 And very good evening to you all. I'm welcoming you to this webinar organized by the SpiceRoot, the Young Doctors Movement of South Asia. And this is for the commemoration of the World AIDS Day, which was on the 1st of December this month. And probably you know that SpiceRoot has organized a few webinars before. And this is one of the webinars of that webinar series. And we had a webinar for the World Diabetes Day, World Mental Health Day, and also for the World Youth Day. And now today we are commemorating the World AIDS Day, a very important day. And among this pandemic of COVID-19, we are facing another pandemic of HIV and AIDS. And so these are very important time and very timely, I think, moment that the World AIDS Day could be commemorated. And just to remember and remind ourselves how important to control HIV AIDS pandemic as well. So today, the webinar is mainly arranged by the SpiceRoot Sri Lanka with the help of all the other SpiceRoot moments. So while welcoming you all for this webinar, all the resource persons and all the attendees, I would like to now invite Dr. Aruni. We record the secretary of the SpiceRoot Sri Lanka to share the session from this moment onwards and to conduct the session. Aruni, how are you? Thank you very much, Sankhar. So as we all know, on the 1st of December, the world unites to commemorate the World AIDS Day and to show our support for people living with HIV and also to increase the awareness and raise our voices to fight the epidemic. So this year's theme is global solidarity and shared responsibility. So as the young family doctors from South Asia showing our responsibility, let's unite to play our role. So though we are struggling, as Sankhar mentioned, with the pandemic, we simply can't forget the epidemic that we have been fighting for the last nearly 30 years. So the SpiceRoot Sri Lanka is very much delighted to organize the event to mark the World AIDS Day on behalf of the SpiceRoot South Asia. Of course, with the help of our partners from the region. The theme for the session today is ending the HIV AIDS epidemic, the role of primary care. So we have four imminent speakers joining us to share their experience and educate our colleagues and guide us on how to be responsible and take responsibility in controlling this epidemic. So let me introduce you our first speaker, Dr. Manjula Rajapaksha. Dr. Manjula Rajapaksha is a consultant, venerialogist at the District General Hospital Calutera. She qualified as a base board certified consultant in venerialogy in the year 2013. And she completed her OC specialized training at St. Mary's Hospital London. And also she has held positions as the secretary and also vice president in the Sri Lanka College of Sexual Health and HIV Medicine. Over to you, Manjula. And she will be focusing on the achieved and the unachieved in controlling the epidemic. Over to you, Manjula. Thank you very much, Aruni, for that nice introduction. And you can share your slides, Manjula. OK. Thank you very much. Sorry for that. Can you see my slides? Dr. Manjula, we can see your slides. Can you put it to the presentation mode by just clicking the button at the right downmost corner near the Zoom? Yeah. I think that's OK now. Yes, yes, yes. Now it's clear. OK. So good evening, everybody. And thank you, Aruni, for that nice introduction. So today we are here. And my first presentation as the first presenter, I would like to talk to you about the HIV-AIDS, the achieved and the unachieved. So as we all heard, we are commemorating a nearly 40-year-old epidemic of HIV in the midst of this newly born COVID-19 pandemic. So in my presentation, I would like to focus on the epidemiology, global, regional, and the local HIV-AIDS epidemiology. With the current HIV-AIDS trends and the National STD AIDS Control Program and its services, and what were the world targets and what we have achieved and the challenges ahead. So we know that the AIDS-acquired immune deficiency syndrome came to the world in 1982 with some people in the US came with the very rare kind of opportunistic infections and cancers. Then it initially named as GRIB, as Gay Related Immunodeficiency Syndrome. But in 1982, since they discovered that many other populations also got this same syndrome, it was defined as AIDS. And one year later, the French and US teams find the causative agent that human immunodeficiency virus as the cause for this. So since then, so HIV causing a very chronic infection, empowering the human immunity with its viral activity and causing a symptomatic severe disease AIDS in its later stages. So now the world has HIV also a pandemic. So currently, according to the UN AIDS estimates, the 38 million people are affected living with HIV at the moment. And you know, Eastern and Southern Africa is getting the more 7 million, but our region Asia and Pacific also have the second highest 5.8 million. And the estimated number of adults and children newly infected with HIV in 2019 was also 1.7 million. And in our region, it's 300,000 new infections in 2019. What about the deaths, the AIDS-related deaths? So 690,000 total HIV-related deaths were estimated in 2019 and 160,000 in our region. But about Sri Lanka. So actually, we are fortunate to be a low-privileged country yet, I'm saying yet. With the adults prevalence less than 0.1%. So current estimates for Sri Lanka, the PLHI, the people living with HIV are 3,600, with estimated new infections in adults in 2019, less than 200. But mind you that we have diagnosed 439 people in 2019. And deaths, AIDS-related deaths estimated less than 200. And we had 43 people out of that 439 people died in 2019. What about the trends? The adults and children living with HIV globally, know the estimated numbers are going up gradually because added to the old infections, the new infections are adding. So the HIV is in the rise. The new infections, the global new infection estimates and the current new infections, the world has reduced the HIV new infections by 40% since its peak in 1998. And the AIDS-related deaths have been reduced by 60% since the peak in 2004. When we see the distribution of HIV infections by population globally, we will see the key populations, what we call the gay men who are MSMs, the men who have sex with men, sex workers and their clients, transgender people and people who inject drugs account for 62% of new infections globally. And when we come to our region, it's interesting that 98% of these new infections are happening among these key populations. So what about the trends in Sri Lanka? So in Sri Lanka, if you take the reported HIV infections, the type of diagnosis, you can see it's in the rise. And from kind of 2016 onwards, the rise is kind of, there is a rapid rise, not a very gradual rise. And also you can notice the rise is more. The HIV infections are diagnosed more in mayors. So compared to 2011, we have 460% increase in men who have infected with HIV, which is kind of alarming in Sri Lanka, while the females remaining at a kind of 20% stable level. So when we see the probable mode of transmission, we can see why these men getting more infected because you can see that the light blue column in 2019, 46% of people got HIV infection due to the male to male transmission. So when we see the diagnosed HIV people, we can see the increase gradually from a heterosexually driven HIV epidemic in Sri Lanka to a homosexual driven MSM driven epidemic again in Sri Lanka, going with the global trend. So we have the AIDS epidemic module. We have postulated according to the available data. So this trend will be continuing if we are not to interfere with our interventions. And also, so as I told you, the estimated new infections are to be declined according to the estimates. But we are repeatedly the new diagnosis, not the new infection, the new diagnosis, I will say, because it involves the new and the old infections as well. So it's in the rise. So what is the reason for this? So when we take the CD4 level, that is the immunity. So HIV virus affect the CD4 lymphocytes. And if the CD4 lymphocytes are less than 200, we say the patients are in the AIDS stage. So severe immunodeficiency. So out of the people, nearly 32% in 2019 were in AIDS stage. And so if the CD4 count is less than 350, we say those people are also in the AIDS stage. So we can see nearly 54% of people who are newly diagnosed with HIV were in the AIDS stage. So we are diagnosing the people at nearly 50% of people at late stages. So then we move to who is giving the response to the STI as well as the HIV. So the National STID AIDS Control Program, Sri Lanka, is responsible for the national response for HIV as well as STI. So we were fortunate to have HIV services incorporated into our existing STI services, even before our first patient was diagnosed in Sri Lanka. So we are responsible for the preventive services as well as the treatment services and also the monitoring and evaluation part happening in related to STIs and HIV. So mainly the preventive services. So you understood that the more infections are happening in this key population. So NSACP also targets these preventive services mainly for the key population. So there are many community-based organizations and non-governmental organizations who support the NSACP in reaching these key populations because you know that the key populations are not always visible. They are a kind of a hidden population. So the HIV STI prevention package with the education and communication, condom promotion and information and HIV testing referring to the HIV clinics all happening with the support of the peer educators in the CVOs. And also we perform the rapid HIV testing for the KP's when they come to the STI clinics as well as as outreach programs. So to cater these key populations, we conduct evening clinics, outreach clinics and also prison