HIV cri­sis wors­ens

Short­age of an­tiretro­vi­ral drugs and lack of di­ag­no­sis is not new in In­dia, but gov­ern­ment does not ad­mit to the cri­sis


In­dia faces se­vere short­age of an­tiretro­vi­ral drugs, but the gov­ern­ment turns a blind eye, as in the past

THE FIGHT against hiv/aids in In­dia is be­com­ing tougher by the day as pa­tients con­tinue to face an acute short­age of an­tiretro­vi­ral drugs. This is an alarm­ing sit­u­a­tion for a coun­try with the third-high­est num­ber of hiv+ peo­ple in the world—2.1 mil­lion. In 2012,about 140,000 peo­ple in In­dia died of aids. Such is the de­mand-sup­ply cri­sis that the gov­ern­ment of a coun­try which is the big­gest pro­ducer of hiv drugs has been com­pelled to seek the help of hu­man­i­tar­ian or­gan­i­sa­tions like Médecins Sans Fron­tières (msf ) to pro­vide medicines.

Ac­cord­ing to the lat­est data of the Na­tional aids Con­trol Or­gan­i­sa­tion (naco), pub­lished on its web­site on Oc­to­ber 16, the stock of nevara­p­ine, an an­tiretro­vi­ral drug ad­min­is­tered to adults, was avail­able only for three days in Kar­nataka. The stock of the same drug in Chandigarh and Haryana was hardly enough for 20 days and eight days re­spec­tively. Lopinavir and ri­ton­avir, drugs used in com­bi­na­tion, were avail­able in Mumbai and Tamil Nadu for 15 days.

In­ad­e­quate sup­ply of an­tiretro­vi­ral drugs is not a re­cent phe­nom­e­non. In the past, when­ever some states faced a short­age, the gov­ern­ment moved the drugs from other states that had suf­fi­cient stocks. But it failed to iden­tify this as a cri­sis and did not take ac­tion to en­sure last­ing sup­ply of hiv drugs. In the past six months, the sit­u­a­tion has wors­ened. Many states are simultaneously bat­tling a short­age of drugs. This has pre­vented in­ter-state trans­fer.

While msf has agreed to do­nate 70,000 tablets of teno­fovir 300mg and lamivu­dine 300mg, ad­min­is­tered as a com­bi­na­tion, the gov­ern­ment has de­cided to pro­cure nearly 13 mil­lion tablets as a short-term mea­sure.It has also re­ceived more than half a mil­lion nevara­p­ine tablets from pri­vate en­ti­ties who have do­nated the drug as part of their cor­po­rate so­cial re­spon­si­bil­ity.

Medicine crunch and de­lays

In Fe­bru­ary this year, the then Union health min­is­ter, Ghu­lam Nabi Azad, an­nounced that the el­i­gi­bil­ity for re­ceiv­ing an­tiretro­vi­ral

ther­apy (art) would be re­vised from CD4 level 350 to 500 (the higher the level of the CD4, the less se­vere is the in­fec­tion). This in­di­cated that those who could not avail hiv/ aids treat­ment at an early stage could now do so. But the gov­ern­ment seemed to over­look the short sup­ply of an­tiretro­vi­ral drugs and did not re­alise that it was un­pre­pared to meet such a com­mit­ment.

Vikas Ahuja, pres­i­dent of the Delhi Net­work of Pos­i­tive Peo­ple (dnp+), says that the cri­sis of short­age of hiv drugs will deepen as buf­fer stocks are fast run­ning out. “Drugs like teno­fovir and lamivu­dine and lopinavir and ri­ton­avir syrup are not avail­able for pa­tients. A few states are al­ready fac­ing a short­age of nevara­p­ine syrup,” he adds.

Loon Gangte from the South Asia chap­ter of In­ter­na­tional Treat­ment Preparedness Coali­tion (itpc) be­lieves that the main rea­son be­hind the cri­sis is a ca­sual ap­proach of all the agen­cies re­spon­si­ble for drug pro­cure­ment and de­liv­ery, which in­cludes courier ser­vice they use. When he tracked a con­sign­ment of nevara­p­ine on Septem­ber 17 this year, he found that the stock sent from Hy­der­abad took a month to be de­liv­ered in Guwahati. The con­sign­ment was kept in a store­house in Guwahati for 19 days be­fore the fi­nal de­liv­ery.

Another fac­tor is the de­lay in ap­prov­ing ten­ders. A ten­der for teno­fovir/lamivu­dine drug was ap­proved by the gov­ern­ment in Septem­ber this year, while de­mand for it was placed in Jan­uary by var­i­ous states. After a ten­der is ap­proved, the stock of medicine usu­ally takes two months to reach pa­tients. Given the present bu­reau­cratic setup, it would take up to 11 months for an hiv drug to reach pa­tients.

