The AIDS warrior: Dr Denis Broun, UNAIDS country coordinator in India

[Guest guest]

The AIDS warrior

India now has about 5.2 million adults in the 15-49 age group living

with HIV. UNAIDS regards the number of HIV infected people in the

country to be approximately 5.7 million, making India the country

with the largest number of infected people. Though adult prevalence

still remains less than one at 0.91 per cent, experts say the window

of opportunity to contain the epidemic is fast getting narrower and

infection is moving from the high risk population to the general

population.

Savita Verma talks to Dr Denis Broun, UNAIDS country coordinator in

India, on the challenges India faces to keep the epidemic under

check.

Dr Broun has worked in all areas of public health with emphasis on

health economics, health systems reform, the pharmaceutical sector

and HIV/AIDS. He has been engaged as a health economist in Africa and

Asia and is also associated with the World Bank in the

pharmaceuticals and vaccines sector. Dr Broun became chief of the

health section of Unicef in New York in 1996 and joined WHO in 1998.

Excerpts from an interview:

Q: How do you see the HIV/AIDS situation, given that India is leading

the world with the highest number of people affected by the virus?

India has the largest number of people living with HIV in any single

country in the world ~ 57 lakh people living with HIV still

represents less than one per cent of the adult population. The

epidemic is confined to specific populations and is not generalised.

The prevalence has been progressing slowly over the last three to

four years.

In a sense, one should be satisfied that it is not getting worse. The

only way to be satisfied is when the epidemic is rolled back and the

number of people living with HIV decreases. This has happened in

Tamil Nadu and southern Maharashtra. It is not happening in most

states where the quality of HIV control still remains to be improved.

Q: States like Uttar Pradesh and Bihar are considered to have low

prevalence of HIV but critics say states with poor health

infrastructure may turn out to be problem areas in control efforts...

There is an HIV issue in UP and Bihar and the two states have

responded to it rather differently. In Bihar, there has been major

political motivation with the new chief minister (taking over) and a

legislative forum on AIDS (coming into place). We hope to see the

effect of that soon. In UP, we don't see that yet. But we hope it

will happen. These are two states where more than 10 per cent of the

working population migrates to other states. They usually migrate

without their families and are more at risk. This is a real issue in

UP and Bihar.

Q: Do you think the number of HIV-infected people may be higher in

these states because we may not have appropriate recording

mechanisms?

The epidemic in India is measured by sentinel sites present in all

states. This year we will know more because until last year there

were 700 sites, this year we have 2,000. So, with many more sites in

the northern states, we will know more about the epidemic in these

states. We will have a better picture of specific districts, and

particularly in Bihar we know that there are districts which are more

at risk than others ~ Nepal border, for instance. We are yet to have

thorough knowledge of what districts are at risk in UP.

Q: Are global resources sufficient to fight HIV/AIDS?

The glass is always half empty or half full. We have increased the

resources for HIV in a major way. Six years ago, I think we had $500

million for HIV. This year, we have $8 billion for HIV. Still, we

consider what is required worldwide is about $22 billion. In India,

it is the same thing. For NACP III (third phase of the National AIDS

Control Programme), the new programme for the next five years, India

requires Rs 1,800 crore. So far, the money has been less than one-

third of that. A real scale-up is necessary. There is a plan to scale

up prevention activities but this will happen only if there is money

to support it. At the same time, India initiated in 2004 a treatment

programme. And treatment is expensive. Fortunately, India has been

successful in securing grants from the Global Fund ~ it secured one

last month. The access to treatment will be financed through this.

Q: How do you see the resource gap being filled?

This is a major issue. What we have seen so far is that resources

have increased and there is no reason for them to dry up. Generating

new ones is difficult, but we see initiatives coming up like a new

one called UNITAID. It will finance drugs for HIV, TB and malaria

through airline taxes.

We are going to see some initiative coming up in various countries

with newly allocated cess or specific earmarked taxes. This money can

be mobilised only when there is political will to do it.

Q: What is the concept of airline taxes?

This has been started by the French government and now several

countries have it. They add a specific amount of money in each ticket

issued in the country. It is done in France, Chile, Mexico, Norway

and more countries are ready to join. (In France, one or two dollars

are added for domestic tickets and a little more for international

tickets). This has generated several hundred million euros and one

hopes it will reach billion euros. This will be another source for

funding for HIV activities. What we see in India is also an increase

in the Union Budget allocation. HIV/AIDS control was dependent on

external aid until last year. Since this year, the national budget

has increased dramatically. And this will have to continue.

