PHA-Exchange> India?s treatment programme for AIDS is prematuRe: British Medical Journal

[Aviva]

BMJ  2004;328:70 (10 January),

India’s treatment programme for AIDS is premature
New Delhi Sanjay Kumar


The announcement by India’s health minister—on the eve of world AIDS
day in 
December—that 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 don’t 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 system’s 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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