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International Journal of Drug Policy 18 (2007) 319–325

Short report

Access, adherence, quality and impact of ARV provision to current andex-injecting drug users in Manipur (India): An initial assessment

Mukta Sharma a,∗, Rajkumar Raju Singh b, Phillip Laishram b, Basanta Kumar b,Haobam Nanao c, Charan Sharma d, Tanvir Ahmed e

a Department of Social Policy, London School of Economics and Political Science, London WC2A 2AE, United Kingdomb North East India Harm Reduction Network, Manipur, India

c Manipur Network of Positive People, Manipur, Indiad Social Awareness Service Organisation, Manipur, India

e CARE Bangladesh, Bangladesh

Received 31 May 2006; received in revised form 22 March 2007; accepted 16 April 2007

bstract

bjectives: This study aims to understand who is obtaining anti-retroviral therapy (ART) in Manipur, and to determine adherence, access,nd impact amongst those who use it. It also explores the quality of these services, their impact and the level of user satisfaction.ethods: A mixed method approach was used for this assessment involving direct observations, analysis of service statistics, and a semi-

tructured survey (n = 226).esults: Less than 5% of current injecting drug users (IDUs) were accessing ART (despite IDUs making up the single largest category affectedy HIV in Manipur). Self-reported treatment adherence amongst patients is poor. Major factors influencing adherence are current alcoholse, the cost of ART, having attending any counselling in the last 6 months, income levels of below Indian Rupees (INR) 2000 and negativexperience of side effects. Client satisfaction is associated with: duration of time spent with doctors, waiting time and how staff treat the

atients. Service quality also requires improvement. A quarter of patients on ART perceive that it has benefited their health and report feelingell. Side effects were experienced by 61% of those on ART. Greater efforts to bring more active IDUs into treatment, whilst improving theanner in which ART is delivered in Manipur are required.2007 Elsevier B.V. All rights reserved.

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eywords: ART; IDUs; Adherence; Access; Manipur; India

ntroduction

The HIV epidemic in Manipur (a state of 3 million peoplen the north east of India) began in 1989 amongst injectionrug users (IDUs). In the course of the next decade the vast

ajority of IDUs became infected with the virus—sentinel

urveillance between 1994 and 2002 indicated more than 50%eroprevalence, peaking at 76.9% in 1997 (Sarkar, Panda,

∗ Corresponding author. Tel.: +44 2089461128.E-mail addresses: m.sharma-alumni@lse.ac.uk (M. Sharma),

orai@rediffmail.com (R.R. Singh), horai@rediffmail.com (P. Laishram),orai@rediffmail.com (B. Kumar), hnanao@rediffmail.com (H. Nanao),haran sc@yahoo.co.in (C. Sharma), ahmed.smt@gmail.com (T. Ahmed).

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955-3959/$ – see front matter © 2007 Elsevier B.V. All rights reserved.oi:10.1016/j.drugpo.2007.04.001

as, & Sarkar, 1997; Sarkar et al., 1995; Sharma et al., 2003).ransmission rates from IDUs to their wives in one studyere noted to be 44.5% (Panda et al., 2000). As of April 2006,

here were 22,857 HIV positive cases reported in Manipur. Ofhese 49% are currently categorised as having contracted HIVhrough injection drug use (Manipur AIDS Control Society,pidemiological Update, April 2006).

The Manipur Network of Positive People (MNP+) esti-ates that there are approximately 5000 individuals with

cquired immune deficiency syndrome (AIDS) in Manipur

ho require anti-retroviral therapy (ART). It is not clearhether this estimate includes those who do not have AIDSet but meet other criterion for ART commencement. Givenhe extreme resource paucity in the region, it is suggested that

