Where’s the commitment to fighting AIDS?

Tackling the disease is not just about infrastructure and funds

Parul Malhotra

LAST month, 39 international research-based pharmaceutical manufacturers who had legally challenged South Africa’s move to import generic copies of their Aids (Acquired Immuno-deficiency Syndrome) drugs withdrew their case. That paved the way for South Africa and, indeed, other developing countries, to locally produce as well import cheaper Aids drugs from low-cost manufacturers.

In February, one such Indian firm, Cipla, offered its antiretrovirals (ARVs) to the developing world and an international doctors’ voluntary organisation, Medecins Sans Frontieres, at concessional rates. It followed this up by reducing the prices of its ARV cocktails in the domestic market. Those which cost between $10,000-$15,000 per capita per annum in developed countries, can now be bought for as little as $900 in India.

These should conjure up visions of palliative Aids care for the millions of HIV (Human Immuno-deficiency Virus)/ Aids sufferers in India. However, Dr Alaka Deshpande, Head, Department of Medicine, JJ Group of Hospitals, is more circumspect. “Even with lower prices, less than 1 per cent of Aids victims can afford ARV therapy,” she says. Which means that, left to the market, ARVT remains a dream for close to 3.82 million out of the 3.86 million currently infected.

The good news is that ARVT can be made more affordable, by three possible means: One, if the government bought them at reduced prices—at $600 per person per annum (pppa) from Cipla and at $347 pppa from Hetero—as part of an offer made by these drug companies to all developing-world governments. However, the firms stipulate that these would have to be distributed free of cost. Two, if the government was to provide economic incentives—subsidies, tax cuts, import concessions, etc—to drug-makers. These would bring prices down further. Three, by negotiating with Medecins Sans Frontieres. Both Cipla and Hetero have offered their cocktails to MSF at $350 pppa.

Now for the bad news. None of the above has been implemented. Mr J R V Prasada Rao, Project Director for the National Aids Control Organisation (Naco), flatly rules out the prospect of providing free and universal ARVT, saying the programme is financially unviable. But rough estimates do not bear him out.

To start with, not all of the 3.86 million infected have to be on ARVs. According to Dr David Miller, Country Programme Adviser, UNAIDS, (a United Nations programme on HIV/Aids), only about 10 per cent would be on ARVs at any given time. Assuming that half of them turn to the public sector, only about 200,000 people constitute the target group. Currently, $350 or Rs 16,450 is the lowest price that the government can hope to get the cocktail for. Add to that an average of Rs 20,000 as the annual testing charges.

“ARVs are potentially toxic and need to be monitored carefully,” says Dr Dinesh Kaul at Sir Ganga Ram Hospital. The per capita per annum expenditure thus comes to Rs 36,450. Therefore, an ARV programme would set the government back by about Rs 700 crore.

Naco—with it’s existing annual budget of Rs 210 crore—obviously cannot take it up. But with a direct tax base of 2.3 crore assessees, if every individual was to fork out an additional Rs 25 a month, the initiative could become financially viable. Market incentives would do the trick as well. Cipla’s Joint Managing Director M Hamied has gone on record that the company’s 3-drug cocktail could cost up to 40 per cent less if import duties and sales taxes were removed. Mr Rao’s reply—”I’m not aware of that. No one has contacted us”—suggests that the government is not listening. As for tapping MSF, while countries such as Cambodia have already received supplies and others such as Cameroon and Nigeria are in the process of striking agreements, India has shown far less dynamism. According to Mr Rao, MSF has been in touch with them, expressing interest. He then goes on to admit that he’s clueless as to when a meeting will actually be set up.

Clearly the issue of ARVs is still peripheral as far as the government is concerned. Apart from bad economics, Mr Rao has additional concerns. “Our health infrastructure, especially in rural areas, is inadequate to deal with them”. Dr Kaul agrees. “For regular testing we need proper laboratories,” he says. Ensuring compliance is also an issue. “We see many patients switching to cheaper drugs and that could lead to resistance,” says Dr Deshpande. Dr Miller shares Mr Rao’s concerns. “Not too much debate should be centred around ARVs.
Instead of investing in ARVs which may or may not be properly dispersed, we should be investing in improving existing and developing new infrastructure”.

But Aids activists beg to differ. Dr Suniti Solomon of YRG Centre for Aids Research and Education believes, “Generic drugs must be made freely available to all who need them. How can you sit back and let people die?” Mona Mishra of Positive Life says, “The attitude seems to be, ‘What’s the big deal about keeping these guys alive since ARVs won’t cure?’”. That, activists feel, is morally unacceptable especially when most of urban India does have the infrastructure to provide quality HIV care and treatment.

By 2005, India is expected to have 35 million infected people. A multi-pronged approach to tackling Aids is essential. So is urgent action. Of course, voluntary counselling, cheaper testing services and adequately trained medical personnel have to be provided in far-flung areas, to prevent emergence of new cases. But by the same token, ARVs are also needed, for they check the virus transmission rate. If they remain inaccessible to most, the Indian population afflicted with HIV/Aids will only mount.

So, what could the government do? “They just need to use all the tools at their disposal,” says Ms Mishra. “But are they ready to do that”? Again, the signs are worrying. In November 2000, Cipla offered the government a free supply of one its ARVs, nevirapine, which dramatically reduces the HIV transmission rates from mother-to-child. Six months on, even a feasibility study of the drug is yet to begin.

Dr Solomon believes that the Indian government must negotiate agreements with drug companies, like African governments have. Immediately after Cipla’s offer, at least four multi-nationals announced price cuts on their Aids medicines sold in Africa. And this may well be the right time for the Indian government to exert pressure. Susan Finston, Assistant Vice President of PhRMA, a representative body of US research-based drug companies, says “We want to work with the government to improve access for those in rural areas”.

“Donation programmes such as Cipla’s should be priority right away,” says Dr Kaul. India also needs to learn from other documented success stories such as Brazil. If a poor country with a corruption problem to match India’s can use ARVT (amongst other approaches) and get it right, why not India? Of course, two big challenges—strengthening the health care system and mobilising more resources—remain to be tackled.
Yet, the biggest challenge is the attitude, a problem of missing commitment. Without political will, even a few billion dollars (which Naco hopes to receive from the United Nation’s proposed $10 billion fund) will be inadequate.