Posted 6:11 AM by Dr. Kay

AIDS and the public health challenge

SOUTH AFRICA HAS taken a historic decision to begin treatment in public hospitals of the five million citizens who are infected with HIV. Now that the country with the world's largest HIV population has decided to provide medical care for the affected, can there be hope that India, which has the world's second largest population infected with the virus, will follow in the leader's footsteps? AIDS treatment in the form of active retroviral therapy (ART) offers no cure for the disease. Prevention is the only way to contain the spread of the virus that causes AIDS. India is doing poorly in prevention, with the recent estimates by the National AIDS Control Organisation showing a 15 per cent increase in just one year in the number of new infections. Much more has to be done in the area of prevention. However, society also has a responsibility to care for those infected with HIV. ART provides the infected with an opportunity to lead a normal life, delays the onset of full-blown AIDS, and reduces the transmission of HIV, especially by infected mothers. The only AIDS care now available in India is in private hospitals. The irony is that while Indian pharmaceutical companies caused an upheaval in the global market by offering anti-AIDS generic drugs at just 3.5 per cent of global prices ($350 versus $10,000 for a year), the Government has refused to take advantage of the achievements of Indian industry.

Three kinds of arguments are advanced against the provision of ART through public health programmes. None of them can stand critical scrutiny. One argument is that AIDS care requires adherence to a difficult regimen of intake of toxic drugs and this is not possible in a poor country. The best answer to this objection is provided by the success story of Brazil. In the mid-1990s, this developing country put in place a universal, free AIDS care programme, backed by community programmes that monitored drug consumption. The result has been extremely good standards of adherence, which have led to a stabilisation of the HIV/AIDS population at half a million, a dramatic reduction in AIDS-related deaths, and a control of transmissions. A second argument is that a poor country cannot afford universal care. ART is expensive and the cost of drugs, testing and monitoring can go up to Rs. 35,000 a year for a patient. The answer to this is that at any point only 20 to 30 per cent of the infected need treatment. This means that universal care in India would not cost more than Rs. 4,000 crores a year. This is equivalent to 0.5 per cent of annual GDP and is by no means unaffordable. The third argument against State-provided care is that AIDS is not the only public health priority in India. The number of Indians suffering from and not receiving treatment for tuberculosis, malaria and diabetes is many times the number affected by HIV/AIDS. These populations cannot be ignored.

AIDS cannot be the only illness receiving close attention, but the absence of a cure makes it a unique kind of challenge today. What is required is public health action of a kind that has been lacking: Government provision of medical services that care for Indians suffering from all the major illnesses. The Government of South Africa has decided to provide medical care for its HIV population after maintaining for years that ART would not make a difference. The Government of India has been involved in denial of a different kind; it has simply refused to acknowledge that it is confronted with a major public health crisis. This cannot continue any longer.