Among all the diseases, past and present, HIV/AIDS has undisputably been the most reported, analysed and politicized. Apart from the increasing incidence of the disease and it's opportunistic allies, TB, fungal, bacterial and neoplastic infections in many countries, and their impact on their economies, there have been both political and social overtones impinging on the future prospects of controlling the disease.
An estimated 42 million people around the World are infected with HIV, 95% of them in developing countries. In 2001, approximately 5 million people were infected with the virus and 3 million deaths were related to AIDS. In Africa alone, 18.5 million lives have been claimed by AIDS, 28.5 million live with HIV/AIDS and more than 9,000 are infected everyday.
The enormous economic burden on society as a consequence of the disease can be measured using the Disease Adjusted Life Years (DALY) model; what is more difficult is to evolve strategies for funding and their gainful utilization. HIV/AIDS was declared a development crisis by the World Bank in 2000, which estimated that per capita growth is falling by 0.5 - 1.2% each year in many countries severely affected by the disease. It has also been forecast that healthcare costs could increase ten fold in the coming years, in the countries affected.
The UN Secretary General Kofi Annan has called for funding of the order of $ 10 billion per year to fight this increasing menace. The WHO estimates that between 6-9 million people in developing countries are in urgent need of retroviral therapy. Of the people treated, if South Africa which has 11% of its population infected is taken as an example, today only around 20,000 in the Country are using the full complement of drugs needed. Those who have access to these drugs are either part of clinical trials, are insured or have means to buy the drugs.
Funding Needs
Apart from the strategies of spreading awareness to prevent HIV infection, there is an urgent need to find resources to treat patients who are already infected or have progressed into full-blown AIDS. At current prices of drugs and treatment costs, it is obvious that the $ 10 billion projected by the U.N. Secretary General is grossly inadequate and modest. The 6-9 million who urgently need the drugs according to WHO is only 15% of the total population who need to be put on these drugs for life-time, both to prevent the spread of the disease among the rest of the population and for its containment.
Prices of HIV Drugs
Currently available therapy, which is effective in arresting the progression of the disease and mother to child transmission, consists of a three drug cocktail with two nucleoside drugs and a protease inhibitor. The costs of treatment in Western Countries range from $ 9000 to $ 15000 per patient per year. Even after the reported slashing of prices by the leading Companies Glaxo Smith Kline, Bristol Myers Squibb, Roche and Merck, the costs are unlikely to be less than half of these, even for developing Countries. The Brazilian Government, which procures the drugs from the cheapest sources, disregarding patent protection for them, still spent $ 4717 per person per year for the required drugs. The Universal access programme cost the Government $ 462 million in 2000 for procurement of drugs alone. The Indian Pharma major, Cipla had offered the Nobel Prize-winning NGO, Doctors without Borders, AIDS drugs at the price of $ 350 per year and for other agencies which distribute the drugs free of cost to the patients at $ 600 per patient per year. The logistics of this proposal are still being worked out.
Even if the lowest costs are taken as the denominator for supply of drugs for the needy, to treat 10 million patients, which would cover only 25% of those affected World-wide, the costs of drugs alone will be between $ 3.5 to $ 6.0 billion per year as per current levels of infection. If the reduced prices offered by the large Corporations or the prices in Brazil are taken, the total costs will be 10 times these amounts. It is thus obvious that the funds requirements projected are grossly inadequate even for buying the drugs, not to speak of the costs of other programmes involving distribution, hospitalization, and preventive strategies and educational progammes. There are however reports of optimal use of resources to handle the various aspects of control of AIDS, such as for example in Uganda. The Government in Uganda has a programme called ABC (Abstinence, Be Faithful and Condoms), which has reduced the incidence of HIV/AIDS in the Country. The success of the programme implies that it has addressed all issues including effective awareness creation among the target population, within the limited resources available.
On a global scale, it is clear that the gap between funding requirements and availability is wide and it is unlikely to be bridged, unless funding strategies are revamped and the wealthy Nations contribute substantially higher amounts to Global Funds for the control and prevention of the disease.
