Thursday, 15 March 2012

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Gaps in the ART programme

A critique of the ART programme through a scrutiny of the working of the programme and interviews with positive people.

More than two decades after the detection of the first AIDS case in India, the disease is now regarded as a “development” problem and not just a public health issue.

Government policy has also moved forward to deal with the reality of a large number of people infected with HIV across the country. In recent years the government has moved beyond an exclusive focus on prevention of new infections to the treatment of those already living with the virus. In early 2004, the Indian government introduced a scheme to provide antiretroviral treatment (ART), with the aim of treating 100,000 people free of charge through the public sector by 2005-end.

‘Antiretroviral drugs for all? Obstacles in accessing treatment: lessons from India’ by Panos India (New Delhi, March 2007), is a collection of reports in which journalists from 14 states and union territories describe and critique the ART scheme of the government. The states include six high-prevalence states (Tamil Nadu, Andhra Pradesh, Karnataka, Maharashtra, Manipur and Nagaland), two medium-prevalence states (Goa and Gujarat), low-prevalence but highly vulnerable states (Punjab, West Bengal, and Uttar Pradesh) and low-prevalence, but vulnerable states (Himachal Pradesh, Union Territory of Chandigarh and Haryana).

The report contains the voices of Positive people, vulnerable groups, health professionals, public health experts, government officials, industry representatives and others involved with the programme. Attempts are made to look at what it means to get ART not only from the government programme, but from other sources.

The interviews were conducted between December 2004 and January 2005; however, the reports were updated through interviews and desk reviews till early 2006. This report therefore, largely reflects the situation more than two years after the programme was started. The issues it raises are still relevant today.

The Panos report identifies the gaps in the programme, highlights issues of concern and shows ways of overcoming some of the obstacles. The critique is placed within the overall framework of low spending by the government on public health in general and increased spending on vertical programmes like AIDS. Even within the framework of the AIDS programme, reports from across the 14 states make it abundantly clear that the ART programme is poorly conceived, implemented and monitored. The public health system is unprepared, with shortage of drugs, equipment and personnel, making adherence impossible.

Communication and counselling are the weakest links in the programme, the report says. Access for vulnerable groups such as sex workers, men who have sex with men and transgenders, as well as those living in rural areas is very limited. Insufficient attention is paid to injecting drug users (IDUs), who often have Hepatitis C co-infections, which are not addressed by the current ART regimens. There is also limited involvement of those affected by HIV and AIDS, especially in planning.

Though women and children were supposed to be the highest priority beneficiaries, women have not been adequately reached by the programme; structural issues that hinder women’s access have not been addressed. The lack of paediatric formulations has hampered efforts to include children in the programme. Even in states with political commitment, the over-reliance on the private sector has reduced the accessibility of ART to those who need it most. Further, inadequate prevention services, particularly in the low prevalence states, as well as stigma and discrimination also hinder successful implementation.

Finally, the number of people getting ART is much less than those who need it. According to a NACO report, “as of December 2006, 55,473 people were receiving antiretroviral therapy through the public sector at 111 centres... Overall, approximately 95,000 people were receiving antiretroviral therapy by the end of 2006, including people enrolled through private facilities. The number needing treatment is at least 508,200, which means there is still a gap of 413,200.”

The latest government estimates of people living with HIV in India have been halved to about 2.5 million. This means that about 250,000 people need treatment – half the earlier estimate. Still, only 95,000 people are on antiretroviral therapy, compared to 250,000 who need it, the report concludes.

Click here to read the full report

InfoChange News & Features, April 2008

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