Budget cuts threaten AIDS and tuberculosis control in India

Abstract

India's national AIDS and tuberculosis programmes are facing fiscal shortfalls that are beginning to show impact on the ground. Dinesh C Sharma reports from New Delhi. Bureaucratic changes and budget cuts are threatening to derail two of India's key health initiatives—the National AIDS Control Programme (NACP) and the Revised National Tuberculosis Control Programme (RNTCP). A total of 2·1 million people in India are HIV positive and about 1·2 million new cases of tuberculosis are diagnosed every year. For a decade, under the NACP, the government has been dispensing free antiretroviral therapy (ART) and diagnostic services through a national network of 510 ART clinics. About 869 000 HIV positive people currently receive first-line and second-line ART. Voluntary agencies are funded to run targeted interventions such as condom distribution and needle-exchange programmes for high-risk groups. However, many ART clinics are running out of stock and community-based prevention activities in some states have been curtailed. Voluntary organisations delivering targeted interventions have been told to dismiss health workers in Maharashtra, one of the states with a high prevalence of HIV. Condom supplies are running out in several states, according to data collated by the National AIDS Control Organisation (NACO) of the Ministry of Health, which runs the NACP, and anecdotal evidence from voluntary agencies. “ART clinics in New Delhi are dispensing doses for 7 or 10 days only, forcing people to either make multiple visits for drugs or skip treatment. Such people can potentially spread infection as viral load goes up and they may also develop drug resistance”, said Paul Lhungdim, a member of Delhi Network of Positive People (DNP+), which monitors daily availability of ART and testing kits at nine clinics in the city. The government guidelines stipulate that each centre should stock 3 months' worth of antiretroviral drugs. “Intermittent stock outs of second-line drugs as well as kits for CD4 counts and viral load testing are being reported from several districts in Tamil Nadu, Kerala, and Pondicherry states. Patients are being forced to travel long distances to come to Chennai for second-line ART, and those who can't afford to do so are simply left to die”, said Periasamy Kousalya, president of Positive Women Network in Chennai. The Ministry of Health is playing down the shortages. “There is no overall shortage of kits or drugs for prevention and treatment of HIV/AIDS. However, sometimes shortages are reported from specific locations, and these are managed by diverting supplies from other locations”, health minister Jagat Prakash Nadda told parliament while admitting that funds for AIDS control in states has been slashed from INR9·28 billion in 2014–15 to INR5·40 billion for 2015–16. For the National Strategic Plan (2012–17) of the RNTCP, the allocation until 2014–15 is INR22·63 billion. A shortfall is looming as the projected expenditure for 5 years was INR45 billion. Administrative changes introduced by the new government in 2014 are delaying release of funds for the two programmes. NACO was merged with the health ministry in September, 2014, and funds to states are now flowing through state treasuries instead of directly from NACO to the State AIDS Prevention and Control Societies. The RNTCP, now integrated with the National Health Mission, faces a similar fate. The release of funds for tuberculosis from state treasuries is taking several months instead of 15 days previously, severely disrupting critical services and delaying payment of salaries to health workers. The combined effect of all the changes, experts and patient groups fear, could undo recent achievements such as the decline in new infections and AIDS-related mortality. “Slashing the budget and not ensuring timely release of funds to community-based organisations for prevention can reverse the gains of the last decade instead of reversing the HIV epidemic”, warned JVR Prasada Rao, the UN Secretary General's Special Envoy for AIDS in Asia and the Pacific. “Not ensuring timely availability of antiretroviral drugs can lead to discontinuation of treatment to several thousands of HIV positive people endangering their lives.” In the case of tuberculosis, delay in rolling out drug sensitivity tests and more effective daily dose therapy could boost drug resistance. Vikas Ahuja, president of DNP+, pointed out that a plan to provide free third-line ART, announced in 2013, was yet to be implemented. NACO is also not following WHO guidelines recommending the initiation of ART when CD4 cell count falls to 500 cells per μL. “This means first-line ART is yet to begin for thousands of HIV positive people as NACO still follows a previously recommended threshold of 350 CD4 cells per μL for starting ART”, Ahuja added. Increased funding and political support are central to the success of key disease control programmes, say experts. “The government has financial capacity to augment domestic resources to cover any future shortfall of external funding”, notes Rao.