Dr B B Rewari heads the National AIDS Control Organisation’s (NACO) antiretroviral treatment (ART) programme that provides free ART through government health centres. A senior physician at the Ram Manohar Lohia Hospital in Delhi, he has been working in this field for nearly two decades. He speaks to Rashme Sehgal about the implementation of the ART programme and its future scale-up
Studies in the West have found that starting antiretroviral therapy (ART) for positive people with a CD4 count of 350 saves lives. However, NACO’s guidelines recommend starting ART only once the CD4 count drops to 250. Positive people with a CD4 count of 350 will be “considered” for ART if they are symptomatic or have mild symptoms. Is there any move to reconsider this guideline? Are there any plans to start studies on this matter?
All I would like to say is that going by past experience, almost 90% of patients come to us when the disease has entered Stage 3. That is why we have not kept any kind of limits.
We have a target of providing ART to 3 lakh adults and 40,000 children infected with HIV/AIDS by 2012. But we already have 2.2 lakh patients under treatment this year. It is for this reason that we have revised our estimate and now expect to have 3 lakh patients under treatment by 2009-end and 4 lakh by 2012.
We are at present intensifying detection by increasing the number of Integrated Counselling and Testing Centres (ICTCs). Already, we have set up 5,000 ICTCs. Earlier, people would not come back to collect their results but now we are following a different modus operandi. We now insist that the ICTC gets feedback from the people who come to it.
Also, every ART centre will cover 15-20 ICTCs. ICTC counsellors will be responsible for ensuring that all patients who need ART receive it. At present 40% of people who come for testing are lost; they may come to the ICTC but do not go beyond that. Our target is to ensure that those who test positive and need treatment receive it.
There are complaints that the service being offered at ART centres is poor and forces patients to go to non-government organisations (NGOs) and the private sector for treatment. What does NACO plan to do about this?
I need to be given specific complaints about patients going to NGOs. Our figures on those getting ART in the NGO sector are incomplete. I would say that there are around 30,000-35,000 patients on ART in the private sector. These patients prefer to go to private doctors for reasons of confidentiality and affordability. They don’t want to be seen standing in queues at government centres. But many of these patients are also shifting from private doctors to government hospitals. This could be because they have exhausted their funds.
On what grounds are you saying this?
In 2007, we conducted a three-month study of ART prescriptions, looking at the sales of these drugs. We found that many private practitioners did not give rational prescriptions. We interacted closely with the Indian Medical Association and insisted that private doctors be trained. Finally, in order to ensure uniformity of treatment, we took the matter to the Supreme Court. On October 1, 2008, the court directed that all private doctors must follow the NACO treatment regime.
There are also complaints that those who are registered for ART in a government centre are not eligible for treatment in other centres.
When the records have been kept in one centre, how is it possible to go for treatment at another centre? It takes more than one week to complete all the tests. There is counselling and the CD4 test.
But we are planning to put all this information onto a smart card. If a patient is travelling, he can go to any ART centre for additional treatment. The details will be read through his fingerprint. This biometric card has been introduced in a pilot phase covering15-20 centres in Andhra Pradesh and Tamil Nadu. The scheme still has to be finalised in the rest of the country.
Nutrition plays a key role in the treatment of this disease. Why does the government not provide nutritional support along with ART? We all know that those who go to the government ART centres are most in need of good nutrition.
There are many aspects to this because we are here talking about nutrition advice, nutrition counselling, nutrition supplementation and so on. We have discussed this problem many times. Storage of nutrition supplements at ART centres is a major problem. We would be required to give three kilos to every patient coming to a centre and since some centres are dealing with hundreds of patients, we are looking at storing several thousand kilos of supplements.
We have 40 centres at present, each handling more than 3,000 patients. We simply do not have the space and are fighting with hospitals for more space. Then we need to figure out how to stop pilferage, maintain supply chains and so on.
We are considering providing a micro-nutrient supplement which can be given in the form of tablets. There are at present an estimated 2.3 million people with HIV. Even 15% of this estimate works out to 3.8-4 lakh patients. We are working to build on providing better nutrition.
What is the number of people needing first-line ART? What is the target for treatment that you are looking at by 2010?
We have expanded rather fast. Initially, first-line treatment started as a pilot project but at present 6 lakh patients have been registered at the ART centres. We are focusing on improving the quality of care. We are starting 150 “link” ART centres. The objective is that once the patient stabilises, his/her treatment can be provided from a link centre which will be located in a place closer to home.
I would like to emphasise that the number of 2.3 million (people living with HIV/AIDS in the country) is a validated figure. The whole emphasis is on people knowing what their status is and this can come about by stepping up the awareness campaign. We can’t force people to come to testing centres. The difficulty is in knowledge leading to changed behaviour.
You have stated that 350 people are going in for second-line ART treatment in 10 centres. What is the number of people needing second-line ART and why are so few people getting this treatment?
As far as second-line treatment is concerned, I would like to point out that in January 2008 we started two centres. This January we have increased the number to 10 centres. The two centres were started as pilot projects and by 2009-end we expect to have 410 patients.
Each patient has to be evaluated thoroughly. If a patient is started on second-line treatment wrongly, he will be gone for life. Clinical experts will have to come together and decide whether a patient should be given second-line treatment. There is no third-line available in India. It is not available from the pharma companies.
There are complaints of drug shortages.
Drug availability is 100% in all the centres. This is monitored round the clock and I must emphasise that we do not have even one day’s shortage. Nobody is denied this medicine in any part of the country.
A YRG Care study found that 14% of drug-naïve (untreated) patients were infected with resistant forms of HIV-1. Please comment.
About the YRG Care study I would like to point out that I don’t agree with the findings. I have not seen the sample size but the validation of 14% has not been found anywhere in the world. I’ve been practising HIV medicine for 12 years. Drug resistance in a live population (as opposed to in a lab sample) is between 2-3%.
How did you start working in this field?
In 1997, this medicine used to cost Rs 30,000 per month to a patient. I was then working in the Ram Manohar Lohia hospital, a government service, and my patients could not afford this treatment. But they kept coming and I developed a good bonding with many of them. I had 200 HIV patients but no treatment other than for opportunistic infections.
The number of patients kept going up; at one point I had 1,200 patients in my hospital but they could not afford treatment. It was then that I started advocacy to provide free drugs.
On April 1, 2004, a pilot project was rolled out by the government. In the first month, 60 patients received ART. Today, every month 10,000 patients are getting enrolled from which 6,000 are put on ART. This indicates greater awareness although I must emphasise that sentinel surveillance shows the figures of this disease have come down from 2.5 to 2.3 million.
How would you respond to the criticism that HIV/AIDS is cornering funds that should be allocated for other diseases, including TB and malaria?
HIV/AIDS has an annual budget of Rs 1,100 crore from which Rs 250 crore is spent on care and support, including treatment. HIV/AIDS has been getting more money because of more NGO pressure. This has ensured that the government puts greater emphasis on treatment. But, of course, people in India are dying of malnutrition, TB and malaria. I have always maintained that funding needs to be balanced out.
InfoChange News & Features, July 2009