INTERVIEW - Dr. Chinkholal

[Guest guest]

INTERVIEW - Dr. Chinkholal

Dr. Chinkholal Thangsing has over 19 years of experience as a

medical professional with 15 years in the field of management of

HIV/AIDS related healthcare services such as clinical care,

psychosocial management and treatment of people living with HIV/AIDS

(PLWHA's) in India. He has also helped in setting up AIDS care

centers, ART treatment centers, conducting awareness, sensitization

and education of healthcare professionals, provision of ARVs drugs

to PLWHA's within India and in the Asia Pacific region. He is

currently working as the Asia Pacific Bureau Chief of AIDS

Healthcare Foundation based in India.

1) What are your views about scaling up ARV treatment in resource-

poor settings?

The availability and use of antiretroviral drugs for treatment of

AIDS in resource poor settings has finally changed the history of

HIVAIDS epidemic and will without doubt chart the prognosis of the

epidemic. ARV treatment has in many ways marked a dramatic reduction

in AIDS related morbidity and mortality. The results of scaling up

of ARV treatment, if institutionalized a few years earlier, would

have had a huge impact on the lives of people in many countries.

This indeed has been the collective response of the UN bodies and

there are many lessons to be drawn in addressing the complexity of

ARV treatment and the introduction of the second line of ARV

treatment in the days to come.

The results of treatment is a cocktail of multivariate responses due

to a variety of reasons – initial regrettable delay, extended

procrastination by policy makers, the apparent inhibitive cost of

the drugs, procurement and delivery difficulties compounded by

inadequate health infrastructure and systems, minimal and poor

laboratory services, acute shortage and deficit of human resources

are few of the contents of the list of hurdles to be overcome to

complete the process of setting up even a single center.

Amidst such overwhelming odds and challenges, there are shining

examples from countries which have bare minimal existence of health

systems and almost non-functional infrastructure, but have performed

incredibly and exceptionally well by maximally utilizing their

limited resources to roll out ARV treatment centers. There are, on

the other hand, countries which are much better equipped in terms of

having a better health policy and healthcare systems and

infrastructure but do a miserable and pitiable job in the scale up

of ARV treatment in their country.

The `collective result' is incorporation of ARV treatment in

resource poor areas has been commendable and acceptable, since it

offers `hope' in a situation of `absolute hopelessness'. There is

much more to be done, reaching out to a higher number of people with

HIV/AIDS, and begin tackling the issues around the second line of

regimen.

The ARV treatment plays an exceptionally crucial and tremendous role

in the prevention and awareness efforts of the epidemic. Care

services promote prevention. This can be seen from the increase in

the number of people accessing VCT and other HIV-related services.

This is one of the most important impacts of ARV scale up program in

resource poor setting.

There's not a moment to lose and we cannot afford to lose steam and

reduce the momentum and the speed which has been achieved. We need

to improve upon existing policies and need to address not only the

present drugs regimens but also to the second line drug regimens

which should surely be the main problem to be handle in a year or

two from now.

Despite the recent successes, there can be no room for the UN or for

the countries to believe that much has been overcome. We must awaken

to the fact that there is much to be done in terms of opening more

centers, providing treatment to more people living with HIV/AIDS and

a `greater visibility' of the impact of the scale up program.

The ART rollout policy and implementation strategies in the resource

poor areas need effective `rediscovery', re-examination and re-

evaluation, positive change and critical review. It must be a

program which is non-stigmatizing, in an atmosphere which is `AIDS'-

friendly with designated yet active participation of stakeholders,

the civil society and PLWHA.. The rollout that showed better success

also reflects political will and participation of key leaders. What

needs to be done is overhaul of the program and replacement of

lethargic bureaucratic program leaders with dedicated, committed,

target-oriented, public- and people-friendly managers.

2) What is the situation for access to antiretroviral (ARV) drugs in

India now?

The ART access has come a little too late and is a little too slow

than one would desire but the availability of the ARV medications is

a landmark in the HIV/AIDS history of India. The access to ARV in

India has currently made a dramatic transformation in the lives of

many with admirable positive effects on the psychic, the emotions of

both infected, affected and the general population's perception

about the epidemic of HIV in India.

The response at the national level, in my view, continues to be

painful and excruciatingly slow. In an emergency situation, broad

goals can be achieved by implementing the roll out with military

precision. The increase in number of people seeking VCCTC services

is primarily due to increased `access of ARV drugs'.

