TREAT Asia Site Profile: Ruby Hall Clinic, Pune, India

February 2006—With an estimated 5.1 million people living with HIV/AIDS, India has a larger population affected by the epidemic than any country in Asia. Rising HIV infection rates and tentative government interventions, coupled with entrenched poverty—a quarter of a billion people, 25 percent of the nation’s population, live below the poverty line—have led UNAIDS to predict that by the end of the decade, India will outstrip South Africa as the country with the highest number of HIV/AIDS cases in the world. This disturbing picture presents a striking contrast with India’s thriving pharmaceutical industry, which produces many of the generic antiretroviral medications that have prolonged life for millions of people with HIV/AIDS around the globe.

The Department of HIV Medicine at Pune’s Ruby Hall Clinic was created in 1997 when HIV/AIDS was already an established threat across the subcontinent. India’s first AIDS case had been recorded in 1987, and in the following years HIV spread among injection drug users in large population centers. The state of Maharashtra, where Pune is located, became one of the first to be classified as high-prevalence.

Today, HIV is well established among men who have sex with men as well as commercial sex workers and their clients, who in turn present a growing danger to married women. The most recent statistics, from 2003, indicate that more than five percent of those among Maharashtra’s high-risk groups are estimated to be HIV positive, as are around one percent of all women at public antenatal clinics—numbers indicating that the epidemic has spread into the general population.

Dr. Sanjay Pujari, director of the HIV Project and principal TREAT Asia investigator at the Ruby Hall Clinic.

When Ruby Hall’s HIV unit was created, “there were very few private hospitals willing to admit and manage HIV infected individuals,” said Dr. Sanjay Pujari, director of the HIV program there. The clinic now handles approximately 600 inpatients annually and another 7,500 outpatients, and the number receiving care increases by up to 25 percent each year. Most of Ruby Hall’s patients pay for their own treatment, with patients who cannot afford the medications receiving them from the Indian government’s free antiretroviral program.

The quality of care being offered to HIV/AIDS patients has improved greatly since Ruby Hall first opened its doors, according to Dr. Pujari. “There has definitely been a change in the attitude towards patients among health-care workers. Today, more and more physicians are willing to treat HIV-infected patients. Family support by and large is excellent.” Perhaps the greatest problems are inadequate physician treatment education and the unavailability of medication—in 2005, the government’s free ARV program was able to reach only 15,000 of the 100,000 patients it had targeted, he said.

Almost 100 percent of HIV drug treatment in India is based on generics, the widespread use of which has resulted in an 80 percent decline in HIV-related deaths in India between 1997 and 2003, according to an October 2005 paper published in Clinical Infectious Diseases. While declining mortality is excellent news, expanded access to treatment bring challenges of its own. According to Dr. Pujari, “over the years we have documented an increase in the incidence of ART-related complications amongst our patients. Addressing these complications requires many more resources than initiating patients on first-line ART.”

“Unfortunately, the choice of first-line backbones in the developing world can’t be translated into the Indian scenario because of the cost constraints,” he continued. “I think there should be an active movement toward lowering the costs of other generic ARVs including protease inhibitors. I feel sometimes it is like history repeating itself. When first-line regimens were introduced, they were expensive and I saw patients die because they could not afford them. Now I am witnessing that in patients who need second-line regimens.”

In addition to clinical care, Ruby Hall provides counseling and laboratory support, including CD-4 counts and viral load testing. The hospital also serves as a TREAT Asia site and contributes to the TREAT Asia HIV Observational Database. The HIV unit has been active in clinical research since its inception, with a particular focus on treatment-related issues in India. One Ruby Hall study looked at the effectiveness and safety of generic fixed-dose ART combinations and another examined the prevalence of lipodystrophy and dyslipidemia among patients taking WHO’s recommended first-line highly active antiretroviral therapy.

Professional education has long been a core activity of the HIV unit at Ruby Hall, most recently with an on-line continuing medical education course that Ruby Hall has piloted with TREAT Asia and HIVeDUCATION for teams of medical personnel across India. “The main advantage of this program is a new format for learning,” said Dr. Pujari. “Developing and implementing good quality training programs is the need of the hour. I am sure, considering the interest this program has generated in India, that it will play a big role in scaling up the training agenda.”

Experts often say that there is no single AIDS epidemic in India but many—among injecting drug users, sex workers, men who have sex with men, and now married women. But reflecting on Ruby Hall’s role in the fight against AIDS in Pune, Dr. Pujari noted the commonalities rather than the differences. “Certain core issues that fuel the epidemic may be uniform across the country,” he said, mentioning poverty, migration, the subordinate status of women, lack of sex education, and illiteracy. “Unless we address these core issues, we may not be able to control the spread of HIV effectively over the long term.”