In search of anti-AIDS strategies

Print edition : August 03, 2002

The International AIDS Conference in Barcelona sounds the alarm regarding the increasing numbers of HIV-infected persons, particularly in the developing countries, and identifies funding as the most important constraint in the battle against AIDS.

THE 14th International AIDS Conference in Barcelona, Spain, from July 7 to 12 brought forth searing reports of a growing orphan crisis caused by deaths from Acquired Immune Deficiency Syndrome in Africa and Asia, an alarming rise in Human Immunodeficiency Virus (HIV) infections among young people and women, an explosive HIV epidemic owing to injecting drug use in countries that were part of the former Soviet Union, and a widening treatment and funding gap between rich and poor nations.

Outside the venue of the 14th International AIDS Conference in Barcelona on July 7, activists demand funding to fight the pandemic in developing countries and cheaper anti-retroviral drugs.-ALBERT GEA/REUTERS

According to the latest report of the United Nations Joint Programme on AIDS (UNAIDS), the epidemic continues to claim millions of lives and roll back years of painstakingly achieved development goals in middle- and low-income countries. The most shocking data come from southern Africa: in Botswana almost half the pregnant women between the ages of 25 and 29 are HIV infected, and Swaziland and Zimbabwe are not far behind. AIDS is knocking not just years but decades off life expectancies. By 2010 over 50 countries will register dramatic decreases in life expectancies - by 35 years in Botswana, by around 25 years in Zimbabwe and Swaziland and by close to 20 years in South Africa.

Funding is the topmost constraint in the battle against AIDS. UNAIDS estimates that about $10 billion a year will be needed for a global response - about five times more than what is spent now. The roots of the resource scarcity are traced to the failure of the G-8 ( Group of Eight) countries to honour their 1970 Organisation of Economic Cooperation and Development (OECD) commitment of 0.7 per cent of national gross domestic product (GDP) towards foreign aid. The result - a massive shortfall of over $120 billion for all development programmes of the entire developing world. With various projects vying for a share of the $53 billion that is at present available each year, AIDS hardly gets the funding it needs. An additional funding mechanism established a few months ago - the Global Fund for AIDS, TB and Malaria - may help ease the cash crunch a little, but as of now the Fund has more pledges and pious optimism than hard cash in its coffers. According to the World Health Organisation's (WHO) AIDS director and epidemiologist, Bernard Schwartlander, 45 million more people will be infected by 2010 if efforts against AIDS continue at the present pace. A sense of anger is engulfing all sections of the AIDS community.

Barcelona 2002 was in some ways a throwback to the agit-prop activism that dominated AIDS meetings of the late 1980s and early 1990s: it was not science and medicine but politics, economics and activism that took centre stage. Yet, there was a vital difference. The gulf between the activists at the heart of the epidemic and those working on its fringes has shrunk so much that it is barely discernible. It appears as though the 'activist' approach has permeated the entire AIDS community. Representatives of donor agencies, scientists and the rest were seen to be speaking the language of the 'activist'. At the inaugural ceremony, UNAIDS Director Dr. Peter Piot declared: "We did not come to Barcelona to renegotiate promises. We are here to ignite leadership, to keep the promise. The quality of future lives depends on the quality of life today... let us bring forward the day when leaders who keep their promises on AIDS are rewarded with our trust, and those who don't, lose their jobs to those who will. We must deliver both prevention and treatment at full scale - that's not negotiable. We must find $10 billion - that's not negotiable."

The meeting drew a record number of 17,000 delegates from nearly 150 countries and an unprecedented number of political leaders, including past and present Presidents and Prime Ministers, first ladies and the royalty. Many, including former Indian Prime Minister I.K. Gujral, spoke at a session devoted to "Keeping AIDS on top of the global agenda". More poignant than many of their declarations of commitment were the huge digital displays that toted up new infections with chilling regularity at the end of each minute. Former U.S. President Bill Clinton summed up the ghastly scene best: "How could we explain to someone from outer space," he asked, "that the world is being consumed by a disease that is preventable?"

