World AIDS Day: Success and challenges of the private sector in HIV management

The major success of private sector is, it has and uses all lines of ART, including rescue regimens, whereas the Government-run ART centres have limitations on using even second-line ART and often faced with frequent stock-outs of anti-retrovirals (ARVs) and follow-up test kits

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The private sector has played a pioneering and leadership role in the field of care and support of HIV/AIDS, mainly because it was early beginner in Anti-retroviral Treatment (ART) and most-importantly there are committed souls who have put in from a decade to more than three decades in this field.

Conversely, lack of trained and committed workforce at ART centres is a serious issue. However, neither the entire private sector is keen in HIV care, nor everyone rejects/dejects HIV/AIDS patients. With improved range of ARVs, major challenge remains with Opportunistic infections (OIs) and Co-infections as well metabolic disorders management.

Success

The major success of private sector is – it has and uses all lines of ART, including rescue regimens, whereas the Government-run ART centres have limitations on using even second-line ART and often faced with frequent stock-outs of anti-retrovirals (ARVs) and follow-up test kits.

Qualification, training, interest in the subject and indulgence for better management of Person(s) Living with HIV (PLHIV) are its plus points.

Its unique selling proposition (USP) is all-inclusiveness – providing holistic care, Post-Exposure Prophylaxis (PEP) even for sexual exposures, not merely professional exposure to medical caregivers and Pre Exposure Prophylaxis (PrEP) (which is not approved in public sector), adult immunisation, managing drug interactions, toxicities, ART sequencing, HIV-Hepatitis (Hepatitis B & Hepatitis C) co-infections and using newest and robust molecules in treatment.

It follows the international principle of Undetectable = Untransmittable, means if the HIV Viral Load becomes undetectable in PLHIV then it is un-transmittable to his/her sexual contacts and from Mother-to-child.

Private sector has an upper edge in managing complications – both HIV related and/or ART-related.

Way back in the year 2010, Dr Margaret May et al UK, established that ‘AIDS Causes Only Half of Deaths in HIV-1 Patients Receiving ART.’

The rest die of Non-AIDS infections (8%), Cardiovascular disease (8%), Non-AIDS malignancies (12% Smoking/Ageing), Intravenous Drug Use (IDU-related) (8%), Liver disease (7%), and here private sector plays better role.

Challenges

India with more than 2.1 million PLHIV does not even have 100 full-time trained/ qualified HIV physicians and the figure remains stagnant, leading to an acute shortage of dedicated HIV physicians. Keeping their interest live and bringing more doctors in this field is a daunting task.

Exploitation of PLHIVs at the hand of quacks, over investigations and haphazard treatment by unqualified doctors, overcharging for surgery, delivery and medical procedures continues unabated. That eventually brings bad name for private sector.

Few of the challenges that the private sectors face, are related to ART Centres such as – no feedback to practitioners, our opinions not respected, our patients face ire from ART officers who use abusive language for practitioners and they re-start patients on basic regimen despite stark evidence of 1st line failure.

Public – Private partnership in real sense can sort-out this. Inadequacy of ARVs for children is a global phenomenon and the private sector is not immune.

PLHIV face varied degree of financial, physical and managerial; discrimination.

Often the doctors are caught in crossfire between hospital managements and PLHIV. However, with implementation of the “HIV/AIDS Act 2017” and penal provisions for discriminators and putting vicarious responsibility on management will change this scenario sooner than later.

Conclusion

Though the proportion of PLHIV taking treatment in private sector may be small, around 10% of total PLHIV, unlike for treatment of other ailments where private sector: public sector division is around 50:50, the private sector has a definite edge over public sector.

Despite abundant clinical material, we lack basic research facilities – both in public as well as private sectors and they are not likely to be at par with the west in foreseeable years.

That brings scope for research collaboration. AIDS Society of India plays catalyst to build–up battery of trained physicians, update their knowledge, network with them, keep them engaged in HIV care and represent them in the times of crisis.

On the other hand it has developed a good interface with the government.

The author is attached to Unison Medicare & Research Centre, Mumbai and also is the President, AIDS Society of India and Governing Council Member, International AIDS Society