inmates also identified as a key population in Sri Lanka. So prison HIV services happening. And with all these, you know that these key populations are belong to a hidden, who are with the kind of illegal behavior which is not accepted culturally or legally. So we have to do many things about create the enabling environment with legal and societal facilitation as well. So the other general population and the vulnerable youth also we have conduct many preventive programs through using the technology also as well because the young people who access the technology are like to access the services through that. And also preventing mother to child transmission of HIV and STI also a main component of NSACP and training and capacity building of health and non-health staff is also done with the NSACP preventive package. So the traditional awareness campaigns are now combined with testing because we know that testing promotes the linking to the care. So the diagnostic and treatment services is the other part of NSACP. So NSACP has 41 peripheral clinics distributed all over the island. So these clinics supports all the diagnosis and management of STIs as well as HIV. So and the HIV diagnostic services are now expanded to other health services like the hospitals from the base hospital upwards levels and to the community and also to the general practitioners as well, especially in Colombo and Gampaha district. So they give diagnose and treat. So we give the NSACP and the other clinics support the diagnosis and the management of STI as well as HIV. So we are giving antiretroviral treatment the effective HIV treatment for the people given for free by the government of Sri Lanka and also the counseling services and the other counseling services for the STI and HIV and also other mental health issues are also handled and referred by the NSACP. And other important aspect is provision of post-exposure prophylaxis mainly for the occupational exposures after needle stick injuries to the health care workers as well as non-occupational exposure also happening in the NSACP clinics. The pre-exposure prophylaxis also kind of a new approach to prevent HIV that is giving a ART before the exposure happens. So I'm not going to talk about that because Namahesh will talk later. So all these are happening in the NSACP diagnostic services. So wondering an evaluation part is also and very important component of preventive and curative service. So we have our strategic information and management unit which gathers all the information and dissemination is taking place. And also from 2017 upwards we have been planning to do the electronic information management system. So I'm proud to say that now many clinics are managing the STI and HIV management through this electronic management system, a Paypalas system. So when we go for the targets, the globe, the world has the targets of ending AIDS by 2030 which was started in 2015. So thinking the fast track targets for ending AIDS in 2030 was to reducing infections. We were then 500,000 by 2020 and also to eliminate HIV related stigma and discrimination because that is very important in achieving the HIV related goals. So to have achieved this goal, the world set the 1990-90 targets, that is the 90% of people who are infected with HIV should aware of their status out of which 90% should be linked to care and on the basis of the COVID-19 pandemic. And also out of which 90% should be fully virally suppressed with undetectable viral load. So this will cause the 30 million people on treatment by 2030 and fewer than 500,000 new infections annually. So have we achieved the targets? So if we take from 2000 to 2019, HIV new infections, so the world is now in a state of crisis with HIV new infections. So the world has been able to reduce the percentage change as 23%. So we have reduced the new HIV infections by 23% but you can see we have not achieved the target. So the target is there with the blue dot and there is a long way to achieve the target and it's related dates also the same. So we have not yet achieved the target even though we have reduced the HIV related dates. And what about the progress of this 1990, 1990 targets? So by end of 2019, the first 90, so we only achieved 81% and then 82% and so 88% who were engaged with care and on effective ART were virally suppressed. What about the regional values? No region was able to achieve it to the 1990, 1990 level and now a region Asia and Pacific. So it's 75% people knew that they were HIV status and out of which 80 engaged in care and non-ART and 91% were fully suppressed. But about Sri Lanka. So our first 90, only 64% of people knew they are HIV status by end of 2019 out of which 80% were linked to care and on started non-effective treatment, 86% were fully virally suppressed. So you can see nowhere in the world we could achieve these targets, the 1990 targets because we are nearly finishing 2020. So the world did not achieve what we expected even though we achieved something. So what are the reasons of this for this? So as you can see the first 90 was the major challenge we could not achieve these global targets. So there are patient-led factors and the physician-led factors leading to this. So mainly the people, the lack of their knowledge about the HIV and also the risk of HIV and about stigma and discrimination whether they will be stigmatized if they come to care and lack of access for testing services in some regions and the cost of testing if it is not available for free and also the thinking about the confidentiality and that there were many physician-related factors. So mainly what we see is the lack of updated knowledge about HIV because not considering HIV as a differential diagnosis was seen among the physicians. So when everything becomes negative only the physicians things can this be HIV and also especially in the kind of general practitioner setup family setup. So fears causing stigma and discrimination to the people because the general practitioners family positions are so close to the families and they might think that offering the test will cause a stigma and also not comfortable taking the sexual history and discussing this risk assessment and also fear of losing the faith by the patient and lack of enough time to discuss in the B.C.O.P.D. setups and the B.C. Words and also sometimes a simple negligence not thinking about HIV kind of negligence had also been seen as a reason. So to achieve 90-90 targets we have to say that we need to test more and also linking is also important. There are link all tips and positives for HIV care. So what we have actually achieved so we have achieved something. So we have we had a progress of this 90-90 targets and you can see from 2017 the testing has been increased and also the pregnant women HIV testing among pregnant women it was a kind of a selective testing in the beginning but it was started universal testing and now all the pregnant women were tested for HIV as well as syphilis and so with that achievement actually you may have heard that we have got the elimination of mother to child transmission of HIV and syphilis in Sri Lanka by WHO in 2019 the third country in the Southeast Asia after Thailand and Malaysia. So we were successful in getting eliminating mother to child transmission of HIV in Sri Lanka. And also we have reached key population even though we could not achieve 100% coverage reaching targets but we have reached key populations the female sex workers, MSMs, Beach Boys and people who inject drugs and also transgender people. So these are some achievements and also HIV testing we have expanded I told you the anti-natal mothers and the blood donors we do the universal testing and also you can see HIV rapid test were introduced to the hospitals from 2018 and we got a good yield. You can see after the highest yield HIV positivity rate was from that rapid HIV test done in the hospitals. So there are many challenges ahead. So in addition to the challenges we already faced this COVID-19 pandemic has put the world even further behind its efforts to end AIDS by 2030 but we can make a crisis and an opportunity. So in this difficult periods the communities were now better recognized for their leadership and their innovative methods. So we have to live in this near normal life for coming years. So this can serve as a platform for future success. So from the lessons we learned from this COVID pandemic and also the HIV epidemic, the HIV response the AIDS response can recover quickly. So the COVID-19 restrictions actually accelerated the innovations in HIV service delivery because the bird is engaged in community-led services where the communities, the PLHIV organizations and the community-based organizations were supporting in many ways the testing people, delivering their medication that kind of support and also use of new technology using some apps. So we use the no-for-sure app from the NSACP to test the youths who are using the technology and also introducing the HIV self-testing we will be introducing very soon and also multi-month dispensing of antiretroviral drugs. So people used to come monthly to collect their HIV medication. But in this pandemic, we were dispensing multi-month actually three to four months drugs for the patient. So these all innovations were happening because of this COVID crisis. So UNNeds set 2025 targets to achieve these ending aims by 2030. So rather than sticking into 90, so we are going for 95. So the important thing is they are putting the people living with HIV and the communities at risk of HIV at the center. So by 2025, so we have to achieve 95% of PLHIV should know their status. Out of them, 95% should be on effective treatment and 95% of them should be virally suppressed. And also 95% of mothers should have the services for eliminating the vertical transmission and