Former U.S. President Bill Clinton with former Indian Prime Minister I.K. Gujral (right) and Rwandan President Paul Kagame at the world leaders' special session on July 11 as part of the conference.-PIERRE-PHILIPPE MARCOU/AFP

HIV prevention efforts are reaching fewer than one in five of those at risk. A "Blueprint for Global Mobilisation for HIV Prevention", drafted by a working group of prevention experts for the Bill and Melinda Gates Foundation and the Henry J. Kaiser Family Foundation, identifies resource crunches and political apathy as key drivers of the epidemic. Dr. Helene Gayle, president-elect of the International AIDS Society and Director of the AIDS/TB programme of the Gates Foundation, said what was required was a massive scale-up of proven HIV prevention strategies. "The cost (of prevention) is $4.8 billion today... we will pay now or pay later, but the longer we wait the more the monetary and human costs will escalate."

Some 400 Indian delegates attended the conference, including a high-level delegation consisting of Union Health Minister Shatrughan Sinha, parliamentarians Oscar Fernandes and Kirit Somiah, the Health Ministers of Manipur, Andhra Pradesh, Tamil Nadu and Jharkhand, and top officials such as Director-General of Health Services Dr. S.P. Aggarwal and Director of the National AIDS Control Organisation (NACO) Dr. Meenakshi Datta Ghosh.

India is grappling with a growing number of HIV infections and AIDS deaths, and HIV-TB co-infections, discrimination against HIV-infected people and a near-complete lack of access to anti-HIV treatment for the needy. Official figures place the number of those infected at 3.87 million - a large-enough number to warrant an overhaul of AIDS prevention and treatment programmes across the country. "AIDS is an issue that requires politicians to come together cutting across party lines. I hope to see soon a special session of Parliament devoted to AIDS and I believe that SAARC (South Asian Association for Regional Cooperation) nations must synergise their efforts to mount a concerted response to AIDS," Shatrughan Sinha told this writer.

UNAIDS warns that the low percentage of general prevalence may mask the real picture: serious rises in HIV infection in many pockets of the country that hold the risk of eruptions involving large populations. Said David Miller: UNAIDS country adviser: "People are impatient with meetings that don't lead to direct action. There was compelling evidence from this conference that we have already lost many an opportunity to save lives. One Indian is infected every minute; we have an understanding of how to stop that from happening and we've got to use that understanding urgently. Treatment for people living with HIV is another key area that is crying out for attention."

About 10 years ago doctors could prescribe little other than vitamins to HIV-infected people. Since then, no less than 16 anti-HIV drugs known as anti-retrovirals or ARVs have come into the market. These drugs cannot cure HIV infection but can keep an infected free from sickness for several years. They can also protect a huge percentage of infants from getting infected from their mothers. Anti-retrovirals have brought renewed life to millions of people and awakened hope in them.

According to the latest reports, AIDS deaths have fallen by 70 per cent in the United States and by 73 per cent in Brazil after the respective governments made ARV cocktails or Anti-Retroviral Therapy (ART) available countrywide in the late 1990s. Patricia Fleming of the Centre for Disease Control (CDC) announced that the total number of infants born with HIV in the U.S. had declined by 80 per cent in the last 10 years, thanks to ART.

It is a different story in much of the developing world. Of the 40 million people currently living with HIV, 36 million are in low- and middle-income countries and nearly all do not have access to ART, says UNAIDS. In developing countries, 96 per cent of the people who need this treatment immediately - six million - have no access.

In 2001, AIDS killed three million people, over two million in Africa alone and 435,000 in South Asia and South-East Asia. Many of these deaths could have been prevented with anti-retroviral treatment. Even now only 50,000 people in Africa get ARVs - only about one person out of a hundred in need, estimates WHO.

WHAT prevents governments from reaching life-extending therapy to people with HIV? Until last year, it was drug pricing that was a deterrent. Treatment with a combination of anti-HIV drugs known as Highly Active Anti-Retroviral Therapy (HAART) cost a patient $10,000 to $12,000 a year in early 2000. In a bid to make ARV affordable to the poor in the African countries, UNAIDS undertook the "Accelerated Access Initiative" in mid-2000. Five drug giants - GlaxoSmithKline, Boehringer Ingelheim, Bristol-Myers Squibb, Merck, and Hoffman-La Roche - participated in the initiative but only GlaxoSmithKline announced a 90 per cent reduction in prices. Further requests to lower the prices were stonewalled by the multinational corporations (MNCs) (which preferred to negotiate with countries on a case-by-case basis) until late 2000 - when the first anti-retroviral generic drugs from the Indian drug company Cipla hit the market. Within no time the prices of branded anti-HIV drugs plummeted to $500 to $800 for low- and middle-income countries.

