An international conference in New Delhi of policy-makers from across the world focuses attention on the development of a vaccine for AIDS and on strategies to prevent the spread of the disease.
AT a two-day international conference of policy-makers held on May 11 and 12 in New Delhi, a consensus was reached regarding new mechanisms to deal with the global problem of HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome). The conference, which was organised jointly by the International AIDS Vaccine Initiative (IAVI), the National AIDS Control Organisation (NACO) and the Indian Council of Medical Research (ICMR), was an outcome of the IAVI's efforts to develop an indigenous AIDS vaccine, after it had signed a memorandum of understanding to this effect with the Indian government. The MoU is the fifth instance of an IAVI-sponsored partnership aimed at accelerating the development of safe, effective and widely accessible AIDS vaccines.
The focus of the conference was on the development of a vaccine, on strategies to prevent the spread of AIDS, and on the need to care for those already affected. Members of Parliament from India and some African countries, along with several non-government representatives, conveyed the message that policymakers were now serious about dealing with the "global emergency". Legislators, Ministers and members of non-governmental organisations (NGOs) from India and eight other developing countries - China, Brazil, Kenya, Nepal, Nigeria, South Africa, Thailand and Uganda - were present. Government representatives from the developed world included officials from the United States, the Netherlands, the United Kingdom and Australia. Their role was to examine the available resources and suggest ways to put them to optimum use. India, as one of the organisers, was represented by the Health Ministry and bodies such as NACO and the ICMR, which functions under it. Prime Minister Atal Behari Vajpayee inaugurated the conference and Congress(I) president Sonia Gandhi addressed the delegates. The Chief Ministers of Andhra Pradesh, Maharashtra and Karnataka made presentations.
A 'Delhi Declaration' was signed, keeping in mind the specific needs and conditions of developing countries. It emphasised the commitment of policymakers to provide leadership and take steps to address the complexities of and the challenges posed by the epidemic. The declaration pledged to identify and address factors such as underdevelopment, poverty, illiteracy, lack of empowerment of women and all types of sexual exploitation that made individuals vulnerable to HIV infection. However, the issue of dealing with other opportunistic infections that accompany HIV infection got sidelined.
New initiatives required to treat holistically all dimensions of the disease were discussed. A vaccine was recognised as one such crucial initiative despite the reality that thus far all research efforts in this direction had been concentrated in the industrialised countries. Also, it was noticed that developing countries accounted for more than 95 per cent of the 15,000 new infections that occurred each day. It was accepted that the prevailing multi-drug regimens or 'miracle drugs' called protease inhibitors were too expensive and complicated to use in poor countries where less than 2 per cent of the infected persons had access to the drugs.
Proponents of an affordable AIDS vaccine estimate that of the current 34.3 million cases of AIDS and HIV infection worldwide, at least 30 million are among the poorest of the poor who live on less that two dollars a day. Nearly 23 million cases of HIV-AIDS are in sub-Saharan Africa, where life expectancy levels have plummeted. Currently, a typical protease inhibitor regimen costs $12,000 a year.
According to the IAVI, scientists have agreed that though a preventive vaccine is the best hope for tackling the epidemic, vaccine research and development commanded only 2 per cent of the $20 billion that the world spent annually on AIDS prevention, research and treatment. Seth Berkley, IAVI president, said that it was a tragedy that since 1984, when the virus was first identified and serious attempts began to be made to create a vaccine, these efforts had slowed down gradually. Money and effort went into other areas as people rightfully demanded drugs and treatment. "It is going to take some time to develop a vaccine but we have to get there as soon as possible," said Berkley. The IAVI had laid the foundation for national AIDS vaccine programmes in South Africa, Australia, India and China. Its scientific efforts are directed at viral strains that are prevalent in developing countries. It has enlisted scientists from these countries as full partners.
According to NACO, there are nearly four million people infected with HIV in India. The prevalence of infection among women is high - one in every four cases. The rates of identified infection are the highest in the six States of Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Assam and Manipur. While advances in research have yielded new AIDS therapies, the cost and complexity of their use have put them beyond the reach of most people in countries where they are needed most. With five vaccine development partnerships, the IAVI has now struck an arrangement with the ICMR and the Ministry of Health and Family Welfare to develop and evaluate one or more vaccines that are appropriate for use in India. J.V.R. Prasada Rao, Director, NACO, promised complete transparency in respect of drug trials and in dealing with the attendant human rights issues and said that civil society would be involved in the process.
