Medical Care for HIV .An Opportunity or Crisis? EPW Commentary

[Guest guest]

Medical Care for HIV. An Opportunity or Crisis?

EPW Commentary April 15, 2006

It is possible to provide antiretroviral therapy for India's growing

population of HIV patients. However, there are concerns regarding the viability

of such a programme. There is also a concern about the

possible effect of ARV therapy on other healthcare programmes. This

article argues that if the present healthcare system is strengthened

and the primary healthcare centres are involved, ARV can prove to be

sustainable.

K Ajithkumar, S Irudayarajan

Infection with the human immunodeficiency virus (HIV) affects

millions of people worldwide. The number of individuals infected with HIV

approximated 40 million at the end of 2004, based on estimates of the Joint

United Nation Programme on HIV/AIDS [uNAIDS 2004]. Most of those infected live

in India, sub-Saharan Africa, south-east Asia and the former Soviet Union.

Although the morbidity and mortality associated with HIV and opportunistic

infections have decreased substantially with the introduction of highly active

antiretroviral therapy (HAART) in the US and much of Europe, the same cannot be

said of the resource-poor regions of the world.

An estimated 14,000 people (five million people per year) are infected with HIV

everyday, with more than 95 per cent of them living in underdeveloped regions

[sahloff 2005]. Once relatively invisible, the HIV epidemic has now become a

visible AIDS epidemic. AIDS is an exceptional infectious disease, posing

challenges in terms of immediate needs and long-term development. India now

appears on the brink of a significant epidemic. HIV has been detected in almost

all of India's states and union territories [NACO 2003].

In seven Indian states, the prevalence of HIV in women attending antenatal

clinics exceeds 1 per cent, making the epidemic generalised. An estimated 0.9

per cent of the population is to be infected by this modern day scourge [Mahal

and Rao 2003]. One of every six new HIV infections occurs in India.

India also now has the largest number of HIV-TB co-infected persons in the

world. India alone was estimated to have 3.8 million infected adults in 2001, a

number second only to that estimated for South Africa. It is estimated that

around seven million (which will be about 33 per cent of mortality due to AIDS)

deaths are expected to occur in five Asian countries (India, China, Thailand,

Cambodia and Myanmar during 2000-05 due to AIDS

(http://www.un.org/esa/population/publications/adultmort/POPDIVNs).

At the same time it is important to note that HIV is not the only

infectious disease causing mortality in India. HIV/AIDS accounted for only 6 per

cent of deaths from infectious diseases. But it is also important to remember

that the time span between the start of the epidemic and peak incidence of HIV

epidemic in India is expected to be 20 years or longer. Interestingly all these

3 diseases are

potentially treatable and either controllable (HIV) or curable

(Malaria and TB).

Emphasis on Prevention Partly because there continues to be no medical magic

bullet to cure HIV and because of the slow natural history of the disease, the

emphasis of HIV/AIDS policies and programmes has, from the earliest days of the

epidemic, been on prevention. This led to a significant " care gap " . There has

been a very active discussion on the feasibility and viability of HIV care in

developing countries [Ritu Priya 2003; Over et al 2004].

Whatever be the arguments for and against provision of free therapy,

no society can neglect an epidemic like HIV/AIDS, which is killing

thousands of people, affecting every walk of life of society. Unlike

in the past, thanks to the international and national pressure from

various corners, now there is a shift in the focus towards provision

of HIV care especially towards antiretroviral (ARV) therapy. The

National AIDS Control Organisation (NACO) and various state

governments have initiated free ARV programmes in 2004.

The attempts to make treatment available were slow probably because

of the low visibility of the disease in the community. This was also

partially due to the slow spread of the epidemic in contrast to the

faster spread of epidemics like SARS. The stigma associated with this disease

and the discrimination against a disease associated with " sex and morality " also

contributed to this slow pace. There were attempts to provide low-cost care to

people with HIV/AIDS to mitigate the impact of HIV-related illnesses from phase

II of the National AIDS Control Programme (NACP) in 1999, when the budgetary

outlay of 12 per cent of NACP was earmarked for care and support, including

treatment of common opportunistic infections, such as tuberculosis, the most

common opportunistic infection in India.

