Sunday 12 April 2009

Long choosing, and beginning late

So how can we do a better job of getting people onto life-saving antiretroviral therapy (ART) sooner, before they fall sick, and risk death as a result? I do have one or two ideas, Tom, if not solutions.

Clearly the first challenge is to identify people infected with HIV earlier. Certainly easier said than done, and as I've discussed before our current 'voluntary counselling and testing (VCT)' program is totally failing in this regard. Effectively passive, it's really provider initiated in most cases, detecting people only after they have to be admitted to hospital with AIDS-related conditions. But from the many questions I get (but rarely answer), it does seem many people are more ready to go to the ubiquitous private labs (Prodia is the best known) for testing, often very soon after their risky activity. Sadly they are usually poorly counselled and rarely referred from such labs.

As far as I know, these labs are not included in the national AIDS action plan. Would it not make sense to recognise their role, and provide guidelines and even accreditation to assist them to do a better job?

Once identified, how do we get them into treatment - and retain them? Clearly we need a better referral system. But if we get them into care soon after they are infected, we know that it may be five years or more before they need ART - based upon the current criteria. It's clearly extremely difficult to expect them to return for regular follow-up - more so since (as I have noted) they'd prefer to forget that they are living with HIV.

The solution is simple - and now increasingly urged: start ART immediately. Hardly a day goes by now, but some study does not report the benefits of much earlier start, and the risks of delaying. Prof. Joel Gallant from Johns-Hopkins, one of my HIV care heroes, was asked recently, if he became infected, when would he start ART. His answer? "Immediately" (Suppose that you were positive). And this is even more important for people with co-infections such as viral hepatitis.

Studies by WHO experts have shown that starting ART immediately would save money in the long term. The challenge of course is in the short term. Even the WHO shows no signs of 'putting its money where its mouth is.'

Other approaches? I am convinced that one barrier to starting ART is that people are doubtful that they will be able to adhere to the every 12-hour schedule of current first line regimens. But in fact the current standard first line regimen in the rich world is much easier: one pill once a day before going to bed. Most people go to bed every day, so they don't need complex reminders, or concern about being late. Clinton Foundation can buy such a pill for little more than US$300 per patient per year - less than the government pays Kimia Farma for the current standard first line regimen. And of course this one-pill-once-a-day ART solves the problem of taking ART during the fasting month.

I've never been a strong supporter of the concept of 'case managers' here. But since we have them, why don't we require them to play a more active role in retaining people in care, especially those do not yet need ART? Get help from peer support groups if they lose contact. Of course they should be doing this already for those on ART, but...

We can - and should - do all we can to make sure that no more Fredy's die from starting treatment late...

Babé

1 comment:

Tom said...

Excellent points as always, Babe! You're absolutely right about the need to improve VCT, and the once a day pill would be great. I've seen folks on ARV in Makassar, for instance, carrying pills around with them and their friends glancing at the clock when the hour rolls around they should take their dose - but that in the best of circumstances when they even have friends who know they are on ARV, and are willing to carry pills around with them. Both of these things - VCT improvements and access to the one-a-day pill, would be great steps. Thanks for yet another great post!