also 95% of people, women have reproductive and sexual health services. So with this, so the collective global efforts that prioritize people can surely transform this COVID-19 crisis into an opportunity to accelerate the HIV response and get back to ending aims by 2030. So that's why we set the theme of World AIDS 2020 as a global solidarity and shared responsibility because it's not no country in the world could be able to eliminate HIV or COVID alone. So it's a global responsibility and global solidarity. So we will be, we can end AIDS by 2030. It's not an impossible target, it's a possible targets, but it requires more commitment, courage and compassion. So with that, I would like to conclude my presentation. So I think everybody, so the young general practitioners, family practitioners will join us to our target in ending AIDS. So thank you very much. Thank you very much, Manjula, for that very comprehensive timely presentation and also summarizing 40 years long epidemic into a nutshell and highlighting what we have achieved and what to be achieved. And also highlighting the lapses on our part as doctors. And just to clarify once again, Manjula, so you mentioned nearly 50% or more than 50% of HIV are diagnosed at a late stage, isn't it? Yes, that's right, yes. Yeah, so it highlights as the frontline doctors in the health system and as primary care doctors in the region, the role and the responsibility that we have to take in combating this epidemic. So yeah, thank you very much, Manjula. Now I would like to move to the next speaker. We have Dr. Mahesh Ratnaika, senior consultant in sexual, senior consultant sexual health physician at Adelaide Sexual Health Center and Infectious Disease Outpatient Clinic. Department of Internal Medicine, Royal Adelaide Hospital, Australia. Dr. Mahesh actually started his training as an inveniology in Sri Lanka and he completed the MD program and then migrated to Australia and now he's a very eminent clinician there and we are much privileged to have you today for our session, Dr. Mahesh. And over to you, Dr. Mahesh and he will be speaking on novel approaches for prevention and treatment of HIV. Over to you, Mahesh. Thank you so much. Let me see how I can share my screen. Can you see my screen? No, Dr. Mahesh, not yet. There's a green button at the bottom of the screen, say share screen with an arrow. Just give me a sec. I think there is a problem in sharing the screen. Till Mahesh is getting on with the slides, I would like to remind the audience, if they do have any questions, they can post in the chat box. So we can, you can ask at the end of the session from the speakers. Just give me a sec. Sorry, I'm doing the recording. Is it okay now? Yes, we can see. You can put it on to the point more. All right, thank you. I'm so sorry about that. So thank you so much for the kind introduction. And today I'm gonna talk about novel approaches for prevention and treatment of HIV. So I'll try to talk briefly about few topics. And if you have any questions, feel free to ask at the end of the presentation. And firstly, I'm gonna do, give a brief on the topics that I'm gonna cover today. The first topic is pre-exposure profile access for HIV. And then post-exposure profile access for HIV. And few things on new treatment options. And a bit on treatment as prevention. And accelerated initiation of ART. So let's talk about pre-exposure profile access for HIV. So PREP or pre-exposure profile access prevents HIV through sex and IV drug use. So I hope everyone knows about PREP and how it works. Sorry. The efficacy of PREP has been proved by several studies done throughout the world. And PREP can be taken either daily or on demand. So daily PREP is about 99% effective. And multiple studies have also proven that daily PREP works. And people can take on-demand PREP, which is taking PREP only when you need it. And it is 97% effective with the original IPA case study. So IPA case study later did an open-label extension. That showed it was about 97% effective. And there is another trial going on in France, which is called Prevenor Study. And which has proven none of the people who are taking on-demand PREP were positive if they were taking it properly. So we take on-demand PREP as effective as daily PREP. And PREP works at population level as well. So New South Wales Health Department released, did a media release recently. And they rolled out their PREP program in March 2016. And they saw their incidence of HIV dropped by one-third after 12 months. And Alfred Health in Victoria also did a press release. So their HIV incidence dropped from 28 in 2009 to 16 in 2017, which was about 43% decline. And their HIV testing rates were increased by 203% during 2017. But yet there was 43% decline in the incidence. So it works at population level. So few things about the guidelines and the eligibility criteria. So the first thing that happened was that few things about PREP guidelines and the eligibility criteria. And Australian National Guidelines have their own eligibility criteria for PREP. So this is assessing the patient's risk during the last three months, as well as future risks. So it could be you have a HIV positive partner who is not on treatment or still have a viral load if they are on treatment, doesn't matter. And if the patient has had any unprotected anal sex with one or more casual partners during the last three months or if they have been diagnosed with rectal gonorrhea, rectal chlamydia, infectious during syphilis during the last three months. Or if they have had chem sex during the last three months or if they have been quantum accidents. And then the recommendations extend for the next three months as well. And you don't have to have had any increased risk behaviors during the last three months. One can say, I would like you to have unprotected sex with casual male partners in next few weeks and the person is eligible for PREP. And so you can read that there are several options or several risks identified by the ASHEM to recommend PREP. And this is just sexual transmission only. And ASHEM also recommends PREP for IV drug users if they share needles. And this is WHO guidelines. The WHO guidelines look at the history over the last six months. And the person should be HIV negative. And maybe the person has a sexual partner whose HIV positive and not viral suppressed or the person is sexually active in HIV incidence, HIV incidence prevalence population and having these risk factors. But remember, before starting PREP, we have to exclude active HIV infection on the person. And his renal functions should be good. Creatine clearance should be more than 60. And if someone has signs and symptoms of acute HIV infection, we would not start him or the person on PREP. So PREP is with tinnophobia, ibuproxial femurate and implicit vein 200 milligrams is a combined tablet taken daily or when they need it. So I'm gonna talk about how to take daily PREP initially. So there are recommendations as to how to start and stop in daily PREP for different patient groups. So for men who have sex with men, they can start daily PREP with a daily tablet for seven days before they have unprotected sex. Oh, they can take two tablets as a step dose and it works after two hours. And then you take one a day as long as you need. And whenever you want to stop PREP, you take a dose 24 hours and 48 hours after the last sexual exposure. That's pretty much it. And all the other patient groups, population groups, including women, they have to take one tablet a day for seven days before it starts working. And then they take one a day as long as they want. And then they can stop the tablet after extending it for 20 days after the last sex. But the important thing is the adherence. So adherence is really important for daily PREP to become successful. So you need to take at least four doses per week to get successful results. And taking on-demand PREP is so easy. People can take two tablets between two to 24 hours before having sex. And they have sex then. And then they take one tablet 24 hours and one on the tablet 48 hours after having sex. And basically they take four tablets at each episode of sex. This is so easy. So a bit about monitoring of PREP. It's really important that people have a HIV test initially and not start in PREP until they get a negative HIV test. So depending in the previous sex behaviors, sexual behaviors, even though you start PREP, you might still need to have a repeat HIV test in six weeks time. And you need to assess side effects each and every time. Hepatitis B testing has to be done initially because tinfoil and ampicidobene are both active against hepatitis B. So if you start someone on tinfoil and ampicidobene with hepatitis B, the people, patients can get severe hepatic flare ups once you stop daily PREP. So it's really important that you exclude hepatitis B before starting PREP therefore. So hepatitis C testing has to be done initially as well as every 12 monthly for people who are on PREP. And basically, it's quite understandably, you need to do STI testing on these people every three monthly and EGFR has to be done initially and in three months and thereafter every six monthly. So bit of an explanation as to why we should do EGFRs is because tinfoil, defoxid fumarate can cause a kidney impairment in about one to two percent of the population. And urine protein creatinine ratio is done for the same reason to monitor kidney functions because you will see patient leak excessive amounts of proteins if the kidneys are getting affected. And obviously you need to exclude pregnancy in females. So basically people come every three monthly, they get their STI testing, syphilis testing, HIV testing and they get a script for three months. And people actually follow their sort of proposed follow-up plans, it's really good to