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20 M. Sharma et al. / International Jo

nly the most advanced cases may be being considered forRT.Whilst ART has been available in the state prior to 2004,

t was restricted to a small group of people. The lack of diag-ostic tools such as CD4 count machines has also contributedo poor treatment commencement decisions. Free provisionf ART began in Manipur in April 2004 on a pilot basis with00 treatment slots targeted at positive women and childreneven though the majority of patients were male current orx-IDUs). Service delivery occurred on an out patient basis athe Regional Institute of Medical Sciences (RIMS), a tertiaryealth facility located in the capital city of Imphal. At theime of data collection (end 2004), 272 people were receiv-ng ART through this facility, of which 200 were male and 72emale. As part of the rapid scale-up plan for ART provisionn Manipur, ART has also became available at the Jawaharal Nehru District Hospital (JLNH) since November 2004.

n May 2006, a total of 1775 individuals were receiving ARTrom these two institutions. The vast majority were males1083), but women (572) and children (120) are increasinglyccessing the service as well. The clinical criterion for com-encing ART is an individual in WHO Stage 4 or 3 with

linical signs and symptoms of severe immunodeficiency.n practice this frequently translates into a CD4 count of200 mm−3, even though this is far narrower than in manyther settings where a CD4 count of 350 mm−3 is used as theriterion for treatment commencement (in line with WHOuidelines). Drug resistance testing for all treatment naı̈veatients is neither recommended nor available in Manipur.

tudy methods

This study was intended to be an evaluation of an exist-ng intervention, and was not designed to assess the accessf IDUs to HAART. The objectives were to understand whoas obtaining ART in Manipur (given that IDUs made up

he largest proportion of those living with HIV/AIDS inhe region), and to explore adherence, access and impactmongst those who use ART. A cross-sectional study designas used for this study. A mixed method approach—relyingn observation of clinic facilities, a review service statisticsnd the administration of a semi-structured questionnaire wastilised. Data were collected between November 2004 andebruary 2005.

A purposive sampling strategy was used. To assist greaterepresentativeness, all clients in the waiting area of the twoospitals were approached for an interview by peers, previ-usly trained in interviewing techniques. In addition, clientsho accessed ART from non-governmental organisations

NGOs) were also included. Of the 247 approached, 226onsented, whilst others were either too ill or declined to par-

icipate. Those accessing ART through NGOs and the privateector were accessed for interview through snowball tech-iques. In the absence of a local social science research ethicsommittee, ethical approval was not taken for the study, but

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f Drug Policy 18 (2007) 319–325

he usual ethical standards were followed including verbalnformed consent and protection of client confidentiality. Noash remuneration was provided to clients but food and teaffered to clients after the interview.

esults

Our sample was largely male (221/226) with 73% report-ng themselves to be between 25 and 39 years old. Educationevels are high with 85% reporting secondary or universityevel education. Nearly 60% were ever married (n = 134).ver 30% were unemployed, whilst the remainder were

ither students, self-employed, or worked for the NGO sector21%). One-third of the sample reported having no income,nd over half reported (n = 114) earning below INR 5000 peronth (approximately US$ 110). So the vast majority of the

ample can be classified as poor. Almost 85% were residentsf Imphal, the capital of Manipur—whilst the remainderravelled in from other districts of the state to access their

edication (n = 32). All reported ever having injected a drug.owever, only 15% had injected within the last 1 year—andnly 4% (n = 9) reported injecting within the last 4 weeks.ife time alcohol consumption was also universally reported.ne-third (31.4%) had consumed it in the last 12 months,

nd only 10% admitted using alcohol within the last 4 weeksn = 23). Over 45% of the latter said that they drank at leasthree to four times a week.

vailability

Generic ART therapy is available in India fairly cheaplynd the associated financial burden has reduced in the lastecade. Stavudine (d4T), Lamivudine (3TC), ZidovudineAZT), Nevirapine (NVP) and Efavirenz (EFV) are the mainrugs available as part of the Indian government funded ARToll out plan. The most commonly prescribed fixed dose com-ination anti-retrovirals (FDC ARVs) in Manipur in 2004ere Triomune, Virolans (d4T 40 mg + 3TC 150 mg + NVP00 mg) and Duovir N (AZT 300 mg + 3TC 150 mg + NVP00 mg) The recent inclusion of EFV is significant as somelients on NVP experience side effects such as rashesStevens Johnson syndrome), which can sometimes be lifehreatening. Liver toxicity is also a key risk with NVP andequires continuous monitoring. NVP is also implicated inxacerbating active hepatitis and may not be the best choicemongst patients co-infected with hepatitis. On an average,he cost of FDC ARVs is in the range of INR 1400–1500or US$ 35) per month. In the case of EFV the cost almostoubles. This has implications for its sustainable use in firstine regimens in resource poor settings.

