Scaling up HIV/AIDS treatment and care in India

Dr. Mannu Setia, a dermatologist and STD specialist at Sion Hospital in Mumbai, India, spent two weeks in Boston as an HMI fellow, working on a special Indian edition of the book HIV. Setia provided a practical perspective on the realities of medical practice in India to help develop a chapter specifically addressing care of the disease in the country. Setia also gave a talk to HMI staff members about the state of the epidemic in India.

Dr. Mannu Setia

HIV is a clinical practice manual aimed at primary care physicians that covers some of the basic facts about HIV infection, the natural progression of AIDS, common clinical symptoms, and opportunistic infections and cancers. Published by the American College of Physicians in the U.S., HIV is co-edited by Dr. Harvey Makadon, HMI’s director of health systems, and Dr. Howard Libman, both of whom are Harvard Medical School associate professors of medicine at Beth Israel Deaconess Medical Center.

One of the goals of developing an edition of the book specific to India is to address the growing need for treatment and prevention strategies that reflect the realities of a particular region. Treatment approaches to HIV/AIDS have largely been created and refined in developed countries, and don’t always translate to settings where access to resources and medications is limited. Most people in India still do not have access to antiretroviral medications that can greatly extend the lives of people with AIDS. “Even with reduced prices of drugs, it is not necessarily affordable,” Setia said.

The cost of treatment is not simply the price of pills; currently, the tests needed to detect and monitor an HIV infection, as well as many of the complications of AIDS, require expensive equipment out of reach for many health care facilities. “The cost of monitoring is more that the cost of monthly treatment,” Setia said. And he noted that this expense makes widespread testing and surveillance difficult, preventing health care workers from determining how widespread infection is and identifying population trends.

Setia said that the World Health Organization has established its own treatment guidelines for resource-limited areas, but these guidelines need to be implemented and used. For instance, using the total lymphocyte count of a patient has been found to be a reliable surrogate marker for infection in cases where a CD4 count is unavailable. “Those sorts of tests which are locally available need to be more regularly followed and discussed,” Setia said. Health care workers need to be realistic about the level of testing and care that can be delivered, and find solutions that match their conditions. “We can’t always follow the gold standard although we would all love to,” he said.

Currently, therapies go to the select few who can afford them, often through the private health care sector. To scale up the delivery of medicines in the country will require efforts in the public health sector. Setia said that the key for the public hospitals is to work together with community groups and nongovernmental organizations to make sure that prevention and care programs reach those who need them most. Many of the people at risk for infection do not necessarily access the public health system, so other organizations can serve as a link between the two. He said that Sion’s program is particularly effective because it maintains strong community ties. “That sort of integrated model needs to be implemented on a large scale,” he said.

That will require training doctors and other health care workers in all the issues that surround HIV—talking with patients openly about sexual behavior and health, monitoring therapy to make sure that patients do not follow partial regimens, and recognizing and treating HIV-related infections. Setia was a member of the group of physicians who helped develop the educational program for WHARF (Wockhardt-Harvard Medical International AIDS Research and Education Foundation), an NGO established by HMI and Wockhardt Hospitals, Ltd. to train Indian primary care physicians and other health care workers in HIV/AIDS issues and care. The program has been highly successful, Setia noted, and participants are committed to train others in what they have learned. As interest has grown, “there are many more people who want to attend these sessions,” he said.

The Indian edition of HIV is expected to be completed later this year. In the meantime, a second U.S. edition of the book was recently issued by the American College of Physicians, bringing the evolving state of HIV treatment up to date.