Re: Need of Dialysis machine for PLHA in Chennai

[Guest guest]

Dear Forum,

Re: /message/9304

We would like to bring to your kind notice a similar situation where Mrs.

Sudha, an ICTC counselor in perumbalur and a founder member of Perumbalur

Positive District level network had passed away on 31.08.2008 due to kidney

failure.

This is the same with a number of PLHAs in Tamilnadu. So we support the request

of Mr. Anbalagan our founder member had posted to the forum.

The situation demands the need for greater access to dialysis machine and

nephrologist for PLHAS.

 

Thank you

Mr. raj,

President,

Tamilnadu PLHA Network (TNNP+)

e-mail: <tnnpplus@...>

[Guest guest]

Dear all,

Re: /message/9304

We read the letter with interest, hence this posting.

We are certainly concerned about the health of individuals and groups, but if we

believe that dialysis machines can get contaminated then the same are not safe

for sharing by PLHA too.

There may be contamination of drug exposed, drug resistant, different subtypes

of viruses. If they are safe then why separate machines for PLHA. Out of fear?

We were also amused by the exaggeration in the posting. To put up a valid point

one need not exaggerate so much. It spreads myths and fers too.

PRAYAS

Prayas health

e-mail: <prayashealth@...>

[Guest guest]

Dear forum ,

This mail from Mr Anbalagan raises many pertinat question on mis informations :

Re: /message/9304

 

1) The ART which includes stavudine , lamivudine and Nevirapine is nor toxic to

Kidney. The drugs which can be toxic to kidney are tenofovir, indinavir and

ateznavir. Many drugs like Zidovudine , lmivudine and stavudine may need dosage

adjustments for patients with renal failure an it should be done under the care

of a nephrologist

2) HIV itself and  drugs used for various dieseses which may be associated or

unassociated with HIV can be nephrotoxic.

3) As pleople with HIV live longer they are likely to devolop various illness

which are common in non HIV infected as well.

4) It is important to prepare PLHAS to live like the majority and the soscity

to learn  to take care of both PLHAS and non PLHAS alike.

5) As per the standard recommendations and if we can follow the infection

prevention protocols HIV is unlikely to be spread by diyalysis.

The following statement from one of the studies by CDC is worth rememebering.

(The global implementation of dialysis and other advanced medical technologies

must be accompanied by rigorous adherence to infection-control practices.

Standards and recommendations outlined by the Association for the Advancement of

Medical Instrumentation  and CDC including sterilization before reuse of all

intravascular patient-care items (i.e., intravascular access devices), are

essential for preventing transmission of bloodborne pathogens such as HBV and

HIV. http://www.cdc.gov/mmwr/preview/mmwrhtml/00037163.htm).

6) Keeping separate Dialysis instruments for HIV infected individuals may not

solve the problem; eventhough this being practiced by some institutions.

 

7) Even though Thambaram is the leading institution in HIV care and a modal for

many other institutions, we should remember that it is not isolated HIV care

centeres the answer but it is the integration of HIV care with general health

care should be the way forward.

8) Superspecialty centers may necessory for HIV also but they can be referal

centers.

Dr Ajith

Trichur

--

Dr Ajithkumar.K

Asst Professor In Dermatology and Veneriology

Medical collge Chest Hospital

MG Kav,Trichur, Kerala ,India

Ph 04872333322 (res)

9447226012

e-mail: <ajisudha@...>

[Guest guest]

Dear Forum members,

Re: /message/9309

This letter is in response to Dr Ajith Kumar and Mr Anbalagan with regards to

the need of separate dialysis unit for PLHIV patients with renal problem and if

there is an indication for dialysis.

I had two such patients who were in need of dialysis as per nephrologists

advice. Both of them were declined of such service by the hospital for PLHIV in

spite of the facility is available for others. They died within days of sending

out of hospital.

Dr Ajith Kumar was quoting that (The global implementation of dialysis and other

advanced medical technologies must be accompanied by rigorous adherence to

infection-control practices. Standards and recommendations outlined by the

Association for the Advancement of Medical Instrumentation  and CDC including

sterilization before reuse of all intravascular patient-care items (i.e.,

intravascular access devices), are essential for preventing transmission of

bloodborne pathogens such as HBV and HIV.

http://www.cdc.gov/mmwr/preview/mmwrhtml /000371630) normal infection control

measures and instrument sterilization procedures will be adequate to take care

of the prevention of transmission of HIV infection thru’ dialysis procedure.

But still a long time will be taken for the hospitals to take up this and come

into mainstream with PLHIV and nephrologists and other technicians to get

convinced. Till then what was the fate of such patients with acute or chronic

renal problems ?

As he suggested an exclusive tertiary care referral center only for HIV clients

with all the facilities like dialysis , ventilator surgical theatre and a

ful-fleged microbiological lab to diagnose all types of OIs may solve these

problems. But when? Will NACO look into the matter?

At least one referral center for the high prevalent states!

It is an emerging need of the hour.

Dr S.Murugan,

Chief Medical Officer,

Peace Community Care Center,

Medical Superintendent and Consultant HIV physician,

Shifa Hospitals , Tirunelveli-627002

Tamilnadu

e-mail: <muruganyes@...>

[Guest guest]

Dear FORUM,

This request is not entirely unreasonable.

Re: /message/9304

 

A study from Columbia had suggested that the HIV seroconversion rate was higher

among patients dialysed at the centre when a new patient who was HIV

seropositive was dialysed there , or when the dialysis centre reprocessed

needles, dialysers, and bloodlines.

An Argentinean study has incriminated cross use of dialyser membranes or a

contaminated multidose heparin vial.

Just as centres maintain a Hepatitis B dialysis machine where every patient has

an earmarked filter exclusive for his/her own use, centres may like to maintain

a machine for HIV positive patients. However, this would add to the costs and

centres may therefore consider peritoneal dialysis on this basis and to avoid

dialyser cross infection.

 

That said, in reality, patients with HIV/AIDS can be dialysed at any dialysing

unit that uses standard infection control precautions. Isolation is not required

unless the patient has concomitant illnesses that require isolation like

pulmonary tuberculosis.

Routine infection control precautions used in dialysis centres are considered

adequate to prevent transmission  i.e. blood precautions, cleaning and

disinfection of equipment and surfaces and restricting non-disposable supplies

to individual patients unless these have been sterilised between uses.

 

Dialysers and AV blood lines of positive patients should not be reused and

should be disposed of in biohazard bags.

 

Strict adherence to standard infection control practices should be enforced for

all patients regardless of their status since patients can be in the window

period of seroconversion.

 

Dr Deepak Batura

e-mail: <d_batura@...>

[Guest guest]

Dear Forum members

Re: /message/9304

The need for Dialysis machine for PLHA in Chennai is not about mis information

or about the side effects of the ART for the PLHA.

 

1. The imporatant issue is wheather people lviving with HIV/AIDS are accessible

for the treatment of renal failure wihich include dialysis of the PLHA both

PUblic and private sector healt facilities.

2. The side effects and the renal failure may be due to the socalled quacks

giving medicine by claiming the cure of HIV/AIDS, becaise of the  common PLHA

not aware of  appropriate treatment options and informations on HIV/AIDS.

 

3. All the public sector, NGO and  private sector health  facilities should

provide treatemnet services not only on ART and other emrging treatment needs

of PLHA in the country.

with regards

Rama Pandian

Founder/President

Tamilnad Network of Positive People ( TNP+)

Reg.No. 760/ 1995

70/269, Labourt Colony

Guindy, Chennai- 600 032

Tamil Nadu, India

E.Mail : tnpluz@...

Mobile : 094440 40469.

[Guest guest]

Dear Forum,

Re: /message/9304

We at DNP+ face a similar situation in Delhi's one of the leading govt. hospital

where one of our friends was admitted. He is HIV positive and he needs dailysis

immediatly, his stomach is geting bigger and bigger each passing day.

 

Before the matter was in our hands, he was look after by NGO who took him to

hospital for 2 weeks trying to get done dailasys. But the Doctor told them the

same thing " it will infect the whole machine with HIV "

 

Then, the matter comes to our(DNP+) hands, we took 2 days to meet the right or

authorsied persons ie. HOD (head of dept.). Here's our conversation:-

 

HOD: What do you want me to do for you?

DNP+:Dr. we want nothing but our friend get dailysis done here and now.

HOD : " Don't you people think about the society? "

DNP+ " Dr. what do you mean? ,we think about the society we form this group

called DNP.

HOD: If we get done your friends dailysis, the whole machine will be infected

with HIV and we can't use anymore. So your friends is important or many other

people in the society who needs dailysis?

DNP+: Dr. did you do HIV testing for all people who will undergo dailysis?

HOD: No

DNP+: Then there a possibility infact a risk that some or many may be HIV

positive. You don't know their  HIV status doesn't mean they are HIV negative.

Even if you test all people for HIV before dailysis, there is still a chance,

some will slip through as there is something called 'window period'. We believe

UNIVERSAL PRECAUTION /infection control is for all irrespective of their

diesease. Anywa  you HAVE to disinfected thoroughly the machine

after performing each dailysis be it HIV positive patient or unknown or HIV

negative or Hep " C " or STI, right?

You may still denied our friends dailysis but he is not the only risk, then why

you selective use UP or Infection control is a greater risk.

Then he rang up few junior Doctor, he ask us to wait outside the room while they

are talking, junior Doctor come out,he call in and said " your friends will be

treat NOW.

 

Peace,

Loon Gangte

DNP+

e-mail: <dnpplus@...>

[Guest guest]

Dear Dr Murugan, Loon Gangte and other forum memebers,

 

Re: /message/9309

 

1. I congratulate DNP + for being able to take the scientifically and

politically  correct stand while not antagonising the system . Also I

congratulate the HOD for being brave enough to take the correct step( which is

not very easy).

But again remember DNP + could do this just because the dialysis unit is not

doing pre dialysis testing for all patients  and that hospital happened to have

an HOD with statesman ship.

To the best of my knowledge majority of dialysis centres in India are doing pre

dialysis HIV and HBs Ag testing.( this is true regarding any intervention

including surgery and cardiac procedures---by the way should'nt we discuss about

CABGs, angioplasties and a large number of life saving and diagnostic procedures

most of which are just a one time procedure unlike dialysis?).

With Provider initiated testing in place now it is not difficult to perform  do

universal pre procedure testing(ethically !).

2. How long are we going to wait for universal precautions? probably for ever !I

do not agree for a specialised center for HIV care for surgery and and dialysis

etc. It is neither possible or feasible. It will make another dumping ground. We

are not able to get basic doctors for ART centers and train them in basic HIV

medicine.

We don't have enough cardiologists and neurologists for general community. How

are we going to get specialists for HIV care that too super specialists? are we

going to take away general super specailaists and train and them in HIV and pay

them heavily and make the system more vertical?

What i indented to say was that :we can have specialised centers for HIV care--

to have consultation regarding  resistance, drug sequencing, specialised

counselling, etc etc not for medical/ surgical complications of HIV.

3. A decision on  Dialysis is more complicated because Chronic renal failure is

another disease --actually much worse than HIV. The treatment is renal

transplant or long term regular dialysis. So the discussion to start dialysis

and sustain it is to be taken after proper and adequate pre procedure

counselling of the patient and support persons and also follow up counselling.

Unfortunately we don't have a national CRF program like that of national ART

program.

4. Still our curriculum - neither medical or nursing seriously address universal

precautions, no administrators take it seriously, no politicians are interested

in it.

We talk a lot about general waste disposal and plastics but nothing about

universal precautions .This leads on to discrimination at health care

settings which in turn  foster stigma.

5. Our experience tells us that the first step to address the stigma and

discrimination is to make the health care professionals confident in service

delivery by training,providing adequate facilities, implementing and replicating

best practices, addressing their concerns and simultaneously implementing and

enforcing guidelines.

Once there is no stigma and discrimination( either positive or negative) at

health care facilities  society Will accept it . We are seeing this in the last

few years of post ART.

 

So let us keep trying just only for PLHAS for the health of all including PLHAs

 

Happy Onam

 

Regards

 

Dr Ajithkumar

Trichur

--

Dr Ajithkumar.K

Asst Professor In Dermatology and Veneriology

Medical college Chest Hospital

MG Kav,Trichur, Kerala ,India

Ph 04872333322 (res)

9447226012

e-mail: <ajisudha@...>

[Guest guest]

Dear forum members,

Re: /message/9304

I discussed this issue with a few colleagues (nephrologists and urosurgeons)

and have following to be considered.

1. Side effects of ARVs, especially those provided in the National ART program

do not have serious renal complications. The figures given in the original

posting were gross exaggerations. Number of HIV infcted individuals requiring

dialysis would be relatively small and that too will not be concentrated in one

part of the country.

Number of HIV UNINFECTED patients requiring repeated long term dialysis in our

country, in comparison is huge. (Estmated to be 3-4 per 10,000 population).

Let alone in public sector even in public sector the facilities are grossly

inadequate.

Mind well most of these patients will require life long dialysis (unless they

get and afford transplant. Costs are tremendous in private sector.

2. Treatment for renal failure (end stage renal disease) in HIV is ART. And

except for Tenofovir and Indinavir not many other drugs have renal side effects.

3. In most public facilities the case burden is so high that there are NO

patients taken for maintenence dialysis. Most patients are given not more than

a couple of sessions and shunted out.

Patients unlikely to get kidney transplant are denied dialysis. And this is not

because the systems are inhuman but because it is simply impossible to cope up

with the case load.

4. This is the situation in big cities and one can imagine the fate of patients

in rural and remote areas. (There, renal disease may not even get diagnosed.)

5. Whatever happened in Delhi is commendable. There also is a facility in Mumbai

with dedicated machine. But if with proper UNIVERSAL PRECAUTIONS there is no

risk of transmission then there is no need for dedicated machines. And there is

little risk as quoted in HIV knowledge base:

Dialysis providers treating HIV-infected ESRD patients must adhere carefully to

universal body substance precautions. HIV-infected patients do not require

special isolation precautions during hemodialysis, and it is permissible to

reuse properly sanitized dialyzers that have been used to treat HIV-infected

patients.

Routine infection control precautions and routine cleaning with sodium

hypochlorite solution of dialysis equipment and of frequently touched surfaces

are sufficient measures with regard to treating HIV-infected patients on

hemodialysis. Precautions such as isolation of HIV-infected patients from other

dialysis patients are unnecessary and could violate medical confidentiality

regulations.

Improperly used machines will even be more risky for immunedeficent patients as

the major complications are due to infections caused by the contaminated

systems.

6. We have been offering peritoneal dialysis to patients, which can be managed

at home too (after proper training). It is cumbersum but possible. Actually

could be managed on a much wider scale.

Of course hemodyalysis Outcomes between hemodialysis and peritoneal dialysis

patients are equivalent, and HIV-infected individuals initiating renal

replacement therapy should be provided the option of choosing either modality.

An advantage of peritoneal dialysis is the reduction of potential exposures to

contaminated blood and needles among dialysis personnel.

Also, peritoneal dialysis patients generally enjoy greater independence and

preservation of residual renal function compared with hemodialysis patients.

7. More often than not it is the human factor that is playing its role. Would a

nephrologist allow sharing of machine? Would patients be comfortable sharing

machines? Would technicians be comfortable to do procedures in busy clinics? I

am not saying that all these apprehensions are well founded but are there.

Someone had asked me this question long time ago " Would you be comfortable

transfusing blood tested elisa positive but DNA PCR NEGATIVE (i.e. with a

false positive test report)? " Though the question was theoretical, one can

understand the palpable anxiety.

8. Why demand under the question " Need of Dialysis machine for PLH in Chennai " .

What difference a /or a few machines at a center going to make? How are so many

PLH travel there? Or are we also then going to demand staying (lodging and

boarding) facilities and travel for those on dialysis?

9. Thus the whole issue needs to be seen in this perspective. HIV treatment

program in India is a Public Health Program. The first line regimens are not

THE best but are " most cost effective " . The second line treatment strategy has

also been adopted from the public health perspective. And so this issue also

seen in the light of " public health reality " in India.

10. Whatever facilities are being provided to PLH (nutritional support, travel

concessions, free ART, free investigations, CCCs, etc.) are all absolutely

necessary and definitely needed. There is no doubt about it. HIV prevalence

fortunately in our country is very low. (Must be overall around 0.6%?). (Must be

overall around 0.6%?).

Do we realize that such facilities are denied to many with similar or graver

health issues apart from HIV? The primary health centers are inadquately

supported for medicines needed for common diseases, malnutrition is a big

problem overall, the public health facilities are overworked and lack

sensitivity, etc. The list is endless.

11. Believe me, and I am talking this as someone who has been fighting for the

facilities and compassionate care for PLH for over 20 years, but recently I

visited the newly opened ART centre under a PPP near Pune, and realized that

the contrast was extremely striking between the general facilities at the

hospital and the ART centre.

The space, the furniture, the ambience. Even if we do not realize yet people do

comment. This contrast is one that probably is also fuelling stigma. Many years

ago on a visit in the USA a friend had sarcastically commented " In USA if you

are coloured, drug injecting, homeless and HIV infected you are lucky as the

state will provide you shelter, food, fridge, HAART, counselor, and everything! "

12. Indian HIV epidemic is still maturing yet the response to it especially by

PLH networks has been far more mature than elsewhere.

It is high time we join hands with others and start demanding " Patient's rights

charter " rather than only PLH rights. Improvement in public health standards

rather than only at ART centers, facilities and concessions for all needy than

only for PLH.

13. I understand that keeping separate identity as a pressure group is

advantageous but unless we join hands with the wider health movement, I am

afraid there could be a backlash, sooner than later.

Vinay Kulkarni

E-MAIL: <prayashealth@...>

[Guest guest]

Dear FORUM,

Re: /message/9304

Many thanks to Dr Kulkarni, for a message which for once is looking at a

situation scientifically and emphasizes the importance of Universal Body

Precaution.

As a physician albeit not actively involved with HIV Affected I fully

endorse your views- it is high time that we as care givers act as if all

patients are to be treated as if they were infected- this statement is not to be

misinterpreted- it only means that a health care worker in his contacts with

all patients should be extremely alert to the principles of Universal Body

Precaution.

I understand that in many settings (not necessarily in Government hospitals

only) availability of appropriate drapes, mechanisms of disposal of waste and

such related measures are not as they should be. An increasing awareness at all

levels including that of private providers is the need of the hour. NACO perhaps

should consider

running a study/ training amongst the Health care service providers on the

importance of Universal Body Precaution.

You rightly and bravely draw attention to those who suffer from other

conditions which are equally deservant of many facilities that are now being

given to the HIV affected.

I was refreshed by this holistic perspective

Regards

Dr Charulatha Banerjee

Dr Charulatha Banerjee

25A, Sarat Bose Road

3B, Sindu apartments

KOLKATA 700020

e-mail: <charulatha.banerjee@...>