As of April 2004, the biggest provider of ART in Manipur

as the governmental sector. ART is dispensed free on ai-monthly basis to patient in person at both RIMS andLNH. However, pharmacies and NGOs remain impor-ant providers of ART, with nearly half of those surveyed

M. Sharma et al. / International Journal of Drug Policy 18 (2007) 319–325 321

Table 1Availability, cost and access to ART in Manipur

Source of ARTRIMS 89 (39.4)JLNH 23 (10.2)Pharmacies + NGOs 108 (47.8)RIMS and NGOs 5 (2.4)

Payment for ARTMyself 54 (23.9)Family + friends 36 (15.9)Free 113 (50.0)Combination of self + family + free 15 (6.6)NGO supports full cost for ART 2 (0.9)Some but not all ARVs free from RIMS/JLNH and NGOs 4 (1.8)

Per month spent for all medications including ART (INR)<1000 92 (40.7)1000–1999 57 (25.2)2000–2999 44 (19.5)3000–4999 20 (8.8)>5000 12 (5.3)

Distances require to travel to collect ART (km)<5 166 (73.5)

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Table 2Correlates of adherence (missed doses)

Factors Ever missed the dose p-Value

Missed Not missed

Alcohol consumer (within 1 month)Yes 16 (17.6) 7 (5.2) 0.003No 75 (82.4) 127 (94.8)

Ever attended counsellingAttended 56 (30.9) 67 (50.0) 0.07*

Not attended 36 (39.1) 67 (50.0)

Attended counselling with last 6 monthsAttended 50 (54.9) 57 (42.9) 0.050Not attended 41 (45.1) 76 (57.1)

ARV typePaying for ARV 55 (60.4) 50 (37.6) 0.001Free ARV 36 (39.6) 83 (62.4)

Income level<INR 2000 43 (47.3) 78 (60.0) 0.041>INR 2000 48 (52.7) 52 (40.0)

Experience of side effectsExperienced 64 (69.5) 73 (54.4) 0.016Not experienced 28 (30.5) 61 (45.6)

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5–19 33 (14.6)20–49 18 (8.0)>50 9 (4.0)

eporting that they access HIV care and treatment, includingRT from them (see Table 1). This may be for three rea-

ons: (i) ART provision through RIMS and JLNH is relativelyecent—pharmacies and NGOs were the only providers till004 and this is reflected in our sample; (ii) people are choos-ng to remain with their previous service providers becausehey can visit the NGO or pharmacy at their convenience andave established long standing client–provider relationships;iii) people waiting to access ART feel at risk of being iden-ified as HIV positive by other members of their communityho may be using RIMS and JLNH for other services. This

s because the facilities dispensing ART in these hospitals arelearly identified as AIDS treatment units.

dherence

In our sample, 41% reported ever missing a dose (92/226).n response to the question “what do you do when you missour dose?” 12% reported doubling their next dose, whilsthe others simply skipped it. This is clearly not a desirableractice. Significant factors associated with missed dosesncluded whether ART was paid for by the client or avail-ble at no cost; monthly income of patient being below INR000; whether a client received any counselling within theast 6 months; experience of side effects; and alcohol useuring the last 4 weeks (see Table 2). When these variablesere put into a logistic regression model, not receiving freeRT contributed the most to missing ART doses (p = 0.001).

hose who were current alcohol consumers were nearly four

imes at risk of missing their ART dose compared to thoseho did not. Interestingly, the same relationship did not hold

or those who reported injecting drugs, even though the num-

vics

* Excluded from logistic regression model as it is not significant at the5% level.

er of current injectors in this study is too small to be able toraw any real conclusions from this.

