By K Ajithkumar, S Irudayarajan
It is possible to provide antiretroviral therapy for India's growing population of HIV patients. This article argues that if the present healthcare system is strengthened and the primary healthcare centres are involved, ARV can prove to be sustainable
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 three 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 programmes from different agencies including the 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 as 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 [John 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.
- John, K R, Dilip Mathai (1996):‘Economics of AIDS Care in a Tertiary Medical Institution in India’ Journal of Clinical Epidemiology, Vol 49: 1:16S.
- 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’, Available from http://www.unaids.org/wad2004/report.html.
Reprinted with permission from the Economic and Political Weekly, Vol 41 No. 15, April 15-April 21, 2006