Wednesday, Dec 03, 2003
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By Ritu Priya
THE HIV and AIDS epidemic started in India in the mid-1980s and is maturing but its full burden is still awaited. The global 3/5 initiative promises to provide anti-retroviral (ARV) treatment to 3 million HIV infected persons by 2005. Indian public health must use this impetus to develop its systemic capacity to provide access to all irrespective of the ability to pay. Besides being the responsibility of the state to do so, the wide knowledge of availability of treatment can contribute to decreasing the stigma against HIV positive persons. Some key challenges will be i) providing comprehensive care and not just ARV drugs, ii) using operations research and localised planning to develop systems to address the diversity of situations, iii) placing positive persons in a central role in this process, and iv) dislodging irrational negative practices and perceptions that already prevail in relation to treatment of HIV positive persons.
ARV therapy is known to delay conversion from HIV infection to manifest AIDS, improve quality of life and prolong it by an average of 4-5 years. However, it is still in the process of development; all ARV drugs have not gone through the mandatory trials, side-effects and early development of resistance has been the experience in all countries where they have been widely used since the mid-1990s. To minimise these problems two or three drug combinations are given, which are started at late stages of infection in the patient. In the several years that precede ARV therapy, counselling and support for measures that prevent other common infections, improve nutritional sustenance and psycho-social well-being, promote safe behaviour to prevent HIV transmission to others, as well as treatment for opportunistic infections such as tuberculosis and fungal infections are required. Therefore, good support services, clinical skills and monitoring over years from the day of confirmation of HIV positive status are necessary. These measures are known to allow a mean of 10 years of normal quality life. However, the common perception has become that "if there is no ARV, there is no treatment for HIV positive persons". This has to be corrected, among both doctors and the lay public.
The crucial issue beyond funding is having delivery systems for safe and rational care since multi-pronged activism has resulted in lowering the cost of drugs. Political will and optimising existing allocations can provide enough resources for the recorded cumulative number of 44,275 AIDS cases (even though the officially estimated real number is about ten times this), since it requires about 2.5 per cent of the total amount allocated for health and family welfare in 2001-02.
Optimal regimens for low resource settings and delivery systems that work in diverse contexts need to be designed and tried out under field conditions. WHO guidelines need adapting for local realities.
Options in institutional structures for service delivery suggested by Indian and global experience are: community centres with medical referral, or a `centre of medical excellence' at hospital level with support services as adjuncts, or developing both and linking them together on an equal footing. Another important issue would be the role for members of Positive People's Networks that are emerging across the country. The institutional mechanism should give them a defined role from the beginning in designing, implementing and monitoring, especially at the sites for operations research.
The setting up of a system for rational care will also influence practice in the private sector. For optimal results, information on the components of comprehensive care for HIV infected persons must be made public knowledge.
Even while this is being done, the surveillance system should be strengthened in such a way that it provides reliable estimates and traces changes in HIV and AIDS prevalence. India is currently estimated to have an HIV seropositivity rate in adults of 0.7-0.8 per cent with 3-4.58 million HIV positive persons. This is low by global comparison. It is much lower than the 5 per cent, 26 per cent and 38 per cent respectively of Uganda, South Africa and Botswana; half of Thailand's 1.7 per cent and of a similar order as Brazil (0.65 per cent) and the U.S. (0.6 per cent).
Experience of the AIDS problem has been varied across Indian States. The National AIDS Control Organisation's sentinel surveillance data shows a generalised HIV epidemic in some States, a concentrated epidemic in a few, and a low prevalence in others. Data for the years 1998-2002 shows that in most of the States with a generalised high-level concentrated HIV epidemic, a decline in HIV prevalence has already begun. Reported AIDS cases follow a similar pattern, 76.6 per cent being concentrated in the seven States with generalised-cum-concentrated HIV epidemics, 8.2 per cent in those with concentrated pockets of HIV infection. Rest of the 15.2 per cent is in the low prevalence States (that hold 54 per cent of India's population among whom we have yet to see the peak of the epidemic), with 7.8 per cent in four major cities. Thus planning for AIDS prevention and treatment has to deal with these diverse epidemiological situations.
The great diversity in stages of the epidemic in different States and within each State poses the major problem in establishing reliable surveillance. As more surveillance sites are added comparisons over time become difficult with `old' and `new' sites being at different stages; somewhere the epidemic is just starting, in others levelling off and in still others the declining phase has set in. NACO's current efforts at generating an aggregated estimate appropriately accounts for several diverse groups States, rural/urban, male/female, high risk/low risk behaviour. However, analysis at local levels so as to trace the natural history and stage of epidemic will make it more accurate and meaningful.
Resurgence of new HIV positive cases has occurred in European and North American countries since introduction of ARV therapy, at least partly due to the complacency that `treatment is available'. Forewarned, we should integrate preventive activities with the treatment and not substitute one for the other. What should also not be lost sight of are the economic and social conditions of disparity that exist and are being accentuated by the current policies of `globalisation'.
(The writer is Associate Professor, Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi.)
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