Almost one-third of the sample reports ever having dis-ontinued ART (74/226). The most important cited reasonor discontinuation was not being able to afford the medica-ion/diagnostic tests required (38/74). Even those who receiveree ART at government institutions are asked to pay for diag-ostic testing every 3–6 months, including CD4 counts. Athe time of the survey, patients were paying INR 500 forD4 counts and waiting between 1 and 2 weeks for the test

as there were only two machines in the entire state, handlingo more than 10–15 testing requests a day). Other tests reg-larly requested were chest X-rays, complete haemograms,iver function tests and tests for hepatitis B and C. Othereasons cited for discontinuation were—experiencing sideffects (10/74); relapsing to drug use (7/74); treatment fail-re and the need to postpone or change ARV regimen (7/74).

small number of clients reported discontinuation becauset was not possible for them to travel to the point of serviceelivery. Miscommunication between patients and serviceroviders had also led to discontinuation in a few cases.

The statistically significant factors associated with ARTiscontinuation in our sample were: experience of sideffects, whether ART is provided free or not, and whetherpatient received any kind of counselling within the last 6onths, and alcohol use in the last 4 weeks. A logistic regres-

ion model with ART dose discontinuation as the dependent

ariable shows that whether ART is free or not is the mostmportant factor affecting discontinuation (p = 0.000). Thisonfirms the crucial role of financial considerations in deci-ion making related to ART adherence (Table 3).

322 M. Sharma et al. / International Journal o

Table 3Correlates of adherence (ART discontinuation)

Factors Ever discontinue the dose p-Value

Discontinued Not discontinued

Alcohol consumer (within 1 month)Yes 12 (16.4) 11 (7.2) 0.031No 61 (83.6) 144 (92.8)

Experience of side effectsYes 55 (75.3) 82 (53.6) 0.001No 18 (24.7) 71 (46.4)

Ever attended counsellingYes 45 (61.6) 78 (51.0) 0.086*

No 28 (38.4) 75 (49.0)

Attended counselling within last 6 monthYes 42 (58.3) 65 (42.8) 0.021No 30 (41.7) 87 (57.2)

ARV medication typePaid ARV 46 (63.9) 59 (38.8) 0.000

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Free ARV 26 (36.1) 93 (61.2)

* Excluded from logistic regression model as it is not significant at the5% level.

Survey data related to adherence counselling indicate thatnly 54% (123/226) of all ART clients were ever offeredny counselling. Of these 114 had received some kind ofounselling at least once within the last 6 months. The risk ofRT discontinuation is 3.6 times higher amongst those whoad not received any counselling within the last 6 months. Ofhe 114 patients who received counselling in the last 6 months,ess than 30% reported ever receiving adherence counselling,r being given any information related to the importance ofaking ARVs regularly and/or dealing with side effects.

uality of service delivery and client satisfaction

This study tried to establish whether any standard oper-ting procedures (SOPs) for ART or other guidelines weresed to ensure the quality of ART delivery in Manipur. Thereas no evidence of any written documents at the time of data

ollection. In the absence of a well-defined quality of careramework for AIDS treatment in India (when this study waseing designed), we adopted a client-centred view of qualitynd assessed it against six basic criteria: quality of staff–clientnteraction; client satisfaction; waiting time for clients; tech-ical competence of staff; confidentiality/privacy; and access.ctual observations at service delivery points and survey dataere used to inform this assessment.

taff–patient interactionRespondents were asked how staff at the facility treated

hem. Only 45% felt that they were treated well. Another 45%elt that they were treated in an “okay” manner. The remaining

0% felt that they were treated very badly. Almost 18% statedhat they were not able to discuss their medical problems withoctors and nurses openly. Over half the patients reported thathe doctor spent less than 5 minutes with them per visit—with

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f Drug Policy 18 (2007) 319–325

