Quality of care and treatment in Antiretroviral Treatment centers – a case study

[Guest guest]

Quality of care and treatment in Antiretroviral Treatment centers – a

case study

It is wonderful to roll out free treatment to HIV patients by NACO.

Three cheers for the same. The cheers may however become louder if

NACO also takes care on the quality of treatment handed over to

people living with HIV in these centers. I was hesitant to write this

but the death of few of my patients has forced me to present the

following cases to the national audience. The hope is that NACO will

soon take remedial measures, sooner than soon so that many lives can

be saved.

Case 1: M.S s/o B.S, 35 years male came to me in June 2006 with

Herpes Zoster, HIV and HCV positivity and Cd4 90. He was offered

treatment for HZ and also advised ARV as the viral load of HCV was

not significant and LFT were within the normal range. He could not

afford ARV's as in his joint family already one brother was taking

them and economy was a constraint. On world AIDS day December 1,

2006, after reading the news about free ARV's he approached me again

and I referred him to the local ART Center in Amritsar. He was put on

AZT+3TC+NVP combination by the center. Unfortunately he developed

rash due to nevirapine, but was continued with the same along with

symptomatic treatment of the rash. The rash kept on increasing and in

the mean time he also started showing signs of jaundice. His LFT`s

were deranged. The patient was admitted in the Medicine department of

Medical College where the ART center is located. This was in

first/second week of February,2007.The treatment patient got in this

tertiary care center was so derogatory and discriminatory that the

patient got himself referred to PGIMER,Chandigarh(which, however was

done only after the relations agreed to sign a paper stating that

they were given good treatment).The patient came back to me .He was

diagnosed to have drug induced hepatitis (Nevirapine appeared the

culprit) and he expired on 23.2.2007 despite our best efforts for

five days in a private hospital. MS died of a cause which could have

been averted by timely action. The only consolation to the family was

that the last few days of his life were neither derogatory nor

discriminatory.

Case 2: K.S s/o B.S, 43 Male was on ARV (d4T+3TC+NVP) ever since

13.10.2002 from me. He presented with Psoriasis and HIV with cd4 38.

Till the time of his referral to ART center, he was at least doing

good clinically and was back to work, earning money for the family.

Coincidentally or otherwise ( I suspect the quality of ARV's supplied

at these centers) the patient started showing signs of clinical

failure after he started getting free treatment from ART, Amritsar.

His cd4 according to that center was 28 in January 2007 and 25 in

February. He started having diarrhea and loss of weight but no action

or second opinion from experienced doctors (like me, who is into

practice and still has to say no, rather has always asked the staff

there to seek help whenever required 24/7 for all patients specially

those who have been referred by me only) of the town was taken.

Result, he was referred to PGIMER Chandigarh in the last week of

February, which he refused and breathed his last on 2nd March, 2007

at his home.

Case 3: L d/o PLK, 26 Female was a HIV widow ever since May 2001 and

was under care of AIIMS, Delhi before coming under my care in June

2004. She was doing well with AZT+3TC+EFV combination clinically,

immunological and virologically but not economically. Somehow she got

married again in August 2006. Because of free availability of drugs

and economic constraints I referred her to The ART Center, Amritsar.

She returned in tears with pledge of never going back again to that

center. Reason – she was put to an awkward situation of questioning

both at ART center as well as VCTC attached to same Medical College

(as she was wearing the bridal make up). Do we need provide free

treatment alone or it is required to be sensitive too.

Case 4; GK s/o BL,27 Male was on d4T+3TC+EFV ever since 22.9.2003.His

Cd4 in the begging were 137 but over the period of time they were

above 250 always and he was doing good clinically. In 2006 he

developed Koch's, and was put on ATT along with. During this period

he was also referred by me for free ARV's and ATT to ART Center,

Amritsar. On completion of his ATT, his ARV combination was changed

from EFV to NVP despite the fact that he was not having any side

effects of Efavirenz and also was doing good. On question the MO of

the center told me that she has such instructions.She (The MO of the

Center) however failed to show me the evidence of such guidelines. I

also switched from EFV to NVP to my private patients but that was

always for the reasons of side effects /or economy after completion

of ATT. When meds are free I do not find any reason of switching ARV

without scientific reason. This is truer in the era of emerging

resistances to ARV's.

Case5: AS s/o MS is on treatment since 13.11.2002 d4T+3TC+NVP. He was

referred to ART Center, Amritsar for reasons of economy again. His

dosage of stauvudine was reduced to 30 mg from 40 (he weighs 90 kg)

just for the reason of short supply. When contacted the MO said how

does it matter for a month or two. My question is then why give 40 mg

at all to anyone. Maintenance of continuous supply is a must. Result

is that for last two months the patient is taking Triomune 40 from

market.

Case6: HS s/o PS, 58 years male went to ART on his own with PHN and

h/o HIV positivity for one year. His cd4 was 600 plus from a private

lab. He was prescribed Majetol for PHN .He developed exfoliative

dermatitis due to the drug –Majetol. He was admitted in the Medicine

department of the Medical College where ART is located. The treatment

matted out to him again like another case cited above was

discriminatory to the extent that he preferred to come to me, a

private practitioner even at the cost of money (it is another matter

that I hardly earn from my practice on HIV patients and only thrive

on my dermatology practice) Don't you think that free treatment with

dignity is the order of the day rather than just free treatment.

Point wise the lessons from various cases respectively are

1. Ensure training people about management of drug reactions.

2. Persons manning ART centers should be encouraged to take help from

local experienced physicians – (may be in whatever set up, e.g.

persons like me who am an American Academy HIV Specialist, and thus

encourage private public coordination).

3. Counseling comes from heart and not by training –the personnel

should be more humane and there should be checks, such examples can

be a set back to the programe.

4. The switching of ARV is a serious matter and should be taken

seriously; for sure it should not be done just for the heck of it.

5. The dosages should be strictly adhered to and continuous supply of

drugs be ensured always. In case some break occurs, please tell the

truth and ask patient to purchase right combination in right doses,

till supplies. Do not play with the lives of patients. Drug

Resistance is a serious matter.

6. Time has come to sensitize all the medical fraternity, that HIV

patients should be provided quality care with a human heart and

approach. Practice what we preach. The disease does not spread by

casual contact-remember always.

To summarize the whole issue I want to conclude that, the

presentation of these cases are not meant to belittle anyone or to

complaint against any one. The sole purpose is to awaken people who

matter. This may induce some heart in giving HAART. I think in

treating diseases like HIV and Leprosy (for which also I work) what

is required more than the brain and training is the sensitivities and

a humane approach.

Dr.Rakesh Bharti, MD, AAHIVS,

BDC Research Center,

27-D, Sant Avenue, The Mall,

Amritsar 143001

Telephone 9814044213

email-rakesh.bharti1@...