The rapid spread of HIV in sub-Saharan Africa is one of thegreatest failures in the history of public health. Given ourdetailed understanding of HIV and the natural course of AIDS,the virus should have been controllable. Yet in some Africancountries 20% of people aged over 15 are HIV positive and 70%of them will eventually die from AIDS.1
India shares someof the same risk factors as Africa,
including a similar patternof health expenditure, an uneven
health infrastructure, andprevalent high risk sexual
behaviours (table A,
By 2010 the number of HIV infections in India is predicted to
rise from 4 million to 20-25 million
We discuss10 important lessons from Africa that could limit
the spreadof HIV in India.
The views expressed in this paper are based on current literaturereviews, economic analyses of the Berkeley International Group (http://big.berkeley.edu),
and extensive personal experienceworking on HIV,
reproductive health, programme management,and international
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
bmj.com). Mathematical models show both the benefits of
early intervention and the importance of focusing on these
India remains a traditional society:its laws forbidding
homosexuality derive from British legislationin the 19th
and the sex industry relies on bribingthe police to operate.
The high risk groups are outside thepolitical, social, and
economic mainstream. Leaders must overcome prejudice and be prepared to
include these groups in designingwell funded programmes.
Focus on cost
effective preventive programmes
Poverty is a major contributor to the spread of HIV and thusconsidered an important focus for preventive programmes. However,the prevalence of HIV can double within high risk groups insix 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 claimthat only socioeconomic change will cure the disease and toavoid controversial interventions, such as distributing condoms to
The most appropriate immediate strategy for India is a targetedapproach in core groups. Its cost effectiveness is well
established. Substantial numbers of cases can be averted by managementof sexually transmitted diseases in commercial sex workers,blood screening, voluntary counselling and testing, treatmentof sexually transmitted diseases in the general population,and providing antiretroviral drugs at childbirth (figure,
The cost of treating one person with antiretroviraldrugs for
a year (at full price) is equivalent to that of preventing
almost 50 cases (figure).
Number of cases of HIV infection that could be averted with $2m AIDS
budget spent on preventive measures or antiretroviral drugs (ARV) from
Cost per life year saved by HIV prevention programmes
Cost/life year saved ($)
Management of STDs for sex workers
Voluntary counselling and testing
Treatment of STDs for general population
Prevention of mother to child transmission:
STD=sexually transmitted disease.
adequate supplies of condoms and antibiotics
In sub-Saharan Africa, too little attention was given to thesupply of condoms. In 2000, fewer than 650 million condomswere distributed (about four for each adult man). TheUnited Nations Population Fund estimates
that at least $1bn(£626m, €881m) is needed for condoms to
controlAIDS, and the gap between demand and supplies is
growing.If we assume that people will spend up to 1% of their incomeon buying condoms, 95% of India's population cannot affordthe $10.65 a year needed for manufacture, promotion, and
India has the advantage of a large, competitive, technicallycompetent pharmaceutical industry, and the government is
subsidisingdistribution of condoms to low income families.
This subsidyshould be extended to antibiotics for
controlling sexuallytransmitted diseases. The international
donor community shouldensure that priority is given to
funding condoms and antibioticsbefore funding other
in projects that can be fully implemented
Africa is awash with pilot projects, yet no donor agency ornational government has set up a systematic programme of basicinterventions for all sex workers in every large city. Sincemost possible interventions have already been tested more thanonce, the need for additional small scale studies is questionable.Larger scale, relatively simple programmes that provide basicservices to all should be given priority over sophisticated,
labour intensive programmes covering a few people. The availableresources should be allocated equally across all the sitesthat need intervention. The sophistication of programmes shouldbe determined by the amount of money available for each site.Although the amount might be relatively small, the programmescould still have a big impact.
Pilot studies of interventions should not be funded if the resourcesare not available to implement the intervention nationwide,however promising it may seem in theory. The worst case scenariowould be one where India's many non-governmental organisationsdivide the limited resources to create carefully crafted, custombuilt programmes and end up having no overall impact on thedisease.
traditional health practitioners in control programmes
In areas where the epidemic has spread beyond the initial highrisk groups, programmes providing interventions for the generalpopulation are essential.
Rural medical practitioners, nurses,Western trained doctors,
and other health professionals willhave to be included. Many
African countries have resisted thenon-medical prescription
of antibiotics. In India, rural medical practitioners often have a
formal training in Ayurvedic or othertraditional medicine
but are not formally permitted to prescribeantibiotics. It
is essential to recognise the role of India'sprivate sector,
which provides care for most rural poor people(see
bmj.com), and realign prescription regulations to reflect
the structure and work of international donors
The Global Fund for AIDS, Tuberculosis, and Malaria now controlsmost of the funding for tackling HIV and AIDS. However, the$2-3bn available amounts to less than one quarter of the annualprojected needs for controlling AIDS.