see them coming every three months over testing and to collect the scripts. And a few new developments on PREP. As I said before, either you have to take it daily or when you need it. But there is a phase three trial ongoing for long-acting injectable cabotegravier which is an integrase inhibitor which can be given every two monthly if the trial is successful. And there is another phase trial, phase one trial presented in International AIDS Society Conference last year. And they did study something called isletravier which is a nuclear side reverse transcriptase translocation inhibitor which they did study for 12 weeks but the mathematical modeling showed that the implant can, sub dermal implant can last for about 12 months. And it's amazing you see that you could put an implant and it works for 12 months for PREP. It's much better than contraceptives. And post-exposure prophylaxis is not a new topic at all but I thought as GPs and people who provide primary care for people, I think it's good to know a bit more about PREP as well. So PREP is post-exposure prophylaxis is 81% effective in preventing HIV but it has to be taken within the first 72 hours. And the duration of prophylaxis is 28 days. So PREP, sorry, it should be PREP. PREP can be prescribed following sexual exposures, needle stick injuries or shared needles and other injecting equipment. So PREP prevents HIV in all these situations. So this is an Australasian guidelines on PREP recommendation. When someone has an exposure to a person with unknown HIV status. So just ignore the estimate risk of HIV transmission for exposure because that risk is calculated with the Australian data. So that's not very relevant but you can see a receptively intercourse. If the partner's HIV status is unknown, we give two drugs, shared needles, two drugs, inserted into intercourse, two drugs. And vaginal intercourse is less risky because the prevalence of HIV in Australia is less than 1,000. So it's probably same for Sri Lanka as well. So we generally don't recommend PREP. And oral intercourse is the next important thing. There is absolutely no risk of transmitting HIV through oral sex unless the person has a big sore on the penis or in the mouth. So we don't generally recommend PREP following oral intercourse. And mucus membrane and non intact skin exposures also unless the source person is high risk of having HIV we don't recommend it. And community needle stick injuries, not in the health care sector. Sometimes people come with needle stick injuries occurring that have occurred in the community. So discarded needles in the streets and so on. So we don't recommend PREP for those situations. So when the partner is known HIV positive, the situation is totally different. But you have some sort of new sort of concept U equals U, which is if the person is undetectable, which means if the person is on treatment and having an undetectable viral load that person cannot transmit the infection to someone else through sex. So therefore, if the partner, person had six is HIV positive and on treatment with undetectable viral load, we don't recommend post-exposure prophylaxis. But if the source person is HIV positive, unknown on treatment status or viral load is not known, then we always recommend three drugs. But even so, you can see, we still don't recommend PREP for oral sex. Unless the receiving partner had a big show in the mouth. But, thankfully, WHO has made this very simple. Basically, if someone is eligible for PREP, the person is going to get three drugs. So what they say is, they acknowledge two drugs are effective, but they recommend three drugs for people, which is straightforward. And you, the CDC guidelines follow the same thing. So this is very straightforward. The Australian system is a bit complicated as usual. So what medications can we give? So basically, we have the entrate viral therapy backbone. So you have tinnophobia, laminuridin as the backbone. So if you are giving two drugs, you can give either tinnophobia, laminuridin, or tinnophobia, intracellular pin as the two drug option. And sideuridin and laminuridin were an option in the past, but even WHO doesn't recommend it whether these days because of side effects with headaches, diarrhea and anemia. So it's not a preferred option anymore. So third drug could be lopinoviritonevia, which is the preferred option with WHO. And WHO also recommend adicinaviritonevia, darunaviritonevia and raltegrubia. Australian guidelines recommend dolutegrubia and rilpurin as well. So that's post-exposure prophylaxis. And let's talk about new treatment options. So this is going to be a little bit technical, too technical probably, but anyway, so basically we have combined single tablets with multiple medications you take as a single tablet a day. So we have abacavilamidinadolitegrubia, which is not very new, comes as Triumec. And then we have tinofevialalphanamide, imprecisantabine and l-vitigrobia with the booster-cobbacistat as genovia. That's not very new either. Then we had the old version of genovia with tinofevidifoxylpumarid, and that's nothing new either. We have odepsy, which is tinofevialalphanamide, imprecisantabine and l-vitigrobia. And then every player with tinofeviproxylpumarid, imprecisantabine and l-vitigrobia. And so the newest one is victavi, which is tinofevialphanamide, imprecisantabine and victagravia. And then simtosa, which is traf-imprecisantabine teronovir-cobbacistat. Then we have destrigor, which is TDF, FTC, 3TC, and low-rivoring. So basically all these are three medications coming as single tablets. So as you know, for HIV, the conventional treatment is with three medications, triple therapy. That's why we say heart-highly active antiretroviral therapy. So these are the options we have at this stage, the latest options including treatment options, which were available within the last, I would say six, seven years. This is all triple therapy. Now we have two drug combinations. We have descoe with tinofevialphanamide and imprecisantabine, which is a backbone, then you have to add another medication to that to make it triple therapy. And adesanovir-cobbacistat is a protease inhibitor. So that is the third drug. You need to have a backbone with tinofevialphanamide or abacavir with lemuridinoimprecisantabine. And deronovir is also protease inhibitor. The boost is cobicistat. Then you have a backbone. Then you have to add deronovir-cobbacistat to that. Then we have brand new options, doletegrivir and ripirin, coming as geluca. And then we have doletegrivir-lamudin, coming as duvato. But the interesting thing about these two medications, geluca and duvato, they can be used as dual therapy. So instead of taking three medications, patients have an option of taking two medication, but still as a single tablet, but they can take two medications these days. That's one of the latest developments in HIV treatment. But there are a few caveats. So let's go to dual therapy options. So duvato, that is doletegrivir and lemudin, you can take one tablet a day, a single tablet, but the viral load should be less than 500 copies millilitre, 500,000 copies millilitre, sorry. And there shouldn't be hepatitis B or any resistance, doletegrivir or lemudin, before we can give duvato. And the next dual therapy option is geluca, which is doletegrivir and ripirin. And so there are some problems with ripirin, have to take it with food, then you can't take any PPIs, due to drug interactions. And there shouldn't be any resistance to either doletegrivir or ripirin. But if all these sort of fulfilled, then people can go on geluca as a single tablet. And another dual therapy, which is an injectable, which is likely to come into the market within the next couple of years, is cabotegriir and ripirin as an intramuscular injection, which can be taken monthly or two-monthly. So this is very interesting, because some of my patients are very keen to not take a tablet daily, because that reminds them of their HIV every time they take a tablet. So I think this population will be benefited by injectables. But as you would understand, most people don't like injections, and there were some injection site reactions, which is probably a bit of a drawback in injectables. But some people will welcome this greatly. And the next topic is treatment as prevention. So this is very interesting. The Ashm, which is the Australian sexual health, sorry, Australian HIV, viral hepatitis, and sexual health medicine society guidelines. They did issue this recommendation, endorsing undetectable equals untransmissible, U equals U. But this says is if someone has undetectable viral load, viral load treatment, he's practically will not be passing the infection to someone else by having sex. So there is evidence since, there has been evidence since year 2016, that a durable HIV viral suppression, less than 200 copies per milliliter, will stop the sexual transmission of HIV. So there is no ambiguity in this recommendation, which is U equals U. There's no may or will or whatever. It's U equals U. Or it's very strong message that will change people's life who are infected with HIV. But this is only for sexual transmission. There's not enough evidence for transmission through blood, or best feeding at this stage. So I think we might get some more information as we go on. So what does mean undetectable? And so different areas and different countries of the world, they will have different definitions on what is undetectable viral load for them. And in my practice, undetectable for me is less than 20 copies per milliliter. Or even less than 10 is undetectable. So if it is less than 10, the lab will say undetectable. Between 10 to 20, it would say detectable less than 20. But if it is more than 20, the lab will give us an actual number. But it could be 50, it could be 200 depending on where