Target or Death Trap?

Target or Death Trap?
By Swapna Majumdar
http://www.sentinelassam.com/sentinel_en/saturday/index.htm
In April this year, the National AIDS Control Organization (NACO),which implements the government's AIDS programme, announced it wouldintroduce free second-line Antiretroviral Therapy (ART) to PeopleLiving with HIV/AIDS (PLHAs) by January 2008. However, even beforepositive networks could rejoice, the news that this would begin onlyafter NACO was able to provide first-line ART to 100,000 PLHAs dashedall their hopes.

"How much longer will people who have experienced failure with thefirst-line drugs and need to move to second-line ART have to waitbefore they are given treatment? The virus will not wait till NACOmeets its goal (providing first-line ART to 100,000 PLHAs). Imposinga condition like this is tantamount to denying them second-line ART,"says Elango Ramchander, President, Indian Network of People Livingwith HIV (INP+).

Over 500 PLHAs and activists will gather in the Capital to articulatetheir dismay during the Global AIDS Week of Action, beginning May 20.They have planned to hold a candlelight march to pay tribute to thosePLHAs who have passed away, followed by a rally and an awareness campto underline the urgency of universal access.

So far, 4,907 PLHAs have succumbed to AIDS-related illnesses since2004, when the government first introduced free ART. Positivenetworks believe the non-availability of second-line ART may havebeen the cause of these deaths.

Although there is no conclusive data at present on the number ofPLHAs who need second-line ART, INP+ believes that about three percent of those on ART (about 3,500 PLHAS) would require second-linetreatment by the end of 2007.

Just how many of these would be women may be hard to say, butconsidering their vulnerabilities, women will be the worst hit by thenon-availability of second-line treatment.

What is worrying positive networks is the recent revelation by theWorld Health Organization (WHO) that one of the health consequencesof HIV drug resistance could include failure or reduction of theefficacy of antiretroviral drugs in preventing mother-to-childtransmission.

"Positive women are already traumatised by stigma and discrimination.A woman is always the last to seek treatment. Denying her the propertreatment she requires, especially if she has decided to have a baby,is as good as telling her that neither she nor her baby deserves tolive. It is a violation of our rights," contends Kousalyaa,President, Positive Women Network.

"There are many women who will need second-line treatmentimmediately. Can we tell them to wait?" she asks. Some of these womenwho live in Tamil Nadu, however, are lucky: they don't have to wait.This is because the UK-based NGO, Children Investment Foundation,provides funds to the state AIDS control society to provide ART,including second-line drugs, to 1,000 PLHAs.

The other not-so-lucky ones will have to buy the second-line drugs ifthey want to survive, says Celina D'Costa, National Advocacy Officer,INP+. "Everyone, including the government, knows that once a personis on ART, s/he cannot stop midway. The treatment has to be lifelong. So, even if the drugs are expensive, they will have to bebought. In a resource-scarce situation, it is the women who willsuffer because the money will go to buy it [ART] for the men or forthe children. In this context, it is imperative for the government tobegin free second-line ART immediately. It must be given as and whenit is needed and not when the government thinks fit," D'Costa avers.

However, NACO does not feel the same way. According to Sujatha Rao,its Director-General, the decision to provide first-line treatment topositive people first was a conscious choice as it was affordable andcheaper to provide. The government would need greater investment andinfrastructure to introduce second-line treatment, she says.

While positive networks agree that greater investment is required,they feel that it is possible to overcome these financial obstacles.This is why INP+ commissioned the Delhi-based Initiative forMedicines, Access and Knowledge (I-MAK) to address the feasibility ofintroducing second-line ART by the government.The study, conducted in 2006, found that of the estimated 5.2 millionpeople living with HIV, approximately 85,000 PLHAs are on ART. Moreimportantly, 62,317 of these are receiving ART through government ARTcentres. These numbers do not just underline the dependence of PLHAson the government, but also highlight how critical the government'srole is in ensuring both first- and second-line treatment.

The I-MAK study finds that NACO can bring down the cost of providingsecond-line ART: First, by recommending waiver of duties and taxes onHIV drugs; and second, NACO can overcome patent barriers by procuringsecond-line drugs prior to patenting and issuing licences in theevent of patenting. More importantly, if NACO achieves its targets ofscaling up ART overall, the approximate cost over five years would beUS $19 million and not US $70 million as calculated by NACO. Out ofthis, NACO's share would be US $14 million, as both UNITAID and theClinton Foundation have already committed to cover the cost for twoyears.

However, the government has still not given the programme thefinancial importance it deserves. Although it has allocated Rs 1,334crore (US$ 302.6 million) for the third phase of the National AIDSControl Programme for ART, it has not deemed it necessary orimportant to allocate any specific budget for second-line ART, saysPriti Radhakrishnan of I-MAK and author of the study.

"The government talks about removing stigma and discrimination; it isa signatory to the United Nations' promise to provide universalaccess to treatment, care and support. Yet, its decision to waitbefore providing free second-line ART is the biggest form ofdiscrimination. We cannot let our friends die because second-line ARTis not seen as a priority by the government," contends Loon Gangte ofINP+.

"Recent research by WHO has shown that ART reduces that incidence ofopportunistic infections which, in turn, decreases both morbidity andmortality. The fact that many HIV+ have died because treatment wasnot available when it could have been given is really shocking. Thisis especially so when UNITAID and the Clinton Foundation have alreadyoffered to fund the first two years of second-line ART," statesRamchander.

However, NACO has yet to accept the offer made by the twointernational donors. Rao feels that since it would take four or fiveyears before the three to four per cent of people who take ART drugsdevelop resistance to the first-line drugs, they would considertaking money from international donors at that stage.

Clearly, NACO does not believe that this stage has already come. Thelonger it continues to remain in denial, the greater will be PLHAs'risk of drug resistance. This, in turn, will mean a higher number ofthose needing second-line ART. Positive networks are hoping that justlike NACO has a target for introducing first-line ART, it will notneed a `target of deaths' to awaken the government from its stupor.(Courtesy: Women's Feature Service)