Microbicides for HIV Prevention

Recently the international Microbicides 2008 Conference was held at New Delhi, India in February. The Conference saw a huge response from all over the globe by different kinds of women and men who were working for or interested in the issue of Microbicides.
So what are microbicides and why the whole fuss about it? The word "microbicides" refers to a range of different products that share one common characteristic: the ability to prevent the sexual transmission of HIV and other sexually transmitted infections (STIs) when applied topically. A microbicide could be produced in many forms, including gels, creams, suppositories, films, or as a sponge or ring that releases the active ingredient over time.
Clearly it is a revolution in reproductive health since the contraceptive pill. Research is still ongoing for finding the perfect microbicide that works for everybody and is safe and effective at the same time.

What makes microbicides unique is the power that they confer on women who can use them on their own without the consent or even knowledge of their partner. This is a major breakthrough that can stall the trend of rapid feminisation of the AIDS epidemic that we are currently witnessing. Despite the numerous efforts for HIV prevention the fact remains that skewed gender relations and lack of women’s empowerment have rendered most of the prevention techniques less effective. Rather, their effectiveness remains hugely dependent on the crucial role men play. It is well known that gender and sexual violence are directly related to HIV prevalence. Microbicide could be just the thing we need in order to tackle this issue of sexual violence and HIV prevention. This is not to deny the importance or effectiveness of condoms but as they say, any technology is as good as its use. So in situations where condom use cannot be negotiated, microbicides can be an effective option.

Without sounding too ambitious, we can actually hope to have a range of microbicide products that serve varied purposes. Such as a microbicide that prevents HIV as well as unwanted pregnancy, and for those who want to have children there can be a microbicide that only focuses on HIV and STI prevention. There are also other issues that need to be taken care of, such as basic product features including colour, smell, and ease of application which can ultimately decide how popular it will get amongst all kinds of women. Like all health technologies simplicity would be an important albeit difficult aim to achieve, but something that will make a seemingly complex technology like ‘microbicides’ a household name. And herein lies the real challenge because as said by Charles Mingus - "Making the simple complicated is commonplace; making the complicated simple, awesomely simple, that's creativity."

For more info on Microbicides visit:
http://www.global-campaign.org/about.htm (Global Campaign for Microbicides)

Pre-marital Mandatory HIV testing

A high-level State government committee for Maharashtra has recommended that pre-marital HIV test should be made mandatory. The committee headed by State Health Minister Vimal Mundada, was formed late last year after a PIL (public interest litigation) was filed in the Bombay High Court asking for such a test.
The proposal could be a first if it becomes a legislation, but it is expected to face stiff opposition.
The National Aids Control Organisation (NACO) guidelines states that mandatory HIV test should not be a precondition for employment or providing healthcare, and in the case of marriage, a test can be carried out only if a partner insists on it.
Personally I think mandatory pre-marital testing is at best a myopic policy that attempts to offer a quick-fix solution that unfortunately cannot work when we are talking about a complicated issue such as HIV/AIDS. Here are some of the reasons why we should be sceptical about this idea of mandatory testing:-

1. Mandatory testing of HIV before marriage does not really serve the purpose of preventing the spread of HIV/AIDS as it does not consider extra-marital relations and pre-marital relations (that can happen after testing!) Majority of the Indian women get HIV infected from their husbands who have sexual relations outside marriage when they migrate/travel for work.

2. Mandatory testing is going to be a very costly public health strategy that is going to require the mobilisation of huge resources. Where will the funds come from this? Instead the govt. can divert these resources for advocacy and IEC (Information-Education-Communication) so that people VOLUNTARILY decide to get tested.

3. I think this issue is comparable to that of forced sterilisation that Sanjay Gandhi had undertaken in the 1970s. Clearly any compulsion of this sort (which involves intimate human behaviour) can open a racket of false certificates as there will always be people who seek the easy way out.

4. HIV testing is not simplistic diagnostic testing. Being a life-altering test there are specific protocols such as pre and post-test counselling that must be adhered to. And anyone familiar with these protocols will know that "informed consent" is a key part of testing procedure. Doesn't manadatory testing violate this aspect?

5. Further this would have the consequence of people simply going of Maharashtra to marry where such tests might not be required! So the worrying question is are we more concerned of reducing the HIV "cases"in Maharashtra rather than India or even Asia as a whole?