you practice. But if the viral load is less than 200, and if the person is on treatment and there's good adherence, you can safely say U equals U. So with the current treatment options, especially with integrase inhibitors, your viral load is patients viral load is likely to be dropping to zero by, I would say six weeks. So once it drops to zero, if you do two viral loads between a four week period and if both are undetectable and if you have a confidence that the patient is taking the treatment, it's safe to say U equals U. And more conservatively that the theory has been, it has to be six months undetectable before we give the green light to have unprotected sex. But with the new recommendation, all you need is good adherence and two negative viral loads over four weeks. So one of the benefits of this concept, obviously you would understand it will diminish the stigma associated with HIV and sort of reduce the barriers for HIV testing and treatment and improve self-esteem and supports the health and sex life of these people and reduces sex passions concern and they can have children safely. So there are a lot of benefits of this concept. And, but the problem is, if the patient stops taking HIV medications, the viral rebound can happen within one to two weeks and they can possibly transmit infection of their partner. So that's really important concept or it's important message because if the people don't be sort of, they are not genuine in what they are saying to the health professional, the things can go wrong. So U equals U is good, but there are few caveats. And there is this concept of accelerated ART initiation endorsed by WHO since 2017 from the top of my head because delays in starting ART can be sort of very disadvantageous for people who are co-infected with HIV or if they have acute HIV, zero conversion or advanced immunosuppression. So as well as there's emerging evidence that ART, starting ART as soon as possible, improves clinical and program outcomes as well. So why, what are the benefits of starting treatment as soon as possible? One is of course the clinical benefit to the patient, all right? So if they are zero converting or if they have advanced HIV, as Manjula said, if it is closer to 200, they might be reaching eight. So that's for their personal benefit. So ART, rapid ART will reduce the viral load and gradually increases the CD4 counts and there's a clinical benefit to the patient. And what is the benefit to the society? So people, these people will drop their viral load as soon as possible and they become HIV non-infectious. So I also start the same day initiation sometimes if they are sort of acute zero converting or with the sexual history, the patient tells me that he has had sex with 10 people in the last three months. I would start the patient treatment on the same day because of the public health benefits. And so the WHO recommendation is rapid ART initiation should be offered to old people living with HIV following a confirmed HIV diagnosis and clinical assessment. And same day initiation should be offered to people who are ready to start treatment on the day. But again, then there are a few limitations. Patient should undergo histrionic clinical examination to evaluate for significant opportunistic infection, especially for tuberculosis and cryptococcal meningitis. So we need to assess patient clinically for signs and symptoms of TB and cryptococcal meningitis or any other significant opportunistic infection. So in that situations, we will defer treatment. You order CD4 count on the day, but you don't need to wait for CD4 results before you could start treatment. And if there are clinical signs or symptoms of TB, then obviously you have a different treatment than SS symptoms and try and diagnose TB or exclude TB. If the TB is diagnosed, recommendation is you start anti-trivial treatment as soon as possible and start HIV treatment within the first eight weeks. But if the CD4 count is less than 50, you need to start treatment earlier than that because there is high mortality if you don't start HIV treatment as soon as possible. And if cryptococcal antigen is positive, I would still delay treatment because they can have cryptococcal meningitis. And with treatment, you can get immune reconstitution inflammatory syndrome, which can increase intracranial pressure and cause complications. So people who have positive cryptococcal antigen should have lumbar punctures. And if they are diagnosed with cryptococcal meningitis, then ART should be delayed depending on the treatment regimen. It could be up to about four months, two months, it could be more. That's pretty much it. So I'm happy to take any questions if you have. Otherwise, thank you so much for inviting me and listening to me. Thank you so much. Thank you very much, Dr. Mahesh, for enlightening us on the most latest prevention and treatment options and also emphasizing how effective the current new treatment available and how it can help in the propagation of the epidemic. And if you have questions, you can post into the chat box and the PNList is, I would like to request from the PNList also, since we are running behind time to reply the queries in the chat boxes so that it will save time. Now, next we have our resource person for the today's session is Dr. Bidu Banerjee. I'm sorry if I'm mispronouncing. He's a senior registrar in the Department of Family Medicine, Artemis Hospital, Haryana, India. And we also have Dr. Ramakrishna Prasad as the moderator. Dr. Ramakrishna is a consultant HIV in primary care and he's both certified in family medicine in USA with expertise in infectious disease. In addition to the residents in family medicine, he holds a master's in public health, infectious disease, and microbiology. And also fellowships in HIV aids, viral hepatitis, and faculty development in family medicine from the University of Pittsburgh. Besides significant faculty and leadership level experiences in the USA and India, he has also worked in other countries such as West Indies and Southern Africa. So now this session is going to be based on his presentations. So it's going to be lessons from patients. And over to you, Dr. Binarjee. Are my slides visible? Yes, Dr. Binarjee. Yes, we can see. Okay. Thank you so much for the moment production. First of all, I would like to thank AFPA and Spice Group for giving this opportunity. So good evening one and all. It's a rather cold evening here in Haryana, Gurgaon in India. And I, Dr. Vidyut Binarjee, would be discussing about a rather hot topic. HIV in India reached and unreached. Where do we stand as of now? And where we ought to be? So I have these objectives for today's program. We'll discuss India's position in terms of HIV targets, share a real life case scenario from our hospital. And using that highlight the importance of primary care physician in HIV care. So the fast track targets have already been explained by my previous speakers very well. We have now moved to the 95 target. And what do our numbers say? So overall India's pandemic is slowing down if we were to see the prevalence of adult HIV. It stands at roughly 0.22%. But yet with the population as huge as ours, we are actually referring to a sizeable number of 2.3 million people living with HIV aids. We have had close to 59,000 AIDS related deaths in the year 2019, which amounts to a decline of roughly 66% decrease from 2010. So where do we stand in the 95, 95, 95 target? That's there on the screen right now. 76% aware of the status of which 83% on HIV treatment which is a substantial improvement if we were to consider 36% ART coverage in 2013 or even 56% ART coverage in the year 2017. And 33% of these people were vitally suppressed. So this is what I'm talking about exactly in numbers from the recent India HIV estimates of 2019. Well, looking at this, this sounds all nice and sweet, isn't it? Are we really happy with this? Let's see. If you look at the graph left top corner, yes, these are plenty. We have 65% of HIV infections and 78% of people living with HIV in India as of 2019 from 10 major states and only because few states like Maharashtra, Andhra Pradesh, especially Karnataka have done a brilliant job. Do we see that the number of people who are living with HIV in India is decreasing? So what we see as national numbers do not exactly translate to progress of all the states. We are home to almost 24% of the global multi-drug resistant and rifampant resistant TB burden in India. We see that the number of people living with HIV associated TB were not reported to have reached the TB care. We need more insights. There are data inadequacies on key population size estimates at a district level. For example, migrant workers who are essentially forming a bridge of population with HIV infection. Yet we do not have much information about their sexual practices. Stigma and discrimination, if we were to go about the 2016 study, one-third of adults demonstrated discriminatory attitudes towards people with HIV. This is even common in the medical fraternity. So this is really saddening to hear but a substantial majority of those infected with HIV when questioned said that many health care staff had this attitude that they got what they deserved, which is a really sorry state of affairs. Now stigma and discrimination be it faced by sex workers, transgenders or sex with men, it would obviously discourage people from attending clinics and health facilities leading to sub-optimal adherence and delays in getting prescriptions different. This would interfere with the viral suppression. Condom usage although is in acceptable ranges in the high risk for key populations and the 41% of men reported using a condom at last higher risk sex. And when we talk about HIV education and approach to sex education, only one-fifth of men and women between ages 