Thousands of people living with HIV (PLHIV) in Manipur have been facing a tough time due to the problem of Anti-Retroviral (ARV) drugs stock-out in the state.
PLHIVs undergoing treatment are required to take ARV drugs regularly and in time without missing a dose to reduce morbidity and mortality and help improve the quality of life.
As ARV drugs supply is out of stock in the state, the Manipur State AIDS Control Society (MACS) has taken up alternative arrangements as a temporary solution to the issue. It advised patients to abstain from skipping the mandatory daily consumption of the drugs. But clients are dismayed by the MACS arrangement.
As Manipur continues to tackle the problem of high prevalence rate of HIV and AIDS, the state government has also taken up various policies and programmes to spread awareness and eliminate the prevalence of the highly infectious disease, under the National AIDS Control Organisation (NACO).
Providing free Anti-Retroviral Treatment (ART) to people living with HIV is one of the successfully implemented programmes in the state.
In Manipur, as per report available with the Manipur AIDS Control Society (MACS), till the period - June 2022, the number of PLHIV accessing free ART was said to be 13,688. Out of which, 13,096 were registered as first line ART, 575 in second line ART and 17 are registered in third line ART.
The free service arranged by the state is being provided in altogether 13 ART centres set up across the state. It may be mentioned that of the 13 ART centres in Manipur, 11 are being run under MACS for providing care, support and treatment to people living with HIV/AIDS, while the other two are managed by Medecins Sans Frontieres, an international humanitarian medical non-governmental organisation, providing care and treatment in the field of HIV, TB and Hepatitis C in the state.
According to NACO, ART was launched on April 1, 2004. The free treatment for infected persons was launched with an objective to control HIV transmission by suppressing the virus with the help of strict adherence to the treatment. To increase life span and ensure that 50 per cent of the patients depending on ART are engaged in productive work.
However, despite the prevailing scenario in the state, where the number of people who are dependent on ARV treatment is increasing every year, the problem of ARV stock-out that reportedly occurs once in a while in the state, after every one or two years, has triggered many questions in the minds of people.
Currently, in view of the situation, the community of ARV users is a worried lot. The users wonder whether the objective of ART programme would be achieved if the problem of stock-out of such life-saving drugs continues to take place in the state.
The state has been facing the problem of “stock-out” of ARV since the last part of April. Taking serious note of the problem, some users’ community even approached the NACO. They sought NACO's immediate intervention to address the plight of ARV beneficiaries.
The problem of ARV being out of stock is reported not only in Manipur. The problem is reportedly happening all over India. In view of the critical situation facing PLHIV all across the country, and responding to the users’ community, NACO said it has written to all existing State AIDS Control Society (SACS) on May 5 and June 7.
Through its appeal letter, NACO urged the project director to take up temporary emergency procurement of ARV drugs. The letter also mentioned that due to unforeseen reasons, their procurement and supplies would be delayed. For smooth functioning of the programme, SACS are authorised to make emergency procurement of ARV drugs.
In accordance with the response made by NACO, MACS has taken up an alternative arrangement. On June 14, MACS issued an order stating that ART patients can procure ARV drugs from the local market to avoid missing the drug consumption during the out-of-stock situation.
MACS also stated that the amount spent on procuring ARV drugs can be reimbursed from MACS through the Care Support and Treatment (CST) division. This can be done by submitting documents such as certificate of SAMO/MO/in-charge of stock out, particular ARV single drugs for the particular period, cash memo to be countersigned by SMO/MO/in-charge of ART centre, ART card of the patient (photocopy) and bank details of the patient to which amount can be credited.
But ART clients were disheartened to see the circular because for them self-procurement of ARV drugs is a difficult and challenging task. Due to stigma and discrimination, many patients or clients consume ARV in a confidential manner. Along with this, many of them are economically backward. They cannot afford the treatment. Because of all these reasons, self-procurement of life-saving ARV drugs poses a challenging task for those seeking treatment.
While speaking exclusively to the Imphal Free Press, president of Community Network for Empowerment, RK Nalinikanta, said that the scarcity of ARV drugs since the last week of April in the state which has a high rate of PLHIV is unfortunate. It is almost similar to non-compliance of the order of the High Court of Manipur, he added.
Following a public interest litigation filed in 2019 in connection with ARV running out of stock in the state, the Manipur High Court had issued an order to maintain minimum stock of ARV drugs for a period of three months at all the ART centres to avoid shortage of drugs, he added.
As the stock-out situation was imminent, the CoNE president further informed that a complaint to Manipur Human Rights Commission (MHRC) was filed on June 8, 2022. Replying to it, MACS had highlighted bottlenecks and limitations at NACO as a factor behind the ARV stock-out in the state. However, the response was found "not satisfactory".
Considering that the state has been witnessing increasing number of PLHIV over the years, concerned authorities should not always wait for NACO action, but they should also have a strategic plan for the state government to implement.
