Tackling India's HIV epidemic: lessons from Africa

June 27, 2003

BMJ 2003;326:1389-1392 (21 June)

Malcolm Potts, Bixby professor, population and family planning1,

Walsh, adjunct professor, international health and maternal and

child health2

1 Bay Area International Group, School of Public Health, University

of California, Berkeley, CA 94720-7360, USA, 2 Institute for Human

Development, University of California, Berkeley

Correspondence to: M Potts pottsmalcolm@...

The rapid spread of HIV in sub-Saharan Africa is one of the greatest

failures in the history of public health. Given our detailed

understanding of HIV and the natural course of AIDS, the virus should

have been controllable. Yet in some African countries 20% of people

aged over 15 are HIV positive and 70% of them will eventually die

from AIDS.1 India shares some of the same risk factors as Africa,

including a similar pattern of health expenditure, an uneven health

infrastructure, and prevalent high risk sexual behaviours (table A,

bmj.com).2 By 2010 the number of HIV infections in India is predicted

to rise from 4 million to 20-25 million1–3 We discuss 10 important

lessons from Africa that could limit the spread of HIV in India.

Methods

The views expressed in this paper are based on current literature

reviews, economic analyses of the Berkeley International Group

(http://big.berkeley.edu), and extensive personal experience working

on HIV, reproductive health, programme management, and international

finance.

Involve high risk groups in all phases of programmes

HIV infection begins in the core groups of commercial sex workers,

intravenous drug users, and men who have sex with men (table B,

bmj.com). Mathematical models show both the benefits of early

intervention and the importance of focusing on these core groups.4–7

India remains a traditional society: its laws forbidding

homosexuality derive from British legislation in the 19th century,8

and the sex industry relies on bribing the police to operate. The

high risk groups are outside the political, social, and economic

mainstream. Leaders must overcome prejudice and be prepared to

include these groups in designing well funded programmes.

Focus on cost effective preventive programmes

Poverty is a major contributor to the spread of HIV and thus

considered an important focus for preventive programmes. However, the

prevalence of HIV can double within high risk groups in six months

and in the general population in three to five years, while

socioeconomic change takes decades to achieve. Moreover, poverty does

not always drive the spread of HIV. Botswana is relatively wealthy

and over 90% of women are educated, but it has a high prevalence of

HIV. As long as the AIDS community highlights poverty, it allows

senior political leaders to claim that only socioeconomic change will

cure the disease and to avoid controversial interventions, such as

distributing condoms to unmarried people.

The most appropriate immediate strategy for India is a targeted

approach in core groups. Its cost effectiveness is well established.5

9 10 Substantial numbers of cases can be averted by management of

sexually transmitted diseases in commercial sex workers, blood

screening, voluntary counselling and testing, treatment of sexually

transmitted diseases in the general population, and providing

antiretroviral drugs at childbirth (figure, table).5 The cost of

treating one person with antiretroviral drugs for a year (at full

price) is equivalent to that of preventing almost 50 cases (figure).5

Secure adequate supplies of condoms and antibiotics

In sub-Saharan Africa, too little attention was given to the supply

of condoms. In 2000, fewer than 650 million condoms were distributed

(about four for each adult man).11 12 The United Nations Population

Fund estimates that at least $1bn (£626m, €881m) is needed for

condoms to control AIDS, and the gap between demand and supplies is

growing.13 If we assume that people will spend up to 1% of their

income on buying condoms, 95% of India's population cannot afford the

$10.65 a year needed for manufacture, promotion, and distribution of

condoms.14

India has the advantage of a large, competitive, technically

competent pharmaceutical industry, and the government is subsidising

distribution of condoms to low income families. This subsidy should

be extended to antibiotics for controlling sexually transmitted

diseases. The international donor community should ensure that

priority is given to funding condoms and antibiotics before funding

other programmes.

Invest only in projects that can be fully implemented

Africa is awash with pilot projects, yet no donor agency or national

government has set up a systematic programme of basic interventions

for all sex workers in every large city. Since most possible

interventions have already been tested more than once, the need for

additional small scale studies is questionable. Larger scale,

relatively simple programmes that provide basic services to all

should be given priority over sophisticated, labour intensive

programmes covering a few people. The available resources should be

allocated equally across all the sites that need intervention. The

sophistication of programmes should be determined by the amount of

money available for each site. Although the amount might be

relatively small, the programmes could still have a big impact.

Pilot studies of interventions should not be funded if the resources

are not available to implement the intervention nationwide, however

promising it may seem in theory. The worst case scenario would be one

where India's many non-governmental organisations divide the limited

resources to create carefully crafted, custom built programmes and

end up having no overall impact on the disease.

Include traditional health practitioners in control programmes

In areas where the epidemic has spread beyond the initial high risk

groups, programmes providing interventions for the general population

are essential.15 Rural medical practitioners, nurses, Western trained

doctors, and other health professionals will have to be included.

Many African countries have resisted the non-medical prescription of

antibiotics. In India, rural medical practitioners often have a

formal training in Ayurvedic or other traditional medicine but are

not formally permitted to prescribe antibiotics. It is essential to

recognise the role of India's private sector, which provides care for

most rural poor people (see bmj.com), and realign prescription

regulations to reflect reality.

