thank you this is very beautifully explained you know you talked about the stigmas and taboos regarding the hiv they you talked about the whole advances that have taken place in recent years about the who guidelines as well and the art therapy was beautifully explained so we are very thankful for you to uh come on stage with us uh i would also request the viewers to put in any questions they have in the comment box or raise the hand and come on state if you they want to uh ask you directly face to face so we have uh one question that by dr sagar that at what time should we start uh art if the patient is having tb co-infection now currently there is a test and treat so even if cd4 is thousand or 500 you start only thing is that wire load should be little bit higher it should not be undetectable and you should not be around thousand two thousand you can wait and watch but all other patient as soon as they test positive we can start airt okay uh uh so uh we have compliments hiv is not transmitted through touch somebody is mentioning can hiv be transferred by touch no it can be transmitted cannot be transmitted to touch even sexual contact with hi positive person unprotected the chances are three out of thousand so zero point three percent chance in one single sex with hiv positive person unprotected yeah yeah hiv chances are not yet uh there are 110 candidate vaccines which have been tried since 88 not one is successful only two vaccines have gone to the phase three trial but in the phase three also they failed uh to the level of thirty five percent thirty thirty percent efficacy wha requires fifty percent efficacy so maybe the mrna platform or dna platform which are originally uh hiv platform a waxing platform used in kobed the kovid platform can be now used in hiv and they are going to work on that uh don't worry about sharing of razor etc because sharing of the razor can give you fungal infection bacterial infection which are called psychosis barbie or tinea barbie which is a fungal infection through barbers but hiv is not transmitted like that hepatitis b can be transmitted syphilis can be transmitted watts can be transmitted what should be a time interval what is the question of sagar what should be the time interval between starting akt and art if the patient has minimum two weeks if there is a tb if the tb then wait for two weeks start att but is a cns tuper class is that you have to wait for at least six to eight weeks not two weeks leadership injury if you need to look at whether that source is positive or not if source is not known then better to take a medicine which is a tenofovir empty setup in one month one tablet every day even is asked that doctor she can't ask so please explain prophylactic dose yeah that's what i told prophylactic dose is uh one tablet of trinomial and empty system they come as a single tablet to drug medication starting within 48 hours to 72 hours maximum after exposure and taken one month daily if the source is high positive or if the source is high viral load then you must add one more drug better to add integrated generator like either raltegravir or diluted gravity but all the drugs are to be doing only for one month is hiv testing first for endoscopies or early manifestation period no hiv testing as soon as the person is exposed you do baseline person may be exposed now but person may have already exposed earlier also so when the person comes to you even for post exposure prophylaxis you baseline whether the person is positive or not only if the person is negative for hiv then you should cut prophylactic course of two drug if the person is already hiv positive then you need to give three duck combination similarly if the person is hiv hepatitis b negative you can give a rapid immunization course for hepatitis b which is a one dose at the time when the person comes seven days 21 days and one year so rather than three doses i wanted to be here you give four doses seven day zero seven twenty one in one year early manifestation period we don't know it can be two to three weeks four weeks but even in my 35 37 years of practice i have seen only three or four patients who which could be diagnosed at a primary stage when the test is negative but the person is already having a virus how to manage hiv and tb as i told you first you will manage tb and then you start hiv but depending on the situation if the cd4 count is very low if buyer load is very high you need to give tuberculosis and hiv treatment simultaneously you just keep a guard you may start a prophylactic course of steroid for 10 milligram or 20 milligram a day and taper or every four days to avoid iris so it depends on situation to situation but generally you should avoid giving art for two weeks any new best better than what the only thing better is a pcr test pcr again is up to type qualitative quantitative qualitative counts the virus and qualitative tells you are positive or negative and they are all done in one and a half hours time now there are what you call point of care test available and within one and a half hour to two hours you get report where we get all this current information i think information is currently available everywhere you can go to naco site naco we can go to who site you can go to cdc atlanta site we can go to aids society of india side we can go to interest rates society site a lot of sites are there but get only authentic information handle situation can uh meet accidentally what in hiv patients accident so nothing would happen there is nothing like accident you just meet greet uh hung that person you don't get hiv by hugging person okay i think that is it for the questions here and i'll thank you dr isha for such an amazing session for the viewers for asking such questions as well thank you everyone thank you very much thank you

BEING ATTENDED BY

Dr. Darius Justus & 685 others

SPEAKERS

dr. Ishwar  Gilada

Dr. Ishwar Gilada

Consultant in HIV/STDs, Unison Medicare & Research Centre | President, AIDS Society of India (ASI) | Governing Council Member, International AIDS Society (IAS)

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dr. Ishwar  Gilada

Dr. Ishwar Gilada

Consultant in HIV/STDs, Unison Medicare & Res...

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