Q: The UNAIDS report says there are 5.7 million cases of HIV in

India, while the National AIDS Control Organisation report says there

are 5.2 million HIV cases in the 15 to 49 age group. How was the

figure of 5.7 million reached?

We have mathematical models which show how the epidemic is broken

down in various age groups. We used that in India to guess that we

have about 1 lakh people under 15 with HIV and about 4 lakh people

over 49 living with HIV. This comes purely from mathematical

modelling. It is not any measurement.

Q: The international community has set a goal to give access to

treatment to all by 2010. Looks like we are not on track?

India will not be on track to give access to all. The question of

defining what is all is difficult. Providing access to all who have

been diagnosed as positive for HIV does not mean providing access to

all who need it. This is where there is a difficulty. If you start

budgeting or even procuring drugs for all but have not identified all

your patients, then you are going to have stocks which will remain

untouched.

If you are able to provide diagnosis and testing to a large number of

people, then you will identify more people who require treatment. The

aim India has given itself is 3 lakh people by 2011. We consider that

it is about half the total number of people who will need anti-

retroviral treatment. But since less than 20 per cent who live with

HIV know that they are HIV positive, it is a reasonable figure.

Q: Are there people who need treatment but are not getting it? Is it

the lack of testing facilities that is preventing people from knowing

their HIV status?

It is both. You have lack of testing facilities. So you have lakhs of

people who die of AIDS without ever being diagnosed. Lakhs! Then you

have people who know they require treatment and do not have access to

treatment. This is for several reasons ~ sometimes because of the

distance from a treatment centre. There are about 100 treatment

centres in India.

It may be because they have started treatment in the private sector

and would like to continue in the private sector because they are

afraid of being discriminated or being stigmatised if they get

treated in a less confidential manner. What we know is that

government covers about 50,000 people at present and probably an

equal number is paying for treatment.

Q: Many people in India need a second line of treatment. The

government says it wants to stabilise the first line of treatment

first. That means many are without drugs needed for their survival.

Your comments...

The government is trying to establish a policy on a second line of

treatment. There have been some meetings, the policy is not yet

there. Given the international experience, about 5 to 10 per cent on

the first line treatment would require a second line every year.

Resistance builds up, it is inevitable.

Q: How many may be needing the second line of treatment?

Probably about 5 per cent of those on treatment. So, if you have

50,000 people being treated in the government programme, 2,500 would

need access to a second line either now or in the coming year. Right

now, their only option is to buy a second line of treatment from the

private sector. And it is expensive.

So there is a need to find additional mechanisms and UNITAID has a

purpose to finance the second line of treatment. India is working

with UNITAID to provide this access. It is difficult because when

universal access to the second line is provided, as has been the case

in Brazil or Thailand, the cost of ARV therapy goes through the roof.

In Brazil, it has more than doubled. So the cost of the second line

is much higher than the first line ~ you can probably multiply the

monthly cost by seven, between seven and twenty, depending on the

type of drugs. For fiscal reasons, I understand, NACO will be

prudent. For humanitarian and health reasons, it is difficult not to

provide access to a second line and appropriate mechanisms have to be

found. For the moment they don't exist.

Q: The survival rate in India?

Yes. More than 95 per cent (survival) after the first year (of

treatment) which is a good figure.

Q: How soon do you see a policy for a second line of treatment in

India?

The policy would be discussed in 2007 but will it be finalised in

2007? I hope so. It will have to happen, there is a mounting

pressure. More and more people need the second line. Will this policy

say there will be free treatment for second line products? I doubt it

because I don't think that the programme can afford it at present.

The big difficulty will be for India to find the best possible middle

way between what is financially unacceptable and what is ethically

unacceptable. Ethically it is impossible to deny access to treatment.

What is financially not viable is to provide access for treatment to

all.

Q: The government plans to change the trafficking law and it is being

said that it would make clients punishable. It is feared that such an

approach would push sex work underground.

It is true. What India is facing is an interesting discussion between

two types of modules. One which is more repressive, which was being

described as the Swedish model, which is we want to protect the voice

of women but we will be punitive towards clients and pimps. And the

Dutch or Brazilian model where sex workers are considered workers

with a job like any other, contributing to health insurance. But

then, they also have a whole set of constraints ~ they are provided a

special place, they are licensed, they have a system of health

monitoring; just like any worker would be monitored on health

capacity to do their work, the same thing would happen for a sex

worker. In India, sex workers want neither. The proposed law has the

risk of pushing sex work underground.

