Posted by Jason Andrews
On July 11, 2010, Nyaya Health inaugurated its Antiretoviral Therapy Clinic at Bayalpata Hospital. In partnership with the National Centre for AIDS & STD Control (NCASC), Nyaya Health will now be able to provide comprehensive care including antiretroviral therapy for people living with HIV in our large catchment area in Achham. This is a significant step forward in our partnership with the Government of Nepal to provide services in one of the most remote parts of the country. On this occasion, it is instructive to look back at HIV services in the Far West over the last five years and how Nyaya Health came to play a role.
In 2005, when Nyaya Health was formed, the situation of HIV in Nepal was bleak. Of the estimated 70,000 people living with HIV in the country at that time, only about 200 were receiving antiretroviral therapy. Services were centered in a handful of ART centers in urban areas that had to cover the entire country. I met a woman in the clinic I worked at in Kathmandu who traveled from Achham–a minimum two days journey each way–to receive her continuing HIV care. The two functioning CD4 counters in the country were not thought to be reliable and were frequently out of order; we often had to send samples to India. Second-line therapy was almost unheard of, and I recall ordering Protease Inhibitors (second-line drugs) from India, which the HIV physician in our clinic had never before seen or prescribed.
If the situation in Kathmandu was bad, the situation in rural parts of the country was dire. The Far Western Hill districts, where Achham lies, are thought to be the most heavily affected districts by HIV in the country due to high rates of labor migration to India. Wishing to see what the conditions were like in these districts, my wife, Roshani, and I decided to travel there in February of 2006. Roshani made a short documentary about labor migration and HIV, while I was helping lead training sessions for home-based HIV care. In the course of this, we met dozens of women infected with HIV, most of whose husbands had died, and none of whom were receiving antiretroviral therapy. It wasn’t the cost of the medications or medical care (nearly free) that prevented them from accessing life-saving care, but rather the financial and social barriers to traveling to and from the urban centers for care. The sharp edge of urban-rural disparities in Nepal was no where more devastatingly manifest than here. Seeing this objectionable–and perfectly remediable–situation was what compelled us to work in Achham; we began laying plans and gathering resources the following month.
The past four and a half years have brought progress. The government has stepped up considerably, with notable support from foreign governments and the Global Fund. As of November 2009, there were 23 ART centers across the country. There are 13 CD4 counters in the country, two of which are housed in Mangelsen (Achham’s district head quarters) and neighboring Silgadhi (Doti district), such that patients in our catchment area would ‘only’ have to travel 3-5 hours for a CD4 count. Traveling such a distance for a CD4 count would be unheard of in the U.S.–or even most parts of Africa–but compared with 36 hours four years ago, this is a mark of success in rural Nepal.
Nyaya Health opened our first clinic in Achham over two years ago, and one might wonder why we didn’t focus on ART initially. One of the biggest problems with HIV care in Nepal is that antiretoviral therapy centers are being built on the back of an inadequate primary health care system. While the medications can prolong lives–indeed their rapid development and establishment through clinical trials is one of the greatest stories of medical science over the past thirty years–their distribution alone is not enough to provide good medical care to people living with HIV. In my clinic in Boston, more than 90% of my patients have non-detectable HIV viral loads (the most proximal goal of antiretroviral therapy); several have achieved this for over a decade. Their problems are no longer opportunistic infections; instead, they are at increased risk for cancers, heart disease, and metabolic disorders, for which we fortunately have the resources to treat. Their care is more complex–anti-retroviral therapy aside–than patients without HIV, given increased incidence of these medical co-morbidities, but life expectancy is now approaching the same as uninfected individuals, though serious racial disparities persist.
In contrast, most medical centers in rural Nepal are inadequately equipped to diagnose and manage common opportunistic infections–extrapulmonary tuberculosis, isosporiasis, toxoplasmosis–nor more routine diseases like hypertension, diabetes, and cancers. The anticipated benefit of antiretroviral therapy without adequate, basic health care services is likely to be limited. This is in no way meant to argue that antiretroviral therapy rollout should be delayed while waiting for a perfect primary care system, but rather that health institutions–governmental and non-governmental–need to recognize the value of basic infrastructure for primary care and simultaneously invest heavily in this in order to lay the foundation for effective HIV care. Nyaya Health focused its resources over the past two years on building a solid primary care system, with adequate laboratory equipment, diagnostic imaging and human resources upon which to build an antiretroviral therapy program.
It is therefore with great excitement–and upon a solid foundation–that we announce the opening of our antiretroviral therapy services. We look forward to continuing to build this health system, offering new services, and working with the government to ensure public sector integration and long-term, system-level sustainability for the people of Achham. Thanks to all of our supporters who continue to walk in solidarity with us on this journey.