HIV Tales from my diary – Tale19

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( Tale 6 of healers suffering themselves )
Healthcare services in developing countries, like India ,are strange. They are strange because every time you visit a healthcare provider , you find a stranger in him. There are no fixed SOP's, mostly. Qualified doctors in their pathy's usually do follow standard text books but those who become doctors by back doors ( read qualify in one type of pathy and practice another , grab a RMP or experience label , at times even degrees through various reservations - ranging from caste ,creed ,politics to money  ) have their characteristic ways of practicing medicine. Hit and trial is their best bet. Copying prescriptions of those ,who are big names in their fields ,is the route for hitting highways for such gentlemen. This also happens with qualified ones at times , specially when they have no time to refresh their knowledge. I am reminded of an ophthalmologist prescribing a certain tube with a suffix " pox" , to a Herpes Zoster ( a sequel of chicken pox of childhood ,in later years of life ) patient. When questioned by a well wisher , he quoted a prescription of a senior dermatologist and said ," I thought it must be for viral ( pox) infections being named Dermapox". The well wisher (me) informed him that it was a steroid and is rather contraindicated. Goes without saying ,how his figure was cut to apologetic levels. Period.
It is in this background that I have to tell a tale of an
RMP,  Dr.  So and so . He had a roaring practice in a border town of Amritsar. He was Jack of all trades and master of none , literally. His Jackalness , however proved to remove his outer coatings. Remember that Panchtantra story of " ranga siyar "- ( folk tale of strange blue colored king ) a jackal after falling in a blue colored tub of a washerman starts scaring Jungle animals because of his strange color. He started thinking himself to be the king of the jungle , a lion. One day , when rain falls , his color runs away and friends call, his reality becomes obvious. The real kings tear away the virtual king , the Jackal. This Jack of medical profession also lost his masque , once he got exposed to an HIV patient's blood while carelessly stitching his wounds after a road accident.  He ignored the exposure and resultant was expected. Once tested positive , he reached me with all relevant tests done. That was the time of two drugs regimen to treat HIV. He was put on Zidovudine and Lamivudine combination ,by me. The doctor was regular in his visits to me initially ,but for once. When I tried to contact him to remind his due medicines etc , he politely and firmly told me not to contact him on phone as his patients may come to know of his status.. He feared the impact of his HIV status on his professional status and personal medical practice. His orders were followed. The doctor patient ,however ,did not follow me. Suddenly ,one day after many years ,he was brought back to me , by his Medico sons ( who were by now in third and final years of MBBS). He was failing clinically, immunologically and virologically. This was obvious too. The whole world by then had learnt to treat HIV with three drugs but Doctor sahib was still on two drug regimen ,which started failing. Loads of counseling, switching to the right combination was my duty which I did once again. Before seeing him off, I shot a natural query" doctor sahib, how many patients of HIV are you treating now a days and with what medicines??".
Sheepishly he admitted ten to twelve and all on the same combination of two drugs ,which he was taking ,on my advise ,some years ago. I saw quackery raising its head instantly. I bowed my head to him for his confession and at the same time  felt like banging my head, to the nearest wall of medical system in this country. Once again ,the doctor so and so , is lost in the jungle of " lost in follow up" cases , but what I have found is that the healthcare system needs much more attention by those who are in authority and matter. Else the situation is like बाड़ ही खेत को खाने लगे ( boundaries start eroding the field ) or we can say what if those who are meant to save our lives ,themselves become life takers.
It's a sad ,sad and  sad tale indeed.
Rakesh Bharti

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HIV Tales from my diary -Tale21