A demonstrator at the venue of the conference.-LIONEL CIRONNEAU/AP

In February 2001 Cipla upset the apple-cart further with an offer to supply AIDS drugs for less than $1 a day. Cipla said it offered the drugs "at a humanitarian price", for Africa, considering that nearly the entire population that needs ART there dies because MNC drugs are priced beyond their reach. Medecins Sans Frontieres, a global charitable organisation of doctors, which had long been pushing for a reduction in ARV prices, promptly signed a deal with Cipla for $350 a patient a year, a thirtieth of the previous U.S. price. But for the Indian market Cipla's combination therapy was priced higher. Even after a reduction in prices in late February last year, Cipla's triple drug cocktail of lamivudine, stavudine and nevirapine cost a patient in India Rs.4,230 ($90.64) a month - more than the African price. "The irony is that low-cost generic drugs from India are being exported, but within the country they are not affordable for the majority of those in need," said Dr. Meenakshi Datta Ghosh. "We need wide-ranging consultations to formulate a rational policy in respect of standard treatment regimens for HIV and AIDS and expanding access to these regimens," he observed. "It could consider the twin public health strategies of social marketing and social franchising with a view to expanding vastly the outreach and coverage of HIV-related products and services that will link prevention with care and support."

In August 2001, Cipla launched Triomune, a cocktail of stavudine, lamivudine and nevirapine in a single bilayered formulation. Triomune costs patients less than $40 a month. The patents for these drugs are controlled by different companies. Britain's GlaxoSmithKline holds the patent on lamivudine, Germany's Boehringer Ingelheim on nevirapine and the U.S. drug giant Bristol-Myers Squibb on stavudine. Cipla also released Nevimune suspension, a formulation of nevirapine with zidovudine and lamivudine for children. Three of Cipla's generic anti-retrovirals were added to WHO's list of safe drugs in March this year.

In the world leaders' special session at the conference, Gujral called for changing the World Trade Organisation (WTO) agreements in order to shorten the validity of drug patents from 20 to five years and said that there should be "no restrictions on the export of these drugs" in generic form. Bernard Pecoul, director of the Access to Essential Medicines Campaign at Medecins Sans Frontieres, said that to encourage competition in pricing, drugs must be locally produced, the import and export of generics must continue and negotiations with proprietary companies must be "forceful".

In developing countries, the health infrastructure has to be upgraded and physicians must be trained to provide ART. Meanwhile, a Lancet study comparing the costs of HIV prevention vs treatment, published just before the conference, reported that for every life-year purchased with treatment drugs, 28 life-years could have been purchased with prevention. The study was carried out by Dr. Elliot Marseille of the University of California, San Francisco, using Cipla's ARV costs at $350 a patient a year and did not include drug distribution costs. The implication is that the scarce resources available to fight AIDS should go to prevention programmes rather than treatment.

The new Executive Director of the Global Fund to fight AIDS, TB and Malaria, Dr. Richard Feachem, in his response, said, "Cost-effectiveness analyses can be well used and it can be stupidly used.... I was driving across Uganda with an economist...and we came upon a horrendous traffic accident. A school bus had collided with a truck. Children were lying all over the road. Some were dead. Some were dying. Others were seriously injured. I said, 'hurry, hurry let us call ambulances and get these children to hospital quickly. Many of them maybe saved.' The economist said, 'No! Let us drive on to Kampala, to discuss seatbelt legislation with the government. It's more cost- effective.' The Global Fund will not be calling on that economist." The conference presented several case studies showing that people living with HIV in a developing country can be successfully managed with ART.

The new global initiatives to increase access to ART include the Global Access Alliance (WHO+ UNAIDS+ International AIDS Society) Treat Asia (American Foundation for AIDS Research). WHO hopes to expand access to some three million people living with HIV by the year 2005. Meanwhile, it will be establishing a network of surveillance mechanisms to monitor drug resistance.

Jaya Shreedhar, a medical doctor, is a health communications consultant to the World Health Organisation.

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