NEPAL: Treatment illiteracy puts HIV benchmarks in peril
A ledger tracking patient ART adherence in Kathmandu
KATHMANDU, 17 April 2012 (IRIN) - Poor understanding of antiretroviral therapy (ART) amongst health officials, clinicians and patients in Nepal could undermine gains in the country’s HIV/AIDS prevention efforts and threaten future progress in lowering the number of new infections.
“Treatment illiteracy is occurring at all levels, from patients who have to keep up with their own treatment, to clinicians who administer treatment, to government officials crafting policies,” said Gokaran Bhatt, coordinator of Nepal’s Country Coordinating Mechanism, the independent body tasked with coordinating all money granted to Nepal by the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria
Government figures for 2012 put HIV prevalence in the adult population at below 0.3 percent, down from 0.45 percent in 2005.
According to Nepal’s first National AIDS Response Progress report
, an estimated 50,000 people are living with HIV, and four out of every five new infections are attributed to sexual transmission. ART was introduced in Nepal in 2004 and 6,483 people are currently receiving antiretroviral (ARV) drugs.
“Given the poverty and geographical challenges in Nepal, we are doing extremely well here,” Sashi Sharma, head of the Internal Medicine Unit at the Teaching Hospital in the capital, Kathmandu, told IRIN.
But many now argue those gains could evaporate if proper adherence to treatment policies and regimens is not exercised.
It is extremely important that patients always follow their ART regimen. “In a resource-poor country like Nepal, adherence is our only option to survive, and the baseline of adherence is treatment literacy,” said Rajhiv Khafle, founder of the National Association of People Living with HIV Nepal (NAP+N
Health workers stress that patients need a combination of counselling and monitoring to help them understand that they must always take their medicines at the same time each day, and that a dose should never be skipped. “Before ART can start, patients have to go through a full two-day counselling session,” noted Madhab Raj Pant, an HIV technical officer who worked in rural Doti District for two years.
To ensure that patients will visit the distribution centre, get tested, and receive ongoing counselling, ART medicines are dispensed on a monthly basis. Nepal currently reports a “lost cases” rate of 9 percent - patients who start on ART and then do not return for three consecutive months.
A variety of reasons can cause patients not to adhere to their regimen. In some areas, difficult terrain makes travelling to the nearest ART distribution centre costly and time-consuming. Bishnu Pokhrel*, who lives in a village in the Doti area, has to walk for a whole day to reach the nearest ART distribution centre. Public transportation is too expensive, and can also be unreliable due to landslides and strikes, he said.
When travel is impossible, some patients turn to HIV-positive friends to borrow doses of drugs. “Borrowing is not good practice. It encourages irregular taking of medication and patients aren’t medical professionals, so they might take the incorrect dose or incorrect pills,” Pant explained.
Breaking away from ART can harm the positive health effects of following a regular regimen. “We sometimes see a drop-off or a gap in adherence after the first six or seven months,” said Pant. “When patients feel better, they sometimes think they are cured.”
ARV treatment illiteracy on the part of clinicians can also cause problems. Dilip Gurung, the executive director of a community support group in the city of Pokhara, reports that he has sometimes seen clinicians change ART regimens several times to try to get the patient to feel better.
“Changing ART regimens can lead to fear among patients, confusion about how to properly administer the new drugs, and drug resistance,” Gurung said.
Public health officials agree. “It scares us if people are administering combinations that are not part of the national guidelines. If the patients on these drugs have problems or build resistance, we can’t help them - the national system can only help people within its guidelines,” said Hemant Ojha of the National Centre for AIDS and STD (sexually transmitted diseases) Control (NCASC
Some outreach workers say drugs alone are not enough. “Clinicians sometimes act as if ART is a solution alone,” said Ekta Mahat, a programme officer at NAP+N. “It’s not - you need nutrition, a realistic access plan based on the patient’s life, education about possible side effects, and discipline to take the medication at the right time.”
According to the NCASC
, Nepal has approximately 196 HIV testing and counselling centres [ ], as well as 35 ART distribution centres and sub-centres located throughout the country
. All ART drugs are distributed free of charge.
But “availability is not necessarily accessibility”, Mahat said. Policies that neglect the comprehensive nutritional, financial, educational, and pharmaceutical needs of people living with HIV/AIDS amount to treatment illiteracy at the policy level.
Moreover, government guidelines and the strategies of some HIV NGOs do not always take the same approach. “When we get a call from a patient whose ART isn’t working, we mobilize to get that person help,” said Khafle of NAP+N. “It’s not a public health approach, it’s a humanitarian approach.”
Observers fear the positive results from national HIV efforts could be diluted if tensions over the administration of HIV programmes continue, and adherence issues hamper implementation.
“Nepal has done extremely well in the last decade,” said Marlyn Elena Filio-Borromeo, UNAIDS country coordinator, “but these gains are fragile.”
*not his real name