Sandhya Srinivasan
MUMBAI, Nov 21 2005 (IPS) – India may be a major exporter of anti-retroviral(ARV)drugs but barely 30,000 people are actually on medication in this country which itself has a burden of five million HIV positive cases.
In April 2004, the government announced a treatment roll-out programme through centres in each of the six high-prevalence states of Maharashtra, Tamil Nadu, Karnataka, Manipur, Andhra Pradesh and Nagaland.
Two centres were also set up in the low prevalence, but politically important state of Delhi, which houses the national capital.
India s population of HIV affected is the second largest in the world and at least 500,000 people need to take drugs lifelong, to keep from falling ill, to go back to work and to prolong their lives.
The programme would offer a fixed-dose combination of first-line drugs. Initially, the government planned to put 100,000 people on anti-retroviral therapy (ART) by the end of 2005 but it would be lucky to reach that target by the end of 2006.
Free ARV drugs were to be made available to HIV positive pregnant women who visited government antenatal clinics, children under the age of 15 and adults with AIDS (auto-immune deficiency syndrome caused by the virus) who went to government hospitals for care and treatment.
But as of July 2005, just 10,255 people were on the programme, the government stated in parliament . Another 9,000 people are on ART through schemes for government employees and workers in the organised sector.
At about Rs 18,000 (400 US dollars) a year, the cost of privately-funded drug therapy remained out of reach for most people known to be affected and needing support.
Not more than 30,000 people are on rational ART nationwide government and private sector, said Jaydeep Gogtey, medical director of Cipla Ltd, a leading manufacturer and exporter of ARV drugs, in an interview with IPS.
Cipla s estimate is based on the industry s tracking of prescriptions. It does not include irrational prescriptions.
Many more people may be on irrational treatment short courses of drugs, two drugs instead of three, sharing medicines etc, according to Sanjay Pujari, a physician based in western Pune city, exclusively practicing HIV medicine.
Activists and health care professionals also suggest that even the limited government programme is poorly conceived and run. The treatment centres are in the cities, while the majority of people who need treatment live in rural areas and cannot afford to sacrifice daily wages and travel long distances for the drugs.
Various tests are not free until the person is actually placed on the programme, putting ARVs out of reach of the poorest, who are most in need of free treatment.
The doctors told me that my husband and I would have to spend at least Rs 1,500 (33 dollars) each, to find out if we qualified for the medicines, says a member of a positive support group run by the Committed Communities Development Trust in Mumbai. I just sold my gold earrings to pay for my daughter s treatment-that too in a government hospital. Where am I going to get more money?
Even when tests are free, the machinery in government hospitals is often out of order, forcing patients to go to private diagnostic centres.
There are reports that people are not properly informed of the drugs side-effects and serious adverse effects, and that teh drugs need to bee taken regularly, life-long.
Vinay Kulkarni, another Pune-based physician, who specialises in HIV treatment, challenges government claims of 96 percent adherence to treatment . The reality is far different, he said.
Also, people do not always know that they may develop drug resistance even with regular treatment, in which case they will need second-line treatment, which is not available under the government programme.
Talk of second-line treatment seems ambitious when even AIDS drugs for children were not available through the government programme for more than a year after the scheme started. The government had earlier stated that children with AIDS would be given priority treatment.
Likewise, people with Hepatitis B, or people being treated for TB, should be given the three-drug combination with Efavirenz. But this was not available for some months after the programme started and has often been out of stock.
Irregular drug supplies have reportedly sometimes forced people to buy the medicines from the market at their own cost-or risk falling ill and developing resistance.
The programme for free AIDS drugs is the product of a long battle starting in the late 1990s. Anti-retroviral drugs changed the prognosis for people with AIDS but at 10,000 to 15,000 dollars per year, these patented drugs were priced out of the reach of most people, even in the developed world.
International health activist groups, such as Medicins Sans Frontieres, were at the forefront of the battle for affordable AIDS drugs, challenging multinational drug companies.
They found an ally in Indian drug companies that had been manufacturing cheaper generic versions of branded drugs and exporting them to Africa and Asia. Indian laws permitted this, as they did not recognise product patents at the time. Multinationals fought the threat to their patent rights, launching a legal suit in South African courts.
In February 2001, the Indian pharmaceutical company Cipla Ltd checkmated the multinationals by offering the three-drug cocktail of first-line drugs to international voluntary organisations at 350 dollars per person per year.
This eventually brought prices down across the board as other Indian drug companies competed for a share in the emerging global market.
India has about 10 percent of the world s generic drugs market. It is among the top five bulk drugs manufacturers, exporting drugs worth 3.2 billion dollars to more than 65 countries.
So it is particularly ironic that while about half of all drugs for AIDS in the world come from Indian companies, their use in India is very low, points out Dr Amit Sengupta of the Delhi Science Forum, a well known, independent policy think-tank. The majority of people can t afford ART even at the lowest rates today.
There are reports from all parts of the country of patients becoming resistant to the first-line drugs. A study by YRG Care in Chennai found that 20 percent of patients were infected with resistant forms of the virus, requiring second-line treatment.
In eastern Kolkata city, the West bengal state project director has reported that at least 50 patients in the government programme require second-line drugs.
The second-line regimen is at least 10 times more expensive than the first-line regimen, because most are under international patents and completely unaffordable for an average person in India with AIDS.
No one knows whether the government will provide them through its programme. The big question is-will the Indian government issue compulsory licences? asks Sengupta. That is something that we will have to see.