The government has strengthened the states' capacity by training

physicians and technicians, installing flow-cytometers for CD4/CD8

testing at selected medical institutions in 25 large and medium-size

states, and allocating Rs 1,250 ($ 25) per patient per year for the

purchase of drugs to treat common opportunistic infections. The

national treatment guidelines also recommend prophylaxis with co-

trimoxazole in people with HIV/AIDS. The care strategy covered about

30 per cent of the estimated 5,50,000 people with AIDS who seek

treatment at government-run and selected NGO hospitals. But this had

a very limited impact on the actual scenario probably because of the

low prevalence of the disease in the community and the fact that the

care facility was available only in very selected places – mostly in

the state capitals.

The existing stigma and discrimination and virtual marginalisation of people

living with HIV/AIDS (PLHAs) resulted in impoverishment of

these patients and that made it impossible for them to access the

available healthcare in a remote hospital or care centre. Many of the people

living with AIDS (PLWAs) with asymptomatic infections were being referred from

southern Tamil Nadu and Kerala to Chennai to receive anti-TB drugs and

co-trimaoxazole, which is already available in the local primary health centres.

The healthcare system was ill- equipped to face the new scenario. There was not

much capacity building done to face this new disease. Many public and private

hospitals continued to deny care for HIV-infected individuals [The Lawyers

Collective 2003].

In the absence of affordable ARV, treatment of opportunistic infections did not

reduce the disease burden on the system. Also there was no serious attempt to

integrate HIV care with the existing healthcare system in spite of the fact that

the epidemic was more or less generalised. But this scenario is changing

following the availability of cheaper ART and financial support for ARV

programme from different agencies including Global fund for HIV, TB, malaria,

and from various international funding agencies. Currently, we are in a

situation where we are facing a pandemic, which calls for

a strengthening of the healthcare delivery system.

The lifeboat is already full with various epidemics including poverty,

infectious diseases, trauma, cancer, cardiovascular diseases, etc, and it cannot

afford to take more people. Here there is a chance to expand the lifeboat if we

are ready to care for a few more people.

We are offered assistance if we can provide care to patients affected by

HIV/TB/malaria. We already know that the infrastructure necessary for HIV care

is almost the same for the care of a general patient.

Interestingly there are studies from India showing that most of the

HIV care is possible at a primary health centre itself [ et al

1996].

What we need for HIV care is a change in our outlook and updating of

our understanding of the healthcare delivery system. We have to look

at least at a few models like the Trichur model, which has proven

beyond doubt that HIV care can be integrated into the existing

healthcare system by strengthening it.

The Trichur model of HIV care integrates all components of HIV care

into the existing system of a referral hospital. Here regular and

comprehensive care is being provided for nearly 1,000 patients during the last

three years without any extra budgetary allotment except for ART [Thimothy,

Ajithkumar and Rajan 2005].

Now it is time to take the right decision. Why don't we see HIV as an

opportunity? Why cannot we strengthen our healthcare system, which can support

both HIV and non-HIV care? After all, most of the

infrastructure necessary for HIV care is useful for non-HIV diseases

also (except for antiretroviral therapy and flow cytometers – which

are, of course, expensive).

We should also be careful about the implementation of the free ART

programme. The free ART programme will not be sustainable without

strengthening the existing healthcare system. Unless we train our

healthcare workers in basic healthcare like testing, counselling and

treatment of basic diseases like TB and candida, it is impossible to

have a free ARV programme.

So we should be vigilant that the intense pressure for ARV does not

scuttle this balance and we end up with treatment centres with flow

cytometers but no microcopy facility for the diagnosis of

tuberculosis and centres with ARV medicines but no medicines for

simple oral thrush. What Should Be Done?

