As part of a radio show I sometimes conduct on Pacifica Radio Houston, I interviewed Paul Arora, a scientist at Centre for Global Health Research, University of Toronto, a couple of weeks ago on some of the latest findings on AIDS in India. Here's a recording of the interview (about 30 mins total). He's extremely knowlegeable and articulate.

http://www.cs.rice.edu/~rajb/aids/

More info on this research is found on their website at http://www.cghr.org/
This work was recently published in the extremely prestigious journal Lancet.

by early 2007, we will have drugs made available to 100,000 people with HIV

That's still too few :(
Any sense how many people are getting treated total?

Thanks Neha - v. important topic!

technophobicgeekthanks so much for the mp3s, you kick ass, i shall listen and write summat back at you...

Ya, Ennis, very true very few. According to this site:

About 36,000-77,000 people were receiving drugs at the end of 2005, of whom only around 24,000 were gaining free access from public sector facilities. It is estimated that around 785,000 people are in need of the medication.

Hi Neha,

The site you linked to in post#3 also has a good review on the HIV/AIDS in India.

India has made very good progress in the last five years in increasing the HIV/AIDS dialogue which was quite non-existent before. There is a LOT more to be done but they are heading in the right direction. India has the intellectual capacity to build a proficient infrastructure to improve their outreach and awareness/education... it will take time and committed personnel to carry it through though. Two major things need to improve however, VCT (voluntary counselling and testing) needs to become more accessible esp for women and ART adherence must be emphasized.

I definitely think that prevention is still the best line of defense against this epidemic. Although i work in the area of hiv vaccine research, i really believe based on epidemiological and clinical data, that a vaccine or ARV will not be sufficient to halt or significantly slow the spread of infection. Social/outreach programs need to be pushed and need long-term funding... there just aren't enough... globally speaking.

I dont want to dampen anyone's enthusiasm, but there are real, practical limitations of ARV treatments.

If an individual is infected with the virus and does not comply with ARV regiments, there is a good chance of the emergence of escape mutants of the virus that can overcome the treatments... (the exact number depends on multiple factors and cannot always be pre-determined). ARV therapy is closely monitored in the US/Canada for such reasons and the course of treatement is altered as needed... this is something third world nations battling the infection cannot afford and will most likely not have access to... (hence the imminent need of better infrastructure and trained personnel).
ARV also has severe side effects and HIV+ individuals tend to face metabolic, liver and heart related health issues... these medical concerns also need to be followed up and given treatment which costs even more money. Again, infra-structure and long-term access/funding are lacking in third world countries.
I am not saying that we should not provide ARVs, of course they are required and will prolong life, but it should not be the end-goal and is not the solution. It can carry us through till we find a better solution.

Sometimes health workers in US/Canada don't understand the fact that HIV+ individuals living in impoverished communities struggle for food and water every day and have children dying of malnutrition or malaria every day... these are more immediate concerns for them... HIV is not killing them today or tomorrow... famine is! Even if drugs are provided to them, what good are they? rather these drugs are considered to be wasted on such communities.

There are so many socio-cultural issues that need to be dealt with as well! Declaring one's HIV status is not always easy... it's not just about telling your family you have a disease, the disclosure usually involves admitting to an affair, admitting to drug use or even worse, admitting that one is gay!... etc. There are many downstream personal consequences that can mean worse to people than having HIV itself.

Anyway.. i will stop now! Thanks for posting something on this Neha!
Solutions are not easy to come by but efforts/progress are being made and awareness is increasing!

Thanks for your comments Sumiti, and I couldn't agree more with your enthusiasm about spreading awareness and voluntary testing. I would hope that the hundred clinics these drugs are going to be disperesed from are going to have the resources needed to follow through on individual treatment. Perhaps not at the pace one would find in N. America but hopefully a tad more than what pharmacy actions of dispensement would offer.

I think empowerment is a surefire method of significantly reducing the rate of infection and the counselling you mentioned has a big role to play.

A very important issue indeed, Neha.
I came across this website (http://www.avert.org/aidsindia.htm) which seems to have collated a lot of raw data on the situation in India. The biggest challenge for anyone involved in fighting the spread of the virus would be the diverse nature of the problem in each region. In the north-east, rampant drug use seems to be causing the spread, while in the south, it seems to be unprotected sex abetted by truck drivers. What is shocking is that all this data is collected from antenatal clinics. Doesn’t this mean that there is no real mechanism to collate data on male victims, who definitely outnumber women and probably are the chief culprits when it comes to spreading the virus?
Though providing treatment for existing cases, awareness campaigns – ah, who can forget those giggly seminars when a bunch of teens are shown the “application” of a condom upon a Reynolds pen - and research for a cure are all important; the singularly fundamental, albeit extremely difficult solution for surmounting this problem would be the eradication of illiteracy. An India where everyone can read, write, and hence has the choice to make learned decisions; now that, would be a dream come true!
Peace

Sumiti, Can't agree with you more about VCT being more accessible for women. I was a field researcher for the NCW in Delhi, back in the day, for a study on Child Prostitution. What I saw in the slums was inadequate access to any kind of medical facilities, and in certain cases a lack of knowledge of facilities that existed.

