Over a week ago, Pramod (name changed), who is on the anti-retroviral treatment (ART), being offered free by the government to HIV positive people, undertook the arduous journey over rough terrain from Tamenglong to Imphal to collect his monthly quota of ART medicines. He was given the medicine for just five days as the centre was facing an acute shortage of these lifesaving drugs. The long and expensive journey, every five days, can prove to be a deterrant for Pramod and he may not stick to his treatment.

Non-availability of medication is a critical matter for patients like him because lack of adherence to treatment schedules could result in development of resistance to the medicines. This is not the first time such shortages have happened in the Care Support and Treatment (CST) plan for HIV/AIDS patients in Manipur, which has the highest concentration of HIV/AIDS cases in India.

Bihar, too, is facing similar shortages. At the beginning of this month, HIV patients in Bihar staged a dharna protesting against the non-availability of drugs at four out of 12 ART centres in the state. They, too, were being given drugs for just 7-10 days instead of a month's supply. The government got the the president of the Bihar Network of Positive People, Gyan Ranjan, arrested for the protest instead of addressing their problems.

Though the incidence of newly infected adults in India has halved between 2000-09, the numbers are still large, with over 19 lakh cases detected by the National AIDS Control Organisation (NACO) out of the estimated 23 lakh. Of this, about 10 lakh have been initiated into the programme to provide first line drugs, free of cost. However, currently, only about 6 lakh persons are benefiting from this programme. About 1. 5 lakh (over 10%) have died and about 60, 000 (6%) have been lost to follow-up.
It costs the government Rs 6, 000 per person per year to treat them on first line drugs and more than double that, Rs 15, 000, to treat those on second-line drugs. The high cost of treating patients who develop resistance makes it imperative to ensure that patients stay on first line drugs for as long as possible without developing resistance. Strict adherence to treatment combined with proper nutrition and lifestyle changes is the only way to ensure this.

Research by the ICMR and others has shown that distance, travel time and costs are the main reasons why patients are not able to access ART services and adhere to the treatment, which is life long. But many patients often don't show up to collect their monthly drugs and miss follow-ups. The government has been working to improve access to treatment by opening more ART centres as well as link ART centres at district and sub-district levels. However, shortage in medicines caused by poor supply chain management could negate the efforts to provide effective treatment.

From January 2008 onward the government has been providing free secondline treatment to those who have become resistant to first line medication. So far, only 5, 500 patients have received free second-line treatment.
Loon Gangte of the Delhi Network of Positive People blames the difficulty in getting referrals for second-line treatment for the low numbers. "When my doctor, who has been treating me on first line for five to eight years, sees a fall in CD4 count and suspects that I might have developed resistance, he cannot even recommend a viral load test to confirm the diagnosis. I have to be referred to a State AIDS Clinical Experts Panel (SACEP) which meets, if at all, just once a week. So there is a lot of delay in the whole bureaucratic process to get into the second-line of treatment, " says Gangte.

The government defends the policy of SACEPs saying that it is an internationally accepted mechanism to prevent patients being put on second-line prematurely. It is feared that since most doctors at ART centres are fresh MBBS graduates, they may lack the necessary experience to handle cases of resistance by changing drugs or referring to second-line.

Incidentally, the government seems to have no record for about 20% of the 10 lakh people who were initiated to the first line of drugs. If 1. 5 lakh patients who died is added to the number of patients lost to follow-up ie 60, 000, it does not add up to 10 lakh. The government feels this discrepancy could be a result of same patients getting registered in different centres. Even with such an overlap of records, two lakh seems to be an alarmingly high number of people to lose track of. These could be at a greater risk of developing resistance. The lofty aims of the National AIDS Control Programme - zero infection, zero stigma and zero death -could come to naught if drug resistance and consequent jump in cost of treatment is not tackled.

VITAL STATS

Numbers that indicate success of free ART in India

Positive cases in India 23 lakh Positive cases detected by NACO 19 lakh Patients registered in HIV care with ART centres 17 lakh Patients ever started on treatment 10 lakh Patients currently on ART 6 lakh, including 31, 000 children Lost to follow-up cases (LFU) 60, 000 Cases of deaths reported 1. 5 lakh NACO estimate of total number of patients being treated in private sector in December 2011 30, 000 Integrated Counseling and Testing Centres (ICTC) in public health sector 9, 000 ART centres 358 Link ART centres 781 Community care centres 253 Patients on second line 5, 500 Centres of excellence 17 ART plus centres 24 * These are approximate figures as the numbers keep changing as new cases are detected or registered