India's AIDS drug strategy gets mixed reaction

[Guest guest]

India's AIDS drug strategy gets mixed reaction

T V Padma

1 April 2004

Source: SciDev.Net

[NEW DELHI] The Indian government started this week to supply free

antiretroviral drugs to 100,000 HIV-positive patients in six high-prevalence

states.

Many have welcomed the move, which was announced last year on the eve of World

AIDS Day, for seeking to provide AIDS drugs to those who urgently need but

cannot afford them.

But some experts fear that the country's weak public health system is

ill-equipped to handle the programme, and that the initiative may backfire as a

result.

The Affordable Medicines and Treatment Campaign (AMTC) – a national initiative

of Mumbai-based lawyers, nongovernmental organisations and people living with

HIV/AIDS, which campaigns for free antiretroviral drugs – has applauded the

programme for shifting the emphasis from prevention-focused strategies to those

that combine prevention and treatment.

In particular, the AMTC says that programme will help reduce the stigma and fear

that surround HIV by portraying it as a treatable condition.

But both the organisation and some public health experts are concerned that

patients may develop drug resistance if antiretroviral provision is scaled up

too hastily without ensuring a continuous supply of the medicines, and the

comprehensive management of HIV-positive patients.

" If false expectations are raised, or if the possible side effects, duration of

treatment, need for monitoring, and so on are not properly communicated, the

programme may falter in no time, " warns Ritu Priya, associate professor at the

Centre of Social Medicine and Community Health at the Jawaharlal Nehru

University in Delhi.

Patients may develop drug resistance, or show cross-reaction with

anti-tuberculosis drugs, she warns. And other important parts of supporting

HIV-positive people – such as treating opportunistic infections, and providing

adequate nutrition and psychosocial assistance – could be sidelined.

According to a representative from the Delhi Network of Positive Persons (DNP),

past experience of government programmes suggests that schemes on paper rarely

translate into practical reality. In the past, for example, patients have not

been warned about the side effects of the drugs, or about the need to take them

throughout their life, he says.

Consistency of funding and drug supply is also uncertain, and the government has

not given details of how it proposes to increase its voluntary testing

facilities to help give more people access to the drugs.

In the first phase of the programme, antiretroviral drugs will be given to

HIV-positive mothers who have participated in the national prevention of

parent-to-child transmission programme (PPTCT); HIV-positive children; and

people with AIDS who seek treatment in government hospitals. Costing an

estimated US$100 million a year, the programme will initially cover 15 centres

in six states where HIV prevalence exceeds 1 per cent of women attending

antenatal clinics.

The second phase of the programme will include antiretroviral provision at all

government hospitals with medical colleges, and the third phase will include all

district hospitals in these states.

Another concern expressed by the AMTC regards the restrictions on those eligible

for free drugs under the programme. " A miniscule [proportion] of women living

with HIV/AIDS have access to the PPTCT programme, " the organisation points out,

adding that in rural pockets with high prevalence of infection, most women give

birth at home.

The much-touted programme began on a low key, and networks of HIV-positive

people have complained they are still unaware where they can access the free

antiretroviral drugs.

According to the National AIDS Control Organisation, the programme will lead to

a 100-fold rise in public sector provision of antiretroviral drugs, and a

50-fold increase in the number of people having access to such drugs in

government hospitals. More than 4.5 million people in India are now thought to

be HIV-positive.

http://www.scidev.net/gateways/index.cfm?

fuseaction=readitem & rgwid=3 & item=News & itemid=1306 & language=1

[Guest guest]

Dear FORUM,

I know that there will be many Indians whose lives will be saved by this

decision provided they live in a high prevalence area or move there quickly.

What needs to be scaled up is the capacity for medical assessment and

Counselling for those who should be receiving the medicine.

Simultaneously will there be a need for much improved counselling services and

anciliary services to help people cope with the regimes. That means also ready

access to testing that is affordable. But don't let the difficulties obscure the

realities that all of the secondary services are useless without an affordable

and permanent supply of medicine.

The Indian Medical Association now needs to prioritise accreditation training

for physicians which is where the fears of resistance are the most likely to

occur due to competency problems.Where there is a will there should be a way.

Once treatment becomes regularised more people will be seeking access to

treatment and priorities will need to be established. Warnings also need to be

issued that it is best to wait as long as possible before embarking on a

lifetime dependency on ART medicine if possible.

There is a moral obligation of course for a government that establishes a

treatment program to also understand that it can't be an on again, off again,

option such as has happened in the recent past with doctors determining who will

and who will not get repeat prescriptions.

It will also be necessary to monitor people who start and make sure the medicine

is working and if it isn't then to establish a structured treatment interruption

program that will ensure that resistance doesn't become a problem.

The science is not a mystery, but like many drugs, to start them and then find

that there are unsufficient resources to continue the supply, such as what is

now happening with Nigerians in Africa, is negligence which can border on

criminality unless there are extenuating circumstances.

For those who are diagnosed and who don't need ARV's immediately they need to

learn how to manage their immune function without the medicine and provided the

resources are there it is possible.

More and more physicians will need to be more competent in treating

opportunistic infections hard and early to avoid compromising the patients

immunity and also to become much more competent on treating the kinds of

sexually transmitted infections that cause immunity to suffer quickly.

But I repeat don't knock the decision to get on with the job. India has been

treading water for too long.

Geoffrey

E-mail: <gheaviside@...>