The answer is to strengthen the healthcare delivery system to cope

with the healthcare needs. The isolated development of HIV care

should be avoided and it should be integrated with the larger

development of the healthcare system. Since India is still facing a

low level epidemic in most parts, the disease burden per primary

healthcare centre or a hospital is unlikely to be high if every

hospital starts seeing HIV-infected patients. This will, in turn,

reduce the stigma and discrimination and eventually stimulate private healthcare

institutions also to accept more and more PLHAs.

For instance, the following services can be integrated at different

levels of care. At the PHC level: (1) training of paramedical staff

in testing (rapid tests) and counselling along with lab technicians,

health inspectors and public health workers; (2) training of doctors

in opportunistic infection management like candidacies, TB, which

will take care of most of the medical care needs; (3) training of

paramedical and auxiliary staff in home-based and community-based

care – this can be useful not only for HIV but for old age,

malignancy, cerebrovascular illness, etc; and (4) basics of ART

management and adherence and provision of ARV dispensing. At the

first referral level, management of tuberculosis, pneumonias,

paediatric HIV, etc, may not need any further infrastructure except

for capacity building.

At the district level, diagnosis and treatment of complications like

neurological opportunistic infections, may need a CT scan, flow

cytometer, advanced biochemistry laboratory, etc, many of which are

absolutely necessary for non-HIV care as well. At teaching hospitals, facilities

for monitoring and research in epidemiology, resistance,adherence, etc, and

management of complications, ARV resistance, etc.

This will need strengthening of labs, training of clinical and non-

clinical staff, etc, which can be used in a non-HIV scenario also.

Email: trc_ajisudha@...

References , K R, Dilip Mathai (1996):`Economics of AIDS Care in

a Tertiary Medical Institution in India' Journal of Clinical

Spidemiology, Vol 49: 1:16

S.Mahal, A, B Rao (2003): `HIV/AIDS Epidemic in India: An Economic

Perspective', Journal of Medical Research 121, April, pp 582-600.

National Aids Control Organisation (2003): `Note on HIV Estimates

2003', http://www.naco.nic.in/indianscene/esthiv.htm

Over, M, P Heywood, J Gold, I Gupta, S Hira, E Marseille

(2004): `HIV/AIDS Treatment and Prevention in India', Modelling the

Costs and Consequences, the World Bank, June.

Ritu Priya (2003): `Health Services and HIV Treatment Complex Issues

and Options', Economic and Political Weekly, December 13, Vol 37, No

50.

Sahloff, E G (2005): `Development of a Vaccine to Prevent Human

Immunodeficiency Virus Pharmacotherapy', HIV/AIDS Journal IAVI, 25

(5): pp 741-47.

The Lawyers Collective (2003): `Discrimination in Legislating an

Epidemic HIV/AIDS in India', Universal Law Publishing Co, New Delhi,

pp 1-19.

Thimothy, Rakkee, K Ajithkumar, S Irudaya Rajan (2005): `Viability of

Providing HIV/AIDS Care in Public Sector: A Case Study from Kerala,

India', Journal of Health Management (forthcoming).

UN HIV/AIDS (2004): `Global Summary of AIDS Epidemic', December,

Available from http://www.unaids.org/wad2004/report.html.

http://www.epw.org.in/showArticles.php?

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[Guest guest]

Dear FORUM,

Ref: The EPW Commentary, Medical Care for HIV. An Opportunity or Crisis? April

15, 2006. By K Ajithkumar, S Irudayarajan.

Many forums seem to converge in the same direction. Probably that is

the reason because of which it is being argued " Can AIDS be treated like any

other disease " ? Debate is also on as we all know whether we can shift our

communication strategy from only Technical awareness creation to wider debates

in society like power structure, rights, dignity, sexual freedom rather than

preaching, and excitement in life post HIV trauma in Human sense.

Undoubtedly, It can be seen as an opportunity. This is the issue

which has brought people from diverse background on the same platform.

This if linked properly with other public health problems will contribute in

" strengthening of labs, training of clinical and non-

clinical staff, etc, which can be used in a non-HIV scenario also " .

Sandip

E-mail <sandip_al@...>