6. It must be noted that mandatory testing can reach those people who get their marriages registered legally; which entails that those who do not get their marriage certificates might not get the HIV test. Unfortunately it is these people who are more likely to be vulnerable to HIV/AIDS as they lack the awareness or inclination for the need for such "unnecessary paper work".

7. Another cost related aspect is that HIV tests need to be confirmed thrice across a period of time with the issue of three different techniques. ( due to the concept of 'window period') Is the govt going to bear the costs of three tests per person? Currently only about 15% of those eligible for ART are receiving it. What does the Govt. want to really know by getting people's HIV test done? Instead, they should focus of enhancing access to services for existing PLHAs. (people living with HIV/AIDS)

8. Although the govt. is providing the assurance that the HIV test results will not be misused in the job market etc. the question arises- How are they going to do this? There is no specific legal stipulation for this.

There are ample experiences about the ineffectiveness of mandatory testing from Germany, Japan, USA and Malaysia. Instead the govt. could introduce MANDATORY HIV COUNSELLING so that people are appropriately counselled about this issue and they volunteer to take the test themselves. After all, the people should also be responsible for their own health !

Take the Lead...Keep the promise!

Take the lead – the theme for this year’s World AIDS Day observance brings forth several issues and revelations.
The theme of leadership indicates a certain level of ‘maturity’ of the epidemic to a level where involvement of various segments of society is necessary. The AIDS epidemic which is more than two decades old has clearly advanced to a level where mere planning is insufficient; It is important that we include a sense of accountability, transparency and participation in our efforts to fight against HIV/AIDS; and it is the role of the leader to do this.
There are thousands of definitions of leadership but one of them seems particularly suited in this context. John Maxwell’s definition of leadership is that “leadership is influence- nothing more, nothing less.” This moves beyond the position defining leader, to looking at the ability of the leader to influence others – both those who consider themselves as followers, and those outside the circle. This also entails that a leader needs to have the commitment, character and charisma required to initiate and sustain desirable change.
Leadership is a catalytic element to garner support and canalise efforts for effective prevention and management of HIV/AIDS. We need leadership in planning, action, advocacy and documentation as each of these is an indispensable link in the chain of strategic events.
Leaders at all levels and strata right from the head of countries down to the village level need to be pro-active in their responses to the fight against AIDS. As succinctly put forth by World AIDS Campaign’s Executive Director Marcel Van Soest, accountability of the promises that have been made so far regarding our commitment to AIDS is required. In 2005, national leaders promised to move towards universal access to prevention, treatment, care and support by 2010. While G8 leaders have pledged approximately US$60 billion to combat AIDS, tuberculosis and malaria, there’s no accountability as to how and when the resources will be dispersed. As a result of the many failed promises, progress to achieve universal access by 2010 has been minimal. At the end of 2006, coverage of children in need of AIDS treatment was only 15%; around 28% of people in need of antiretroviral treatment were accessing these medicines and an estimated 11% of HIV-infected pregnant women in developing countries were receiving anti-retrovirals for prevention of parent-to-child transmission. Now it is important that leaders across the world show a real commitment to the cause of AIDS by translating rhetoric into action.

Along with this we need to also create new leaders to plan and sustain strategies for the second generation of this epidemic for which a cure seems far too distant in the near future.
The leadership theme also highlights another important element - the element of participation and leadership from within the community of people living with HIV/AIDS. This stems from the universal consensus that empowerment and participation of HIV infected people can truly bring about the ultimate change in knowledge, attitudes, behaviour and perhaps even alter the course of the epidemic. Power (or empowerment as we know) cannot be given - it has to taken, as rightly pointed by Hannah Arendt. Hence it goes without saying that empowering PLHAs by integrating and including them in strategic planning is essential. Since the ‘community’ of PLHAs itself is diverse with sub groups of various kinds such as north-south, young-old, IDUs, alternative sexualities and many more, we need to seek leadership from all these quarters. Only when marginalised groups take the lead can we have policies that are effective and more inclusive.

