An antenna to AIDS

[Guest guest]

An antenna to AIDS

Think out of the box to face this grave health challenge. Also think big

Ranjit Roy Chaudhury (Indian express 7/6/04)

The NDA government provided a window of hope to persons with HIV/AIDS. I refer

to the decision of the former health minister, Sushma Swaraj, to provide them

with antiretroviral medicines in the national programme. In the process, she had

affirmed the right of such patients to medicines. Many of her predecessors had

brushed the issue aside, saying a poor country like India could not consider

providing antiretroviral medicines to these people. It is up to the Manmohan

Singh government to persist with this policy.

It is a fact that medicines can prevent a person with HIV infection from

suffering from AIDS for as long as 15 to 20 years, provided they are taken

regularly. Several countries in Europe, the US and countries like Brazil provide

anti-retroviral drugs to their population.

The paradox is that while Indian pharmaceutical companies were providing

antiretroviral drugs to other national health programmes in Africa at the

cheapest prices in the world, our own people were not being provided such

medicines. Today, fortunately, the scenario for such treatment is far more

favourable than was the case in 2000. There is political commitment to the

HIV/AIDS programme. There are numerous NGOs working in the field with expertise

and commitment. Funds are readily available. The Global Fund for HIV, TB and

Malaria has already provided US$ 2 billion for the Indian programme. The Bill

and Melinda Gates Foundation has put aside 200 million dollars for it. Industry,

uptil now, have largely confined the programme to combating HIV/AIDS at the

workplace by surveillance and counselling. It is hoped they will, as a first

step, provide funds for treatment of their own workers with antiretroviral

medicines. Indian pharmaceuticals are willing to provide the national programme

with anti HIV drugs at very cheap prices.

Given these positive trends, we need to plan out a clear cut strategy. People

with HIV, if provided medicines, can live with dignity. It is up to us to make

that hope into a reality. One of the first management issues to be looked at is

that the national programme should be truly a national programme. All

government, non-governmental and national and international agencies should at

least know what is being done and there should be no duplication of effort and

waste of resources. The National AIDS Control Organisation (NACO) needs to be

restructured and given more power.

The first issue is which type of HIV/AIDS persons should be given treatment in

the six states selected by the Indian government for launching this programme in

2004. Pregnant mothers with HIV need to be given the treatment. This decision

has already been taken. Fortunately, a single drug, Zidovudine or Nevirapine,

can be used for this purpose. This is the only instance when a single drug can

be used. In all others, at least three different drugs will have to be

administered. Infants born of HIV infected mothers would also need to be given

one of the two drugs.

Persons with HIV infection who are just beginning to show signs of the AIDS

complex should be the next category of persons. There are clear cut indications

which would demonstrate when HIV carriers are going to go downhill. That is the

moment to intervene. In the private sector and in case of affluent persons,

treatment can be given also to asymptomatic HIV carriers and to patients in the

acute phase of the illness. It is important to decide which combination of drugs

should be used and also whether the drugs should be administered separately or a

tablet which is a combination of two or even three medicines should be used. The

standard practice recommended is to use two of the drugs known as Reverse

Transcriptase Inhibitors and one of the drug which is a Protease Inhibitor. This

combination is known as the Triple Combination Therapy. This is effective and

reduces the viral load in the plasma to undetectable levels and induces clinical

improvement. The choice of the medicines to be used in the national programme

should be made on the following considerations: cost of the medicines, their

efficacy, side effects induced and the ease of administration. If a combination

is to be used it should be clearly determined that any one drug should not

affect the effectiveness of the others. Negotiations should be carried out with

the pharmaceutical companies to get the prices which are best for the consumer.

The Central Vigilance Commission may be requested for approval to conduct such

negotiations.

There are two essential components of this programme. The antiretroviral drugs

must always be available because if they are not, not only will the confidence

of the people receiving the medicines be eroded, but also the treatment would

become erratic. The system of procurement, storage and distribution of medicines

should be streamlined. That this can be done has been demonstrated in Delhi

where the system introduced by the Delhi Society for Promotion of Rational Use

of Drugs provides 90 per cent of the medicines prescribed to patients at

hospitals of the Delhi Government. This whole exercise could be handed over to a

private agency on a franchise system. There should be no breaks in the treatment

because of lack of medicines.

The second feature is to ensure that the medicines being procured and

distributed are of good quality. It is possible to ensure this by rigorous

screening of purchases, quality control inspections of the pharmaceutical houses

for Good Manufacturing Practices, by introducing a set of criteria which must be

fulfilled and by having a Two Envelope System, transparent and evidence based,

for procurement.

Finally, the medicines have to be prescribed well. These medicines are effective

but these are also medicines which would induce side effects and harm the

patient if they are not prescribed at the right dose for the appropriate period

of time. Doctors need to be trained and re-trained in rational prescribing of

antiretroviral drugs. The medicines should be prescribed according to Standard

Treatment Guidelines.

A huge, nationwide programme of training doctors, nurses and pharmacists in

proper prescribing of these medicines has to be initiated and sustained. The

pharmacists have already made a declaration in 1997 together with WHO to work

jointly and actively in this field - a call echoed by the Community Pharmacy

Section of the International Pharmaceutical Federation. The tuberculosis

programmes would guide us to ensure that the mistakes made in that programme are

not repeated. For this, private practitioners must be made equal partners in

this programme.

The writer is chairman, National Sub-commission on Macroeconomics and Health