Even Twenty years after the discovery of HIV, there was still no vaccine. A vaccine trial did fail in 2003. This was, an envelope vaccine ,aimed at stimulating neutralizing antibodies and it was unable to protect against infection ,in phase 3 trials. Despite this failure more than 20 HIV vaccines ,designed to stimulate T-cell responses ,were being developed. The world was worried “Will any of them work?”
The medical fraternity, in countries like ours ,however,were still struggling ,to get a strong foothold ,even ,in diagnostics. I am reminded of one ,Dev Raj from Pathankot. Dev Raj was in his mid fifties having a good Bussines, a happy family and was well settled in life. His health , however , was showing not so good signs. Loose motions , fever , some glands etc were bothersome symptoms specially after the local doctors were unable to manage his health. One of his distant relation working as a resident in Dayanand Medical College , asked him to travel down to Ludhiana, so as to ensure ,a proper diagnosis and treatment for his falling health. Extensive diagnostic evaluation ,led to a suspicion of a type of malignancy. The word ” Cancer” becomes scarier, if it descends to personal levels. Dev Raj was dejected , depressed and felt defeated. He was aware of side effects of cancer treatment in terms of both money and side effects. It was with this awareness ,that he came back home and there started a search for treatment by alternative medicines. Assurances by the practitioners of alternative medicines remained like wishes which were not horses. Back to allopathy, Dev Raj now went to a smart GP of his own town. The GP turned out be real smart and looked at his ailment from new and fresh angles. He was not overawed ,by the labeled diagnosis ,of and by a , tertiary care teaching hospital. His out of the box thinking ,took the actual disease out of box. He could detect HIV in him. But his smartness buck stopped there. Now a search for HIV specialist was on. It was ,at this point ,that the so called ” Cancer patient” ,landed in my clinic. This was 14 years ago. Today Dev Raj is once again leading a happy and healthy life. His story of “from rags of ill health “to “riches of good health ” is now history for me. Thanks to the smart GP and the antiretroviral drugs. I can not imagine any doctor can miss the diagnosis of HIV these days, after so much awareness about the disease. It’s been thirty four years ever since the medical world was introduced to the virus, after all.
I am , however a fool ,who keeps on living in a paradise of his own thoughts.

What happened with Hardeep Singh in 2017 ( fourteen years later then Dev Raj Saga) outsmarted my thinking and showed my ignorance about ignorance of others in medical field. Doctors still miss the diagnosis by yards.
Like Dev Raj , even Hardeep was suffering. He had fever which was refusing to bow down to best of doctors , medicines and a long list of investigations.
September 2016 to June 2017 was a running period for Hardeep’s family. Jammu today , Srinagar tomorrow, one day to Jalandhar , other to Chandigarh. They were running helter and skelter and were getting out of steam. The pause came ,through ,once again a smart GP ,taking the bull by its horns afresh. Lo , behold your breath, the culprit in Hardeep’s body was also HIV. A Dev Raj story replayed.
I am ashamed of the evaporation of the thirst for knowledge amongst our own folks.
Why do we still waste nine months ( in this much time a human being can his or her progeny ) in diagnosing a simple infection ,which is totally manageable ,these days.
I wish the buck stops here. No Dev Raj or Hardeep has to run from anywhere to anywhere. Let no doctor miss HIV , let history be not repetitive.
Rakesh Bharti

HIV Tales from my Diary

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HIV Tales from my diary -Tale 23

Suba Singh was in his thirties , a truck driver by profession . He used to go on for long journeys and be absent from home for long time. In November 2000, he was ,however,desperate to cut short his journey and return home early. His wife was all set to deliver him the gift of fatherhood and like any living ,he ,also ,was anxious to see his progeny. This was the time to have some spice added to his life , which so far , was like any other trucker- dull, boring and monotonous. It was as monotonous as that of a pulley which is used to take out water from the well seeing the role going up and down day in and day out. Like all other extremely mobile truckers ,who will ferry endless cargos of freight the length and breadth of the country, he will also , ship tea from Assam, computer parts from Bangalore and exotic flowers and vegetables from the far southern states of the subcontinent, have a very stressful life away from home. Distressing moments ,will come only ,when he ,like all others, will stop ,at dhabas ,on roadside,

to shower for the first time in weeks, eat daal n chapatis and sleep on knitted charpais there. With little else to do ,it was also common ,for him too , to buy sex. Sex would cost peanuts ,literally and was the cheapest entertainment on the highways. The local women and teenage girls used to cost as little as 30 rupees, At times , he will have fun with his helper boy as well.