15 to 49 had comprehensive knowledge of HIV. So there are many things that we need to cover up on many fronts. Moving on, we'll come to the case scenario through which we are going to discuss some of the changes and practice that could probably. So we had a 50-year-old emaciated gentleman brought to us on 17th October at 5 a.m. in the ER in a drowsy state with a sudden onset of breathlessness after the patient was fed milk. As per his attendance, although the patient had been drowsy for the past three days, his sensorium had worsened from the past one day. Vital short mark, tachycardia, hypotension, tachypnec, initial saturations of 60% on room air and patient was fibril. So the ABG was effective of type 1 respiratory failure with severe metabolic lactic acidosis. Just to give you a brief background on this gentleman, so he was suffering from low mood and poor attention from almost six months and had poor orientate for three months and generalized weakness for three months. Both were progressive in nature and he also was having several syncopal episodes for 14 days and uncontrollable hiccups. Few days prior to this admission, he developed fever. So family history wise, he's married with two children and the elder daughter is 11 years old, younger son, seven years old. The sexual history could not be collected because the patient was an altered sensorium. Previous prescription had labeled him a case of anorexia nervosa with depressive disorder and we had a few scattered prescription from multiple physicians and some blood workup which showed basically anemia and low PLC count and his chest x-ray was something like this. There were bilateral ill-defined opacities, unremarkable high-less shadows. At the time when this patient came, we are hospital obviously was completely filled with the cases of the pandemic and this is what everyone would probably be thinking of COVID. So basically provisional diagnosis in ER stood at Sari-like illness, possibility of aspirational pneumonia, sepsis with type 1 respiratory failure and septic acidosis in short. To summarize this case, so little did we know at that time that this gentleman is going to be with us in the hospital for little over one month and substantial duration of that was spent in the ICU and we had counseled the wife which came in positive for HIV1 subsequently the HIV RNA PCR copies and quantitative was sent and CD4 counts were found to be as well as 29. So why are we discussing this case in particular? So this was not a very usual case. There were multiple complications. This gentleman had anemia, thrombocytopenia, altered sensorium, and the patient was intubated and was in the ICU. So we investigated, we investigated and found only things that we found were Candida and Klebschela pneumonia and we started on culture sensitive antibiotics and antifungals. We wanted to look for CMV, possibility of CMV and due to cost issues the PCR couldn't be sent. We just sent the IgG which came in positive and after a lot of thought Valganzai Klovir was started as treatment. So what happened was despite all of this although the patient came out of a ventilator and the oxygen requirements were still there and the chest shadows were not improving. So the workup for PCP all came in negative completely and we thought of MAC as well and nothing came up. But after a lot of thought we finally initiated treatment for tuberculosis including MAC coverage. So basically this gentleman was discharged as a case of HIV wasting syndrome along with Candidaeases. Sepsis septic shock LRT which is Klebschela with possible PCP and CMV infection. And we still were doubtful about almondary TB and MOT that is non-tubicular mycobacteria. So discussing this case there was involvement of so many specialties and what exactly went wrong. Is this the way generally HIV case should come to us? So we have a few pertinent concerns over here. Did the primary care physician miss the bus? Really anorexia nervosa, depressive disorder, a 50-year-old male, less likely, very less likely, yet there's diagnosis and we could see that the patient and attendants were hopping doctors because all prescriptions were from different doctors. Or maybe the anorexia nervosa was a diagnosis of denial. Maybe the patient's consent was taken. He was probably evaluated and found to be HIV positive, but he wasn't still ready for this diagnosis. He was not agreeable to this diagnosis. We'll hold that up. We'll discuss about it in detail. The other concern is are we looking at a patient-centered holistic approach or are we just venturing diagnostic thirst when we have to involve so many specialties and there is so much cost burden on the patient. So I'll elaborate slightly on the Kubler-Ross grief cycle here. So this was a model that was studied by the scientist Kubler-Ross and she gave it for terminal illness. She had proposed that grieving generally progresses in five stages, those being denial, anger, bargaining, depression and acceptance. So there is this very specific pattern about grieving in HIV because till the time the patient is in a phase of denial or anger for that matter, the patient generally tends to grief in isolation. Unlike other terminal illnesses, let's say for cancer, because here the patient cannot disclose this diagnosis to the most close ones, the most near and dear ones. So that is bad as a support system for the patient. And once the patient probably starts coming to the phase of bargain where he's overwhelmed and still helpless and he's probably wanting another diagnosis, please God, why me? Why this diagnosis? And subsequently, you want the patient to actually enter the phase of depression because that is the road towards acceptance because at bargaining level, also these patients tend to shoot out and they remain in denial or they don't accept that diagnosis and there is a risky behavior patient tend to do drugs from habits. So coming towards acceptance is obviously the right course of action because the stigma associated with this disease is such and also the poor knowledge because still for majority population, just this diagnosis of HIV AIDS is maybe they're faced with death. It is for them like a death sentence because they're not aware. So when we discussed about holistic care, I think the best care, only healthcare providers who are offering a patient-centered non-judgmental care will manage to establish a smooth journey from probably an effective diagnosis to appropriate psychological, psychosocial support and then continuity of treatment. So let's go through these components of this cycle. So the first one being the team approach towards the diagnosis. So that doesn't mean involving all specialties from the bird crew and investigating in all directions. It is basically that we need to involve the psychologist and physician together to get him prepared for effective therapy, him or her for effective therapy. Now, customization of pharmacotherapy, only with the right knowledge about the HIV infection to the patients that only comes when the doctor or the physician treating first has the right amount of knowledge about it and the knowledge and understanding of pharmacokinetic and pharmacodynamic aspects of therapy. But the physician brought Taylor-made regime for her or his patient. The physician has to utilize existing supports, be it a community support, family support or spiritual or religious support. And only necessary referrals, very, very important that we only stick to necessary referrals because only if there are certain coexisting medical ailments that need to be taken care of beyond the treating physician's scope, only then referral. Monitoring is not just monitoring of the lab parameters. It is also monitoring how is the patient taking the disease, the mindset, because we have to catch hold of certain behavioral patterns because this is not a disease, not taking anything away from the specialists who are doing great in our country. But for example, this treatment is not like the treatment of CKD by an aphrologist. You don't just start and diagnose CKD and then as the patient knows, he has to undergo dialysis and continues. Here, the patient in between treatment might lose confidence, may stop taking medications, may not disclose it to you and that can cause all sorts of problems. So drug resistance could be there and you don't get the right kind of viral load suppression. And coming to life goal setting, that is very important. That is why we are emphasizing that HIV primary care physician has an important role because life goal setting is not something that you could probably get at a multi-speciality hospital taking care of your treatment. You have to know the patient being a family physician, have a great rapport with the patient and only then you can set effective therapy and discuss with him or her for realistic goals for her or his life. Tell them about U is equal to U as has been highlighted by my previous speaker and that might be very liberating for the patient. So as a family physician, our goals should be, I think the five C's at the heart of family practice are contextual, comprehensive, continuous, coordinated and first contact care. And in addition, obviously wherever possible, because no matter how rich our country continues to get, we are always a resource poor nation in terms of medical facilities. So cost-effective care. And I would like to quote Dr. Davis Shetty from his FedEx talk over here that a solution that is not cost-effective, especially in our country, is not a solution at all. So some take home points. National and global initiatives for HIV care, a lot is being done but not enough has been utilized yet. More family physicians trained in the art of HIV medicine and with the awareness of emerging drug resistance are needed in primary care setting. Patient-centered non-judgmental