A 25 year old woman (who looked 45) cornered my co-researcher and I for the 'golis'. We realised, after a nerve-racking moment of terror (we were both 19 & very green) that she wanted birth control pills. The dispensary which gave out free pills was less than 200 metres away. Once she knew about it, she was registered and 'set' for about Rs 20. But that was one of the fortunate neighbourhoods that actually had a dispensary and a sex education program in place.

I hope things have changed, and am glad of the initiatives I am reading about. But I agree with Ennis. It's not enough.

On a different note, Harper's Magazine had an article a couple of months ago on 'AIDS and the corruption of medical science'. They talk about the clinical trials of nevirapine and nelfinavir. Will Nevirapine be one of those drugs that is recalled five years later because of it's side-effects which could include Liver Failure?
I'm curious to know if you knwo anything about this.

Thanks already.

well I was also surprised by the news of India topping in terms of most no. of HIV + people. Well easy to see, the target by early 2007 too will fall short. As eveyrone has already stressed, prevention and education alone can curb the menace.

Although a lot has been done on education sector but it has been mostly limited to urban metro like Mumbai, Delhi, B'lore wherein thru free counselling call centres, radios, stage shows attempt has been made. The other part of India wherein women still are not unaware of hygenic safeguards (they use their blouse without caring for hooks during periods etc) are still left out of the loop. Apart from opening such 'special' centres I think such medicines should be distributed to govt. hospitals and if arrangement can be worked out private hospitals as well. This will take partly take load of infrastructual problems and give people more avenues 'closer' to their home wherein they have been going more regularly.

And sometimes back I blogged about revertionist attempt like this by WB govt. which shud be thwarted without considerations whatsoever of sensitivity. The problem that we talk of has to be tackeld no matter whatever sensitivities are involved.

hello - cbc had a piece last night on Thailand's war against aids - the fact that caught my attention was that the situation had reached a crisis in early nineties - but today the rate of hiv infections has dropped down from 140K to 20K - this is heralded as a major success. the case study being highlighted in that radio program was a hospice in the largest urban slum in thailand. other than that, do you have any insights on the critical success factors for that battle - what worked, what can the rest of the world learn?

btw - happy day of the federation to you all. enjoy!!!

Yes, but Thailand went out and worked closely with sex workers and customers to get condom use way up. I can't see that happening easily in India, where denial of sex is such a large part of society / politics.

Although it's not very PC to say, what I've learned from friends who research HIV is that it's less important to try to change the behavior of large numbers of people and more important to change the behavior of that small number of highly promiscuous people. That means that you have to acknowledge them first, and deal with them without stigmatizing them. This wont be easy for India.

Yes, but Thailand went out and worked closely with sex workers and customers to get condom use way up. I can't see that happening easily in India, where denial of sex is such a large part of society / politics.

Ennis, it has already happened in India, very successfully. Denial may be a phenomenon in the holier-than-thou middle classes in India, but sex workers usually are a whole lot more pragmatic. I highly recommend reading the findings at the web site I mentioned earlier (http://www.cghr.org/) or listening to the interview for the recent findings regarding this.

In places like Sonagachi (Kolkata) and also in South India, sex worker education programs have had a huge effect on bringing new infection rates down. North India is still a bit of an unknown territory, though.

hello - cbc had a piece last night on Thailand's war against aids -

hi, i'm new here to the forum. just thought i'd drop in n say hi. i've been reading for awhile, and i think u guys r awesome! :)

>>Free HIV Drugs in India

Free Kerosene: We know how well that worked. Adulterated kerosene which blew up stoves in housewives' faces.
Free Sugar: We know how that worked. Adulterated Sugar mixed with mica and limestone which drove boys and men to the hospital for phallus operation due to crystals stuck in their...
Free Rice: We know how that worked...
Free mid-day meals: How many food poisoning cases happen to young children...
Free this ... free that...

And now free Aids drugs. Can't wait to see how this blows up in their face. Of course, a whole lot of innocent lives would end, but hey, you can't make an omelette without breaking some eggs!! Somebody needs this reward, that grant, this tour, that offsite meeting. People with inflated egos making centralised decisions, getting kickbacks, building lavish bunglows, sending their children to Yameriga to study.

