HIV/AIDS has not taken as savage a bite out of India’s population as was predicted a few years ago. Indulekha Aravind on what is being done and whether the news is all good
By 2010, India will have 20-25 million people living with HIV/AIDS and will have overtaken South Africa as the country with the most HIV patients. At least, that’s what the US’s Central Intelligence Agency predicted in a 2002 report.
That report had the backing of Microsoft founder Bill Gates who pledged $100 million to fight AIDS when he visited India later the same year — his philanthropic foundation’s single biggest donation until then.
But here we are in 2011, and the number of adults in India with HIV/AIDS is estimated at 2.39 million, or 0.31 per cent of the adult population (age 15-49)*. Instead of rising, the number of new cases between 2000 and 2009 has fallen by 50 per cent. On his visit to India this year Gates said there would be no more funds from the Bill and Melinda Gates Foundation for HIV/AIDS. Its effort would focus instead on healthcare in Bihar.
What happened between then and now? Is the dip in numbers owed to concerted efforts to vanquish the disease? Or was the threat exaggerated? And are we really in the clear now?
First, the numbers. Ever since the first case of HIV/AIDS was reported in India in 1986, this has been a contentious area. International agencies accused India of under-reporting cases, while the agencies were thought to be exaggerating the threat to promote their own interests.
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The agency officially tasked with tracking the spread of the human immunodeficiency virus (HIV) is the government’s National AIDS Control Organisation, or NACO. But that has not stopped other estimates from popping up. Take the CIA report. To a question in Parliament, the then minister of state for health Panabaka Lakshmi said that no Indian organisation or scientist, to her knowledge, had been involved in the study on which the report was based!
A clearer picture started to emerge in 2007 when NACO announced a dramatic dip in the number of those estimated to be living with HIV/AIDS from 5.2 million a year earlier to 2.5 million. Until then, NACO had arrived at its estimates by testing blood samples every year from designated “sentinel sites” such as antenatal clinics and clinics treating sexually transmitted infections and extrapolating this data to the general population. This method has limitations — for example, women attending antenatal clinics do not represent the female population in general since they would mostly be younger and would be having unprotected sex (so prevalence would be slightly higher) but the method was accepted for lack of a better alternative. To balance this, in 2006, 112,000 blood samples from the general population (outside the sentinel sites) were also tested for the first time, as part of the National Family Health Survey. This has given a more accurate picture. Since 2007, international agencies like WHO and UNAIDS havealso started taking NACO’s estimates into account, reducing the wrangling over numbers.
“The announcement of the decline was a case of bad science,” says L M Nath, epidemiologist and former director of the All India Institute of Medical Sciences. “When the same methods were used with previous years’ figures you could see that the actual dip was much less, since the prevalence itself was smaller.” But he does confirm that there has been a decline in the actual numbers: “There has definitely been a decrease in both prevalence and incidence of HIV/AIDS in India, mainly on account of greater awareness.”
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Nath’s view is shared by Suniti Solomon, the doctor who documented India’s first case of HIV in 1986 when she tested a group of female sex workers in Chennai. “The current [reduced] figures do present a true picture,” she says, “because there is so much being done to contain HIV/AIDS in the country. There is no longer a fear that we will go the Africa way.” Solomon set up the first voluntary testing and counselling centre in India for those affected by HIV.
Not everyone is buying the new figures. Anjali Gopalan, who founded the NGO Naz Foundation in 1994 to combat HIV/AIDS, says we are yet to get a true picture of what is happening on the ground. “We shouldn’t be patting ourselves on the back yet,” she says. “There has been some improvement in the situation because of targeted interventions, but a lot remains to be done.” NACO’s latest figures show a decline in HIV prevalence among female sex workers, but indicate a rise among injecting drug users and men who have sex with men (the three “high risk” groups) in certain pockets. Gopalan’s NGO also runs a home in Delhi for children affected by HIV/AIDS.