holistic care remains the essence of approaching a person with HIV and probably long back things were sensed by this great physician and teacher Sir Robert Hutchison. And I would like to quote him over here, from putting knowledge before wisdom, science before art and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same. Good Lord deliver us. I'm a lighter note. Here is HIV in India and this is your friendly neighborhood family physician trying to hold on to where we have reached and trying to pull in what has been unreached so far. I would like to thank Spice Root and AFPI for this opportunity. Dr. Seema Deerbam, a senior consultant at my hospital, under whom the patient was admitted, Dr. Arpigen, senior consultant at my hospital in internal medicine and HIV medicine, Dr. Arpigen Grasab, who has mentored me through this presentation. Without his support, this wouldn't have been possible. Dr. Pranit, I do not frankly have words to describe at what orders he has helped me out with this presentation. Dr. Jyotika, Secretary Spice Root, immensely thankful for this opportunity. My dear colleagues, Dr. Anadi Prakash Mishra, Dr. Divya, Dr. Tamal Hazra, and Dr. Neeraj Kumar, who have been taking care of all my irritability and tantrums. And two of my friends, Pavan Kriya Kaurthiwal and Dhania Meryan Thomas, who have provided timely creative distractions when I was getting irritable. Thank you so much. And I would take any questions or if the time permits or maybe we can have them in the chat box as suggested. Right. Thank you very much. Thank you very much for that interesting presentation. I really love that, especially the note you made about the holistic care. So thank you very much for that. And also for enlightening us about the status of HIV and the management plans in India. And also a special thank also I think Dr. R.K. for mentoring him. So thanks. Thank you very much. Thank you. Thank you so much. Thank you so much. Thanks. So we are moving on to the next talk. Our next speaker, Dr. Aruni Veerakon De Silva is a board certified specialist and a senior lecturer in family medicine in the faculty of medical sciences, University of Sri Jawa Dhanapura Sri Lanka. Aruni is the national secretary of the spice route movement as well. And interestingly, Aruni has a postgraduate diploma in wind rheology, which made us to select her unanimously as the best speaker to talk to you on this topic. Aruni, over to you to talk to us on HIV infection, the role of the general practitioner. Yes, Aruni, you are ready to go. Can you see the screen? Yes, we can see. Okay. Sorry. Since we are a little bit behind time, I would like to go through, take a quick go through in my slides. And just in the start, I would like to take three points from the three speakers. The first from Manjula, Manjula highlighted that the HIV infection is diagnosed late, more than 50% is diagnosed at the late stage. And from the second speaker, the marvelous opportunities that we have, the medication for prevention and prevention of transmission and also for the treatment making, I mean, the life expectancy near normal and also providing the opportunity for the people living with HIV to lead a near normal life. And then from the third speaker, the primary care missing the bus. So keeping all these three points in mind, let's go through what our role should be in the management of and combating this HIV epidemic. So I would like to focus on five areas where a GP can play an important role. The first is the increasing awareness among our patients, next promoting safe sex. And the most important out of all that is HIV testing, because by now you must have understood that testing is the key to fight this epidemic because we have such wonderful options for prevention and management of HIV. Then comes the prevention and guide opportunities, the management after occupational exposure. This of course, since there have been multiple questions on the chat group, I have posted to the chat, the relevant information, so I would cut time on that. Then the most important is to support the people living with HIV and their families. So coming into the GP role, the most important is to detect the high risk populations that we are dealing with. So most of you all know the sex workers, the men having sex with men, and then the patients who have multiple sex partners, tourist industry workers, migrant workers, prisoners, drug users, victims of sexual violence, internally displaced populations, war victims, and patients with STI, STB, hepatitis BC. And this is a summary of the high risk populations where we should target our health education and screening. So when we say about identifying our high risk populations, the most important is the sexual history. Most of the time, we feel a bit backward in stepping into the sexual history, especially when we are having a good doctor-patient relationship with our patients, and we have been knowing the patient for a long time and even the family, we feel a bit reluctant to ask the sectional history. So what are we going to ask? We have to ask about the Kuitake. That's a first sexual exposure when it happened and the age at Kuitake. Then the type of sexual act. So can you remember what is said about the MSMs, the men having sex with men, that these MSMs are the population who drives the epidemic in most of the world. So the receptive venal intercourse is associated with the highest incidence of HIV infection followed by insertive venal intercourse and receptive vaginal intercourse. So then we have to ask whether the act was protected on, protected, that is whether they use condoms appropriately, and also a few details about the partner, whether it is the marital, the stable or the casual partner, their occupation, and also about their risk behaviors. And we have to take a detail history about the last sexual act, the partner details, when did it occur, the type of fact, and whether it was protected or unprotected. Why do we need such detailed sexual history? Sexual history is a way of assessing the risk of acquiring HIV. Then it helps to tailor made the health education and counseling based on their high risk behaviors. And also it helps us to manage and time the screening test. And also it helps to interpret the reports and also it gives us an opportunity to encourage partner screening. So promoting safe sex, I think all primary care doctors, we know we have to find time for opportunistic health promotion and prevention. So once we come across high risk population, it is wise to grab the opportunity to educate them on HIV and how to prevent. And also all primary care doctors should be competent and confident and should not be reluctant in promoting condoms. And also they should be feel very confident in demonstrating how to use condoms and so on because it is a key skill that is necessary to protect yourself from HIV. Right, so as emphasized early, the global target is to screen, screen, screen and detect HIV people at a very early stage. So screening is one major area where the general practitioners can play a major role to help and take responsibility in fighting against HIV. So my next few slides are based on the national HIV testing guidelines of Sri Lanka. So HIV screening is based on five principles or the five C's that is counseling where we give the necessary information before doing the test, the pre-test information, then ensuring our patients about the confidentiality, obtaining consent before the testing and ensuring correct results. That is as doctors we have a responsibility to ensure that our testing is done in a trustable laboratory and adhering to quality assurance mechanism. The final C stands for connect to care after testing whether it is negative or positive based on the patient's risky behaviors. We have to connect our patients with other resources, the STD control programs, the STD clinics and so on to support them to protect themselves from HIV and for the positives to get the proper treatment. So in most of the countries the recommendations on testing varies. So based on the prevalence of HIV and available resources, in some countries it is recommended that you give a suggest testing with minimum information and give the opportunity for the patient to opt out. And written consent is not required for HIV testing, verbal consent is more than enough. So what is available as screening test, we have the fourth generation test which combines HIV antibody and the antigen. So narrowing down the window period to two to three weeks and also we have the rapid test which utilizes again checking for the antibody as well as the antigen which can be whether results can be available in a very short time like 20 to 30 minutes and it could be done at point of care and even in the feed making HIV testing more acceptable and available. If the screening is positive it is followed by confirmatory test done on a different sample using immunosay, the western blot or the molecule assays. And at the moment in our country in Sri Lanka the confirmatory test is available only at the national reference lab. A screening is not just one go process especially if there is an ongoing risk for HIV. So we have to consider repeat testing and also based on the last exposure we might have to repeat the test considering the window period if the patient is within the window period we need to have we need to repeat the HIV test in six weeks and maybe even in three months in rare occasions if we have strong doubts. Right so what are the strategies of testing we have client initiated testing that is a patient who is aware of HIV and have a self-evaluation of the possibility of having HIV stepping into a doctor and asking for the test. So this is an opportunity that we should not miss so we should be able to cater these patients by at least drawing the blood and