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Rational use of ARV medicines
Presented by Bharat Rewari, India.
B.B. Rewari1, S.P.K. Raj2
1National AIDS Control Organisation, New Delhi, India, 2Knowledge for Development Foundation, Health, New Delhi, India
Background: In India more than 30 ARV formulations/combinations are approved by the DCGI. The National AIDS Control Organisation (NACO), India has updated ART guidelines in May 2007. There are about 123,000 patients on ART at 137 government centres. Though the guidelines are adhered to by these centres, availability of ARV medicines in the market and their marketing promotion by pharmaceutical companies, leaves scope for prescriptions that are not in conformity with standard treatment guidelines. NACO recommended regimens are:
Preferred first line: AZT + 3TC + NVP
Alternative first line: (1) AZT + 3TC + EFV (2) d4T +3TC + (NVP or EFV)
Other option: TDF + 3TC + (NVP or EFV).
Methods: NACO commissioned a study in 2007, ‘ART Medicines Accessibility Operational Issues’ with the objective of analysing ARV medicines prescribed by private doctors, drug sales data, pharmaceutical promotions, and information from retail pharmacists/chemists, with structured questionnaire and interviews.
Result/observations: Among the 3 drug regimen/combination available in the retail market combination of Didanosine/Lamivudine/Efavirenz and Emtricitabine/Efavirenz/Tenofovir do not match the NACO guidelines. Besides, there are 2 drug regimen/combinations like Zidovudine/Lamivudine, Stavudine/Lamivudine, and Ritonavir/Lopinavir. Single drugs of Nevirapine, Efavirenz, Zidovudine, Lamivudine, Indinavir, Nelfinavir, Stavudine, Didanosine and Atazanavir are also available. Among private doctor prescriptions, over 50% do not conform to national guidelines.
Conclusion/interpretation: The main reason for drug resistance is non-adherence to ARV therapy by doctors and non-compliance by patients, coupled with easily available ARV formulations in chemist shops. In this context, the concept of 1st line, 2nd line, etc become irrelevant. Emphasis on stigma drives patients towards private doctors in confidence rather than government hospitals. Strong advocacy programmes and regulation on rational use of medicines are necessary.
Disclaimer: Study by NACO was funded by WHO
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