Suba Singh's marathon was like an unending race yet he could romp home ,in time. His wife also waited till his arrival. She presented to him , the much awaited gift ,the very next day of his arrival. His joy knew no bounds. He was blessed with a daughter ,with all fingers and toes intact, a nose like him and big eyes like her mother , hale and hearty. He was a proud , happy father now. He was enjoying the break , carrying the little bundle of joy in his arms. He made merry and had feast for full one week, almost. The gay period was over soon and the time to start a new journey ,to Mumbai , arrived like a pre-monsoon shower without warning. He wanted more rest and to stay longer but his employer was getting restless. The employer wanted the shipment to be delivered before the onset of foggy winters. Reluctance was writ large on his face ,when he had to leave behind the joys of his life. The unhappiness of separation ,stretched a little too far ,as he fell sick on the very next day of his journey. He had loose motions and vomiting . The highway doctors suspected food poisoning and treated with antibiotics, ORS etc. Treatment helped him to carry on with the journey , although slightly behind the schedule, yet reach the destination. His health did not recover full and final. Upon touching his destination, he rushed to a hospital. The journey ,which landed him in the hospital ,looked like reaching the dead end. The doctors of the hospital ,declared him ,to be carrying HIV. Distressing moments of highways ,were turning into most stressful times of his life . The announcements of bad days were loud and harsh. They were harsh for many other reasons too. The treatment of his ailment was either not available or was insufficient world over and costly too. Those were initial years of managing HIV and were characterized by treatment failures and disappointments. Although, 1985 was the year when clinical trials began with direct acting dideoxynucleoside reverse transcriptase inhibitors (NRTIs), the first being azidothymidine (AZT) and by 1987, treatment with AZT, later called zidovudine (ZDV), was approved for use in patients with advanced HIV. In short succession, three other NRTIs were approved for use in HIV-1 infection: zalcitabine (ddC), didanosine (ddI) and stavudine (d4T). Each had its own particular toxicities and none is widely used today. To avoid the toxicity profiles, attempts were made to administer drugs sequentially and to alternate therapies. But the availability of those drugs at affordable prices in India was still a distant dream even in 2000, when Suba Singh needed them. At most Cipla was making dual combination of AZT and 3TC ( Zidovudine and Lamivudine) by the name Duovir, available those days. The cost was 4000 Rs. Per month. Dr. D. G. Saple ( a national authority on HIV management) prescribed him the same and he remained in Mumbai for three months or so. His resources started drying up and the employer also refused to help further. Friends started showing chameleon colors. Suba Singh's parents however were the rock in which he could rest his body. They were ready to sell off their ,whatever ,land for the son. Dr. Saple asked him to see me while in Amritsar as were running a NGO and Dr. Saple was aware of it. Suba Aingh returned home and reported to me. I could arrange the same Duovir to him through the company at half the price. The antiretroviral drugs started showing its effect and he regained his health to quote an extent. His faith in me and drugs increased. He could resume his journey again. His visits to me became scarce. After many months , one day he reported sick to me. He suddenly felt like running out of steam. His body used to tire with the ease he used to control the tyres of his truck. He was feeling like filling diesel in his body all the time. Although, he was regular in his HIV Medicnes and was feeling good all along, yet a fear creeped in his mind after this weakling episode. Routine tests revealed severe anaemia and some chest congestion. His blue nails and pale conjunctivae were pointing towards the drugs , he was taking. Zidovudine is known to cause bone marrow depression and this anaemia. The chest congestion was adding salt to the injury. Hospitalization was the natural consequence. HIV patients are best treated as a team. The involvement of chest physician thus was a must. The hospital admission worked wonders for his recovery till a fateful night. It was a cold foggy wintery night. Me and the chest physician were delighted to see his recovery. Hemoglobin levels were , however still away from the satisfaction level. We two decided to infuse another unit of blood to him. I proposed to do that the next day , but my co consultant looked like in a hurry. The resident also sort of connived with him , as the blood was already available. Both wanted to transfuse blood that night only and discharge the patient next morning. They wanted to save his hospitalization money. Their intents were beyond doubt. But , my doubt was directed towards a possible transfusion reaction. It is always difficult to manage reactions at odd hours in all middle level hospitals where resources are in a crunch at nights. Two is to one vote and I was defeated. Defeat ,however ,came in pairs. Even Suba lost his battle for life. He did not develop reaction but died of , may be due to overload . An early morning call from the hospital to the two consultants was a mere formality. We could only see his pale , motionless face with no pupillary reflexes numbing our own reflexes. We were looking for a place to hide our faces and face the widow of Suba Singh with one and a half year daughter in her lap.

