BMJ: India must change health priorities to tackle HIV

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BMJ 2002;325:1132 (16 November)

News roundup

India must change health priorities to tackle HIV

Ganapati Mudur New Delhi

India could have between 20 million and 25 million people infected

with HIV by 2010, the highest number for a single country, says an

unclassified US intelligence report. It has also identified China,

Ethiopia, Nigeria, and Russia as other countries set to experience

the " next wave " of the HIV epidemic.

The report from the US National Intelligence Council said it would be

difficult for any of the five countries to limit the growing epidemic

by 2010 without major shifts in priorities. In all five countries,

the report said, risky sexual practices are driving infection rates

upward, health services are inadequate, and the cost of education and

treatment would be overwhelming.

The report has also cautioned that, as the costs of antiretroviral

drugs drop in these countries, drug resistant strains of HIV may

spread, because of " the inconsistent use of antiretroviral therapies

and the manufacture of unregulated, substandard drugs. "

Indian doctors say the projections for their country seem exaggerated

but concede that greater access to anti-HIV drugs could lead to

faulty prescription practices that might set the stage for the

emergence of drug resistant HIV strains. " We're already beginning to

see irrational prescriptions, " said Dr Sanjay Pujari, director of the

HIV unit at the Ruby Hall Clinic in Pune, Maharashtra.

The cost of drugs used against HIV has dropped in India from 8000

rupees (£104; $166; €164) a month to 1600 rupees a month. " But it is

unfortunate that medical practitioners have to depend a lot on

information from pharmaceutical companies to write prescriptions of

antiretroviral therapies, " said Dr Alka Deshpande, head of the

department of medicine at the Grant Medical College in Mumbai.

No audits have been done of antiretroviral prescription practices in

India. " Most cases only come to light when patients change doctors, "

said Dr Pujari. He says he has seen patients who had been prescribed

single drugs, or combinations of two antiretroviral drugs, when

standard guidelines recommend the use of at least three drugs.

While standard guidelines demand that antiretroviral treatment is

begun only after the patient's viral loads and CD4 counts have been

monitored, some doctors have expressed concern that the

antiretroviral drugs are used like antibiotics. " There appears to be

a haste in prescribing antiretrovirals without appropriate

communication with patients about the need for lifelong treatment and

risks, " Dr Pujari said.

The Indian government's own estimates put the current number of

people infected with HIV at four million, and the health ministry had

earlier this year announced a plan to achieve " zero level of

transmission by 2007. " Some doctors have described that goal as

unrealistic and unachievable.

The US intelligence report has said that among the five countries

Ethiopia and Nigeria would be the hardest hit, with a prevalence

among adults projected at 20%.

In Russia the number of infected people could expand from less than

two million today to eight million by 2010, exacerbating the

country's decline in population and creating even greater economic

problems.

The report predicted that China would have 10 to 15 million people

infected with HIV by 2010, but in India and China the impact will be

lessened because these people will remain diffused among very large

populations.

Microsoft chairman Bill Gates pledged on Monday a US$100 million

grant to slow the spread of HIV in India. The new India AIDS

initiative will seek to expand access to proven HIV prevention

interventions.

However, India's health minister Shatrugan Sinha has rejected the

report's projections. " It is completely inaccurate to claim that

India will have 25 million people living with HIV by 2010, " Sinha

said.

http://bmj.com/cgi/content/full/325/7373/1132/b

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