Travel restrictions for people with HIV/AIDS

Globalisation has made the world a much smaller place with ease of transport and greater accessibility in literal and figurative terms. People travel a lot more than what they used to earlier. Despite condemnation at the global level regarding travel and entry restriction for people infected with HIV there are some countries that place such entry restrictions, with a few even banning visits just for short trips like tourism or business travel. Such restrictions have been condemned by organisations such as UNAIDS, who point out that they serve no useful purpose at all but are highly discriminatory.
Since the late 1980s the United States has effectively banned routine entry for people with HIV. If you’re HIV-positive and want to visit the US you have to go through a very complex procedure and obtain a special visa which can take months to obtain. People with HIV who have travelled to the US without this visa have sometimes been stopped by immigration or customs officials, detained, and deported. On World AIDS Day last year, the US president, George Bush, announced that he’d issued instructions to allow “a more streamlined process” for the issuing of entry visas for people with HIV.
But new draft guidelines issued by the US government suggest that people with HIV will still have to obtain special permission to enter the country and will only be allowed to visit the US twice in any twelve-month period for visits of less than 30 days.
The draft guidelines still require people with HIV to visit a US embassy or consulate before their planned visit and to declare that they have HIV. For a visa to be issued, it’s also necessary for a person with HIV to be in good health, have enough medication for their proposed visit, and to understand the “nature, severity and communicability of HIV.”
This immediately eliminates anyone wanting to visit another country for medical treatment purposes.
But more than anything what it does is the exact opposite of normalizing the disease. By placing specific restrictions only for HIV countries like the USA are perpetuating the fear, discrimination and ignorance that experts have been trying so hard to dispel since two decades.
The restrictions violate the basic human rights of HIV infected people failing to recognize that they are individuals with legitimate needs like other people. A simple wish that a person might have of seeing the world could become a battleground for medico-legal issues due to such travel restrictions.
Moreover such a hypocritical attitude by USA is detrimental to the fight against AIDS and totally against the democratic image that Uncle Sam tries to project.

If this virus does not see any national or regional boundaries, why should we?

Twelve statements to improve the situation of women with HIV/AIDS

Women with HIV/AIDS need the following:
1. Encouragement and support for the development of self-help groups and networks.
2. The media to realistically portray us, not to stigmatise us.
3. Accessible and affordable health care (conventional and complementary) and research into how the virus affects women.
4. Funding for services to lessen our isolation and meet our basic needs. All funds directed to us need to be supervised to make sure we receive them.
5. The right to be respected and supported in our choices about reproduction, including the right to have, or not to have, children.
6. Recognition of the right of our children and orphans to be cared for and of the importance of our role as parents.
7. Education and training of health care providers and the community about women's risk and our needs. Up-to-date and accurate information about all the issues for women living with HIV/AIDS should be easily and freely available.
8. Recognition of the fundamental human rights of all women living with HIV/AIDS, particularly women in prison, drug users and sex workers. These fundamental rights should include employment, travel without restriction and housing.
9. Research into female infectivity, including woman-to-woman transmission, and recognition of and support for lesbians living with HIV/AIDS.
10. Decision making power and consultation at all levels of policy and programmes affecting us.
11. Economic support for women living with HIV/AIDS in developing countries to help them to be self-sufficient and independent.
12. Any definition of AIDS to include symptoms and clinical manifestations specific to women.

-- The International Community of Women Living With HIV/AIDS (http://www.icw.org/)

Gokulashtami and the AIDS Fight

“Goals are met when we coordinate our efforts with those of others”

This small quote beautifully summarises one of the best, most effective techniques for achieving set targets and goals.
The fight against the HIV virus is one such long drawn battle that will take a while to win. But with team work we can effectively put a brave front against the threat of this disease.
The recently celebrated festival of Gokulashtami especially the fun-filled practice of breaking the ‘dahi handi’ has much to teach us if we look closely.

The traditional festival had a token ‘dahi handi’- an earthern pot tied between two poles, with groups of young boys trying their hand (and feet, to put it literally!) at breaking the 'handi' or the pot much like the young Lord Krishna would do in Mathura. The coveted pot would be filled with the traditional mix of curds, fruits and other goodies along with a few coins of money. Today of course those few coins have been replaced by lakhs of rupees funded by several high profile politicians and community groups. As expected, the rising prize money has pushed skywards and with it the height of the handi. The modern day ‘dahi handi’can easily mount upto 30 feet with these youngsters forming anything between six to eight tiers of human blocks to reach the prize.

The way these human pyramids are formed to reach towards the goal is symbolic of the great amount of teamwork and meticulous planning that is required for the achievement of any set target. Further, the entusiastic young men have to brave the buckets of water playfully hurled at them by onlookers to prevent them from breaking the pot.

