As AIDS drug prices plummet for Third World, questions still abound

LONDON It's time for some very clear thinking about how to deal with the appalling impact of AIDS in Third World countries, particularly in Africa, where most of the world's cases reside and where some devastated communities are 70% HIV-positive. Five leading pharmaceutical companies have dropped their Third World prices dramatically for components of HAART (highly active retroviral therapy), which for those who can afford it has turned a diagnosis of HIV positive from a death sentence into something considerably more bearable.Fourteen of the drugs that can be used in HAART are listed below, and prices in the rich world will remain the same at around $10,000 a year for a full 'triple therapy', but the World Health Organization (WHO) and UNAIDS have negotiated immense price reductions for seven of them: AZT + 3TC will be available in Africa at US$2 per day, 3TC at US$0.58 per day, Nevirapine at US$1.22 per day, ddI at US$ 0.85 per day, d4T at US$0.15 per day, Indinavir at US$1.6 per day and Efavirenz at US$1.3 per day. This amounts an effective reduction of treatment costs by a factor of ten.Cipla, the Indian generics manufacturer, is also negotiating with the South African and other governments to produce antiretrovirals (ARVs) for prices even one-half of these.But is this really enough to make a difference? As Manela Majola, Treatment Action Campaign Coordinator for the Western Cape Province, one of the nine provinces of South Africa, told BioMed Central: "Most of the people here with HIV are from poor backgrounds, and unemployed. Even if the drugs are sold at US$100 a year, the unemployed couldn't buy them. Most of the people I've come across who are HIV positive are battling to get something to eat. You tell me how they are going to be able to pay these prices? But if these drug companies can sit down with us and work out a way in which the drugs could be cheap enough that the government could afford them, and if the government could make them available free of charge to the unemployed, then we could really help.""The Treatment Action Campaign educated me about AIDS. In my community I began to convene workshops, awareness campaigns, marches — most of the people are not dying because they do not care, they are dying because of ignorance. Because they don't know how they get infected. I told the community that there are treatments, but they are very expensive. So I said we have to stand up for our rights and fight the drug companies."Steven Forsythe, a Senior Scientist with the Futures Group International in Washington DC, who last year ran a forum on HAART economics in developing countries said: "I agree that at $350 per year [the Cipla prices], ARVs are still out of reach of most African countries. We did a willingness to pay of people with AIDS in Kenya, for example, and found that less than 1% of these people were willing and able to pay this amount. This means that at this price, only the rich will be able to afford ARVs. In fact it might be argued that subsidised access to ARVs is really a way to shift resources away from the poor and to the rich."There are also serious medical concerns regarding the introduction of ARVs at this price, Forsythe argues. "Since a limited number of drugs are being offered by Cipla, clients who fail treatment would have to switch to much more expensive medications. Furthermore, since viral load tests [a component of the complex HAART treatment regime] are still very expensive, it is likely that these tests will be eliminated and drug resistance will become much more common in these countries."Strikingly, fears of increasing resistance to and 'virologic failure' of HAART has prompted the announcement of a new UK–Canada–US HIV treatment trial — OPTIMA (Options in Management with Antiretrovirals). The study, scheduled to start in June, will evaluate the best treatment strategies for HIV-infected patients for whom HAART has failed."At the same time, I think it needs to be recognised that the price reductions we are seeing are truly dramatic," says Forsythe, "much greater than I would have predicted even a year ago. While I don't think we are quite yet at the point of affordability, I do believe we are getting closer. I estimated in Kenya that the price of ARV therapy would need to come down to about $120 a year in order to be affordable for the government. However, I estimated that even if these drugs were free, this could not be achieved because the non-drug costs of ARV therapy are greater than this," he added.Meanwhile in South Africa a cluster of the major manufacturers of ARVs is continuing to challenge the government over its plan to import generics. According to the government, AIDS represents a 'national emergency' and so would be allowed under the international 'TRIPS' agreements which establish patent rights worldwide. A South African judge has given the companies until mid-April to make their case in court, and meanwhile the companies have dropped their prices to Africa in an attempt to keep generics out and to protect the principle of patent protection.After all, as Professor Andrew McMichael, Head of the Medical Research Council Human Immunology Unit at the University of Oxford says, "The pharmaceutical industry went for the drugs, and they've done a fantastic job. Whatever you think about the prices, the science is superb. They've come up with reagents that really work — and they are the first real antibiotics for viruses."So, some argue that it seems reasonable the companies should have a return on their investment. Otherwise they will not do similar research in the future, when it is needed. The issue of AIDS control and treatment in the Third World is an issue for governments and philanthropy, say AIDS experts, and fundamentally the solution is economic development for the poorest of the world — in education and health infrastructures, in communications, in farming and fair product pricing and wages. Dropping the prices of drugs is only the tip of the iceberg.Finally, what drugs are we talking about, who makes them, and how long will their patents actually last? Here are 14 of the main drugs that are used as components of the 'triple therapy' prescriptions:Nucleoside analogue reverse transcriptase inhibitors:• Zidovudine (AZT) or 'Retrovir', Glaxo Wellcome, patents expire 2005;• Didanosine (ddI) or 'Videx', Bristol-Myers Squibb, patents expire 2006;• Zalcitabine (ddC) or 'Hivid', Hoffman La Roche, patents expire 2006-08;• Stavudine (d4T) or 'Zerit', Bristol-Myers Squibb, patents expire 2008;• Lamivudine (3TC) or 'Epivir', Glaxo Wellcome, patents expire 2009-16;• Abacavir or 'Ziagen', Glaxo Wellcome, patents expire 2009. Protease inhibitors:• Saquinavir or 'Ivirase' or 'Fortovase', Hoffmann-La Roche, patents expire 2010;• Ritonavir or "Norvir', Abbott, patents expire 2012-14;• Indinavir or 'Crixivan', Merck, patents expire 2013;• Nelfinavir or 'Viracept', Agouron, patents expire 2013;• Amprenavir or 'Agenerase', Glaxo Wellcome, patents expire 2013;• Lopinavir (80%) + Ritonavir (20%) or 'Kaletra', Abbott, patents expire 2012-16. Non-nucleoside reverse transcriptase inhibitors:• Nevirapine or 'Viramune', Roxanne Laboratories (USA) & Boehringer Ingelheim Pharmaceuticals (rest of world), patents expire 2011;• Delavirdine or 'Rescriptor', Pharmacia & Upjohn, patents expire 2013;Efavirenz or 'Sustiva', Dupont Pharmaceuticals, patents expire 2012-14.

As AIDS drug prices plummet for Third World, questions still abound

lites benefit? And what about drug resistance?

Interested in reading more?

Become a Member of