Rational drug use is another key concept that is important for an effective HIV/AIDS-related treatment programme. It is about finding ways to make the best use of drugs, by prescribing them sensibly and taking into account all the information that you have about:
• the health problems you are treating; • the facilities that are available; • the people who need the treatment;
• the drugs that are available and accessible to them; • their economic and social situations; and
• their beliefs and practices with regard to drugs and treatments.
Rational drug use is supported by answering questions such as:
• Is the drug really necessary?
• Is the drug the correct one for the condition?
• Is the drug being used according to standard treatment guidelines?
• Is the drug suitable for the person – for example, a child or pregnant woman? • Are the dose, frequency and length of treatment correct?
• Are any other drugs being taken that might interfere with this one? • Is the drug likely to be available?
• How expensive is the drug? Can you afford it? • How effective is the drug for this condition?
Irrational drug use (when drugs are not provided in a sensible way) can happen when:
• a drug is used that is ineffective for the condition;
• wrong or insufficient advice is given to the patient about using the drug; • too high or too low a dose of the drug is used;
• the drug is given for too long a time; • the drug is given for too short a time; and
• too many drugs are given at the same time, with similar or conflicting effects or causing increased risk of side-effects.
Ways to encourage rational drug use include ensuring: • appropriate and independent information;
• training of health workers; • consistent drug supply; and
• understanding views and beliefs about drugs.
Appropriate and independent information. Unbiased and accessible information about drugs
encourages rational drug use. The information should be written by people who do not have a financial interest in the things they are writing about, and the information should be in language that people understand. Budgets for treatment work should always include some money for buying up-to-date reference books and information about drugs, including official treatment guidelines and EMLs. Old information about drugs can be dangerous because it will not include recent updates about drug safety or about new drugs.
Training of health workers. In addition to having good information, health workers need
training in providing effective treatment. All health workers need to keep up to date with the latest information on new drugs, new diseases and new ways of dealing with all kinds of
training to keep people up to date and to refresh their understanding of good practice and the role of drugs in treatment. An NGO/CBO must ensure that sources of information are kept up to date and that time and funds are available to allow workers to access new updates.
Consistent drug supply. Rational drug use will only be possible if the necessary drugs are
continuously available and accessible. If not, it is difficult to encourage rational prescribing and the use of an essential medicines list. People will seek alternative drug supplies from private doctors or pharmacies and will not always get the continuing support they need for their treatment. For example, many countries suffer from interrupted supplies of TB drugs. This affects treatment and prevention of TB and encourages the disease to become resistant to the drugs. It also discourages patients and health workers, and wastes money and medicines. If this happens, treatment is likely to fail, and expensive alternative drugs will be needed to overcome drug-resistant bacteria.
Understanding views and beliefs about drugs. What people believe about the drugs they are
taking is a very important part of any treatment. If people think their drugs will not work, they are less likely to start taking them or to use them correctly. It is vital to find out what people know and think about drugs – for example, through discussions with community groups. You might have to change the way drugs are prescribed or provide education for community members to improve their understanding about drugs and the way they are used.
Participatory group activity
AimTo build awareness about rational drug use in HIV/AIDS-related treatments.
Instructions
1. Explain the aim of the activity.
2. Read out the following case study to participants:
A woman has had mild diarrhoea, with loose stools, but no blood or mucus, for two days. She goes to see a health worker who prescribes the following medication: co-trimoxazole, two tablets twice a day for five days; tetracycline, 250mg, one capsule daily for three days; vitamin B injection.
3. Ask participants to identify why this prescription is not an example of rational drug use. Encourage the participants to ask each other questions and to make comments.
4. Ask participants what would be a more rational prescription for the health problem. Correct any inaccurate suggestions.
5. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
• What could be the consequences if drugs are prescribed irrationally? • Who needs to have at least basic knowledge about rational drug use? Why?
Facilitators’ notes
• The facilitator for this activity should be someone who is very familiar with rational drug use and confident about information relating to the specific case study. This will help to ensure that clear and accurate information is provided to the participants. (The example on the following page provides the correct advice on the rational prescription.) • Remember that the aim of the activity is to build awareness about rational drug use,
rather than build medical knowledge. Make sure, therefore, that the activity does not become too technical or intimidating for participants who lack detailed knowledge about drugs or treatment.
Handbook on access to HIV/AIDS-related treatment
Example
At a skills-building workshop, NGO/CBO participants studied the following case study:
A woman has had mild diarrhoea, with loose stools, but no blood or mucus, for two days. She goes to see a health worker who prescribes the following medication: co-trimoxazole, two tablets twice a day for five days; tetracycline, 250mg, one capsule daily for three days; vitamin B injection.
They then identified why this prescription is an example of irrational drug use: • The most important treatment for diarrhoea has been forgotten – drinking plenty of
fluids and using oral rehydration solution to stop dehydration.
• The woman only has mild diarrhoea and is not passing blood or mucus, so she probably does not need an antibiotic. She definitely does not need two different types of antibiotics (co-trimoxazole and tetracycline).
• The prescription does not specify the strength of the tablets to be used. If an antibiotic were needed, co-trimoxazole would be suitable in the correct dose, but not if the woman is already taking it for long-term prevention of HIV/AIDS-related opportunistic infections. • Tetracycline can be used for diarrhoea, but is not usually the first choice. Doxycycline is
more useful. Also, the usual adult dose of tetracycline is 250-500mg three to four times a day, for at least five days. A three-day course of one 250mg tablet a day is unlikely to work and could cause the woman to build resistance to the drug.
• An injection of vitamin B is unnecessary. Injections can be dangerous, especially if unclean needles are used. Vitamin B injections should only be given if there are specific symptoms of vitamin deficiency.
Participants identified that a rational prescription would involve giving the woman the correct advice (based on a hearing a detailed history of the problem). It would focus on helping her to improve her situation rather than wasting time and money on unnecessary drugs. It would include the following advice:
• mild diarrhoea usually clears up in a few days without drugs; • plenty of fluids and oral rehydration solution should be drunk; • directions on how to make and use oral rehydration solution;
• how to prevent diarrhoea through better hygiene and safer water; and
• a return visit is recommended if the diarrhoea does not improve after two more days. The facilitator then led a discussion about what had been learned from the activity. For example, participants agreed that rational drug use is vital for both the good health of the person and the reputation and resources of the NGO/CBO.
Reference: Adapted from a workshop on access to HIV-related treatment, India HIV/AIDS Alliance and the International HIV/AIDS Alliance, India, February 2001.