It is unfortunate that NACO also informed about temporary emergency procurement of ARV drugs on May 5 when the state was already reeling under ARV drugs stock-out issue. The state government’s failure to take up the said arrangement even after a gap of more than a month is also a big dampening factor, he added.
While appreciating the state government for its effort to cope with the stock out issue, he said, “CoNE is happy to learn that MACS is reallocating the drugs to ensure that clients do not skip their doses. But how do such systems continue? On normal days, patients have the privilege to collect one month's dose or three months’ dose at one time. Due to the scarcity of ARV drugs, the clients have to collect the drug after every five to six days which poses a big burden to them.”
Referring to the circular of MACS issued recently that suggested ART patients to procure ARV drugs from the local market, stating it would reimburse the amount of expenses incurred, he said that maximum of the ART patients are economically backward and most of them do not have any bank accounts.
The current charge for ART first line is Rs 2,000 to Rs 2,500 per month and second line ART is charged Rs 3,000 to Rs 3,500 per month. Most of the patients do not have enough money to shell out such an amount. As such, self-procurement policy would not be feasible at all for all PLHIV patients in the state, he pointed out.
Nalinikanta further alleged that the problem of stock-out of ARV drugs keeps happening due to the lack of seriousness from the authorities concerned. They should have ensured enough stock of ARV drugs for the patients, he asserted.
“The ART free treatment was rolled out 18 years ago. The authority concerned should be well acquainted in maintaining proper procurement of the necessary drugs for HIV-AIDS patients. Therefore, occurrence of stock-out issue in a small state like Manipur shows lack of concern and commitment by the authorities concerned in addressing the problem of HIV or AIDS and PLHIV,” he lamented.
Also, referring to the announcement made by Chief Minister N Biren Singh during the last World AIDS Day observance ceremony in Imphal on doorstep delivery of ART to clients, he opined that the government should not announce any policy and programme until and unless proper analysis or research of ground reality is carried out. The state government, both previous and present one, used to announce policy and programmes for PLHIV, but the programmes were hardly implemented in the state.
Speaking to the Imphal Free Press, general secretary of the Social Awareness Service Organisation (SASO), RK Tiken said that the effectiveness of the ART completely depends on maintaining its adherence. Therefore, the problem of ARV running out of stock that occurs every one or two years would ultimately demean the value of ARV therapy.
The state government should always remain cautious in preventing such kinds of issues by ensuring alternative arrangement in time. Otherwise, the state can never achieve the target of HIV/AIDS elimination, he added.
“The state rolled out ART free treatment since 2004 with an objective to eliminate HIV in the state and provide healthy life to PLHIV. To achieve this, MACS and other concerned service providers are putting all their effort into it. But this kind of out of stock issue would give a great threat in addressing the public health issue related to HIV/AIDS in the state. As such, the state government should not only rely on the NACO programme but should also have their policy and programme that no problem of acute shortage of ARV occurs,” he suggested.
Tiken said that SASO being a service provider, they have been receiving queries and enquiry about the current ARV stock out situation in the state since last week of April. The state government can even declare the present scenario as a health emergency and speed up the ARV procurement process. But unfortunately such an immediate measure is still not seen even after more than a month, he said.
SASO general secretary recalled that there was a time when a transport allowance of Rs 150 per month was provided to ART clients in the state. Such facilities are no longer provided. Most of the PLHIVs are economically deprived. They suffered a huge setback when transport allowance was scrapped. As such, it might not be feasible to implement the policy of self-procurement which the state government suggested in a recent circular, he pointed out.
“The complaint we made today on the stock-out issue is for the safety of the society. If our state continues to face such drug shortage from time to time, how can we solve the HIV issue? Therefore the state government should deal with the matter very seriously and meticulously,” he added.
Token urged the legislative members of the state to revive Manipur Legislative Forum for AIDS (MLFA), keeping health issues as their priority.
However, Joint Director, MACS, Abhiram Mongjam said that though there is shortage of ARV drugs, arrangements are being made to ensure that not a single patient misses their daily drug consumption. They used to reallocate ARV from ART centre with abundance of ARV to centre where stock is completely dry.
Mongjam further said that they used to disburse ARV for three months together in every distribution. But considering the chances of occurring in a complete stock out situation as high, they are managing the situation by providing the drugs for a week or 10 days. This change in strategy has sparked off panic in them. But there is no need to worry as the state government will start the procurement process soon. Tenders would be floated soon for the procurement of ARV drugs, he said.
Hence, the clients should cooperate with them until the ARV drugs are successfully procured, he appealed.
“It is for the first time that MACS is suggesting self-procurement and reimbursement of the same amount. I am very sure many clients may feel awkward on hearing this system. But they should cooperate with the system for the time being to prevent from missing their daily consumption of treatment drugs,” Mongjam added.