The IAVI has concluded a vaccine development partnership, which has brought together researchers from India and Therion Biologics, a United States-based biotech firm, to create AIDS vaccines that are designed to suit the specific strain of the virus found in India. This vaccine, Modified Vaccinia Ankara, is intended to stimulate the production of immune cells that kill cells that are infected with HIV. The vaccine will enable the immune system to launch a swift attack in the event of HIV infection, controlling the virus before it is able to take over. According to IAVI, the research has indicated that people with naturally high levels of these HIV-specific killer cells have resisted infection for years despite repeated exposure to the virus through risky behaviour.
According to the IAVI, so far no vaccine has been introduced simultaneously in the North and the South. Initially, it took 15 years or more after a vaccine became licensed in industrialised nations, before its price dropped to such a level that it was affordable in developing countries. In addition, adequate systems had to be put in place to ensure the distribution of the vaccine. Regulatory delays could also prevent the vaccine from reaching the target populations. Speakers at the conference expressed similar concerns about manufacture and distribution.
Departing from the usual method, an AIDS vaccine would be first administered to adolescents and adults and then to children. It is significant that the IAVI recognises the problems of affordability and pricing in developing countries and to that extent it has come up with a blueprint to ensure global access. At present, vaccine-making expertise remains mostly with the private sector. The IAVI has suggested a system of tiered pricing, which will be based on the ability to pay and in which a global purchase fund will be set up by the wealthy countries to subsidise the difference between the lowest tiered vaccine price and the cost that a country can afford.
Infrastructure concerns were also voiced in the conference. According to the IAVI, in most countries the six basic vaccines that are currently administered to infants can be purchased together for less than $1 a dose. But the costs of delivering these vaccines are 10 to 20 times as much. According to David Apuuli, Director-General, Uganda AIDS Commission, vaccine trials in his country started four years ago and were completed in 2000. He told Frontline that the results had not been yet published.
"Having a vaccine is one thing, but to have a system to put it in place is another challenge," said Apuuli. He explained that a vaccine for HIV would have to be given to every segment of the population. Apuuli said that the key to success in the war against AIDS was awareness campaigns among the people. Drugs, he said, were never considered a cure for the infection, but were seen only as a mechanism to prevent the circulation of the virus. The answer, Apuuli said, is to have a vaccine, while simultaneously implementing all other preventive mechanisms.
Dr. M.S. Abdullah, Chairperson of the National AIDS Control Committee, Kenya, was sceptical about the issue and said that there was no certainty that the vaccine would work. The best means, he said, was for people to abstain from practices that caused HIV and AIDS. Abdullah was apprehensive that while Third World countries would be used as laboratories for testing, the vaccine would be made available first in the First World. "They put in their money. We put in our people," he said.
The conference set the pace for a rethink on established forms of treatment for HIV/AIDS and there was the realisation that the "same mistakes as in the case of anti-retrovirals (ARVs)" should not be committed. ARVs, both the IAVI and the Indian side concurred, were expensive and toxic. At the moment, cost-effective interventions seem to be the guiding factor, though no one has stated that vaccines will emerge as a cheap alternative. Apprehensions about costs and delivery mechanisms were expressed across the board.
Other issues that found mention at the conference were those of stigma and discrimination and the need to create an enabling environment through legislation, technologies like female condoms, human rights and ethical dilemmas, the role of care-givers, opportunistic infections, access to care for marginalised groups, global resources and the adoption of new technologies for AIDS prevention. Issues that were left out included a comprehensive critical analysis of the current systems of treatment, existing per capita health allocations and expenditure by governments, the state of the public health infrastructure and delivery mechanisms, poverty and its impact on the health of people, and other opportunistic infections that are relevant as HIV and AIDS. If the 'Delhi Declaration,' which was titled "Parliamentarians' commitment towards a world without AIDS," with its list of 14 pledges, has to be meaningful, policy-makers need to commit themselves equally to eradicating poverty and underdevelopment.