Proceed with caution---HIV Aids

Eight years after starting the programme of providing single-dose nevirapine to cut mother-to-child transmission of HIV, the National AIDS Control Organisation (NACO) is reassessing the monotherapy strategy. Although hailed as a miracle that reduces the chances of vertical transmission by 45-55 per cent and protects thousands of children around the world from getting infected with HIV at the time of birth, the single-dose regime has been found to cause drug resistance in mothers and babies. Drug resistance is a major problem, especially where the drugs available to treat the virus are few and the cost of second-line drugs is prohibitive. With drug resistance rising steadily for various reasons, including a lack of compliance by those undergoing treatment, compounding the risk through wrong medical intervention is obviously unacceptable. There is a great compulsion to maintain the efficacy of existing drugs and reduce the risk of treatment failure. Nevirapine, after all, is one of the first-line drugs used in India. Realising the implications, NACO has taken the first step by entrusting the Pune-based National AIDS Research Institute with a study to assess the feasibility of using one or more drugs in addition to nevirapine.

Adding more drugs should not lead to a situation where a change in strategy leads to more individuals becoming resistant to multiple drugs. There is a possibility of such a situation arising because, unlike the single-dose of nevirapine given to mothers at the onset of labour and to babies immediately after birth, a combination therapy is given for a few weeks to the mother and for one week to the baby. Drug compliance is a critical issue. There is evidence to show that patients, in rural as well as urban areas in India, either stop the treatment midway or miss some doses. This leads to drug resistance, which is dangerous. Any decision by NACO to switch over to multiple-drug therapy should factor in this vital aspect and make provision for counselling individuals at the time of initiation of the treatment and also for following up patients to ensure greater compliance. Unlike the WHO Directly Observed Treatment Short Course (DOTS) for TB, the combination treatment in the case of HIV lasts only a few weeks. Some countries in Southeast Asia have shown that compliance is good when patients are meticulously counselled. There are no short cuts and the only sound way is to proceed with caution and on the basis of careful evaluation.