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Expensive H.I.V. Drugs Further Instability in South Asia

Kamala Sarup, Kathmandu, Nepal, July 7, 2005

An unidentified 35-year-old HIV-positive woman (left) receives advice last Novemeber from Nighat Kamdar of All Women Advancement and Resource Development (AWARD), a Pakistani N.G.O. dealing with AIDS and H.I.V.-infected patients, in Peshawar. (Photo: Tariq Mahmood / AFP-Getty Images)

The growing H.I.V./AIDS epidemic in South Asia is a national security issue. If the rate of infection increases, H.I.V./AIDS could possibly threaten the stability of South Asia. Although concern among the South Asian population about the spread and impact of H.I.V./AIDS is significant, governments continue to give the problem a low priority.

It is clear enough that H.I.V./AIDS attacks human security. It has slashed life expectancy, and destroyed families. H.I.V./AIDS is a threat to the right to life. It threatens to overwhelm health budgets as the cost of H.I.V. treatment continues to skyrocket. H.I.V./AIDS is growing in severity for a variety of reasons: increased travel, urbanization, changing sexual habits, and conflict. H.I.V./AIDS also undermines national security by degrading civil governance, causing a disruptive loss in the labor force, and posing an enormous burden on government health budgets which impact a country’s ability to secure food, shelter, health care, education and all forms of security. As adults fall ill and die, families face declining agricultural productivity.

South Asian countries are struggling to cope with the growing H.I.V./Aids epidemic because they do not have access to the new and expensive drugs used in Western countries. In countries where no free drugs are provided, the problem is worse. In Asia, victims of H.I.V./AIDS have been deprived of CD-4 Cell Count facilities, and of the widely available ARV [antiretroviral] drugs. Standard treatment with antiviral drugs is just too expensive for most people in the region. An effective H.I.V./AIDS vaccine is still a dream. Why are these drugs so expensive?

In Vietnam, India, Thailand, Bangladesh, and in Nepal for example, patients buy cheap black market drugs, or only take the drugs they are prescribed when they can afford to buy them, stopping when they cannot afford them and eventually restarting again.

Dr. Mark Nelson, director of H.I.V. services at London’s Chelsea and Westminster Hospital, said to BBC News Online: “Patients were unlikely to be denied the drug because of its high cost.” But many patients in Asia with an infectious disease live in poor, rural areas, so they cannot afford the often-costly diagnosis, treatment and prevention plans.

Though the life-prolonging ARVs bring relief to the people living with H.I.V./AIDS and increase their life expectancy, poor people have not been able to afford them and it is also beyond the governments’ budget capacity to provide the drugs to all H.I.V./AIDS patients for life. With the cost of counseling, social support and medical care, the figure is a lot higher.

“Western drugs and pharmaceutical raw materials have become so expensive in Asia because many medicines are not available,” P.M. coordinator Amrit Pandey said. “Those medicines that are available have experienced dramatic price increases or are available only on the black market.

“The problem is more acute for even South Asian countries, which do not have the money to fund the expensive antiretroviral drugs,” he added. “The cost of the medicine is high, so the local people do not have easy access to buy it.” Recently, the 146-nation World Trade Organization decided to allow poor nations to make copies of branded medicines to fight killer diseases.

Even the check-up charge is costly because of the kit, which is very expensive. If the CD-4 count is persistently below 500, the immune system is considered to be slightly weak and the patient is at a gradually increasing risk of infection. And if it drops below 200, patients are at a much-increased risk.

It is useful to have the CD-4 count measured regularly to monitor the immune system and to help decide if and when to take anti-H.I.V. drugs and begin treatments to prevent infections. Similarly, it also helps monitor the effectiveness of any anti-H.I.V. drugs the patient is currently taking.

The kit helps to monitor the viral load and to determine when to use the drug, which is impossible without the kit. On the other hand, six million people already infected with H.I.V. in the developing countries need access to Antiretroviral Therapy (ART) if they are to survive. Only four million have access to ART.

“In combination with conventional drugs to treat opportunistic infections, ARVs can indefinitely prolong the life of an H.I.V. patient as long as the treatment is not temporary,” Pandey said.

He further said, “Typically, the complaint has been that anti-retroviral drugs made by pharmaceutical companies are too expensive for the developing countries, and that what is needed are cheaper generic drugs.”

On the other hand, H.I.V. patients in parts of Asia run a serious risk of developing resistance to antiretroviral drugs due to the range of drugs available to them, stop-start treatments, and lack of counseling and monitoring. The Report by Treat Asia finds that there are so many companies and drugs that Asia is at risk of rapidly creating drug-resistant versions of H.I.V.

In China, where Nevirapine is a standard component of antiretroviral triple therapy, 50 percent of 500 rural patients who took the drug for up to 11 months have become resistant.

Dr Edward Telzak, director of the Aids program at the Bronx-Lebanon Hospital Center in New York, said, “The medicines often don’t make people feel well. Gastro-intestinal upsets, diarrhea, weakness, rashes; and some people have trouble swallowing the large numbers of pills.”

Resistance to drugs occurs because the virus can undergo genetic mutations when it replicates. What complicates matters even more is that people who develop a resistance to a certain drug are more likely to become resistant to the entire class of drugs. Patients who develop drug resistance to Nevirapine need to take different types of drugs, which are patented and much more expensive.

