India's Political Leadership Gathers for Update on HIV/AIDS and Vaccines
By Subhadra Menon
Here in the world’s most populous democracy, rival political parties seldom show unity, whatever the cause.
But a rare display of shared commitment recently took place at the International Policymakers Conference on HIV/AIDS (New Delhi, 11-12 May 2002),* where India’s Prime Minister Atal Bihari Vajpayee and Opposition leader Sonia Gandhi each spoke about the epidemic and the extreme urgency of uniting the country in battling the disease and its devastating consequences. It is estimated that nearly 4 million people in India are living with HIV/AIDS.
The conference was attended by about 200 delegates, mostly policymakers from India (including several state Ministers and about 30 Parliamentarians), but also including representatives from seven other developing countries (Thailand, South Africa, Nigeria, Kenya, Uganda, Brazil and Nepal) that are either conducting or preparing for vaccine trials (except Nepal). The meeting served to inform delegates about the state of the epidemic, both globally and within India, and of efforts on prevention, care and coping with the devastating consequences of HIV/AIDS for affected families, communities and entire countries. It also highlighted AIDS vaccine development and provided an opportunity for political leaders from participating countries to swap experience and expertise on vaccine programs and clinical trials.
Prime Minister Vajpayee emphasized the unlikely political alliance. “For all of us in India, controlling the spread of HIV/AIDS and taking good care of its victims has become an urgent national task,” he said. “It is a concern that is shared equally by the Central and State governments, as also by all political parties.” Opposition leader Gandhi also underscored the significance of the meeting’s mixture across party lines. “This presence should reaffirm our national resolve to combat, in the most vigorous manner possible, the serious HIV/AIDS crisis in the country,” she said.
But while there was strong consensus on many issues, including the urgency of scaling up current prevention efforts and building a strong AIDS vaccine program, there were clear differences on issues of treatment and care, especially on the feasibility of making anti-retroviral drugs (ARVs) more widely available. The government’s national program does not include plans for expanding access to ARVs, except in the case of mother-to-child transmission (where a strong national drive to provide treatment is underway). In his speech, Prime Minister Vajpayee emphasized cost as a key obstacle. “Even after removing all excise duties on them—our Government has done so in the recent budget—such multi-drug therapy will still cost between 1,200 and 20,000 rupees (US$30 to $400) a month,” he said.
In contrast, Gandhi highlighted the availability of cheaper generic alternatives, especially those made by Cipla, a Mumbai-based pharmaceutical company that is now a world leader in producing them. “It is ironic that Indian pharmaceutical companies have emerged as suppliers of AIDS control drugs to the world and are being welcomed in other countries, while we ourselves are reluctant to involve them in the national AIDS control program,” she said. “This is a paradox that needs to be resolved.”
Vaccine Programs in Developing Countries
Within India, AIDS vaccines were declared a high priority several years ago, and the government has committed to help develop and test suitable candidates (including through collaboration with IAVI; see IAVI Report, February-March 2001). But with a wider conversation about these trials now beginning in India, questions ranging from scientific and logistical issues to trial ethics and political acceptability are on the minds of many stakeholders. Against this backdrop, several talks on how other developing nations got started in AIDS vaccine work and what lessons they have learned so far attracted strong interest.
One common thread running through these presentations, despite the countries’ very different levels of readiness, was a clear recognition that broad political commitment must be in place to support vaccine trials and mobilize public opinion behind them. Another was the importance of placing vaccine programs within a broader context of AIDS-related initiatives on prevention and care.
Two speakers discussed the situation in Thailand. Parliament member Cholnan Srikaew described the country’s “100% condom campaign” launched in the early 1990s and its wide outreach of STD diagnostic and treatment centers. Both of these arose, he said, through “a committed alliance between the government and the public to fight AIDS.”
Thailand’s Senator Jon Ungphakorn presented a mixed picture of the situation today. With new infection rates in most groups markedly below those of a decade ago, “our country is getting into a state of complacency, lulled by the international attention and initial success [of our programs],” he said. And he added that “there is no place for such complacency:” infection rates among injecting drug users remain high, there is continuing discrimination against people living with HIV/AIDS (especially in employment) and children of HIV-positive parents, casual sex seems to be increasingly common, and HIV is no longer the government’s top priority.