sending it to a relevant laboratory or of course if we do have the rapid test in our clinics we can provide our patients with the rapid testing and giving their results within one hour or so and there will be a video at the end of the session demonstrating how to do the rapid testing. Then comes the provide initiated testing. So a provide initiated is the doctor decides okay this patient needs a savage testing. So it is routinely done for all pregnant mothers, all patients with TBs, all patients with STIs, all patients with hepatitis B and C and also for healthcare workers who have accidental exposures and also for drug dependency programs. Right then comes the people who we decide whether we are going to offer testing based on their risky behaviors. So family members, siblings of people with HIV infection and patients who are suspected of having primary HIV infection and other HIV-indicated patients which will be dealt a little bit later and also when having sex with men, the female sex workers, beach boys, present inmates and also the youth and also migrant workers, tourism, tourist workers and also persons with multiple sex partners. So not only the AIDS defining illnesses there are other conditions which we might encounter in our general practices like bacterial pneumonia, dementia, severe seborrheic dermatitis, oral candidiasis, chronic diarrhea, unexplained weight loss and unexplained blood disc, crazy hours, generalized lymphadenopathy. All these conditions we might come across in our day-to-day practice and we should not wait as our last resort and to exclude all the other conditions. We have to consider to offer HIV testing in these patients. Right and supporting the people living with HIV they go through a lot of suffering and we have to think of psychological support and supporting the family as well. As doctors we have to know, we have to appreciate that they are people with human rights. So we have to act to reduce stigma and prevent discrimination and we have to be non-judgmental especially when we are dealing with these marginalized populations like men having sex with men and the sex workers and so on. Coming to the last bit of the presentation, counseling for HIV testing like I mentioned we have to give the minimum information and get the consent. So if we are having the time to do a pre-test counseling we should educate them about HIV AIDS and the improved outcome nowadays with the modern medication, the natural history has become much more acceptable and transmission can be nullified by the available treatment. And so highlighting the benefits of diagnosis and also highlighting the availability of the services for the patients, we can encourage them to take up the test and also guarantee confidentiality. And if the test is negative, if the risk is ongoing we still have to link our patients with other resources like the STD clinics and if they are positive we have to explain them what is the meaning of being positive and the follow-up needed for the confirmatory testing and linking with them with the treatment services and so on. And also we have to find out soon after giving this bad news, we have to find out how they are coping with the results at that moment and make sure they have a safe journey home and make sure that they have a lot of support during the very early phase where they are going to be stressed out and frustrated about their new issue. So next we have a very short video explaining the rapid test and over to Dr. Supoon, can you play the video please? Yes, I will. Can you put stop share? Okay, sure. Right. There are different types of HIV rapid test kits are available in Sri Lanka. It could be either HIV antigen and antibody test or antibody only test. It may be HIV1 and 2 antibody test. Today we use HIV antigen and antibody homorepid test. First you take the rapid HIV test tray. If you are performing more than one at a time we need to label them with a number and the time of the test. We need to clean the skin using a sock with antiseptic. Then prick the finger using a sterile lancet. Squeeze the finger and collect the blood into a capillary tube at least one centimeter color. Then blood transfer to the rapid HIV test tray. Next you add the buffer solution. How do we interpret the results? Check the strip after exactly 20 minutes. This is the control band and this is the antigen line and antibody lines. If the control band is not available, test is invalid. If a control band is present but no other band is there, test is negative. If all three bands are positive considered as positive, either antigen band or antibody band with control band is considered as a positive. You can see this patient's strip has only control band. Therefore it is negative. Lancet capillary tube and test strips need to be disposed into a sharp beam. Overduce. But Aruni, I have a special request from Dr. Ramakrishna Prasad. I think he is here. I think he is there. Dr. Ramakrishna Prasad is a specialist in primary care sexual health. So I'm really happy if we can have him with us and if we can speak a few words because he is a very good resource. I met him at Bangalore and he is a very nice man as well. So Dr. RK, over to you. First of all, Dr. Sankhar, really my privilege to be part of this. Thank you so much, Dr. Aruni as well. This video that you showed is so empowering. In two and a half minutes, you've shown the entire procedure of how someone in their own practice can do point of care testing. First of all, this has been a session. I think the central point here, at least from my perspective, is that we as family physicians must not forget that we are here to treat patients. We are here to treat people and their families in a non-judgmental holistic manner as Dr. Bidyoth had showcased with the patient-centered non-judgmental model. I think this session is also very timely and we're living at a time where two things are happening. One, very positive in the HIV world and one, something we need to guard against. What is positive is we have a whole array of solutions and definitely the incidence is going down. HIV is no longer the death sentences it used to be, even a decade back. HIV is a chronic disease and I in fact tell my patients when they first get diagnosed that, you know, with treatment and if they work only with, if we work closely with together, then they can hope to live just as long and just as well as they might have hoped to live without infection. So these are very positive developments. We have medications, even I, when I was a fellow and just before that, a decade, 10-15 years back, we used to treat HIV with a handful of pills. Today, most people require one pill once a day and they do exceptionally well. But what we need to guard against is there is increasing complacency as well. Many, many times there is an imagination, especially among professionals, that HIV is now a problem which has been solved and this complacency is something we need to guard against. So thank you for this opportunity to speak and really my pleasure to be here. Thank you. Thank you very much, Dr. Prasad. I think it's very enlightening and it's a very wonderful message to wrap up the session. And since we are running behind time, we would like to take one question from the audience. Dr. Supoon, do you find any important unanswered questions that we can put into our panelists? No, I think all the questions were answered. I will just share. I just took the questions into a word document and the question is in black and the answer is in blue. So the last question which was answered is some consultants request HIV test status before surgical procedures routinely. Is this allowed? Dr. Indika Karunathi has asked this question. I think it's directed to you, Dr. Arani. I think we'll shall we put this question to Dr. Manjula. Manjula will be able to, are you with this Manjula? Yes, she's with us. Yes, Arani. So it has to be with the patient's consent. So we know routinely the cardiologist before the CABG's they routinely request the HIV test. Not only the HIV actually, all the blood bone diseases hepatitis B, C as well as HIV, they request some gynecologist, they request before the major surgery. So that's up to them to decide, but it's not the mandatory testing because they can't refuse to perform the surgical procedure if the patient does not like to get the test done. So it's not the mandatory with the patient consent. Actually, you can always do it and we give the report. Thank you very much, Manjula, for that very clear, straightforward answer for the question. And now let me conclude this session by thanking our valuable resource persons. Thank you very much, Manjula. Thank you very much, Mahesh, all over from Australia. I know it's your very much part you have passed your bedtime and you are remaining with us. Thank you very much for your sharing your expertise and also thank you, our resource persons from India for sharing that expertise and time with us. And also I would like to take this opportunity to thank Dr. Vino Dharmakulasimha, who is concerted meteorologist at Panathura-based hospital for preparing the video for us on rapid HIV testing and also Mr. Hasankar Mendis, who is the head attendant of Panathura-based hospital for videography and editing the video. And also a big thank you for Harris, the CEO, Wonka for facilitating this event and giving the technical support and of course all my colleagues from Spice Route, South Asia, the Leads of South Asia, Spice Route and the Regional Council for the encouragement to make this event and success. And at last but not least, I would like to thank all the participants for their enthusiastic participation. A very big thank you and please join us with our future CPD programs. Thank you very much and a very good night. Thank you. Thank you and good night. Thank you Aruni.