I've seen that movie before.

M. Nam

as a mouse in the medical profession (read mouse as: scutmonkey, rat, lowest in the ranks i.e. medical student) the more I study disease the more I realize that best cure is prevention...not "cure" as in the ARV's which essentially allow the person to live longer to further infect or create worse mutant versions of the HIV with others. Now I am not saying that the people who have the disease should be ignored but the media and the government should realize that the presentation of this news should be: Health authorities in India are accelerating a campaign to promote safe sex, with a secondary mention of the pills.

We need to promote casual discussion of safe sex in India and worldwide way before we start believing that our problems can be solved with pills.

We need to promote casual discussion of safe sex in India and worldwide way before we start believing that our problems can be solved with pills.

Erm, perhaps we should start off by ensuring that it is safe to discuss casual sex in India:)

This is a great initiative for free ARV's for 100,000 but it really is a drop in the bucket. I'm in Punjab right now studying HIV and I'm learning anecdotally from meeting patients that the people who make the treks out to the doctors or VCT centers are really a small small minority. Most HIV positive people where I'm stationed, especially in villages, are unaware that ARV's exist and sentence themselves to dying a quick death, without seeking the help of professionals. I second the call for prevention, with a very strong need for AWARENESS building. Education is the most important social vaccine to HIV out there.

Special thanks to sumiti, I learned a lot from your comment.

Harper's may be radically left-wing but a couple of months back, they had an interesting article on nevirapine toxicity: http://www.harpers.org/OutOfControl.html...i can't help wonder if this Free ARVs in India has more going on in the background than is readily apparent. As someone who has worked in the field in NYC, drug toxicity among HIV patients (who may or may not have additional MICA issues going on, is something that is looked upon as the lesser of the two evils (death being the ultimate evil, i suppose)-especially if its via 'established' drugs such as nevirapine or combivir..

Totally agree with Sumiti...
I have reasons to view the program with healthy scepticism. I worked in the hospital where the first free government ART centre in the country was set up…

One of the main problems faced was non-compliance, there are so many side effects that the patients aren’t really raring to go when it comes to taking those pills. The tragedy of course is that even a few missed doses could lead to the emergence of a dangerous new mutant, with devastating consequences for everybody.
Devastating for the patient as we only offer them first line therapy for free, and for everybody else as the emergence of the new mutant would also mark the end of the utility of the currently used drug (which might have taken 15 yrs and a few million dollars to develop and some more money to re-engineer and manufacture in India ;) )

On another note, I have seen patients, sex workers with out proof of residence and ration cards who cannot get enrolled in the government program without these documents(and before you rant at bureaucracy… these documents are necessary so that compliance can be assured in some way, for example in the DOTS program for TB the health worker comes home if you miss a dose)

And the Nevirapine single dose that is being used for treatment of mother to child transmission is not the best way to go according to many reports…

But in spite of all of this and more… it’s a commendable initiative…

On a different note, Harper's Magazine had an article a couple of months ago on 'AIDS and the corruption of medical science'. They talk about the clinical trials of nevirapine and nelfinavir. Will Nevirapine be one of those drugs that is recalled five years later because of it's side-effects which could include Liver Failure? I'm curious to know if you knwo anything about this.

I read the harper article a little while ago and it is the only one of the kind that i have read... it also only states the case of one woman. I would not discount the article completely but would definitely take its claims with a grain of salt.

ANY drug has side effects. After some chemotherapeutic drugs, ARVs are right up there as some of the most toxic drug regiments. They do have harsh side effects and in rare cases where the reaction to the drug may be overly severe, the consequences can be lethal if the treatment is not monitored properly. That is probably the case of Joyce Hafford, mentioned in the harper report imo. But this is also true for many other therapies: for cancer, for rheumathoid arthritis etc.

Also, as Jaded mentioned in post 19, currently, nevirapine alone is not clinically used to prevent mother to child transmission, there are dual and triple drug therapies. The combination of drugs used is based on the physician’s discretion and on the patient’s HIV stage/status. There is a substantial amount of trial and error that goes into determining optimal therapy combinations… it has changed several times in the past few years and will continue to change. In the process, inappropriate drug doses and sub-optimal combinations are used and do lead to extra toxicity for some patients with downstream complications.

Medical science is not a black and white science… it has many shades of grey. It can be frustrating, but the challenge lies in working within the limitations to one’s best capacity and in constantly reviewing the process.

nevirapine alone is not clinically used to prevent mother to child transmission, there are dual and triple drug therapies

The thing with single dose nevirapine(as far as I remember from med school/internship... since I dont actively prescribe ART now) is that single doses can rapidly lead to resistance, and wherever possible more complex regimens are preferred