4% indicating that the doctor spent between 2 and 3 minutesith them. When asked “what did you dislike in your last visit

o the place from where you get your ARVs”—nearly 18%ere unhappy with staff behaviour. Complaints ranged fromoctors not listening to patients, not answering questions oraking the time to explain things to clients, and simply beingude. Many patients also reported that doctors and nurses didot want to touch them or examine them.

aiting time for patientsMore than two-third reported having to wait for more than

0 minutes to get seen by a doctor when they went to col-ect their ART. Nearly 39% reported waiting for more thanhours. Given that in the government hospitals there are noaiting areas, people stand or sit for hours in corridors. Inne site (RIMS) we found patients waiting for up to 4 hoursn an open area during winter. When the average waitingime is combined with transportation time, most clients arepending over 3 hours for getting their ART. When patientsere asked “what did you dislike the most about your lastisit to the place where you collect your ARVs”, nearly oneuarter (23%) cited the long wait and the lack of any seatingrrangements.

onfidentiality and privacyThe infrastructure in the facilities offering free ART (par-

icularly RIMS and JLNH) does not offer any privacy toatients or support the maintenance of confidentiality. Therere no separate rooms for counselling, and where sectionsf the room have been partitioned for counselling purposes,hese are not sound proof. In one observation visit we foundwo counsellors crammed into one room. There were eightther people present in the room. A male counsellor was talk-ng to a female patient and a female counsellor was talking to

male. The space between their desks was approximatelyinches. The atmosphere in the room was unsuitable forny kind of confidential or private discussion—particularlyelating to sex and alcohol/drug use. The point of serviceelivery in RIMS and JLNH are advertised as “ART Unit”,hus proclaiming that people waiting in the corridors areIDS patients.

echnical competence of staffAt the time of data collection, reportedly six doctors in

he entire state of Manipur were proficient in treating AIDSatients with ART. These doctors have developed their skillsn the job and very few trainings and orientations have beenrganised for them. The lack of training regarding clinicalssues and management of co-infection with hepatitis C virusHCV) is a major area where technical competence of staff

eeds improvement. The fact that so many patients complainhat doctors are spending less than 5 minutes with them is alson indication that they are not trained to deliver high qualityRT.

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count of above 200, the majority of clients on ART reportedfeeling well—with only 26% indicating that they did not feelwell at the time of the survey. The reported CD4 counts maynot be an accurate reflection of treatment success or failure as

Table 5Self-reported impact of ART

No. (%)

M. Sharma et al. / International Jo

lient satisfactionAlmost 60% of the patients said that they were satisfied

ith the service, whilst 40.5% were not. Significant factorsssociated with satisfaction levels were: length of time spentith the doctor; average time required to get seen by the doc-

or; and how doctors and nurses treated patients. In a logisticegression model, the treatment of patients by medical staffontributed more to satisfaction levels than other variablesp = 0.000).

A clear relationship between satisfaction levels and thelace where ART and related care is delivered existsp = 0.000). Those accessing ART from government facili-ies were less likely to express satisfaction with the servicess compared to those accessing them from pharmacies andGOs. RIMS performed the worst on this indicator withore than three-quarters of all patients (76%) express-

ng dissatisfaction with the service. Patients receiving ARTnd care services from NGOs were most likely to beatisfied—with only 2% indicating dissatisfaction of anyind. This is because NGO services are likely to be smaller,ersonalised, confidential and flexible. Patients are likely toave a reduced waiting time and access to a waiting areaTable 4).

