IRIN Focus on HIV/AIDS initiatives

One of the major issues discussed at the international AIDS conference in Durban last year was the question of making anti-AIDS drugs available at a more affordable price to people living with HIV/AIDS – the majority of whom are in sub-Saharan Africa. But even before the conference there was a realisation among activists that bold new steps had to be taken to not only make the life-saving drugs more available, but also to develop a more coordinated response to ensure they are accessible to the poor. Nearly a year after the conference, there is still no coordinated effort even though drug companies have started to lower prices. This IRIN focus attempts to make sense of the welter of initiatives and drug offers available to governments. The initiatives In May last year, two months before the Durban conference, UNAIDS announced the ‘Accelerating Access’ programme, which it said was a “new public/private sector initiative”. In a press release on 11 May UNAIDS said that five major drug companies - Boehringer Ingelheim, Bristol-Meyer Squibb, Glaxo Wellcome, Merck & Co and F.Hoffmann-La Roche – had “indicated their willingness to work with other stakeholders to find ways to broaden access to care and treatment, while ensuring rational, affordable, safe and effective use of drugs for HIV/AIDS-related illnesses”. In a November 2000 bulletin  UNAIDS explained: “Countries or regional groupings of countries who wish to negotiate with these companies do so directly with each individual company, or with the facilitation of the UNAIDS co-sponsors and Secretariat as requested.” According to the agency, a number of countries including Kenya, Zimbabwe, Swaziland, Uganda, Senegal and Rwanda have formally sought the assistance of UNAIDS in developing national strategic plans to improve access to care, support and treatment. However only three countries – Rwanda, Senegal and Uganda – have reached agreements with four pharmaceutical companies to provide antiretrovirals at reduced prices. According to Medecines Sans Frontiers (MSF) even with the negotiated discounts, Senegal is still paying between US $1,008 and US $1,821 per patient per year for combination therapy – way beyond the reach of most Senegalese.   In a February 2001 bulletin  UNAIDS acknowledged that the prices offered by the companies do not include any additional costs such as charges by wholesalers or retail distributors. Last week UNAIDS said its tender process had identified 34 potential suppliers of HIV-related medicines and diagnostic equipment, 29 of who are from the generics industry. “An analysis of these will be publicly available in mid 2001,” a joint UNAIDS/WHO statement said. The process is aimed at acting as a guide for governments. Another initiative is the World Bank’s Multi-Country HIV/AIDS Programme (MAP) for Africa. Through the initiative an initial amount of US $500 million in “flexible” and “rapid funding” has been made available to African countries to scale up their national HIV/AIDS efforts. According to the Bank, the money would be committed to individual HIV/AIDS projects developed by countries, using standard international credit agreements. The problem with this initiative, critics have argued, is that countries would get themselves into more debt if they wanted to make use of this facility. What the drug companies are offering One of the first proposals on price cuts was made by Pfizer last year. It said it would give, free of charge, its expensive drug Diflucan to AIDS patients in South Africa suffering from cryptoccal meningitis, a lethal brain infection. In 1999 Pfizer sold about US $1 billion of the drug. Although the offer was made last year, the company only recently finalised the arrangement with the South African government. “An agreement has been signed with the South Africans. The donation is valid for two years and patients who start taking the drug during these two years will have access to it free of charge for the rest of their lives. Because once therapy has begun it must be continued on a daily basis for rest of the patient’s life,” a spokeswoman for Pfizer told IRIN. The normal retail price of Diflucan is between US $13 and US $17 a day. The generic version known as Fluconazole sells for about US $1.50 a day in Thailand where Pfizer’s patent is not honoured. “The drug is being distributed through the normal channels within the South African health care system. Pfizer decided that it would be best if we used the existing facilities,” the spokeswoman said. Between 2 and 8 percent of AIDS patients become infected with cryptoccal meningitis. In July last year the German company Boehringer-Ingelheim said that it was willing to supply Nevirapine to the South African government free of charge, for a period of five year. The