Universal access to treatment by 2010 - Where are we? A view from India

Submitted by bharathi about 3 months ago

Universal access is a global commitment to scale up access to HIV treatment, prevention, care and support by 2010 for all those who need it. The movement, enshrined in the 2006 UN Political Declaration, is led by countries worldwide with support from UNAIDS and other development partners including civil society.

The out-patient department of Victoria Hospital in Bangalore, Karnataka, India, is housed in an old, cavernous and somewhat dilapidated building. The 1000-bedded government hospital, which is more than 100 years old, provides free comprehensive medical care to urban and rural Bangalore districts.

The reception area has sheets of paper pasted on the walls which indicate the way to room 55 on the second floor. Room 55 is actually an entire section of the floor which has been cordoned off to house the antiretroviral therapy centre.

It consists of a records office, a room for patients to meet the counselors, one for dispensing medication and a doctor’s consultation room.

By the end of the day and a neat stack of large envelopes labeled with the names of patients and containing all their details is placed on a table, ready for data entry. The stack reveals more than 80 patients have visited the antiretroviral therapy (ART) centre that day. They have been examined, advised further treatment if required, counseled and returned home with their monthly medication.

Dr V.S. Parvathi, Senior Medical Officer at the ART centre, says: “3,711 HIV positive people are registered with us. Out of these 1,851 are on ART. We pride ourselves on the hassle-free systems we have in place, which allow people to get their monthly medication with the least amount of inconvenience.

“We also have systems to track each person registered with us, considering the importance of adherence. In the event that any of them shows signs of dropping out, we immediately follow-up and ensure they stay with the treatment” she says.

Feedback from people accessing medication at the hospital endorses her claims and they report that barring a few inconveniences – such as blood tests which involve waiting in long queues, lack of amenities such as drinking water and toilets, and occasionally dealing with temperamental staff - the process is largely straightforward.

Aside from Victoria Hospital, Bangalore has four Government ART centres which cater for the needs of people living with HIV from Bangalore Urban and Bangalore Rural districts. Talking to people using the services at these centres also reveals a good degree of user satisfaction.

Is this an indication then that the state of Karnataka, or at least the city of Bangalore, is on its way to achieving universal access to treatment? Is it also reasonable to assume that the situation in the rest of India might also be as good?

World Health Organisation figures show that an estimated 28,000 people who availed ART medication in India in 2004 increased to 158,000 people in 2007. The 2007 figure includes 35,000 people who availed medication from private sources but even if that figure were removed, the upscaling efforts are impressive.[1]

There are, however, indications that access to treatment is not uniformly good. In Karnataka, which has a population of around 5.8 million, the State AIDS Prevention Society reports an adult HIV prevalence of more than one per cent in several districts. The state has some 40,000 people, including children, on ART as of March 2010.[2] Exact figures are difficult to obtain but a large number of these people live in districts, particularly in North Karnataka.

Mallamma (30) hails from North Karnataka and is a migrant. She works in a garment factory in the outskirts of Bangalore. She is living with HIV but not yet on ART. For her check-ups and treatment for minor illnesses, she prefers to visit SEWA Clinic, a private clinic which offers free services for HIV positive people.

“Even when I lived in my village, I did not use government services even for coughs and fevers because doctors in these places do not care. Aside from that, I did not even know that government services are available for people living with HIV.

“The doctor here respects me and I don’t have to wait in long queues. I am sure of getting treated within a short while of coming here. This means I don’t have to take an entire day off from work” she says.

The challenges of travelling long distances can put people off attending clinics and continuing their treatment thus leading to non-adherence.

Ms P Saroja, President of the Karnataka Network of Positive People (KNP+), says: “People living in remote areas travel great distances to get their monthly medication. This means being away from home for the entire day or more. For every test or investigation they have to undergo, there are problems as there is a scarcity of equipment in district hospitals.

“They have to wait long hours to get services and this means losing wages, besides spending on bus or train fares, and if they are unwell, they just don’t feel strong enough to cope with the wait. These factors come in the way on adherence and large numbers of them drop-out of medication owing to this” she says.

Her colleague, Mr N.M. Devendrappa, Programme Manager of KNP+, has years of experience working with HIV positive people at district levels cites the example of Bagalkot District Hospital.

“The hospital has more than 17,000 pre-ART cases registered but the gap between facilities available and demand is so big that most patients are not able to get their testing and medication needs addressed.

“National AIDS Control Organization (NACO) has established link ART centres in order to increase access and make it easier for patients to get services and medication but these are not well accepted yet because patients fear they will face stigma at the places which are closer to their homes” he says.

Indeed, some people are so wary of the stigma they may have previously faced at local clinics, they are willing to travel further afield to avoid this potentially happening again.

Mary (name changed by request) is a woman living with HIV who travels 100km to Bangalore to use private facilities, even though there are Government facilities closer to her village.

She says, “I feel upset when the doctor in the Government hospital refuses to examine me and only looks at me from a distance while prescribing treatment. I only get my monthly medication free but then have to buy medicines for other illnesses such as skin problems.

“That is the reason I prefer to come here to a private clinic. The doctors here are kind and give me confidence that I will live” she says.

Poor quality of services, which can include unsympathetic staff, are increasingly blamed for poor uptake. Dr B Satish, who practices at the private SEWA Clinic, says: “The Government has established facilities and enabled reasonable access to treatment.

“But if usage is not commensurate with availability, this is owing to disparities in quality and lack of awareness among the community. These factors need to be urgently addressed.”

Ms Saroja of KNP+ believes networks like hers could help to address this. She says: “Positive people’s networks and peer counselors have a huge role to play in ensuring that people access the treatment available in government facilities.

“And yet, our role has been minimized throughout the years. Unless this changes, we will continue to have a situation where despite facilities being available, universal access will be a goal which cannot be achieved.”

[1] http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_IN.pdf

[2]www.nacoonline.org/upload/Care%20&%20Treatment/Patients%20alive%20and%20on%20ART/On%20ART%20March%202010.pdf

Keywords: Access to treatment ART HIV India universal access

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