Funding Of The AIDS Programmes
Funds for HIV/AIDS are required for treatment, prevention, education and R&D for drugs and vaccines. A Global Fund launched in January 2002 has distributed so far $ 1.5 billion for 160 programmes in 85 countries in its first and second round grants. During the last year, the Fund fell short of $ 1.6 billion, which was to be made available in the third round. Fund by Fund, an NGO organization contends that the wealthy nations have been contributing too little to the Global Fund. In 2002, the World Bank provided $ 1 billion as interest free loans for African AIDS initiatives. Several charity organizations, such as the Gates Foundation have pledged $ 100 million or more each for the development of new drugs and vaccines for HIV/AIDS.
The US Congress has approved the proposal from President Bush to allocate $ 15 billion for a five-year period to tackle the AIDS epidemic in Africa. The funds, however, are targeted to the selected 12 Countries in Sub Saharan Africa and two in the Western Hemisphere, Haiti and Guyana. This is in addition to $ 1 billion being made available to Global Funds to fight AIDS, TB and Malaria.
Most Countries including India, Brazil and many others have their own National programmes initiated and funded from local resources and external aid, by the respective Governments.
Politics and HIV/AIDS
There has been increasing criticisms from various quarters that the disease and its aftermath have been highly politicized, particularly by the developed countries. Even the figures quoted for incidence have been challenged, for example by the South African Prime Minister. Some of the extreme views include the charge that the funding programmes are motivated by political considerations to subjugate developing countries and make them even more economically dependent on the developed world for survival and growth. Even the U.S. approval of the grant has been criticized since the allocation is restricted to only those Countries, whose Governments, the U.S. Government approves and favours. There have been comments that Bill Gates' charity for AIDS was motivated by his vested interests in promoting the cause of the U.S. Multinational Pharmaceutical Companies in some of which he has investments and interests.
These criticisms would appear to be unfair and unwarranted, even though it is well known that funding Agencies do have a bias towards friendly countries, whether the funds are for AIDS or development programmes. On the operational side, there are reports of misuse of funds, fights over the control and management of grants even within the non-profit Non-Governmental Organizations.
The Doha declaration (Para 6) was a major victory for the developing countries affected by the AIDS epidemic. The Declaration provides for liberal Compulsory Licenses for drugs when they are acutely needed for managing diseases of the developing countries, such as AIDS, TB and Malaria. In other words, the spirit of the Declaration is based on the concept that when there is a conflict between public good and private interests as reflected through enforcement of patents, the former should prevail over the latter. While this matter was to be finalized by the TRIPS Council before the end of 2002, due to the intransigence shown by the U.S., the issue is yet unresolved. The U.S. stand is that the DOHA Declaration should be restricted to only those diseases specifically mentioned in the Declaration and no other, since extension to other areas will jeopardize the interests of the R&D based pharmaceutical industry,. who are the prime discoverers of new drugs. Disputes on this issue could well create a further political divide between the developing and developed countries.
AIDS and Social Stigma
The prospects of speeding up the control programmes on HIV/AIDS are further shrouded by the Public's attitude to the disease and the social stigma attached to it. Social responses of fear, anxiety, denial and stigma have accompanied the disease from the very beginning. Discrimination by Doctors refusing to treat, Hospitals refusing to admit, Schools expelling students, Employers denying employment, Insurance Companies refusing to insure, disowning by the families and friends, have become literally nightmares for HIV positive cases and AIDS patients, not only in developing Countries, but also in the developed World The Social organizations who are keenly aware of these problems and their impact have been largely ineffective.
Strategies For Success
Overall, the various factors outside the accepted realm of prevention and treatment of people who are HIV positive and patients who have AIDS, call for renewed multi-pronged strategies to fight this dreaded disease and its impact on Society. The success of these strategies will depend a great deal on how the issues are integrated into a common goal and roadmaps developed to meet the challenges posed by the disease, which so far has shown no signs of abatement, at least in selected area around the globe.
- The author is one of India's top scientists and industry observer