The same spirit is required in our fight against HIV/AIDS.Earlier when the disease was still in its stage of infancy, medical efforts were considered sufficient. But gradually as the disease assumed epidemic proportions there was an increasing need for bringing forth a multi-speciality approach. This widened further on and today after more than two decades we know that AIDS is not merely a medical problem but a wider issue. In fact the prevalence of AIDS can be considered as one of the key events that will direct the course of global development in this new millennium. The fight against AIDS has to go against all obstacles of war, unrelenting religious leaders, harmful behaviours, political turmoil, inadequate budgets, lack of human resources but the fight must go on unrelentlessly.
Just like the rising towers of the ‘dahi handi’ the stakes are getting higher for the fight against HIV/AIDS. When one observes the agile youngster who reaches to the top most level of the human pyramid, we can see a joy that only successful goal achievement can bring. This joy is unaffected by any fear of falling from that dizzying height. Such a confidence is possible simply due to the unfailing support and encouragement from the mass of people below. Likewise in our fight against the AIDS epidemic, multi-disciplinary teamwork and coordinated efforts from all quarters is necessary for success.

Many people bemoan the increasing commercialisation that has set into the traditional celebrations today. Such community based festivities mean a good opportunity for political parties and would-be political leaders to market themselves and establish their names. There have been a few cases of AIDS prevention programmes serving as good chances for fame-crazy celebrities to generate political mileage and international donor support in certain under developed regions. While some amount of publicity and “bandwagon-ism” does help, it is important not to lose sight of the real goal i.e. grappling with AIDS and even eliminating it – just as new age ‘govindas’ must not forget that the real reward is the curd, the money just happens to be a bonus.

Cost sharing for provision of ART (Anti Retroviral Therapy)

In resource poor countries like India, although generic drugs are available, 93% PLHAS are deprived of access to antiretroviral therapy. (NACO, 2005) Considering this in mind, ARCON (AIDS Research and Control Centre) was established with the specific objective of ‘enhancing access to ART’ as per the GFATM (Global Fund to fight AIDS, TB and Malaria) Funding Round 2. There was a felt need for systematic and rational provision of ART services that would promote adherence to the drug regime. ARV drugs as it is well known, have numerous dangerous serious side effects that are the main hurdles in good adherence. The possible danger of drug resistance makes the life long continuation of these medications complicated, though necessary.
Hence ARCON sought to provide quality diagnostic, clinical, and counselling services for ensuring the rational use of ART. Understanding the significance of a multi-stakeholder approach, it has established linkages with private and public sector for enhancing access to ART. The cost price of the drugs is negotiated with the pharmaceutical companies and is nearly 40% less than the maximum retail price.

In order to make the programme self-sustainable, a graduated cost recovery program was envisaged at ARCON. Although it is recommended that ART be provided free of cost, in limited resource settings such as India there is an urgent need to enhance access to larger numbers of HIV infected people. With free ART the access in terms of number of patients is less, since there are several patients vying for them. However with a cost sharing mechanism, the scope of the patients reached is widened. So for instance if the cost of X medicine is Rs.100/unit and we have a budget of Rs.200 we will be able to provide only 2 doses of the medicine free of charge to one patient. If on the other hand we establish a cost sharing mechanism wherein the patient contributes for half the cost of the medication, the same Rs.200 can provide two patients with medications. Thus, with cost sharing there is enhanced access to treatment.

Any ART provision program must look at long-term sustainability, as the threat of possible drug resistance is very real. Cases of drug resistance in the dysfunctional health systems of African countries such as Malawi aren’t rare. While scaling up should be a definite priority in AIDS treatment, it must be ensured that the required health infrastructure is in place.

ARCON has a Tier system of co-payment where patients are categorised as per their willingness and ability to pay. Four tiers have been allotted wherein the patients pay 100%, 75%, 50% or 0% respectively; the fourth tier comprises of below the poverty line patients who are given ART free of cost.

There are other important aspects of this model such as social equity. Patients who can afford to pay for more than 60% of the cost of ART subsidise the cost for those with partial or no ability to pay. However the patients in the paying categories still get the treatment at a much a lower price than they would have paid in a private setting. Additionally, the concerns for privacy, confidentiality and inability to wait in long queues are also kept in mind. Though we cannot place a price tag on these they are vital pointers in health related decision-making, especially for patients with chronic diseases such as PLHAs.

Hence there is a need to revise some of the long held beliefs with respect to public health such as the felt necessity for “free health services”. Our own data has proved that people value a service much more when they pay for it (even partially); it also makes the service sustainable and accessible to larger numbers in the long run.