It is important that organisations that support sex workers on AIDS

prevention continue to be able to access them, continue to use peer

pressure among sex workers to make sure that there is consistent

condom use. There is a danger that it will be more difficult with the

proposed provision of the trafficking law.

Taking decisions too fast or unilaterally does not usually result in

appropriate solutions.

Q: Do you think legalising prostitution will help?

Each country has its own culture, constraints, preferences, and there

is no real proof that one model is better than the other for women's

rights, public health or prevention.

So it's difficult to have a preference. I think there are two guiding

principles ~ one should be the rights of the women that comes first;

this right is also the right to good health and right to prevention.

The fact that women are trafficked into sex work and are forced to do

the job is not right. At the same time there is a public health need.

The HIV epidemic in India is driven by sex work mostly. Now, it is

always easy to say that sex workers pass HIV to clients. The question

is how do you confirm that? There is a question of public health, of

women's rights and it is also a question of how things are perceived

by the overall population, the overall legal culture of the country.

This is something which has to be decided locally.

Q: Do you think MSM (men who have sex with men) may be playing a

major role in driving the epidemic in India?

We have no idea. It probably plays a role. We don't know enough

because a lot of them are in hiding. And you have to consider that in

India there is a relatively large trans-gender population.

Q: Does Indian law make reaching prevention efforts difficult for men

who have sex with men?

On that we are much more assertive because branding homosexuality a

crime is a way of ignoring the reality of sex preferences of 2 to 5

per cent of the male population. This is what we find also in the

Indian surveys. This becomes a high risk population which is the

leading driver of the epidemic in some other Asian countries. In

Australia and Japan, the epidemic is led by men who have sex with

men.

Q: What is UNAIDS' stand on access to second line of AIDS treatment?

UNAIDS says that definitely there should be access to treatment. We

also say there should be a major mobilisation of resources for it and

nearly multiplying by two and half the resources available. If India

were to be able to find twice the amount of NACP III, I am sure it

will find money for the second line of treatment as well. There will

have to be a specific financial policy for it which is not yet in

place. All these discussions will take place in 2007.

Q: How much money is India likely to get from UNITAID?

It is too early to say. UNITAID is collecting funds. So far, funds

are being disbursed either through the Global Fund or through the

Clinton Foundation.

Q: The Indian government plans to involve the private sector in AIDS

treatment. Will it not lead to resistance building up among those

under treatment, considering that the private sector may be more

interested in making money?

I don't think so. The private sector is a partner in TB treatment,

for instance. They respect standard guidelines of the government and

they do not try to make money out of it.

The same would apply to HIV. There is no alternative. A large number

of people access care through the private sector and will continue to

do so. It will be a good thing. It's important that doctors who are

involved in it and health personnel respect the government guidelines

so that there can be a unique monitoring system and consistency.

Q: How is vaccine and microbicide work going on?

Vaccine is probably a long way off. If we are looking at a vaccine

that will protect against HIV, it is not expected to come before 10-

15 years. If we are looking at a vaccine that could attenuate the

effect of HIV, that might be closer. We have such a vaccine in phase

III trials which may be available in five years.

Q: Where are trials on vaccine going on?

There are several trials going in many countries. India has two

trials of vaccine in phase I. They are at a very early stage ~ in

Chennai and Pune. These are preventive vaccines. But we have vaccine

in phase III trial in Thailand, South Africa and Uganda, There may be

some products coming up. A microbicide is expected to become a

woman's capacity to protect herself. Right now, we do not have any

microbicide which would be protective against HIV. One of the

difficulties with microbicides is that they have to be effective. You

cannot take the risk of telling people you are going to use

microbicide and be protected while they are not (protective). Any

microbicide which is less effective than condoms should not be

acceptable.

Q: What are the major challenges for India in its fight against

HIV/AIDS?

There are many. First is implementing NACP III, which says that

scaling up of prevention will go up from a relatively low percentage

of high risk population to 80 per cent. Second is programme

management, ie, having the capacity, people, methods to manage these

interventions in such a way that the money is used effectively. The

third is the issue of injecting drug use. This is serious. The

problem is not so much of heroin. Police are doing a good job to keep

it under check.

The problem is sharing injecting material for pharmaceuticals that

are bought and used by drug users. Morphine derivatives and spasmo-

proxyvon are used by drug users. These are registered and sold in

pharmacies. The problem is sharing syringes and needles. The

programmes of harm reduction with needle exchange, providing

substitution for injectable products are still in infancy in India.

This has to be scaled up a lot.

(The author is Special Representative, The Statesman, New Delhi)

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