Underspending of donated funds is common and helps curtail theresources available and deter future allocations from the donor.Implementing agencies spend a great deal of time preparingproposals; donors require time to analyse unsolicited proposals,to prepare, and to review requests for proposals. A more costeffective strategy would be for governmental and foundationdonors to set achievable output goals, specify how much moneythey wish to allot to this particular area, and then inviteevidenced based proposals from possible implementing agencies.This would draw on the rich experience of agencies in bothdeveloping and developed countries, simplify the work of donors,and pre-empt the second guessing of the donor's goals. Supportfor output based services should ensure that money followsresults and increase the efficiency of both non-governmentaland governmental programmes.
international meetings waste resources
Large meetings cost a great deal in airfares and living andopportunity costs. The communication of ideas and initiationof new collaborations at such meetings has fallen over theyears, and the meetings have become platforms for non-evidencebased lobbying.
Meetings that deal with specific topicsand focus on science
are likely to remain useful.
lobbying for increased use of antiretroviral drugs
Infected people in rich countries who benefit from antiretroviraldrugs form a compelling lobby for extending treatment elsewhere.However, individuals at risk of infection do not lobby forinvestment in prevention of HIV and AIDS. When prevention
programmessucceed, it is impossible to say that any one
person is alivebecause of them.10
Any objective effort to allocate the limitedresources
available to confront the HIV epidemic in India willhave to
take these asymmetries in lobbying into account.
One emerging lesson is that money spent on antiretroviral drugsis money removed from prevention, and vice versa. The GlobalFund for AIDS, Tuberculosis, and Malaria has allocated 60%of its first $378m of grants to support HIV projects, and 21of 28 countries receiving grants will use this money to purchaseantiretroviral drugs.
These drugs are difficult to use (exceptto prevent mother to
child transmission) and, even at the greatlyreduced prices,
are very expensive, especially when the necessarytesting,
monitoring, and counselling costs are included (figure).In extreme cases they may even encourage increased rates ofunsafe sexual behaviour.
Even if there are further massive reductions in drug prices,the costs will remain beyond the reach of individual and communitysubsidy in much of India. Nevertheless, there will be intenseemotional pressure to mount token subsidised antiretroviralprogrammes. The people who benefit will probably be those whoare most educated or have access to specialist care. The exampleof Thailand, where an increase in antiretroviral drug coststook money away from prevention budgets and was associatedwith an increase in HIV infections, must shore up our commitmentto prevention.
policies are based on latest evidence
In hindsight, the investment Africa made in safeguarding theblood supply rather than focusing on high risk groups was probablyover enthusiastic. In the 1980s, the scientific evidence thatother sexually transmitted diseases facilitate the transmissionof HIV was not acted on quickly enough. Evidence is comingout of Uganda that sexual abstinence and reduction in the numberof sexual partners can help reduce prevalence of HIV.
Religions such as Islam, Christianity, and Hinduism emphasise certainaspects of sexual abstinence and reproductive health. Religiousorganisations could therefore be used to help prevention alongsideprogrammes to distribute condoms and treat sexually transmitteddisease.
Attention needs to be given to the increasingly strong evidencethat male circumcision slows transmission of HIV. In a recentstudy in Uganda, 30% of uncircumcised men became infected fromtheir HIV positive female partners compared with none of thecircumcised men.
Finding ways to offer circumcision to Hindumen (who are
generally not circumcised) could slow transmissionof HIV and
other sexually transmitted diseases.
Despite its devastating effect, HIV is a fragile, difficultto transmit, and easily destroyed virus. A microbicide thatwomen can use secretly and effectively to protect themselvesagainst HIV infection would be valuable.
Western managersestimate that development of a 60% effective
microbicide wouldcost $775m. Although this is achievable,
the microbicide wouldnot reach the market before 2007 at the
earliest, which willbe too late to contain the spread of HIV
in India. A concertedeffort should be made to use these
resources in ethical researchframeworks that fit the
enormous risk of death in developing countries. The suggestion that
lemon juice may be an effectivemicrobicide should also be
Decisions aboutwhich programmes to implement should be based
on cost effectiveness.Comparable and rigorously collected
data are needed on implementationcosts and on consumers'
willingness to pay for prevention and therapy.
national and global budgets now
Government investment in AIDS prevention in all countries hasbeen a story of too little too late. Large investments at theoutset of the epidemic will slow progress more than those ata later stage. India currently invests R300 crore (£43.5m)annually, much less than needed.16
This simple lesson in epidemiologyneeds to be understood by
external donors, the Indian government,and foundations. The
Macroeconomic Commission on Health urgesa 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.
The number of cases of AIDS in India will probablyexceed 20 million by 2010.
The limited resources should beused for large
cost effective programmes to decrease spreadof the
Money spent now will be much more effectivethan
money spent later in the epidemic
Adequate supplies ofcondoms and antibiotics
must be secured
Prevention should begiven priority over
tables and figures giving HIVstatistics are available on bmj.com
We thank Mike Musante, Russell Green, Stephanie Heise,
ElliotMarseille, and Ndola Prata for their contributions to
analysis,editing, and graphical presentation.
Contributors: MP conceived the analysis and led the
writingof the paper. JAW led the overall data collection and
helpedwrite the paper. MP is the guarantor.
Funding: Fred H Bixby Endowment, and grants from the
Gates andHewlett Foundations.
Competing interests: None declared.
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