Research on private practitioners' HIV/AIDS management practices

[Guest guest]

Abstracts of four recent publications on private practitioners' HIV/AIDS

management practices are presented below. These publications are the result of

research conducted in Pune by the Centre for Health Research and Development, a

unit of the Maharashtra

Association of Anthropological Sciences. The project was supported by the DfID

Tuberculosis Knowledge Programme of the London School of Hygiene and Tropical

Medicine (LSHTM), and by the World Health Organisation (SEARO).

1. Urban private practitioners: potential partners in the care of patients with

HIV/AIDS

Natl Med J India: Jan-Feb 2005: 18: 1: 32-6

Authors: Sheikh, K.; Rangan, S.; Deshmukh, D.; Dholakia, Y.; Porter, J.

BACKGROUND: The private medical sector is an important source of healthcare in

India. Increasingly, concerns have been raised about its role in the care of

patients with HIV/AIDS. Evidence about private practitioners' existing

management practices will help to create policies addressing this sector.

METHODS: A central urban area of Pune city was selected for its high density of

healthcare facilities. Private practitioners in the area were interviewed using

a structured interview schedule. Based on a 1-year recall period, the schedule

covered different aspects of the practitioners' HIV/AIDS management practices

including diagnosis, treatment and referral. RESULTS: Of the 215 practitioners

interviewed, 66% had tested and diagnosed HIV infection. Fifty-four per cent had

been consulted by HIV-infected clients 'shopping' for alternative diagnoses or

treatment. Overall, 75% of the respondents had been consulted by HIV-infected

clients for treatment. Of these, 14% had prescribed antiretroviral drugs,

sometimes without adequate knowledge of the guidelines for their use. Other

supportive and symptomatic treatments were also frequently prescribed. Private

practitioners commonly referred HIV-infected clients for management to other

private doctors, or to public hospitals. There were variations in respondents'

practices by sex and system of medicine. CONCLUSION: Private practitioners are

actively involved in diagnosing and managing patients with HIV/AIDS. Some of

their management practices are inappropriate and need to be remedied. There are

also concerns about gaps in the continuity of care of

HIV-infected persons, for which networks between providers need to be

strengthened. Public-private partnerships must be created to improve the flow of

information to private practitioners, and Include them in the national health

framework.

2. Managing uncertainty around HIV/AIDS in an urban setting: Private medical

providers and their patients in Pune, India

Soc Sci Med: Oct 2005: 61: 7: 1540-50

Authors: Kielmann, K.; Deshmukh, D.; Deshpande, S.; Datye, V.; Porter, J.;

Rangan, S.

Changing epidemiological patterns and the advent of new rapid diagnostic

technologies and therapies have created considerable uncertainty for providers

working in HIV. In India, the demand for HIV care is increasingly being met by

private practitioners (PPs),

yet little is known about how they deal with the challenges of managing HIV

patients. To explore HIV management practices in the private medical sector, a

survey was conducted with 215PPs in Pune, India, followed by in-depth interviews

focusing on the social

context of practice among a sub-set of 27PPs. Drawing primarily on interview

data, this paper illustrates a number of uncertainties that underlie the

reported actions of providers in a competitive medical market. PPs perceive HIV

as a 'new' and challenging disease

for which they lack adequate knowledge and skills. Combined with the perceived

high cost and complexity of antiretroviral treatment, preconceptions about HIV

patients' social, financial and mental capacity lead to highly individualistic

management practices. While

these fall short of clinical 'best practice' guidelines, they reflect adaptive

responses to the wider uncertainties surrounding HIV care in urban India. By

highlighting contextual issues in PPs'

management of HIV patients, the paper suggests the need to explicitly

acknowledge the social, moral and economic bases of uncertainty beyond the

clinical setting.

3. Private providers and HIV testing in Pune, India: challenges and

opportunities.

AIDS Care: Aug 2005: 17: 6: 757-66:

Authors: Sheikh, K.; Rangan, S.; Kielmann, K.; Deshpande, S.; Datye, V.; Porter,

J.

We explored HIV testing practices of private medical providers in an urban

Indian setting in Pune, western India. 215 private practitioners (PPs) and 36

persons-in-charge of private laboratories were interviewed in separate surveys.

77% of PPs had prescribed HIV tests and 94% of laboratories had performed HIV

tests, or collected samples for HIV testing. Among those providers who had

prescribed/performed tests, practices which violated national policy guidelines

were found to be common. 55% of PPs and 94% of laboratories had not

prescribed/performed confirmatory HIV tests, 82% of PPs had conducted routine

HIV screening tests, 53% of

PPs and 47% of laboratories had never counselled patients before testing, and

39% of laboratories reported breaching confidentiality of test results. PPs'

knowledge about HIV tests was also inadequate,

with 28% of PPs who had prescribed HIV tests being unable to name the tests they

had advised. Prolific HIV testing in the private medical sector is accompanied

by inappropriate practices and inadequate knowledge, reflecting deficiencies in

the implementation of policy guidelines. The perspectives and needs of private

providers, the major source of health care in India, need to be acknowledged.

Supportive and regulatory mechanisms can be used to

involve private providers in the delivery of better HIV testing services.

4. Continuity of Care for HIV-patients in the Private Medical Sector, Pune,

India

Proceedings of the XV International AIDS Conference, Bangkok: 2004: Appendix:

49-53: E710L6580: Medimond S.r.l

Author: Sheikh, K

India’s important private medical sector is well resourced with facilities for

HIV testing and treatment. A study was conducted on private practitioners’ (PP)

practices in HIV care, in Pune, India. A majority of PPs had prescribed HIV

tests, but PPs’ ability to manage HIV/AIDS was variable. PPs accounts shed light

on the absence of continuity of care for PLHA. Patients often did not return to

their

GPs after an HIV positive test result. These " floating " patients were reported

to be suppressing their status, and “shopping” for alternatives. 54% of the 215

PPs in the survey were consulted by “shopping” patients who had been diagnosed

with HIV elsewhere.

Referrals to public hospitals also reflect a trend of “dumping” unwanted,

non-affording patients. While concerns around testing, counselling and

treatment occupy centre-stage, basic goals of continued patient care may remain

unmet in a fragmented health system. Existing networks between providers must

be strengthened, in order to address concerns of continuity of care in HIV/AIDS.

PDF copies of the articles are available from maaschrd@...

Kabir Sheikh

E-mail: <kabirsheikh@...>