Universal and free AIDS care

By C. Rammanohar Reddy

INDIAN PHARMACEUTICAL firms now offer hope to the millions in the poor countries of the world who are infected with the Human Immunodeficiency Virus (HIV), the disease which causes the Acquired Immune Deficiency Syndrome (AIDS). They have offered AIDS medicines for export at $350 a year for every patient, compared to western market prices of as much as $10,000 to $12,000. Governments in the South can now at least contemplate providing their HIV-infected citizens with highly active anti- retroviral therapy (HAART), the medication which, while not a cure, helps patients lead a productive life. The irony is that India itself has so far shown little initiative in using the Indian drug industry's capabilities to provide free universal care to the 3.86 million Indians now infected with the virus.

Two reasons have been offered for why universal care is not possible in India. One is that counselling, monitoring and compliance are as important as affordability of drugs. The second and more vocal argument is that even at $350 a year the AIDS cocktail is not affordable in a country where the per capita annual income is only $440. (The lowest retail cost of an annual dosage of drugs in India is presently Rs. 42,000 - $900 - much higher than export prices mainly because of taxes, packaging and retail margins.) Even for a developing country these are not arguments but only excuses to avoid providing care. Since 1997, Brazil has provided free care for every HIV-infected Brazilian who seeks it. The programme runs on active health care combined with provision of generic versions of AIDS drugs that Brazil produces locally. The result is that new infections have been controlled, HIV transmissions lowered, AIDS-related deaths brought down and the HIV population is now less than half what had been projected for 2000. India's per capita income is only one-tenth Brazil's while its HIV population is eight times larger, so the Brazilian experience may not seem very relevant. But given the prices Indian industry has been able to come up with and the experience of Indian doctors there is no reason why India cannot administer a similar programme to cope with its AIDS epidemic. A careful listing of costs suggests that universal and free HIV therapy is feasible in India.

(1) Size of programme: Not all of the 3.86 million Indians infected with HIV need HAART immediately. Health personnel such as Dr. N. Kumarasamy of YRG Care in Chennai who have been working with HIV/AIDS patients state that epidemiological studies point to 20 to 30 per cent of the infected requiring therapy. That would be 800,000 to one million people. (2) Cost of drugs: Retail prices are now Rs. 42,000 a year. But bulk purchases for a universal programme could save on packaging, retail margins and perhaps even taxes. Prices should then be closer to the rupee equivalent of $350. Dr. Y.K. Hamied, Chairman of CIPLA, the company which has turned the spotlight on prices, is confident that by 2003 the drug cocktail could cost as little as $200 a year. But a conservative estimate of costs would be Rs. 16,450 ($350) for each patient. (3) Costs of monitoring/testing: As the AIDS cocktail is extremely powerful patients have to be monitored regularly for side-effects. The costs of such tests are considerable. At Rs. 26,000 a year they cost more than the medicines. (4) The total cost then is an annual Rs. 42,450 for each patient. A universal AIDS care programme in India would therefore cost the Government between Rs. 3,400 crores and Rs. 4,300 crores every year.

As everyone is aware, there are other issues to consider as well. First, administration of these medicines on a massive scale will be a challenge in itself. Most important, compliance has to be ensured. If patients do not stick to the complicated regime, they could develop drug- resistant strains of HIV. But again as Brazil has demonstrated it is possible even in a poor country to devise an innovative compliance regime, involve community groups and motivate health personnel to ensure adherence rates even among illiterates that are reportedly no lower than in California. Here in India, Dr. Kumarasamy reports rates of up to 90 per cent among those who are buying the AIDS cocktail. Second, is it correct to spend so much energy and money on AIDS at the expense of other health concerns? In India the numbers in TB, malaria and diabetes are much larger. Here again Brazil offers hope. The mass movement that HIV therapy has become there has meant that the people's demands in other health areas have also increased, leading to a general improvement in the quality of public health services. There is no reason why that cannot happen in India as well. And the unique nature of the fatality of HIV/AIDS means that it does require special attention. Third, can Indian industry produce drugs on the scale that a universal programme would require? Dr. Hamied is confident that with more and more Indian firms entering the business this will not be a problem. Besides, Indian industry is now already manufacturing up to 14 types of drugs. Moving from the simplest $350 cocktail to another in order to deal with side- effects in some patients could also mean more expensive medicines. But the CIPLA chief predicts that these costs ($500 to $2000) should also keep falling. Fourth, the AIDS cocktails now being produced in India at low cost were all patented before 1994 - prior to the TRIPS agreement of the WTO. But patents on the next and more effective generation of drugs are likely to be protected by TRIPS, so local production will violate the WTO agreement. The Government will then have to overcome opposition from the patent holders among the multinational drug firms and issue compulsory licences - provided for in TRIPS - to Indian firms so that they can produce and sell these drugs at affordable prices.

It all finally comes down to costs. The Government has indeed considered a limited HAART programme. Mr. J. V. R. Prasada Rao, Director of the National Aids Control Organisation (NACO), says that rough estimates - assuming 10 per cent of the infected need treatment and, of them, half use private services - point to an annual cost of around Rs. 1,300 crores which is considered unaffordable because this would be more than Central Government spending on all public health programmes (Rs. 810 crores in 2001- 02). The NACO Director says there is a need to ``prioritise'' health concerns in India. The NACO is hoping instead that India will receive some assistance from the proposed $7-10 billion health fund which the U.N. is proposing for malaria, TB and AIDS, though that fund would focus on Africa. But India does not have to wait for foreign aid.

The cost of a universal programme (Rs. 3,400 crores to Rs. 4,300 crores a year) looks large. But it is as little as 0.28 to 0.35 per cent of India's GDP, which is not a large burden to carry. And with falling prices this is likely to be an over-estimate. In any case, a 5 per cent surcharge on corporate and personal income taxes will yield enough to finance this universal programme. In the absence of such a programme, no more than 5 to 10 per cent of the HIV carriers, those who can afford the medicines, will be on HAART. The rest will have to make do with treatment of their ``opportunistic'' infections. This would only precede a gradual and wasting death from AIDS for hundreds of thousands of Indians. As HAART also contributes to a reduction in the virus transmission rate, its inaccessibility for most of the infected will only mean that the Indian population afflicted by HIV/AIDS - already the second largest in the world - will keep growing.

The only cure for AIDS is its prevention and India does need to do a lot more in this respect. Indeed, if India had done better in prevention it would not now have had millions of its citizens struck by the deadly virus. But the 4 million Indians now infected with HIV cannot be abandoned to a wasting death when an affordable therapy is available. If the numbers about HIV infections are correct, the country is facing its biggest ever epidemic that in its devastation will spare no region or socio- economic class. In the absence of universal therapy the tragedy will become a catastrophe that is likely to surpass what is now unfolding in Africa. The issue has long since ceased to be one of ``violating'' patents on drugs. It is one of respecting life. There is no alternative then to a state-run universal and free programme that provides HIV therapy to any Indian who needs it.

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