drug has been shown to reduce mother-to-child HIV transmission. The South Africa government has been unable to take up the offer because clinical trials regarding the safety of the drug are still being conducted at various hospitals around the country. The South African Medical Research Council has not yet registered Nevirapine, although it is widely available internationally. Last month Merck announced that it was cutting the price of two of its antiretrovirals. The company said in a statement that patients would now pay US $600 per year for Crixivan and US $500 per year per patient for Stocrin. “Merck will make no profit on these medicines in the developing world,” the statement added. “These prices apply to the developing world and will be made available to all customers (governments, NGOs and private-sector employers) who can make the medicines accessible to patients. The only condition is that the medicines must be used in the country where they are sold and not exported.” Crixivan is a protease inhibitor and Stocrin a non-nucleoside reverse transcriptase inhibitor. A protease inhibitor is a class of medicines that inhibits the protease enzyme that the HIV virus depends on to replicate itself. Although public health officials in South Africa welcomed Merck’s announcement, they pointed out the drugs are still beyond the reach of many. “That is more than most people earn in one year,” a senior department of health official told IRIN. “It may be a step in the right direction but this is still way too expensive for the vast majority of Africans among whom HIV figures are the highest,” she added. According to MSF, Indian generic manufacturer Hetero sells the equivalent treatments for about US $347. Per Wold-Olsen, president of Merck’s human health business in Europe, Middle East and Africa, said the UN access initiative has made it possible for the company to have “direct discussions with more than a dozen developing countries”. But, he noted that although “significant progress” had been made “patients were not getting access to medicines as quickly” as Merck had hoped. Also in March, Bristol-Myers Squibb (BMS), the third-largest drug company in the US said it would cut the cost of two of its AIDS drugs. BMS said in a statement that the price reduction would fall under the existing partnership with UN agencies. “Under this programme, the company’s medicines to treat HIV/AIDS – the nucleoside reverse transcriptase inhibitors Videx and Zerit – will be available in every country in Africa that wishes to participate at a price of US $1 per day – 15 cents per day for Zerit and 85 cents per day for Videx. These are below costs,” BMS said. The company added that the patent for Zerit would be made available free in South Africa. Videx can be bought in Thailand for about 36 cents. Last week, Abbott Laboratories announced it would offer two of its antiretrovirals and a test for HIV at a discounted price. The offer involves the protease inhibitors Kaletra and Norvir and the “Determine” test kit. The company has not yet said what it would charge for the drugs or the test. In the United States an annual supply of Norvir costs about US $7,100 wholesale, with Kaletra costing about US $6,500 per year. Last year sales of Norvir globally made an estimated US $200 million. Abbott’s price reduction is allegedly unique because the company has enlisted the help of Irish consulting firm Axios International to help distribute the drugs, an article in the ‘Wall Street Journal’ said last week. “Abbott is providing its drugs in the most responsible way because it plans to also make sure that there are clinics and infrastructure in place so that drugs actually reach patients,” the newspaper quoted a drug analyst, Legg Masson, as saying. In its statement Abbott said that it would continue its “ongoing dialogue” with representatives from WHO and UNAIDS to “optimise access to anti-retroviral therapies and use of diagnostic tools”. Last year the world’s largest drug manufacturer GlaxoSmithKline (GSK) said that it was significantly reducing the prices of its antiretrovirals – Epivir, Retrovir and Combivir. As a result, as part of a triple combination regimen Combivir would cost about US $2 a day. “These preferential prices are offered to UN-supported and nationally led HIV prevention and care programmes for use in international partnership programmes which simultaneously address the healthcare infrastructure and drug distribution aspects which are necessary to ensure access to safe and effective treatment,” GSK said on its website. Vicki Ehrich from GSK’s external relations department in London told IRIN that GSK was involved with the UNAIDS Accelerating Access initiative. “In addition we support UNICEF’s mother-to-child programme and GSK has been offering its