Uganda, another country widely touted for its successes in AIDS prevention, was discussed by two speakers (David Apuuli of the Ugandan AIDS Commission and Alex Coutinho of The AIDS Service Organization, Uganda’s largest AIDS NGO). They described the consistent leadership from government and church in HIV/AIDS awareness and prevention campaigns that helped reduce prevalence rates from double-digit numbers to the present level of 6%. Social marketing for condoms and universal primary school education have also been key elements of the national response, as have the commitment of media (100 radio stations now help spread HIV/AIDS information) and of roughly 200 NGOs working on HIV/AIDS. They also outlined some big challenges ahead: an urgent need to decentralize support systems and thereby improve facilities for care and treatment; a need to mobilize internal resources (70% of Uganda’s HIV programs are funded by outside donors); increasing involvement of the private sector; and battling a growing complacency among youth.
Coutinho also pointed out that Uganda’s prevention successes came on the heels of an epidemic that reached such high levels of HIV prevalence that few families have been untouched by AIDS deaths. And he urged countries which still have low infection rates to mount an early, aggressive response or risk paying the price of delay in human lives. He also emphasized that government and NGO’s have worked closely together in Uganda, which has helped NGO’s have far more impact.
Dirceu Greco, a clinical AIDS researcher from the University of Minas Gerais in Brazil (and member of the National AIDS Vaccine Committee), spoke about his country’s experiences with both AIDS vaccines and treatment. Strong government leadership, early involvement with vaccines and a Presidential decree mandating that ARVs (including many generics produced in Brazil) are made available without charge through the public health system, have been Brazil’s strengths against HIV/AIDS. There has also been strong civil society participation at all levels of decision-making, as well as solid partnerships among scientists, health professionals, NGOs and HIV-positive individuals. Greco sees Brazil’s biggest challenges today as battling high rates of new infections in some areas, the persistence of stigma and discrimination, and a need to improve monitoring of HIV care. Access to Future AIDS Vaccines
Meeting participants also heard a report on a policy workshop that took place the day before the main conference. Discussions there focused on identifying the key policy challenges raised by AIDS vaccine trials and by the goal of providing rapid access to an AIDS vaccine as soon as one is licensed. Participants also discussed how these challenges can be addressed and what concrete activities could be undertaken now, particularly by collaborations among developing country policymakers.
Looking to specific issues and situations that can inform the vaccine access debate, Brazil’s Dirceu Greco and Bansidhar Mishra of Nepal reported on access to treatment and care in their countries. Both presentations emphasized the need for developing country leadership to start working towards access to future vaccines and highlighted links between access to treatment and access to vaccines.
The second half of the workshop focused on the role of policymakers in meeting the challenges of HIV/AIDS. Two case studies of successful collaborations were presented: (1) a report on the Asian Forum for Parliamentarians of Population and Development (AFPPD), by Shiv Khare, Executive Director; and (2) the experiences of TASO, in involving Uganda’s community leaders and parliamentarians in the fight against HIV/AIDS, given by Alex Coutinho.
The Delhi Declaration
Throughout the meeting, Parliamentarians also engaged in backroom negotiations that resulted in a joint statement they dubbed “The Delhi Declaration.” Signed by representatives from all participating countries, the Declaration commits signatories to provide and advocate for strong leadership in fighting the AIDS epidemic, including the development of AIDS vaccines, and to build on pledges made at last year’s UN General Assembly Special Session on HIV/AIDS (UNGASS). While similar in many ways to the final statement issued at UNGASS, the Delhi Declaration represents the first time that parliamentarians from developing countries have committed as a group to action on AIDS and vaccines. To follow up on the Declaration, the participating parliamentarians (including Indian representatives of the different political parties) are making plans for an international working group that can continue the dialog and plan concrete joint activities.
*Co-sponsored by India's National AIDS Control Organization (NACO), the Indian Council on Medical Research (ICMR) and IAVI.
Subhadra Menon is editor of SANKALP, IAVI’s Indian newsletter on AIDS vaccines. She formerly covered health, science and environment as Principal Correspondent at India Today, India's largest selling news weekly, and has also written for Frontline magazine, The Indian Express, Times of India, The Economic Times, New Scientist and Scientific American.