ccessIt is estimated that in 2006, only about 2000 of the approx-

mate 5000 individuals who need ART (even though theumber is probably greater if WHO criteria are applied)re getting them in Manipur. Current IDUs constitute lesshan 5% of those who are currently accessing ART. Evenf ART is free, several issues continue to impact on patientccess and uptake of services—such as the cost of diagnos-ic testing, treatment of opportunistic infections, treatmentf co-infections, primarily HCV, the cost of nutritional sup-lements, doctor fees, cost of transport and the cost of lostarnings. These costs are frequently borne by the patient. Forxample, 54% reported spending more than 2–6 hours for

very trip to refill their prescription. Nearly two-thirds (57%)aid that they spent over INR 50 for transport to and from theoint of service delivery. Another 60% spent between INR000 and 5000 every month to treat their illness, including

able 4orrelates of client satisfaction

actors Ever discontinue the dose p-Value

Satisfied Not satisfied

verage time spent with the doctor≤5 min 42 (31.8) 70 (76.9) 0.000>5 min 90 (68.2) 21 (23.1)

verage waiting time required to get seen by a doctors≤60 min 99 (76.2) 10 (11.0) 0.000>60 min 31 (23.8) 81 (89.0)

taff–client interactionGood 132 (100) 69 (75.8) 0.000Bad 22 (24.2)

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f Drug Policy 18 (2007) 319–325 323

he cost of tests and nutritional supplements. Geographicalccess to services for more than one quarter of the patientss poor. Sometimes seriously ill people have to travel overkm each way on cycle rickshaws, two wheelers, bicyclesnd crowded buses to get their medication.

elf-reported impact on patient lives

Responses to how the availability and access to ARTffected the lives of those living with AIDS were frequentlyouched in language relating to being given a second chance,elieving in the “future” and becoming “normal”. A beliefn their futures is reflected in aspirations related to familyuilding as well.

The vast majority of respondents (80%) reported thathey can take care of all, or most of their household chores.pproximately 15% felt that they could not undertake mostf their household duties. Only 5% felt that they were com-letely unable to do so. Half of the respondents felt that theyan undertake or continue paid work. Another 31% felt thathey would undertake work if it is not too strenuous. Only9% felt that they could not engage in paid regular workiven their current health status.

The benefits of free ART provision were not just describedn physical terms. Several clients reported having a betterelationship with their families as their health improves. Thevailability of free ART removes the tension created by thenancial burden borne by other family members (Table 5).

Despite less than one-third of the patients reporting a CD4

elf-reported health statusFeeling well 165 (73.9)Not feeling well 59 (26.1)

ast self-reported CD4 count<50 19 (8.4)51–100 45 (19.9)101–150 39 (17.3)151–200 52 (23.0)>200 68 (30.1)

as experienced side effects 137 (60.6)

ypes of side effects related to ARTRashes 31 (13.9)Depression 19 (8.5)Loss of appetite 19 (8.5)Hearing problems 7 (3.1)Eye problems 27 (12.1)Sunken cheeks 19 (8.5)Darkening of skin 23 (10.3)Peeling of skin 16 (7.2)Liver problems 62 (27.8)

324 M. Sharma et al. / International Journal o

Table 6Correlates of “feeling well”

Factors Self-reported health status p-Value

Feeling good Not feeling good

Last time CD4 count≤200 102 (63.0) 51 (86.4) 0.000a

>200 60 (37.0) 8 (13.6)

Experience of side effects

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a Independent sample T test, unequal variance assumed.

n many cases, they precede the commencement of treatmentnd are not carried out regularly (due to cost and accessibilityssues) (Table 6).

iscussion

Before considering the implications of these data, two lim-tations of the study should be considered. First, the ex- andurrent IDUs obtaining ART treatment in Manipur (at NGOs,IMS or JLNH) are not a random sample. The sample size islso not large enough to eliminate sampling errors. Second,his study did not collect any clinical data, and all behaviourals well as clinical data are self-reported and are subject toecall bias and other inaccuracies. Additionally the study can-ot make any claims to be an assessment of access of IDUso ART.

Despite these shortcomings, the study offers usefulnsights into client perspectives and quality issues in ARTelivery. It shows that whilst the availability of ART inanipur has increased significantly from 2004 onwards, cur-

ent IDUs are excluded from treatment. Given that IDUs formhe majority of all AIDS cases, this is a clear indication ofreatment exclusion. The paucity of oral substitution treat-

ent (OST) may be a key factor that contributes to this.he provision of OST will help stabilise chaotic lifestylesnd encourage treatment consideration. It will also free upnancial resources for many IDUs (which usually goes intorocuring drugs) and their families to use for the provision ofiagnostic testing, hospital care and nutritional support—allf which are required even if ART itself is provided free ofost.

