Comments on NACO draft Guidelines for ARV

[Guest guest]

Dear FORUM,

In the last few months there is a welcome change in our outlook regarding

HIV and everybody is talking about cheap,universal (and Free) ART in India

Thing seems to be changing rapidly.

There is no doubt ART should be available to every HIV infected individuals

and those who need prophylaxis.

At the same time we should be very carefull in our steps to wards this

goal.Why are we thinking about Universally available ART now after 20 yrs of

silence on treatment issues? Is it because we are convinced about the issue

or because we are pushed by somebody?

Are we prepared enough ?Have we done enough home work?Do we have a public

health program,or strategy on this?

How are we going to address the issues of regular supply of medications (we

many a times fails to provide free regular supply of paracetamol/ORS / IV

fluids and many life saving drugs in the government health care system).

How are we going to monitor prescriptions?What are we going to do with side

effects of ART-both acute and chronic.(especially nevirapine induced

hepatotoxicity).

Do we have any plan regarding cheap second line therapy-for

both Nevirapine intolerant and resistant people.

What are we going to do with patients who cannot tolerate AZT or Stavudine? just

deny treatment after giving hope?

What about immune reconstitution syndromes we are going to see atleast in the

early period of the program?

We don't have enough no. of (adequately) trained Health care providers,CD4

or Viral load facilities.The track record of many of our doctors in

adhering to rationale regimen is less than satisfactory.

We have our own experience from TB control and Leprosy control which which

failed to control the epidemics with chemotherapy without any proper

monitoring system. These programs made an impact only when strict monitoring

and control over the medications was implemented with provisions for regular

supply. Now we are discussing about life long treatment and adherence

without any monitoring system.

Many of us think Brazil is an example we can follow. But to the best of my

knowledge,Brazil has higher per capita income,less no of patient( and

population to feed). Also Brazil is much different from India socially and

politically.

We should also be careful about the impact of this program on the general

health care system. It should not become another black hole which suck all

resources from other programs. AIDS should not end up as a reason for

borrowing more money because there are people ready to give.

What will be our strategy if our private health care system which generally

doesn't accept (at least in Kerala)PLHAs ; make availablity of ART program

in government system an excuse for not accepting patients?

Are we going to come up with a reasonable ;well run program like RNTCP or

just going to bargain and reduce the price in the market and make the drugs

available for resistance and in turn make market for medicines which are

costly and unaffordable.In that case we are not going to make much

differance in the overall scenario except that the strains will be multi

resistant than the wild ones.

There are experts arguing that it is not areson to worry But remember HIV

mutates much faster than AFB and many studies from US says the prevalance of

resistance is as high as 50% .

I had the unfortunate oppertunity to see patients with multidrug resistant HIV

infection fighting with both drugs and HIV when I visited that country.It is

very unlikely that acountry who doesnot have alternate drugs for MDRTB will

have adequate fund for MDR HIV.

Except for a well planned national program ,reduction of price can be a

recipe for disaster in India. I feel this is the right forum for a

discussion on these issues and it is the time to start discussing .

In this context i feel the time given by NACO to discuss draft ARV

recommendation to be very short.

Is one week not too short a time span for suggesting changes on such an

important document?Shouldn't there be wider discussion among experts from

various parts of India working with deferent setups?

Also probably we should think about definite and simple protocols which

will fit the national program.

Dr Ajithkumar.K

E-mail: <trc_ajisudha@...>