ARV access requires massive awareness campaigns, workshops, IEC

programs and visibility of such services, promoting treatment access

and highlighting availability of ARV drugs. We need key personnel

with the grassroots understanding and a partnership between the

bureaucrats and technocrats involved in HIV/AIDS treatment in the

country.

The apathy of certain programme implementers and bureaucratic

obstacles has hijacked the HIV/AIDS programme depriving the PLWHA's

access to drugs. The mediocre efforts with its inevitable results

are what we have today – for every person who accesses ART there are

10 others who need it and another 10 people dying without ARV access.

3) Indian generic drug companies are manufacturing low-cost ARV

drugs for sale in Africa, but they are more expensive in India.

Please comment.

That the well know phrase `Made in India, Cheaper for Africa' is an

often quoted expression which will haunt us till some bold and

drastic steps are taken to change the situation. This has been a

constant stumbling block, often an embarrassment, without an

apparent immediate remedy These to me are a `measurement tool' which

candidly reflect and summarize the apathy, irresponsible approach of

the UN system, and its ward, the Government and the disinterest of

the civil society in the provision of ARV drugs in India.

It is my personal agenda and mission to try to educate myself and on

this frequently raised `issue' and find an acceptable answer. The

answer is still in the air for the complexity is mind-boggling. The

bold landmark production of generic ARV drugs by an Indian

pharmaceutical company sets the ball rolling with such brutal force

that it has caught many unaware that the ARV drugs could be made

available with a fraction of the cost in resource poor countries.

Things are bound to change. We have to collectively share the

responsibility of the present situation, i.e. the government, the UN

agencies, WHO, the GO's, NGOs, PLHA groups and the general

population. If the government only removed the sales tax, if the UN

agencies and WHO make it more easy for the pharmaceutical companies

without compromising on quality of course, and if positive peoples

network take a bolder stand and continually raise their feeble voice

to a louder tone and the general population begin to awaken to the

reality of the situation and the pharmaceutical companies seriously

make the effort to bring down the cost, if high prevalence states

purchase in bulk, India would get the ARV drugs at a much cheaper

price than Africa where international borders, shipping cost and

other taxes would not be required within the country.

4) What immediate measures do you suggest for better access to

medication in India and the region?

The immediate measure to scale up ARV medication access rests

heavily on the actual commitment and zeal of people endowed with the

power of making right and positive changes and transformation of

existing incompetence to effective system.

1) UNAIDS, WHO should put pressure on the government, the NACO and

the State AIDS Control Societies to deliver.

2) Inclusion, active participation and the deployment of

International and National NGO's working in the field of HIVAIDS to

assist the program with the required technical skills and capacity

and help set up the ART Centers

3) ART roll out policy, plans, strategies, and guidelines should not

get lost in the files and offices of the HIVAIDS authorities. All

stakeholders, beneficiaries should have a clear understanding that

without a commitment from the authorities, these will forever remain

on paper only

4) Action-oriented leadership with an understanding of the urgency

and who would act. Leadership ready to involve the right people,

machinery with an appropriate zeal, and unshakable commitment must

lead the national treatment access program.

5) A core team of leadership drawn from UN agencies, National AIDS

Control Organization, PLWHA groups and credible international and

national NGO's should be instituted or revitalized to revive the

program.

6) Programme managers should be made more accountable for

implementing the programmes at the national, state and district

levels.

7) Set up an `ART Access Task Force - AATF' with different

stakeholders to help the launch access at the national level and

region wide massive educational campaigns on ART treatment.

5) Are issues of accessibility and affordability of HAART in India

different from others in the region?

The Indian Pharmaceutical companies have introduced the generic

version of HAART and PLWHA in resource poor settings have

acknowledged this humanitarian move. Thus accessibility of HAART is

not a problem in India as it continues to be in many Asia Pacific

countries. The major issue however continues to be

its " affordability " for a large number of PLWHA from the socio-

economically handicapped and disempowered community, no matter how

low the prices are.

The first line of ART drug regimen though `cheap and affordable'

compared to non-generics are not affordable when one has to take it

regularly and for years together which ultimately makes

it `unaffordable' to many even in India. However, people in India

fare a lot better than many countries in the region in terms

of `access and affordability of HAART' from neighboring countries in

the region where access and affordability is a lot tougher, much

more difficult and different.

6) How is India faring when it comes to community-based HIV

prevention, care and impact mitigation?