Second, adherence to ART is sub-optimal with signifi-ant proportions reporting discontinuation and missing ofoses. This has serious implications for the emergence ofrug resistant strains in the region. Whilst economic condi-ions at the individual and household level are the key factornfluencing this, the lack of adherence counselling and alco-ol consumption must also be addressed. Given that drugse is a chronic relapsing disorder, relapse prevention coun-

elling and access to substitution therapy are important toolsn improving adherence in this population.

Discussions relating to ART adherence must bear inind the high prevalence of HCV and HBV co-infection

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mongst IDUs in Manipur. In our study 57% of respon-ents reported being currently infected with tuberculosis,CV or HBV. In other clinical studies HCV antibodies were

ound in more than 90% of IDUs in different studies (Devi,ingh, Mara, Singh, & Singh, 2004; Eicher, Crofts, Benjamin,eutschmann, & Rodger, 2000; Saha et al., 2000). Co-

nfection is common in IDUs—HIV and HCV co-infectionas reported amongst 52.4% of 250 IDUs studied by Devi,rajachand, Singh, and Singh (2005). Co-infection withCV (particularly Genotype 1) presents serious challenges

or treatment, particularly in those with concurrent drugse. Patients with underlying liver disease are at increasedisk of hepatotoxicity related to ART (Sulkowski, Thomas,haisoon, & Moore, 2000). It is also been noted that progres-

ion to cirrhosis is accelerated in those with co-infection asompared to those with HCV alone. Depression and mentalllness associated with HIV and HCV can also contribute toon-adherence (Reynolds et al., 2004).

Third, the quality of services needs to be improved. SOPsnd quality assurance mechanisms also need to be developedrgently. Key issues for patients are: long waiting hours, longistances of travel, no privacy, congested rooms, no oppor-unity for discussion with doctors, need for counselling andnformation on how to manage co-infection and side effects,ost of diagnosis, better management of ART units, poor staffompetence and need for family counselling for entire fam-lies on ARVS. It is important that doctors take the timeo listen to and examine patients adequately, not just fromhe view of patient satisfaction, but treatment success andompliance. We suggest that resources urgently need to bellocated to improving infrastructure in these facilities sohat an optimal level of patient confidentiality can be alsonsured.

Fourth, despite the several areas needing improvementhat have been outlined above, Manipur offers an example ofow a very poor and conflict ridden state can scale up ART.he overall impact of free ART provision in Manipur haseen very positive. It has offered PLWHAs a chance at livingeaningful lives, and it is allowing families to be together for

onger. This is invaluable and most patients are very aware ofhe life line that ART extends to them. So despite the limita-ions outlined previously, the continued roll out of free ARTn Manipur is highly desirable.

onflict of interest

None.

cknowledgements

We are grateful to the individuals living with HIV whoarticipated in this study. Our appreciation is also due to thetaff of the North East India Harm Reduction Network, Socialwareness Service Organisation, RIMS and JLNH for their

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fforts in improving lives of PLWHAs and supporting thistudy.

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evi, K. S., Singh, N. B., Mara, J., Singh, T. B., & Singh, Y. M. (2004).Seroprevalence of hepatitis B virus and hepatitis C virus among hepaticdisorders and injecting drug users in Manipur—A preliminary report.Indian Journal of Medical Microbiology, 22, 136–137.

icher, A. D., Crofts, N., Benjamin, S., Deutschmann, P., & Rodger, A. J.(2000). A certain fate: Spread of HIV among young injecting drug usersin Manipur, North-east India. AIDS Care, 12, 497–504.

anda, S., Chatterjee, A., Bhattacharya, S. K., Manna, B., Singh, P. N.,Sarkar, S., et al. (2000). Transmission of HIV from injecting drug users totheir wives in India. International Journal of STD & AIDS, 11, 468–473.

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