Reconsider the structure and work of international donors

The Global Fund for AIDS, Tuberculosis, and Malaria now controls most

of the funding for tackling HIV and AIDS. However, the $2-3bn

available amounts to less than one quarter of the annual projected

needs for controlling AIDS.16

Underspending of donated funds is common and helps curtail the

resources available and deter future allocations from the donor.

Implementing agencies spend a great deal of time preparing proposals;

donors require time to analyse unsolicited proposals, to prepare, and

to review requests for proposals. A more cost effective strategy

would be for governmental and foundation donors to set achievable

output goals, specify how much money they wish to allot to this

particular area, and then invite evidenced based proposals from

possible implementing agencies. This would draw on the rich

experience of agencies in both developing and developed countries,

simplify the work of donors, and pre-empt the second guessing of the

donor's goals. Support for output based services should ensure that

money follows results and increase the efficiency of both non-

governmental and governmental programmes.

Large international meetings waste resources

Large meetings cost a great deal in airfares and living and

opportunity costs. The communication of ideas and initiation of new

collaborations at such meetings has fallen over the years, and the

meetings have become platforms for non-evidence based lobbying.10

Meetings that deal with specific topics and focus on science are

likely to remain useful.

Confront lobbying for increased use of antiretroviral drugs

Infected people in rich countries who benefit from antiretroviral

drugs form a compelling lobby for extending treatment elsewhere.

However, individuals at risk of infection do not lobby for investment

in prevention of HIV and AIDS. When prevention programmes succeed, it

is impossible to say that any one person is alive because of them.10

Any objective effort to allocate the limited resources available to

confront the HIV epidemic in India will have to take these

asymmetries in lobbying into account.

One emerging lesson is that money spent on antiretroviral drugs is

money removed from prevention, and vice versa. The Global Fund for

AIDS, Tuberculosis, and Malaria has allocated 60% of its first $378m

of grants to support HIV projects, and 21 of 28 countries receiving

grants will use this money to purchase antiretroviral drugs.17 These

drugs are difficult to use (except to prevent mother to child

transmission) and, even at the greatly reduced prices, are very

expensive, especially when the necessary testing, monitoring, and

counselling costs are included (figure). In extreme cases they may

even encourage increased rates of unsafe sexual behaviour.18

Commercial sex workers in India

Even if there are further massive reductions in drug prices, the

costs will remain beyond the reach of individual and community

subsidy in much of India. Nevertheless, there will be intense

emotional pressure to mount token subsidised antiretroviral

programmes. The people who benefit will probably be those who are

most educated or have access to specialist care. The example of

Thailand, where an increase in antiretroviral drug costs took money

away from prevention budgets and was associated with an increase in

HIV infections, must shore up our commitment to prevention.19

Ensure policies are based on latest evidence

In hindsight, the investment Africa made in safeguarding the blood

supply rather than focusing on high risk groups was probably over

enthusiastic. In the 1980s, the scientific evidence that other

sexually transmitted diseases facilitate the transmission of HIV was

not acted on quickly enough. Evidence is coming out of Uganda that

sexual abstinence and reduction in the number of sexual partners can

help reduce prevalence of HIV.20 Religions such as Islam,

Christianity, and Hinduism emphasise certain aspects of sexual

abstinence and reproductive health. Religious organisations could

therefore be used to help prevention alongside programmes to

distribute condoms and treat sexually transmitted disease.

Attention needs to be given to the increasingly strong evidence that

male circumcision slows transmission of HIV. In a recent study in

Uganda, 30% of uncircumcised men became infected from their HIV

positive female partners compared with none of the circumcised men.21

Finding ways to offer circumcision to Hindu men (who are generally

not circumcised) could slow transmission of HIV and other sexually

transmitted diseases.21 22

Despite its devastating effect, HIV is a fragile, difficult to

transmit, and easily destroyed virus. A microbicide that women can

use secretly and effectively to protect themselves against HIV

infection would be valuable.23 Western managers estimate that

development of a 60% effective microbicide would cost $775m. Although

this is achievable, the microbicide would not reach the market before

2007 at the earliest, which will be too late to contain the spread of

HIV in India. A concerted effort should be made to use these

resources in ethical research frameworks that fit the enormous risk

of death in developing countries. The suggestion that lemon juice may

be an effective microbicide should also be investigated.24 Decisions

about which programmes to implement should be based on cost

effectiveness. Comparable and rigorously collected data are needed on

implementation costs and on consumers' willingness to pay for

prevention and therapy.

Increase national and global budgets now

Government investment in AIDS prevention in all countries has been a

story of too little too late. Large investments at the outset of the

epidemic will slow progress more than those at a later stage. India

currently invests R300 crore (£43.5m) annually, much less than

needed.16 This simple lesson in epidemiology needs to be understood

by external donors, the Indian government, and foundations. The

Macroeconomic Commission on Health urges a large increase in donor

funds to confront AIDS and other important diseases. Such increases

are both justified and achievable, given the size of the world

economy.25

Summary points

The number of cases of AIDS in India will probably exceed 20 million

by 2010.

The limited resources should be used for large cost effective

programmes to decrease spread of the disease

Money spent now will be much more effective than money spent later in

the epidemic

Adequate supplies of condoms and antibiotics must be secured

Prevention should be given priority over antiretroviral treatment

---------------------------------------

India stands on the brink of a major HIV epidemic. However, by

examining where public health initiatives went wrong in Africa, the

international community may be able to help India avoid the

devastating effects seen in Africa

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