In a meet­ing or­gan­ised in May this year by the Depart­ment of aids Con­trol un­der the Min­istry of Health and Fam­ily Wel­fare, lack of co­or­di­na­tion be­tween naco and the states was recog­nised as a ma­jor hur­dle in hiv treat­ment. In its le­gal no­tice to Union health sec­re­tary Lov Verma in Au­gust, dnp+ asked the gov­ern­ment to en­sure a ro­bust de­liv­ery mech­a­nism, such as emer­gency pro­cure­ment, trans­fer of medicines to art cen­tres strug­gling with short­age and an on­line track­ing sys­tem to mon­i­tor stocks.

This con­tin­gency plan might work in the short run, but is the gov­ern­ment plan­ning any long-term mea­sure to avoid such a cri­sis in fu­ture? When Down­ToEarth con­tacted Verma, he said the gov­ern­ment is work­ing on it, but de­nied that the coun­try is fac­ing a cri­sis in the avail­abil­ity of hiv drugs.

Other bot­tle­necks

Be­sides a short­age of drugs and ad­min­is­tra­tive de­lays, there are other ob­sta­cles that hin­der qual­ity hiv treat­ment in the coun­try.One of them is the ab­sence of di­ag­nos­tic mea­sures. Vi­ral load (VL) test­ing for rou­tine hiv/aids treat­ment is a key rec­om­men­da­tion of the World Health Or­ga­ni­za­tion’s 2013 guide­lines on art.A VL test de­ter­mines the

"The gov­ern­ment is work­ing on a long-term mea­sure to en­sure last­ing stock of an­tiretro­vi­ral drugs, but there is no cri­sis in sup­ply" "The cri­sis in the sup­ply of HIV drugs is due to the ca­sual at­ti­tude of all agen­cies in­volved in drug pro­cure­ment and de­liv­ery"

amount of hiv virus in the blood, which can bet­ter in­di­cate how some­one is re­spond­ing to treat­ment. A who survey last year showed that ac­cess to hiv di­ag­nos­tic and mon­i­tor­ing ser­vices is poor across low- and mid­dlein­come coun­tries.

In In­dia, the bar­ri­ers are many. A VL test has to be first ap­proved by State aids Clin­i­cal Ex­pert Panel (sacep). In­dia has only 10 VL test fa­cil­i­ties. The ap­proval process re­quires the pres­ence of the pa­tient. This leads to de­lays.For ex­am­ple, peo­ple from the North­east have to travel all the way to Kolkata for the test, which de­lays timely treat­ment.

sacep in Ma­ha­rash­tra has not rec­om­mended VL test to hiv+ pa­tients in the last one-and-a-half years. Eldred Tel­lis from Mumbai-based non-profit Sankalp Re­ha­bil­i­ta­tion Trust says, “When I ap­proached sacep, the of­fi­cial asked me what is the point of rec­om­mend­ing the test if VL kits are not avail­able.”

hiv treat­ment does not solely de­pend on drugs and di­ag­no­sis. Given the stigma at­tached to the dis­ease, pa­tients need holis­tic care and support to live with dig­nity. In­dia fails on this count, too. Ac­cord­ing to K R Antony, for­mer di­rec­tor of the State Health Re­source Cen­tre, Ch­hat­tis­garh, the gov­ern­ment stopped fund­ing com­mu­nity care cen­tres (cccs) in April 2013. “Th­ese were es­tab­lished by naco in 1999 to pro­vide coun­selling and drugs to hiv+ peo­ple. They pro­vided crit­i­cal care to 2.5 mil­lion pa­tients in the coun­try,” he says.

The gov­ern­ment stopped the fund­ing as it be­lieves hiv/aids treat­ment will be taken care of by art cen­tres and dis­trict hos­pi­tals. “But majority of the art cen­tres are un­able to de­liver as they are un­der im­mense work load. Th­ese cen­tres are not ad­e­quately pre­pared in terms of staff strength and fa­cil­i­ties to pro­vide pa­tients with the care they need. The per­son­nel in dis­trict hos­pi­tals are not trained for pal­lia­tive care ei­ther,” he ex­plains.

msf cam­paign co­or­di­na­tor Leena Meng­haney says In­dia has to un­der­stand the ur­gency of the sit­u­a­tion and chalk out a longterm strat­egy to tame hiv. “Lack of medicines or di­ag­nos­tic kits will ham­per the coun­try’s ef­forts in bring­ing hiv/aids un­der con­trol,” she adds.


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