E-drug: Correct use of antiretrovirals
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[I searched the UNAIDS and WHO/EDM site for information on correct
use of antiretroviral drugs, but did not find any. That worries me, as
for the next couple of years we may be fully occupied with making
ARVs available in the developing world, to discover thereafter that use
is woefully inappropriate. After all, it went that way with other
essential drugs. What will we do to control poor sales practices from
ARV manufacturers (see message below)? HH]
Bulletin of the World Health Organization 2003, 81(2), p.153.
News: Antiretroviral misuse in Mumbai, India
Many patients who have tested HIV-positive in Mumbai are consuming
antiretrovirals (ARVs) in fits and starts because of their unstable
financial circumstances. The warning comes from the Indian
community-based organization Sankalp and the Committed
Communities Development Trust. For lack of reliable counselling,
patients are unaware that once started, ARV treatment has to be
lifelong and without a break.
Patients are also not briefed about the hidden costs of therapy, such
as the need for regular, and expensive, laboratory tests, or the
possibility of severe side-effects.
AIDS specialist Nagesh Shirgoppikar says there is a strong case for use
of ARVs amongst patients whose CD4 cell count, a measure of
immune status, falls below 225. Patients with such conditions have
experienced a lifesaving reversal of symptoms when properly treated
with ARVs, but treatment involves care and knowledge as well as
medicines.
This advice is being undermined by the expanding interests of
pharmaceutical companies and private doctors in Mumbai. According
to a senior doctor, patients are being directly approached by medical
representatives of drugs firms and persuaded to start ARV courses.
Apart from violating the patients' right to confidentiality, this often
puts them on therapy when they don't need it, and no monitoring is
done, he said.
AIDS drugs companies appear to be racing to expand their Indian
markets. Given the current haphazard prescribing and consumption
practices with AIDS drugs, many doctors - not just quacks - are
experimenting with their own dosage and drug combinations. These
factors could lead to HIV developing drug resistance. If that happens,
the Indian government will face the enormous problem of how to help
those who have already started on the therapy. The majority of AIDS
patients in India come from the poorer strata of society, who are the
most exposed to haphazard and sporadic therapy.
The rush to market ARVs and the chaotic treatment of AIDS patients
was also underlined by government officials at a recent workshop in
Mumbai, where they complained of a "mania for HIV testing" by
doctors, in both the private and the public sector. Official policy in
public hospitals in Mumbai does not encourage HIV testing unless
there are clinical symptoms warranting suspicion of AIDS. But private
hospitals insist on compulsory HIV testing before patient admission,
even if they have no clinical symptoms of AIDS. Nongovernmental
organizations have pointed out that an HIV-positive "certificate", in
the absence of proper counselling and on the basis of a single ELISA
test, is seen as a death sentence by the patient and his family, and
this view is endorsed by an ignorant medical profession.
While India's National AIDS Control Organization (NACO) stipulates a
minimum of three ELISA tests before a person can be confirmed to be
HIV-positive, most patients cannot afford three tests.
Rupa Chinai, Mumbai
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