With the UNAIDS observation that over 95 percent of Indians with HIV

do not know they have the virus, which may also be masked by

tuberculosis and other opportunistic infections, the continuing

reports that surfaced in national limelight of issues such as

denial, fear of hostile reactions not only from the community but

even from the healthcare institutions and from workplace has a lot

to say how India fares on its community based HIV prevention, care

and impact mitigation program and strategies.

The knowledge of HIV/AIDS is surprising low till today even though

there are high levels of awareness reportedly from the states

labeled as high prevalence states. The level of commitment to

community based HIV prevention varies from the high prevalence to

highly vulnerable to low prevalence states which is unhealthy trend

as many of the highly vulnerable or low prevalence states have high

prevalent pockets or districts. Therefore, it is recommended that

the government and donors should treat every state, districts sector

as `highly vulnerable' and equal status of preventive efforts, care

and impact mitigation programs should have an equal status.

NGOs working selflessly with zeal and commitment have contributed

significantly to the government's efforts to community based HIV

prevention, care and mitigation program in India. The policy,

strategies, plans are on the right track but how does one sustain

the momentum and continue with an increasing commitment and

seriousness will tell the tale of success or failure of the

community based HIV programs and care and mitigation of HIV in India.

7) When a woman with HIV visits your office for the first time, do

you evaluate her care differently than you would evaluate a man's

care? What is their situation?

The moment a patient walks in my office they receive a warm welcome

and an extended hospitality, for the next few minutes belongs to

them irrespective of their gender, class or creed. I try to make

them feel comfortable and set few activities to build a good rapport

immediately. The initial assessment at this first encounter of a

woman with HIV is a little different from man as they are different

physically, psychologically and mentally. The basic history taking

and examination are more elaborate as we have to deal with issues

related to reproductive health, and sexual history and even a

gynecological examination which are gender and biologically specific

and unique to a woman.

In a woman one has to consider various criteria such as age,

menstrual, obstetrical history and pregnancy. The other procedures

such as the basics of clinical evaluation, physical examination,

testing for Viral load and CD4 immune status remains quite similar

in both genders with the exception that gynecological examination is

there in women.

While evaluating care for a woman various issues are taken into

considerations which are unique and different from a man with

HIVAIDS such as family, marriage history, special test such as Pap

smear. The attending physician has to be sensitive to issues such as

confidentiality as woman are more vulnerable to the ire and

accusation of family members or spouse. By the time the session is

over the woman in my clinic will be equipped to handle issues on

such as safe sex, child care, preventive issue, on reproductive

health, PMTC and on medications and OI management specific to woman.

8) Do you see different side effects in women than in men?

With an increasing number of patients accessing ART drugs in

resource poor areas there has been an increasing number of recorded

of side effects in women but not significantly different in men.

However, adverse effects such as peripheral neuralgia, neuritis

seems to occur more in women whereas lipodystrophy seems to be more

frequent in men than women having the same ART drug regiment.

The occurrence of side effects of ART drug `Nevirapine' in women

with higher CD4 with hepatitis which could be life threatening is

more likely than in man. The cause of such a reaction in the female

gender has not been ascertained and need more studies.

However, in my experience and those of colleagues in the developing

countries there is no record of any huge or significant differences

between women and men; which maybe due to the fact that such drugs

are not prescribed in an individual with high CD4 other than for

PMTCT.

In summary in my experience at the current scenario it appears that

women are more tolerable to ART and are able to handle the side

effects as well as men. With increased accessibility and

affordability the number of women accessing ART therapy treatment is

bound to increase and hopefully we will be able to get a clearer

understanding of the side effects of ART drugs in women – which I am

sure the severity will be at par or not significantly or not very

different than those commonly experienced by men.

9) Do you think policies and health care systems in different

countries result in variable responses to HAART?

Indeed policies and healthcare systems result in a variable response

to HAART but are not the only criteria to success of ART program.

The availability and existence of policies and well established

healthcare systems invariably play a major role in the execution and

aid the implementing highly successful programs. The difference in

policies and health care systems does result in variable response to

HAART. The policies and infrastructure and healthcare systems in

different countries designed to meet the ever increasing healthcare

challenges which HIVAIDS epidemic is variable.

The response and result to HAART does not `rest' solely on policies

or healthcare systems but much more on the individual

country's `positive response'; dedication and commitment to serve

its people that contribute to the success or failure of the HAART

program. Countries which have taken `ownership' of the program,

constantly and consistently `responsive' to the healthcare needs of

its people; promote and endorse the practice of transparency

and " accountability " with proper tracking, monitoring system in

place produces better results that just the existence of policy and

healthcare systems.

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