Even after passing of so many years of that night , I get goose bumps, imagining my spineless action of that night. I wish , I could have vetoed the blood(y) action that night. It is said that extra ordinary people burn fingers while doing fire worship हवन करते हाथ जलाना ) and the doctors learn by mistakes. This mistake was unpardonable.Although , I was not the direct party in the act, yet ,can not wash my hands off ,the mistake too. Facing the widow after few months was the real task. As a face saving I am helping the widow and the orphan by way of free medicines. Rest of their needs ,are taken care off by the deceased' younger brother , who has taken them in his fold and accepted to grow old with them. Suba Singh's daughter , who is HIV positive too is now in plus two and appears determined to be a doctor one day. I long ,to live to see her ,find a cure for HIV. Till then , Suba's debt to me will remain unpaid.

Rakesh Bharti

Counselling techniques in HIV and STD

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Dr.Rakesh Bharti will be delivering a talk on Techniques of counselling in HIV &STD during forthcoming ASTICON @ Mysore on 28th September,2013.
Here is the abstract of the same


STD & HIV patients need counselling because some of these are life long and all are attached with lots of social stigma. These patients have long and short term needs. Short term when they are either not effected or are too scared ( no knowledge, inadequate and wrong knowledge courtesy GOOGLE baba). Removal of their ignorance is our short term goal and their need. For those who are infected  with recurrent or life long diseases need counselling so that in the long term they can learn to live with the disease despite the disease.

Both these short and long term goals can be achieved easily if one learns the art of counselling. Counselling is an interpersonal  interaction which is actually a helping process where one has to explicitly give ones time and attention and skills so as to assist the patient explore their own situations, identify their problems and find solutions in their own ways. Counselling entails imparting knowledge,help in crisis and encourage change when needed. It can be done anywhere by anyone,who has learnt the art.

Counselling has four stages

1. Rapport forming

2. Demystifying 

3. Supporting

4. Closing the relationship

One may adopt different approaches to counsel but should have qualities of caring,empathy,self awareness,cultural sensitivity and patience.

Counselling techniques should include 

Active attention,

Reflection of feelings

Questioning and interpreting 

Summarising.

The talk will elaborate the techniques with examples .

Dr. Rakesh Bharti

   M.D,AAHIVS.

Dr.Rakesh Bharti meets Dr. Toby Maurer

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Dr.Bharti with Dr. Toby Maurer in the department of dermatology of San Fransisco General Hospital on 15th August,2013

AAG Activist visiting USA

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Dr.Rakesh Bharti will be in USA from November 4th to

Alternate therapies and HIV

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AIDS INDIA site has some interesting ongoing debate on alternate pathies in HIV management---here are some excerpts

e: http://health.groups.yahoo.com/group/AIDS-INDIA/message/11844

Mizoram Drugs Control issues warning

Some Ayurvedic medicines have been found to contain allopathic drugs.

Published on 08/17/2010

Aizawl, August 17: Mizoram Drugs Control Administration on Tuesday has issued a warning on the use of some Ayurvedic medicines meant for remedies of erectile dysfunction called by some doctors as the Indian Viagra which have been found to contain allopathic drugs.

A recent study conducted by the Delhi Institute of Pharmaceutical Sciences and Research (DIPSAR) has found the presence of allopathic drugs in many formulations commonly marketed as Ayurvedic or Unani remedies for people having erectile problems, an official statement issued by the state drugs control administration said.

The statement said that Slidenafil and Tadalafil, which are prescription drugs, as well as allopathic medicines are found in Ayurvedic medicines like supersonic, titanic K2, Sikander-e-Azam and 2much Gold.

It warned, "Slidenafil can be fatal for someone who is already taking medicines that contain nitrates and it can also cause coma and hypertension if not taken judiciously.

"The DIPSAR also found nicotine in tooth powder of Vicco and Muska Gul and also toothpaste like Dabur Red, Arodent, Dentobac and IPCO," the statement added.

http://igovernment.in/site/mizoram-drugs-control-issues-warning-38222-

Ayurveda hindering HIV therapy, dump it'

Published: Thursday, Aug 19, 2010, 0:34 IST

By Jyoti Shelar

Friends,

Re: http://health.groups.yahoo.com/group/AIDS-INDIA/message/11844

No one can doubt or question any "Pathy" including Ayurveda.

This is not the pathy but its practitioner who can be doubted--my area of concern (as I stated in some earlier mail too) is that such studies should be well designed and not that in the name of Ayurveda we get carried away and allow all sorts of trial that too on human beings (Including PLHWA).

We in Amritsar rejected one such ill designed trial based on false notions--had we done that the persons concerned would have started selling their medicines on the pretext that the trial is approved by NACO ( as they could manipulate NACO-to give it to ethical committee for approval,of which I was a member).

