Battling disease

With yet another shortage of HIV/AIDS drugs, India needs a strong law to end the problem

Government agencies must be compelled to iron out messy bureaucratic systems that cause stock-outs, say experts.

Since September, health activists have been complaining about the shortage of HIV/AIDS drugs. Antiretroviral therapy centres across the country have been reporting shortages of the life-saving drugs, condoms and testing kits provided by the National AIDS Control Organisation under the government’s free treatment programme.

Patients who came into Delhi's hospitals to collect a medicines for the month were sent away with 15-day doses or sometimes just enough to last them a week. Karnataka felt the crunch in early October. “We had a problem in the first week of October,” said BT Thyagaraj, assistant director for care and support at the Karnataka State AIDS Prevention Society.  "At that time the stock from Andhra Pradesh was shifted to here."

He added that Karnataka now has a buffer stock for more than two months.

The HIV/AIDS drug shortage is a recurring problem in the second half of every year and NACO is used to redistributing its resources, sending medicines where they are most required. This year, however, the shortage has been so acute that the organisation has had to take more extreme measures. Patients have asked to replace Nevirapine, one of the three drugs that make up the ART cocktail and of which there is a shortage, with another drug called Efavirenz. “Medically that is not a very good idea because someone who was on Nevirapine may not respond to Efavirenz or may even have side effects to it,” said Nochiketa Mohanty, India Programme Manager at AIDS Healthcare Foundation.

Programme undermined

The drug shortage has also stopped NACO from adopting more ambitious World Health Organisation guidelines for treatment, Mohanty points out. NACO usually starts ART treatment for patients whose CD4 cells count falls to below 350. Last year, WHO recommended that treatment be started for anyone whose CD4 count dropped below 500. This would mean making almost twice the number of ART drugs available, since more patients in the earlier stages of infection would become eligible for treatment. In view of the drug shortage, NACO has kept its ART initiation criterion at the 350 CD4 count.

HIV/AIDS activists blame the crisis on delays in the payment and procurement process and the lack of a good information technology-based method to forecast what quantities of ART drugs will be needed through the year. A strong HIV/AIDS law will help clean up government systems when it comes to controlling the disease, activists say. But the HIV/AIDS bill, which is expected to be taken up in the winter session of parliament, falls short on several points says Surekha Shetty, senior legal officer with Lawyers Collective.

The United Progressive Alliance government introduced the bill in the Rajya Sabha in February and it has since gone back to the health ministry’s standing committee for comment and suggestion from civil society. One problem area in the bill that legal experts are trying to get changed is the provision on treatment of HIV/AIDS patients. In its current form the bill provides that:
 “The measures to be taken by the Central Government or State Government under section 13 shall include the measure for providing, as far as possible, Anti Retroviral and Opportunistic Infection Management to people living with HIV or AIDS.”

The words “as far as possible” does not ensure that the government will provide free first-line, second-line and third-line treatment along with viral tests, infection management and nutritional support. Although NACO’s mandate is to ensure all of the above, it can shrug its shoulders and not be held responsible in case of a stock-out. “If there is a HIV law that guarantees complete treatment then hopefully the government will have to ensure that there are no stock-outs,” said Shetty.

Legal experts are also hoping that the final version of the bill will include a stronger definition of discrimination, a provision for free treatment and compensation for people who are occupationally exposed to the disease, provision for a health ombudsman in every district who can make emergency orders and special procedures in court for civil and criminal penalties in case the HIV/AIDS law is flouted.

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