AIDS TREATMENT NEWS Issue #347, July 28, 2000
John S. James

* MSF (Medecins Sans Frontieres, also known as Doctors Without Borders, which made news earlier this year for winning a Nobel prize for its work) studied drug prices internationally and talked to generic manufacturers in Brazil and Thailand, and learned that the drug price for certain modern antiretroviral combination treatments could be reduced to as little as $200 per year in developing countries, assuming large-scale production (all prices in this article are in U.S. dollars). At this price, treatment could be feasible in most of the world through private and/or public funding.

$200 per year is about a tenth of the "85% reduction" price from the recently announced public-private partnership of UNAIDS and major pharmaceutical companies. It is also much less than current generic prices in countries which allow generic competition with antiretrovirals, all of which are patented in their country of origin (although not in many developing countries). These higher generic prices reflect much smaller production runs, which must recoup high set-up costs.

MSF also noted that there are precedents for great price differences in essential drugs between developing and wealthier nations. For example, oral polio vaccine costs 33 times less for international health organizations than the price the U.S. government pays--which is a fraction of the catalog price which an individual in the U.S. would pay. (By suggesting widely different prices we do not mean to imply that U.S. proprietary drug prices should not be reduced--only that they do not need to be reduced to 2% or 3% of current levels, the prices viable for many African or other developing countries.)

$200 per year for antiretroviral combinations would not pay for research to develop the next generation of drugs. But the current situation, where people in poor countries are left to die without standard treatments, does not pay for this research either.

The $200 per year figure provides a target to work toward, and a place to begin in planning for making treatment access more available. It allows work to begin on providing simpler treatments (including opportunistic infection prophylaxis, nutritional improvement, clean water, and other approaches)-- without the issue of accepting a lower standard of care (no antiretrovirals regardless of medical need) for the developing world.

The full report (Campaign for Access to Essential Medicines. HIV/AIDS MEDICINES PRICING REPORT. SETTING OBJECTIVES: IS THERE A POLITICAL WILL? by Carmen Perez-Casas with co- authors Daniel Berman, Pierre Chirac, Toby Kasper, Bernard Pecoul, Isabelle de Vincenzi and Tido Von Schoen-Angerer) is available at http://www.accessmed-msf.org (or see http://www.msf.org). It was released by MSF on the opening day of the conference, July 9.

* Brazil is now providing antiretroviral treatment to over 80,000 patients, through generic production within the country. But before the Durban conference, its success was not completely known internationally, even to specialists. Generic production has resulted in a price drop of almost 80% within the last five years.

* At the Durban conference, ACT UP Paris organized a meeting between health ministers and generic manufacturers. We could not attend as it was closed to the press so that participants could speak freely, but we heard that it was very successful, with the beginnings of a bargaining dialog on potential drug purchases.

* Also, this conference highlighted a shift in thinking on prevention. Many have feared that treatment would take resources away from prevention, which could save many more lives per dollar spent. Now there is growing agreement that prevention is indeed the most important, but also that treatment must be possible for prevention to work, as otherwise people have no incentive to be tested.

* Several major pharmaceutical-company donation programs were announced at the time of the conference. Boehringer Ingelheim said that it would donate nevirapine for preventing transmission from pregnant women to their children. Merck & Company and the Gates Foundation announced a $100 million five-year program for Botswana. Abbott will donate financially to four countries, two of them in Africa (Tanzania and Burkina Faso).

* On July 17 the Treatment Action Campaign (TAC) announced a "defiance campaign" to import fluconazole, an important antifungal, into South Africa, from countries where it is many times cheaper. For more information see the TAC Web site, http://www.tac.org.za/

* The July 9 rally and march in Durban just before the conference, mostly by Africans, showed that the movement for treatment access is developing broad public appeal in Africa, not limited to AIDS specialists and activists. Organized primarily by TAC, the march drew between 2,000 and 5,000 participants--apparently the largest AIDS march ever in Africa.

Before the conference, if a health minister from a developing or least-developed country wanted information on how to move toward access to HIV treatment, it was difficult to know where to begin. Now the path is more clear.

From the MSF Report

* "Solely because of the price change [of fluconazole, from $7.00 per capsule to 30 cents when generic production was allowed], cryptococcal meningitis has become a treatable illness in Thailand."

* "Nowadays, it costs an HIV/AIDS patient living in Thailand $9 per month to prevent cryptococcal meningitis, a life- threatening disease. But if this person happens to be in South Africa, he/she will pay $123 per month for the same product supplied by the public sector (nearly 14 times more). To purchase this same drug from the private sector would cost 71.4 times more."

* "One of the most striking examples of what is possible comes from Brazil. Locally produced antiretrovirals are sold at a fraction of their global price. A generic form of zidovudine (AZT) is 14 times cheaper in Brazil than in the U.S."

* "In Brazil where [ddI and d4T] are produced locally as generics, the total monthly cost of dual therapy combination is the cheapest at $78 per month, followed by Thailand, where both products are also available locally as generics, at $96 per month. In Uganda, where no generics are available, the total cost comes to $342 per month..."

* "Mechanisms to reduce the cost of HIV/AIDS treatment:

"1. Role of generics. The most recent patent on all products in this report [which included 6 antiretrovirals, but no protease inhibitors] was granted for efavirenz on 17 August 1992, before many developing countries put their patent systems into effect. This means that practically speaking, generic versions of all these products could be made available today in a significant number of developing countries; countries only need to identify quality affordable suppliers and register these products with regulatory authorities. However, patent status is a national issue and needs to be researched on a country-by-country basis.

"2. Intellectual property rights: Public health safeguards. Since the creation of the World Trade Organization (WTO) in 1994, and the completion of the Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement, more and more countries (WTO had 137 member states as of 14 June 2000) are obligated to grant 20 year patent protection for drugs. According to the TRIPS agreement, this minimum standard must be enshrined in national law by 2006 in all signatory countries. Developing countries had a deadline of January 2000, with some exceptions, while least developed countries have until 2006 to change national laws. In practical terms this means that poor countries will soon lose access to affordable life-saving medicines unless they write TRIPS safeguard provisions into their national laws..." [The report discusses three major safeguards: compulsory licensing, parallel imports, and "Bolar" provisions (which allow generic manufacturers to prepare their manufacturing process and regulatory approvals before a patent expires, so that their product can be ready to market at the time of expiration).]

* The report includes seven recommendations. The first one is:

"Governments from both developed and developing countries, WHO, UNAIDS, NGOs, with the input of both proprietary and generic pharmaceutical companies, should work together to find sustainable solutions for countries that do not have adequate access to life-saving and other key medicines."
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