By Zofeen Ebrahim
KARACHI, Aug 18 (IPS) - ''I’ve been running temperature for the past 25 days and lost about five kg in the last one month... just feel so weak every day,'' says Mohammad Sohail, 28, who tested HIV positive a little more than a year ago. His CD4 count is 152.
The strength or weakness of a person’s immune system is calculated on the basis of CD4 count. The normal range is between 600-1,500 cells per cu mm of blood. The count helps health providers decide when to put an HIV positive person on anti-retroviral therapy (ART).
HIV positive people are those found to have, in their blood, the human immunodeficiency virus (HIV) which affects the immune system and causes acquired immune deficiency syndrome (AIDS).
According to World Health Organisation (WHO) guidelines ART must be started when the CD4 count falls below 200.
Despite noting Sohail’s temperature chart and examining a report from his doctor, the government-run referral centre he visits has run no tests on him. But he is being administered antibiotics.
Sohail is among the 175 HIV positive cases currently registered at the Centre of Excellence at Service Hospital, where the Sindh AIDS Control Programme is running the Enhanced HIV/AIDS programme. Of these 60 are on ART.
For the last four months Sohail has been visiting the centre regularly, waiting in line for up to four hours. "The commuting takes another two hours. These visits are taking a toll on me, physically and financially.’’
Each trip to the centre means taking leave from work for a day. He has recently been employed by Dr Saleem Azam for an AIDS prevention project funded by the European Commission on a salary as there were no jobs available for former drug users like him.
But despite his low CD4 count, he is yet to be started on ART that may not cure, but makes the difference between living on the margins and leading a better quality of life. "They (doctors at the referral centre) tell me I look quite fit and don’t need the drug," says Sohail quietly.
He is convinced the indifference is due to his being a former drug user. ''When I complain of discrimination doctors say they fear I may revert to drugs and do not want to waste time and the medication on.’’ Sohail has been drug-free now for over five months.
It is this discriminatory attitude that is making Azam’s work on harm reduction difficult.
Working with intravenous drug users (IDUs) for the last 25 years, he has, at the moment 5,000 IDUs registered with his organisation, the Pakistan Society (PS), which also runs two rehabilitation centres. Almost all of his clients are people from the streets.
"The government is excluding drug users from HIV treatment. This is really dangerous as this population is fuelling the epidemic," says a piqued Azam. In Sindh, 30 percent of all IDUs are HIV positive.
There are over 35,000 to 40,000 IDUs in Sindh and according to the last study conducted in 2000 by the United Nations Office on Drugs and Crime, there are over 60,000 IDUs all over Pakistan. "Careful estimates would now put the figure between 80,000 to 100,000," says Azam.
Officially, the total number of confirmed HIV/AIDS cases in Sindh has gone up to 1,841 and the number of such cases reported from across the country stands at 3,364. Authorities, however, say the unregistered number could well be over 80,000.
Azam’s words echo those of Prasada Rao, Asia Pacific regional director for UNAIDS, the U.N.-joint programme against AIDS. Rao says access to ART is unacceptably low among IDUs because of a "lack of information, exclusion and widespread stigma and discrimination".
For the HIV prevention programmes to be effective, says Azam, these should reach out to IDUs specially.
In the last one year, ten people under his treatment died after they were refused treatment at the state-run hospitals. "About eight months ago, I had to bribe a doctor in Civil Hospital by paying him Rs 4,000 (66 US dollars)) just to operate on one of my clients which should have been done free of charge. Recently, one client died because the Jinnah Post Graduate Medical Centre refused admission on one pretext or the other and, without informing us, shifted him to a shelter run by the Edhi Foundation charity, where his condition deteriorated and he slipped into coma. This is nothing new and happening all the time," Azam said.
The vice-president of the National Association of People Living with AIDS Farid Ahmed Memon faces the same discriminatory attitude. ‘’The Sindh AIDS Control Programme (SACP) told me I don’t need to get the CD4 test done. Imagine if it’s happening to me -- and I know most doctors there -- what the others must be going through."
But Dr Azra Ghias, director of the Centre of Excellence established and run by Enhanced HIV/AIDS Control Programme, says: "No, we don’t discriminate among the various people living with HIV/AIDS nor do we write them off. Everyone who comes to us is our responsibility and our priority. Anyone who needs an ART will get it. But it’s a drug that needs hundred percent compliance and adherence. We do treat IDUs who are drug free for at least four months and who come to us through an NGO. That way we can assure its compliance."
And yet of the 20 HIV positive people registered with PS who have been approved for getting ART by the SACP, only three are getting the drugs "There are almost 100 more who fit the bill," says Azam.
"If this is not discrimination what is? It’s the SACP that runs the tests and register these people, then why the delay? They even have their own standards of gauging who needs the ART and who doesn’t,'' complained Azam.
"CD4 count of less than 200 was the earlier benchmark; it has since been revised by the WHO to 300 and we follow their guidelines," said Ghias.
Azam argues: "Why wait till the person is really sick and on his deathbed to qualify for the drug, why not start earlier? With the formation of the Global Fund to Fight AIDS, TB and Malaria, and ready availability of cheaper generic drugs, why this discrimination against drug users?"
According to the Ghias, one missed dose may cause immense harm. "We spend Rs 30,000 (496 dollars) per month per patient and just one missed dosage would mean his/her resistance to the first line and we’d have to start the person on the second line which is very expensive. That is the reason for our reluctance to giving ART to a drug user who may not know night from day."
But while many await their turn to receive ARV, Azam says there is an urgency to scale up access to other care options. People like Sohail could be diagnosed and treated for opportunistic infections such as tuberculosis, to which people with HIV are especially susceptible.
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