As is evident from the letter written by the President of Indian Drug Users Forum (IDUF) to the Secretary, Department of AIDS, Government of India, several ART centres across the states of Manipur, Meghalaya, Nagaland and Tripura are facing a complete stock out of CD4 reagents for months and some CD4 machines have been out of use for the past 4 months.
CD4 tests are a critical tool for initiating anti-retroviral treatment in people living with HIV. Currently the NACO's guidelines recommend that people with HIV should start antiretroviral treatment (ART) when their CD4 count falls below 350 CD4 cells/mm, as per the 2010 WHO recommendations. The test, which is done free of cost at the Government centres, is also repeated at regular intervals. However several centres where CD4 testing is done free of cost are now without kits or reagents.
Despite several official reminders from SACS (State AIDS Control Society) of all these 4 states to the Lab Service division of Department of AIDS, no response has been received as yet. When the state level PLHIV networks raised these issues with their respective SACS they were told that states are not allowed to procure their own testing kits which are centrally procured by NACO. So supply chain mechanisms continue to plague the department as was evident in past stock outs.
DNP+ and the IDUF also have been writing to NACO to highlight the shortage. According to them, “The stock out is related to the never-ending issues with procurement that India faces in many of its public health programmes - the routine but deadly delay in tendering for drugs or medical products. Procurement of HIV medicines and medical tools such as CD4 and viral load kits or reagents is undertaken at the Central level through a procurement agent, M/s RITES Ltd. who have been contracted by Ministry of Health and Family Welfare to undertake procurement under various Programme Divisions of the Ministry of Health & Family Welfare, including NACO and Revised National Tuberculosis Control Programme (RNTCP). But in reality the contract of the procurement agent, M/s RITES Ltd. was not renewed by the said Ministry for almost two years, which has resulted in serious delays in the procurement of TB medicines and now CD4 kits or reagents for the HIV programme.”
It would be worthwhile to mention here that the new WHO guidelines for treating and preventing HIV infection encourage all countries to initiate treatment in adults living with HIV when their CD4 cell count falls to 500 cells/mm³ or less - when their immune systems are still strong--as recent evidence indicates that earlier ART will help people with HIV to live longer, healthier lives, and substantially reduce the risk of transmitting HIV to others. Governments of Algeria, Argentina and Brazil, are already offering ART treatment at 500 cells/ mm³.
In a recent interview given to Citizen News Service, Dr BB Rewari from NACO had said: "We have been using 350 cells/ mm³ as cut-off of CD4 count for long now to begin ART. However for those people with stage 3 and 4 diseases, all TB patients and pregnant women are provided ART irrespective of their CD4 count. However whatever be the CD4 cut-off, people are still presenting late to us and the challenge that remains is to detect them earlier at a higher CD4 count. Another challenge is to scale up testing so that more and more people know their status and our gap between those requiring ART and those on ART is reduced further.”
These are laudable sentiments indeed. But in the absence of a proper and free flowing supply mechanism for ART drugs and HIV testing kits the will remain mere words. "Last month civil society and TB activists publicly protested in front of the Ministry of Health against the stock out of TB medicines. Now we are protesting the stock out of CD4 kits in the HIV treatment centres. It is shocking that doctors will not be able to initiate or monitor treatment of people living with HIV. This is unacceptable," said Loon Gangte from Delhi Network of Positive People.
Citizen News Service - CNS