Jack Summerside from the British charity Terrence Higgins Trust said: “Fuzeon is an important extra treatment option for people with H.I.V., particularly for those who have used up other treatments available. But it is costly and even more difficult to take than existing H.I.V. medications.”

There are only three classes of H.I.V./AIDS drugs in Asia, which means poorly thought-out drug programs could leave patients much fewer treatment options and force them to take newer, more expensive drugs.

W.H.O. expert Don Sutherland said “If you don’t give the drugs to H.I.V./AIDS patient, you have 100 percent failure. What’s wrong with saving 50 to 60 percent of those lives?”

“This is not just a medical issue, it has impact on every sector of the economy and society,” H.I.V.-positive Nahara said in New Delhi.

In addition, throughout Asia, there are few doctors to treat AIDS patients, so those who can afford the antiretrovirals often obtain the drugs over the counter, and self medicate.

“It is a human rights-based commitment on the part of drug manufacturing companies and governments to cut down the prices. Price of ART had to be brought down to make it accessible for the poor.” Nahara said.

Asian countries are very vulnerable as the region has all the ingredients necessary for the spread of the virus. In addition, the prevalence of poverty provides a fertile breeding ground for the spread of H.I.V./AIDS. Many people migrate within and outside the country for employment. They often do not have access to information and early treatment of sexually transmitted diseases. “The high risk groups like sex workers, their clients, injecting drug users or migrant workers need to get the drugs first. There must first be a concerted national policy to address the epidemic and a well-organized mechanism to deliver therapy,” Nahara said.

Parts of Asia and south Asia are experiencing a devastating epidemic of H.I.V./AIDS. In some of the countries, an estimated 50 percent of the population may be infected. A record five million people were infected worldwide last year alone; over one million were in Asia.

Asian women and children in poor communities are particularly vulnerable in the region. The lack of funds is severely limiting the treatment of AIDS victims, the number of which is increasing quite alarmingly. An AIDS epidemic threatens the robust economies of Asia, with increasing trade, travel and migrant labor fueling its spread.

In Asia, China is becoming a flash point for the disease. After years of neglect, the Chinese government is finally taking action to stop the rampant spread of H.I.V./AIDS. Cambodia, one of Asia’s poorest countries has the highest rate of infection of H.I.V./AIDS. The numbers are indicative of how H.I.V. is moving from an epidemic among high-risk groups, like sex workers, to an epidemic among the general population.

Even United Nations Secretary General Kofi Annan warned that women were becoming the unwitting victims. He encouraged “leaders everywhere to demonstrate that speaking up about AIDS is a point of pride, not a source of shame.”

Asian manufacturers are having trouble keeping costs down because many of them rely on increasingly expensive imported raw materials.

Lack of access to ART is a global health emergency. The New York Times recently reported on an odd problem — that there are too many companies making too many generic antiretroviral drugs to treat H.I.V. British pharmaceutical giant, GlaxoSmithKline (GSK), has also been criticized for a “scam” in failing to get its drugs to South Africans with H.I.V. Three years ago, GSK granted a so-called voluntary license to a South African drug-maker to make generic versions of its H.I.V. drug. But not one pill has been produced since.

“We hear millions of dollars are coming for H.I.V./AIDS,” Nahara said. “But this is reflected in huge office buildings, expensive vehicles, advertisements, conference seminars and dinners. International organizations have made puppets out of the victims who are made to participate in their seminars … Unless there is a joint effort of the community, donors and the government, problems cannot be solved.”

Asia’s H.I.V. infection rate is up. It’s sad and unfortunate that governments in the region are unable to provide affordable care for their own patients.

“We cannot forget how AIDS activists in Singapore called for the subsidize AIDS drugs. Unlike many other developed nations, Singapore does not offer a state subsidy for the drugs, which are too expensive for many Singaporeans,” AIDS activist from Nepal, Namu Rana said.

Dr. Monica, from a local N.G.O., said, “Two types of H.I.V. diagnostic tests are currently on the Asian market: enzyme-linked immunosorbent assay (ELISA) tests and rapid tests. ELISA tests are the most widely used H.I.V. diagnostics in Asia and are the most accurate. However, ELISA tests are fairly complicated, require laboratory support, and do not provide immediate results.

“Alternative rapid tests,“ she continued, “provide results in minutes, and do not require laboratory support. Many ELISA tests are available (produced by companies such as Abbott Laboratories, Organon, Roche Diagnostic Systems, and Sanofi Diagnostics Pasteur), usually at a cost of $1.20 to $1.60 per test.”

She also said “Paying for antiretroviral medication for all Asian H.I.V./Aids sufferers would cripple the regional health budget. Even international funding may not be enough to ensure a sustainable policy to give patients antiretroviral drugs.”

Governments in Asia have to ensure proper training of health staff for selecting patients, and there needs to be a well-organized infrastructure to take the drugs to the patients. If Asian countries don’t unite their forces and take proactive measures to fight the disease quickly, an epidemic cannot be ruled out.

Kamala Sarup is editor of Peace Media, online at www.peacejournalism.com.

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