Not only does NACO gather data on the spread of HIV/AIDS, it is the government body tasked with leading the effort to contain it. Through a series of five-year plans known as National AIDS Control Programmes, NACO has been working in partnership with NGOs since 1992 to contain the disease. Since HIV/AIDS affects less than 1 per cent of the population, and according to NACO’s studies these sufferers are concentrated in certain sections of the population and in a few states, the agency’s focus has remained on prevention.
NACO is now implementing its third plan (2007-2012) with an outlay of Rs 8,023 crore. The bulk of the funding is coming from international agencies like the World Bank and the UK’s Department for International Development, with the Indian government chipping in 15 per cent of the budget. With the global economic climate worsening, however, and HIV/AIDS in the country apparently stabilising, is there a fear that the promised funds will dry up?
The Gates Foundation, for instance, is currently handing over the programmes under Avahan, its anti-HIV/AIDS initiative in India, to the government, and will not offer funds beyond the $375 million already announced.
NACO says there will be no funds shortage, because the government has given an assurance that it will step in to make up any shortfall from the foreign donors. A NACO official says, “The next phase will be a continuation of the third plan and there will not be any significant escalation in costs.”
One area where costs could increase, the official admits, is in the scaled-up provision of free antiretroviral drugs. NACO now spends nearly Rs 235 crore a year on free treatment and counselling. First-line treatment now costs Rs 5,000 per person per year, while second-line treatment, given when the virus develops immunity to first-line drugs or when the patient does not respond to the latter, costs Rs 35,000 per patient per year. The provision of second-line treatment will now have to be scaled up in phases, in conformity with a Supreme Court judgement.
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Even so, prices are a far cry from what they were when antiretroviral drugs were first launched. The credit for this should go to Indian pharmaceutical companies who manufacture low-cost generic versions of the drugs. According to a 2010 study by international drug purchase facility UNITAID, Indian generics manufacturers have supplied more than 80 per cent of donor-funded AIDS medicines to developing countries in the last seven years. Of the $76 million PEPFAR (the US President’s Emergency Plan for AIDS Relief) spent on procuring generic antiretroviral drugs in 2007, $64 million went to Indian companies, says Bino Pathiparambil who tracks the pharma sector for brokerage and equity research firm IIFL.
Though firms like Cipla and Aurobindo have cornered a chunk of the estimated $900-million global generic market, Pathiparambil says antiretroviral drugs do not contribute significantly to the firms’ bottom line, because of the low price points. There is still worry that low-cost generics could get caught in intellectual property disputes. In July this year, however, Commerce Minister Anand Sharma said that India would use the flexible terms under the agreement on Trade Related Intellectual Property Rights to continue making low-cost antiretroviral drugs.
Unfortunately, there is no pill, generic or patented, for the stigma that people affected by HIV/AIDS face. Neelam, who works as a peer educator with two NGOs, found out in 2007 that she had contracted the virus from her husband. “As soon as it became known that we were HIV-positive, my in-laws moved out and an uncle stopped visiting us. I haven’t told my parents yet because I don’t want to lose them, too,” says this 28-year-old mother of two.
Fear and misconceptions are not restricted to the layman. “When I found out I had HIV, the doctor told me I would live for six months at the most,” says Anita (name changed), 40, who now works at Gopalan’s Naz Foundation in Delhi. Six years after that dire diagnosis, Anita is very much alive and undergoing antiretroviral treatment. “Things have improved from earlier, when people used to get beaten up if it was known they had HIV/AIDS. But still, I hope one day it will be seen in the same light as cancer or tuberculosis,” says Neelam, wistfully.
Stigma is just one of the challenges. “Just the other day, I had a couple coming in saying they had unprotected sex even though they both knew the husband had HIV,” says a medical officer at the ART (anti-retroviral treatment) centre of Ram Manohar Lohia Hospital. “When you are faced with behaviour like this, how will it be possible to eliminate the virus completely unless a vaccine is discovered?”
Those working to contain HIV/AIDS, whether doctor or social worker, caution against letting our guard drop. “We still cannot afford to relax. The drop in incidence will continue only so long as awareness levels remain high,” says AIIMS’s Nath. The battle, clearly, is far from over.
*All figures from NACO, unless stated otherwise