Where is the best place to take antiretrovirals ‘ with a private doctor or through the public sector? Many would argue the public sector is more efficient and effective.
Patients who are part of a well-controlled anti-retroviral programme in the public health system are more likely to take their medicine than those in the ‘anarchic’ private sector, says the University of Cape Town’s Professor Robin Wood.
Wood, who is overseeing 500 patients on ARVs, says that the assumption that middle class patients on medical aid will be better at taking drugs than poor patients in public health is wrong, and most likely racist.
‘The private sector is unregulated,’ says Wood. ‘There is no financial incentive for a private doctor to monitor adherence so they prefer to simply write out a prescription and not monitor a patient.’
If patients are not given the right treatment regimens and don’t take their drugs properly, there is a danger that they will develop drug-resistant strains of HIV and become immune to treatment. They could then infect others with these drug-resistant strains.
There is widespread anecdotal evidence that a number of private doctors are not prescribing ARVs properly. Many have been given only one drug on the basis that they could not afford more. Others had scraped together enough money for a month’ supply, unaware that they needed to raise this amount every month for the rest of their lives.
A Durban doctor who runs a community clinic said she had seen patients on ARVs but did not know what they were. ‘They also didn’t know how to take them and were given a week’s supply at time,’ she said. ‘They would go back to the doctor when they could afford more drugs, which could take four to eight weeks. Some were on one or two drugs instead of three, and even with these the doses were not right.’
Nurse Smangele Dube said a relative who has a medical aid was put on to ARVs immediately after she tested HIV positive. ‘There was no need because her CD4 count was 460 and she was not sick. The doctor has never monitored her viral load or her CD4 count in the four years that she has been on treatment.’
A private sector study conducted in Zimbabwe describes “therapeutic anarchy,” with doctors and pharmacists using ‘any ARV that they could lay their hands on’, according to a recent edition of the British Medical Journal (BMJ).
In Senegal, monotherapy, dual therapy, and intermittent treatment were common in the private sector, while a survey of Ugandan private medical facilities showed that monitoring of CD4 and viral load tests were rare.
Some 80% of patients referred to specialist centres in India had been prescribed incorrect doses and only 10% had managed to adhere, says the BMJ.
In South Africa, research has consistently shown that the public health sector is far better at treating sexually transmitted infections (STIs) than the private sector. However, most people seek out private doctors if they have STIs, including HIV, because of the stigma attached to such infections.
But Dr Des Martin, president of the Southern African HIV Clinicians’ Society, says private sector care is improving. About 3 000 private doctors have been trained to treat HIV, and his society has 6 000 members who attend meetings and get a journal.
‘The problem is, new doctors are trained in the public sector which is not using ARVs while many doctors graduated before HIV became such an issue and they don’t know how to treat patients,’ said Martin.
- The HIV Clinician’s Society can be contacted on (011) 453 5066.
In South Africa, some 20 000 people get ARVs in the private sector while 24 projects offer 1 500 public sector patients the drugs. In the rest of Africa, the figures for people on government-run ARV programmes is as follows:
- Nigeria – 15 000
- Uganda – 10 000
- Botswana – 6118 (the only Africans country offering free universal access to ARVs)
- Cameroon – 6000
- Malawi – 3000
- Senegal – 1500
- Mali – 700
- Burundi – 600
- Benin – 600
- Togo – 450
(Source: Generic Antiretroviral Procurement Project)