Re: NACO: A paradigm shift in Indian HIV/AIDS

[Guest guest]

Hi,

Without prejudice to the govt's proposal to provide free AIDS

treatment in gov't hospitals, I would like to point out that in this

country good intentions seldom translate into good policy

implementation at the ground level.

As with the case of sub-standard drugs being dispensed through govt.

schemes, this scheme also opens up the possibility of siphoning of

ARV drugs to be sold in the open market.

The govt. needs to involve NGOs operating in this field to help

monitor the efficacy of the scheme. Right now that is probably the

best bet to ensure that the scheme would not turn out into another

scam.

Sam

E-mail:[samuel_jacob@...]

[Guest guest]

Sir,

Provision of free medicines for HIV can actually be counterproductive. At

present,most doctors are not familiar with basics of HIV treatment and just

having free medicines will not solve the problem.On the other hand, it is

possible that it may only encourage spread of drug resistance. HIV treatment

programmes could have the same problems of logistics as the TB programme.

SANDEEP SALUJA (INTERNIST]

C 38 SOAMI NAGAR

NEW DELHI 110017,INDIA

E-mail: drsaluja@...

[Guest guest]

Dear FORUM,

Ref; Sandeep Saluja's observation. Provision of free medicines for HIV can

actually be counterproductive

I have some reservations on making such assumptions. I would kindly appleal all

the physicians to believe what data says and not our assumptions that India does

not have human resources. Infact there are physicians who are practicing HIV

medicine for the past 3-4 years in Gujarat state alone. Infact they had come

over to the University of South Florida to fine tune their skills in HIV

research. So let us not assume but believe that we have enough trained manpower

to handle this problem.

On the Government part it has to make some important decisions as to incorporate

key physicians to treat HIV and set up stringent guidelines in conformation with

the local standards. Let us see the light in front of us than assuming that it

is still dark ahead.

Arun Karpur

e-mail: jaideva76@...

[Guest guest]

Dear FORUM,

I am really surprised to read this discussion. Did we wait till every physician

was trained in managing TB? What training was conducted when Pyrizinamide first

came in.

it is not question of training but that of an experience and desire to be

updated that make the difference. Think of all the new drugs coming in the

market for treatment of exsisting diseases and ask yurself a question- did we

train all doctors in using these new medicines?

Of course our preservice curriculum needs to strengthened on priority basis but

at the same time there has to be a mechanism to make the practicing physicians

to update their knowledge as a requirement to continue to practice.

From my experience of working in India upto 2000 I can say that most physicians

get the information and knowledge about new drugs from the Pharmaceutical

Company Reps!

There are several webisites available that offer Continuing Medical Education

for the Physicians in all speciality including HIV/AIDS. Medscape and

BodyPro.com are just a few to name. The HIV is growing in India soon there will

be a need for thousands of physicians capable of effectively managing the

patients on ARV.

Again, we need to remember that adherence to the treatment is key to avoid

resistance and ensure lowest possible viral load. Of course preservice needs to

be strengthened, it is not only govt responsibility to train doctors already

practicing.

Thanks Chandrakant

Dr. Chandrakant Ruparelia

E-mail: rupa_rupa_99@...

[Guest guest]

Hello to the list,

I am surprised that Dr Chandrakant is surprised that we need a paradigm shift in

HIV/AIDS care, support and treatment leading on to better prevention prowess.

How long have we been presiding over more and more infections, more and more

preventable deaths, more and more stigma related deaths and family breakups.

I am unhappy that he is comparing managing TB with managing HIV. This is the

typical chalk and cheese analogy in my non medical opinion.

I have now completed 30 years involvement in care and support programs with more

than my share of funerals through to a position where teams of exceptionally

well experienced doctors manage the whole epidemic in our country along with a

team of para medical professionals to ensure not only a good knowledge base but

effective outcomes in better adherence and better undetectible viral loads with

less and less toxicities.

2004 marks the 4th year of my involvement in this field in India and the second

year for East Africa and how very different are these epidemics.

The starting point however was to recognise the need for competence in

prescribing practice and it was achieved by the government recognising that

certain skills such as are required in the oncology field and authorising only

those doctors with requisite skills to prescribe under a simple peer monitored

licensing scheme.

That this would be a significant paradigm shift in medicine in India is to make

a significant understatement.

I am reminded of the arrogance of practicing physicians whose prescribing

practices were and still are dangerously defective when they were challenged

about the client management only to scoff with scorn that a non medical activist

would question a doctor. Then of course there are the people who draw their

medicine without medical supervision. You know the analogy, every indian is his

or her own doctor.

We also have a problem in India where all ARV drug combinations available are in

the form of three drugs in one pill. When the need arises to change one or two

combinations to avoid an unwanted or unexpected toxicity it is not that easy.

The example that comes to mind is removing D4T due to its tendency to worsen

peripheryl neuropathy. Not possible without the option of separate drug pills.

Already we have an increasing number of competent physicians in HIV management

but they are now trying to manage 100's in their case loads with very little

affordable capacity for monitoring themedicine or supervising for adherence

issues.

Then there is the lag in bringing effective nutritional scientists on board as

part of the management team coupled with counsellors, dispensers with up to date

knowledge, therapists and natural medicine therapists to handle the stigma,

distress and side effects of living with HIV.

In my experience there is a complete absence of hope messages immanating from

VCT's in post +ve test counselling and even less community support.

Paradigm shifts are required everywhere but India does not need to fumble in the

dark. The light in most of these areas is well documented and help is available.

I agree with the comments that it is not the government's responsibility to

upgrade experience for doctors choosing to work in HIV medicine. Web sites are

an adjunct but an association of HIV doctors will help as well particularly

since the playing field and the rules change often.

Recognising that similarly to diabetes HIV needs to be a team approach of

doctor, patient, nurse and associated therapists to maintain good health. TB is

very different. Doctor prescribes and patient adheres and the drugs just do

their work if the methodology is followed strictly. I have conducted interviews

around patients who are multi drug resistant to TB medicine and there is a

lot to learn especially since India has more of these patients than any other

country in the world. We do not want to score highly in the multi drug resistant

HIV medicine stakes as well.

Heres to a welcome paradigm shift that reduces the statistics and I would also

want to see initiatives advancing from the community level upwards rather than

from the top down so that outcomes were as effective as the rhetoric.

Geoffrey

Geoff Heaviside

E-mail: gheaviside@...