antiretroviral, Retrovir, at preferential public sector prices for low income countries with a high prevalence of HIV and has given 30,000 free courses of AZT to prevent mother-to-child-transmission,” Ehrich said. “A problem that we have encountered is that the demand for the free stock of Retrovir has been below what was anticipated and thousands of treatment courses will have to be destroyed as they expire.” AIDS activists have argued that GSK has not done enough in cutting costs and in making AIDS drugs more affordable. “They have said this is what we are planning but the reality is that they haven’t really come up with anything yet. And yet they are arguably the largest drug company in the world, manufacturing the vast majority of the antiretrovirals that are needed,” one activist told IRIN. “The problem surrounding access to drugs in the developing world is far more complex than pricing alone,” Ehrich noted. “Experience has shown that partnerships are essential if progress is to be made. Factors such as the political will of the national governments, the commitment of donor countries to fund the affected country programmes, and the development of infrastructure are all necessary parts of the solution.” The generic factor Last month Indian generic drug maker Cipla said it would supply a triple-cocktail of AIDS drugs to the world’s poor at less than US $1 a day. Cipla said that it would make the offer available through MSF for US $350 per patient per year and to governments for US $600 per patient per year. Indian drug firms are allowed by local laws to manufacture drugs that are patented elsewhere in the world, providing that the process is different from the original patented process. Cipla is offering three drugs: Stavudine, Lamivudine and Nevarapine. BMS holds the patent on Stavudine or Zerit in most of the world, GSK has the patent on Lamivudine or Epivir and the German company Boeringer Ingelheim owns the patent on Nevarapine or Viramune. What the critics say Some AIDS activists have argued that what is desperately needed at this stage in the fight against HIV/AIDS is a much more coordinated approach. Imagine that you are a health minister from a poor developing country and for years you have been battling to get cheaper drugs, said the South African health official. Now you hear about all these offers from drug companies, which way do you turn? Where do you go for advice? “Let’s face it,” she added, “at the moment we have the UNAIDS initiative which is great, but still doesn’t go far enough. They need to play a far more active role in helping governments decide which is the best route to take. They need to maybe get in on the whole negotiating process with the drug firms. If we have some kind collective body negotiating on our behalf we as the developing world stand a far better chance in getter a good deal.” She went on: “Maybe what we need to see happen is the creation of a whole new agency that would deal with the procurement and distribution of AIDS drugs specifically; that would negotiate on behalf of governments and make sure that the drugs they are buying are what they really need and suites the specific conditions of that country and not what the drug companies tell them they need. Let’s face at the end of the day, for the drug companies the bottom line is what counts,” she added. In an editorial in the ‘New York Times’ last week, Carol Bellamy, UNICEF’s Executive Director said that attention was now turning to the question of how to deliver AIDS drugs to those who need them. “This is no simple proposition, but it is feasible ... Now UNICEF is prepared to step forward as the lead United Nations agency in the procurement of antiretroviral drugs on behalf of individual countries,” Bellamy said. “The immunisation campaign that began in the early 1980’s succeeded because we were able to develop effective strategies for funding procurement and distribution of vaccines – and these same approaches can help the world fight AIDS.” Sources within the pharmaceutical industry told IRIN that they could not imagine drug companies accepting a coordinated response. “Of course drug companies agree that a more coordinated response to drug access issues is needed, but to say that they will give up their rights to negotiate with each country individually? I don’t see that happening,” one source said. “By negotiating with each country individually we get the best possible deal. Don’t forget most drug companies have now got specific programmes through which they channel aid in the form of free drugs, free equipment and providing qualified medical help. But ultimately patents are being protected and profits ensured,” she added. For more information on treatments and conditions please see:
http://www.aids.org/FactSheets/ Also IRIN’s HIV/AIDS weekly: