PHA-Exchange> India?s treatment programme for AIDS is prematuRe: British Medical Journal
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Mon Jan 12 07:50:04 PST 2004
BMJ 2004;328:70 (10 January),
Indias treatment programme for AIDS is premature
New Delhi Sanjay Kumar
The announcement by Indias health ministeron the eve of world AIDS day in
Decemberthat from 1 April 2004 the government will provide free
antiretroviral drugs to 100 000 HIV positive people in six states with high
prevalence of the infection has left the bureaucracy and AIDS experts
confused and in a state of shock.
The poor infrastructure, few facilities, and lack of training have prompted
serious apprehension among those working in the field.
"We have burnt our fingers with tuberculosis, and now we will burn our
fingers with HIV," warned Alaka Deshpande, head of medicine at the JJ
Hospital in Mumbai, where more than 15 000 people who are HIV positive have
been enrolled for treatment.
"If we dont give the drugs properly and monitor the patients, they are
going to develop drug resistant HIV very rapidly, and that situation would
be catastrophic," she added.
Dr Deshpande contends that most doctors are not trained to start patients on
antiretroviral treatment: "Even those who call themselves AIDS experts do
not bother about essential CD4 counts or the viral load of patients before
starting or during treatment," she adds. There is no drug resistance
surveillance mechanism in place in India, she warned.
Manipur state, the Indian state with the highest number of people with HIV
who are also intravenous drug users, has only one CD4 counting machine in
the entire state. "Patients have to wait for months to get their CD4 counts
done," said L Birendrajit Singh, general secretary of the non-governmental
organisation Social Awareness and Services Organisation at Imphal.
Adherence to antiretroviral treatment is a constant problem, and many
patients stop mid-course as they cannot afford it any longer, cannot sustain
its toxic effects, or just feel better, said Dr Deshpande.
"We need to learn from the experience of directly observed therapy short
course (DOTS) for tackling tuberculosis," said Dr Jai Prakash Narain,
coordinator of HIV/AIDS and tuberculosis at the South East Asia Regional
Office of the World Health Organization. "Mechanisms have to be developed to
ensure that at least 90% patients take the pills, as in tuberculosis," he
added.
Dr Narain identifies critical elements as uninterrupted drug supplies;
laboratory capacity for CD4 monitoring; expansion of voluntary counselling
and testing; training of healthcare workers; monitoring of resistance to
antiretroviral drugs; and strengthening of the health systems capacity to
deliver the drugs.
"Unless these critical elements are in place one should not even start the
programme," he warned, adding that a bad programme could be worse than no
programme at all.
Dr Narain said the experience of Brazil, Malawi, and Thailand shows that
antiretroviral treatment is possible, replicable, and sustainable for
reducing the burden of morbidity and mortality, making HIV a chronic
manageable disease and no longer a death sentence.
"We are in the planning stage and will scale up the programme in a
staggered, phased manner and will be on target," Dr Pyare Lal Joshi, one of
the project directors of the National AIDS Control Organisation, told the
BMJ.
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© 2004 BMJ Publishing Group Ltd
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