Second Line ARVs in India: An exchange of letters between Agua Buena and Global Fund
20 December, 2006
Mr Tafiqur Rahman
South and West Asia Center
The Global Fund
Geneva, Switzerland www.theglobalfund.org
Dear Mr. Rahman
Thank you very much for taking the time to send me this letter explaining your point of view about the Global Fund project in India. Your original letter is attached as a .pdf file.
At this moment, the situation regarding the unwillingness of the Indian government to provide second line medications is critical, yet as you yourself have stated "the government of India has not decided yet to introduce second line medications"
I would like to raise some points and ask a couple of questions, based on information I obtained during my recent visit to India. Questions specifically directed for you appear in bold face and are underlined below.
1) I believe that the Global Fund was created to save lives. Does it really make sense to start PLWA on treatment, and then for those who develop resistance, simply allow them to die one or two years later for lack of second line treatment? This seems contradictory to all of the basic principals of the Fund.
2) You yourself have speculated in your letter that "the first year alone would cost over $3 million….and in later years it would cost approximately $70 million or more" Where is the concrete evidence for these estimates? Until a tender is issued and people come forward for treatment, no one knows exactly what the prices will be, and how many people need treatment. Figures such as $70 million can appear very scary to decision makers, but I know of no hard evidence to support this, I must request that you explain this figure. $70 million when and for how many and based on what evidence ?
3) India at this moment has local generic production and distribution of all second line medications that would be necessary at the present time for PLWA, through companies with reputations for assured quality such as Ranbaxy and CIPLA. This differentiates India from any other country in the world. "List prices" are still perhaps high for these medications, but all Indian generic companies have indicated that dramatic price reductions would occur if the government would issue a tender to actually purchase the medications.
4) It is very significant that you make no reference in your letter to funds available at this moment in existing Global Fund grants specifically designated for purchase of anti-retroviral medications, information that is clearly available on the Global Fund website in the India section. (www.theglobalfund.org) In the Round 4 grant, approved in 2004 and signed in 2005, $77 million is available over 5 years clearly designated for ARV purchase, yet, in your letter, you have not specifically referred to these funds or whether or not these funds have been disbursed. You refer to a recent disbursement to the of $17 million, but it is not at all clear that these funds have been disbursed for ARV purchase, as the 4th round grant project also includes an additional $70 million in components other than purchase of ARVs. Could you please indicate very specifically how much of the $77 million available for ARV purchase has been disbursed to NACO, since the grant agreement was signed?
Also in the Round six grant for India, which could be available as early as March of 2007 an addition $85 million is specifically designated for purchase of ARVs. This grant runs through 2012, thereby assuring sustainability of available funding for five more years.
5) PLWA who need the medications NOW are told to wait "a few more months," as you state, until the government can establish a policy. Why would the government not begin second line ARV treatment for those who need them, while policies are being determined if it is a question of a few more months? Those who need second line treatment now, many of whom I met on my recent visit, may be dead by the time these medications become available.
6) Given the fact that it is the Country Coordinating Mechanism (CCM) that needs to also make decisions that affect the issues being discussed above, I feel that the Indian CCM needs to prioritize the need for comprehensive care and treatment, which includes second line medications. The CCM has the option of insisting that these funds be disbursed in a timely fashion given the needs which exist NOW. The CCM can also request a "restructuring" of existing grants in order to meet emerging needs, but there is no evidence that this restructuring is even needed in order to request that funds for second line medications be disbursed now.
7) Unfortunately your letter gives the impression of an "exclusive" dialogue between the Global Fund and the government of India, but excludes reference to the role of Civil Society in this process through the CCM. All of the Civil Society people I met during my five weeks in India (several hundred in fact) were strongly in favor of utilizing some existing funds NOW for second line medications, but their voice seems silent in your letter. Could you please comment on this.
8) The Indian government continues to make the distinction between first and second line drugs, as if they must choose either one or the other, in terms of meeting the needs of PLWA. No other country, even those nations that are poorer than India, makes this distinction. Second line treatment is part of the continuum of comprehensive care that is recommended by all of the International Agencies of Cooperation. Granted that there may be limits in some countries, but India at this moment has more Global Fund money (specifically designated for treatment access) sitting in the bank than any other country in the world. In my opinion this is unacceptable.
Dr. Rahman, I think this debate is critical to the lives of many people in India who need second line treatment. I appreciate the advances that have occurred in the past two years in terms of the overall panorama related to ARV access in India, which are significant.
But I would still hope that you would respond to the issues I am raising above, and I would also hope that Indian CCM would issue a statement in relation to these issues.