India抯 treatment programme for AIDS is premature
http://www.100md.com
《英国医生杂志》
The announcement by India抯 health minister梠n the eve of world AIDS day in December梩hat 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抰 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抯 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.(New Delhi Sanjay Kumar)
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抰 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抯 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.(New Delhi Sanjay Kumar)