Bangalore: The nodal officer at the antiretroviral treatment (ART) centre at JN Hospital in Imphal, Manipur, pleads on the phone: “Can you take my message to the National AIDS Control Organisation (Naco)? They should cut down on bureaucracy; my patients are suffering,” says K. Priyokumar Singh, a physician who has been treating patients infected with the human immunodeficiency virus (HIV) for the past 20 years.
Since the last few months, he’s been seeking stocks of an AIDS drug, Tenofovir, that he wants to substitute for two more commonly prescribed drugs—AZT (Zidovudine) and Stavudine—which cause side effects such as peripheral neuropathy (a neurological disorder) and muscle atrophy (where a 25-year-old starts looking like a 60-year-old) in some patients.
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“Of the 3,078 patients that come to our centre every month, a substantial number cannot be given AZT or Stavudine; but I can’t give Tenofovir either. They have to be sent to the centre of excellence. The process is so cumbersome that my patients never get the drug,” he said. Incidentally, the World Health Organization on Monday issued a new guideline that requires phasing out of Stavudine as this drug, even though most widely used, causes serious side effects in long-term use.
Drug dispensation bottlenecks such as these are a blot on the otherwise looking-to-be-successful attempt by Naco in stalling the spread of HIV. “The ongoing mid-term review shows the programme (National AIDS Control Programme-Phase III, or NACP III) is on track (of infection reduction by 2012),” said a senior Naco official who didn’t want to be named “as the review is still in progress”.
“For the first time, we have done data triangulation (synthesizing data from three sources). The analysis is not yet complete, but broadly speaking, it appears that we might have to relook at the categorization of districts (high or low prevalence),” said the official. NACP III may be on track, but AIDS managers need to factor in the reality that the economic slowdown has led to the shrinking of global funds and most countries would have to make critical choices in financing.
Of the Rs11,585 crore budget for NACP III, the Indian government’s contribution is Rs2,861 crore; the rest comes from several international agencies. The biggest chunk of this, Rs2,683 crore, comes from the UK’s department for international development and the World Bank, and Rs2,237 crore has been committed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, which, incidentally, is facing a corpus shortfall of around $3 billion (Rs13,950 crore today).
This model of financing may not be sustained in the long run. According to a study published in the December issue of Health Affairs, India could require as much as $2.4 billion a year in 2031 to tide over AIDS, while South Africa would need $3.5 billion and China, $3.4 billion. “Middle income countries need to expand domestic funding for AIDS in line with their ability to pay,” said the study.
Using mathematical modelling for the first time, the preliminary findings of the global “AIDS 2031” project suggest that in its 50th year, the AIDS pandemic would still be around, with one million people getting infected every year, and the funding requirement for developing countries could reach $35 billion a year, three times the current level.
“According to the highest estimate, India’s requirement could be $2.4 billion by 2031, but if the right policies are formulated and implemented the annual cost could be much less, even half of it,” said Robert Hecht, a co-author of the study and managing director of Results for Development Institute in Washington.
“In per capita terms, it could turn out to be about a dollar per person, which is less than 0.1% of the GDP of the estimated $3.3-3.5 trillion Indian economy (in 2031),” said Hecht, a former World Bank economist who also led its health, nutrition and population division. To that end, Naco isn’t looking so far into the future. “As regards budget, we seem to be set for NACP III; I can’t say about 2031,” said the Naco official.
In fact, one advantage Naco has, according to Vijay Talwar, chief executive of the William J Clinton Foundation India, is that even though it works with a variety of international donors, it has managed to localize the implementation of the HIV/AIDS programme and this would facilitate the transition.
He plays down the concern of diminishing donor involvement. “I don’t think foreign partners will irresponsibly walk away. I am sure every partner that Naco works with has a phasing out or transition plan in place,” said Talwar.
Costing pressure is imminent as 3-5% of AIDS patients would soon need a second line of anti-retroviral drugs that are 8-10 times more expensive than the first line of drugs.
“In the long term, the challenge is to make available the third line and other newer drugs at affordable cost to the patient,” said Amar Lulla, joint managing director of Cipla Ltd. “The new drugs are covered under the new patent law, which recognizes product patents, and hence, Indian generic companies can only introduce them if they are allowed to do so by the innovator company or by the government under a compulsory licence,” he added.
Talwar believes the price battle isn’t unwinnable. Since 2000, AIDS drug prices have come down by 60%. “Prices have been declining year-on-year and I don’t see that stopping in the coming years.”
Money is only one part of this epidemic management. On the ground, structural changes are required that would reduce vulnerability to AIDS and produce a more sustainable response. “The most pressing need of the hour is a greater amount of involvement from the government at the state and the central level to counsel and motivate patients and make them understand that it is not the end of the world,” said Rajasri Lahiri, medical officer at Calcutta Rescue, a non-profit organization providing free medical care to the economically weak since 1979.
Even those implementing Naco’s programme say the state’s integrated centres for treatment and counselling are ineffectual.
At least 30% of HIV infection in the Punjab region is due to quacks using infected needles, said Santokh Singh, ART in-charge at Guru Nanak Dev Medical College and Hospital in Amritsar. “Neither is anybody cracking down on quacks nor are we reaching out to the families of those infected,” said Singh.
Moreover, mainstreaming the issue is necessary. “Prostitution is one of the oldest professions in the world. Still, people have pseudo social values. That is exactly where intervention should move towards,” said A.K. Srikrishnan, research manager of the Chennai-based YRG Centre for AIDS Research and Education.
“We are not saying ‘you shouldn’t be doing it (having sex with a sex worker)’, but that you should do it in a way that is comfortable for everyone, including yourself.”
Aveek Datta in Kolkata and Anupama Chandrasekaran in Chennai contributed to this story.
Graphics by Sandeep Bhatnagar / Mint