NEWS

Antiretroviral misuse in Mumbai, India

Rupa Chinai

Mumbai

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 life-saving 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.