I agree with our distinguished teachers Dr.Alka and Dr.Maniar that we should encourage such trials,but I will like to add "with Caution".

Advocates and practitioners of Ayurveda may be claiming that the centuries-old system has a solution for the dreaded AIDS, but the National Aids Control Organisation (Naco) is not prepared to buy any of it. It has asked all medical colleges to stop experimenting with Ayurvedic treatment on HIV patients.

The organsation feels that the alternate treatment is destroying the importance of antiretroviral therapy (ART) and other therapeutic drugs for HIV. Acting on its order, the Mumbai District Aids Control Society (MDACS) has already stalled all such ongoing studies by students and doctors at various medical colleges in the city.

"Ayurvedic treatment or any other kind of immune boosters is not the mandate of Naco," said Dr SS Kudalkar, project director, MDACS, adding that Naco's letter clearly stated that the HIV patients underestimate the importance of ART and other prescribed drugs when they are put on alternate treatments.

According to Kudalkar, Naco has specified that any HIV patient, whether under the ART or not, should not be included in any such research papers.

"Very often the patients start thinking that Ayurvedic treatment is curing them but they suddenly find that they have reached an advanced stage of the disease. This is mainly because they start ignoring ART while taking the other line of treatment," said Kudalkar.

This is the reason why a student from Nair Hospital, who had recently applied for a research paper on 'Ayurvedic treatment as an immune booster' for HIV patients, was discouraged from proceeding with her work. The ethical committee set up by the college asked her to switch to another topic.

"The student's research was on neem, tulsi, haldi, cloves and other such harmless items as immune boosters for HIV patients. If the life span of an HIV patient can be increased through such easy techniques, then such studies should be promoted by Naco instead of discontinuing them," said a senior professor from the hospital, who refused to be named.

Another study by consultant physician and professor of medicine, Dr AR Pazare, from KEM was discontinued after Naco's order. The study which had completed one year, used an Ayurvedic drug as an immune booster for HIV patients. It had yielded positive results in increasing the CD4 count in the patients. The CD4 cells indicate the health of a person. The researchers are now seeking permission from the Centre to re-start the study.

http://www.dnaindia.com/health/report_ayurveda-hindering-hiv-therapy-dump-it_1425452

Friends,

Once again I reiterate that there is no "pathy" which is good or bad--it is their practitioners.

I want to highlight one case. This man in his late thirties presented with Cd4 less than 200 five years ago and was advised to start a combination of AZT+3TC+NVP, he did so also,but because of side effects (nausea and vomitting) decided to switch over to homeopathy on the assurances of a local homeopath of repute (he is considered the best in Amritsar).

His wife also started the same .Good thing was despite being under homeopathy ,the couple kept me in the loop. Two years ago when the wife had Herpes zoster with dissemination and started loosing weight and started showing rapid decline in Cd4, she started the ARV's and doing fine and is off Homeopathy. But the husband continued the same till the beginning of this year, when he presented to me with some fulminating skin infections and Cd4 below 100.

The skin infection refused to go despite best and suitable (after culture and sensitivity) antibiotics and Cd4 kept declining and the homeopath kept reassuring and thus distracting patient from starting ARV's.

The patient and homeopaths arguments were that his weight is not falling,so he can not be a candidate still for ARV's.Refusing to go to ART center,this man kept getting his Cd4 tested every week almost from different labs in the hope that there is something wrong with the labs.

Result today after confirming a Cd4 below 50 from atleast three different labs, he reluctantly agreed to start the ARV and after a good counseling session lasting for more than an hour-he purchased the medicines.

Lo behold your breath,he still went to the homeopath and again postponed the therapy.God save this man.

Moral--

1. I would love to even educate practitioner of other pathies and convince them that till they really have a breakthrough (proven by scientific research,as is done with allopathic medicines)tehy should not give false hopes to PLHWA.

2. The idea of treating PLHWA is not only increasing the Cd4,the ARV's kill the virus too and only problem is that the ARV can not fight the HIV army to finish.

Rakesh

Dr.Rakesh Bharti,

Bharti Derma Care and Research center,
27-D,Sant Avenue,The Mall,
Amritsar143001,Punjab INDIA
Email-rakesh.bharti1@gmail.com
9814044213 / 01832277822 /01832278522