HIV and Aids bad news for drug prices in middle income countries

Middle-income countries with large numbers of people living with HIV will no longer benefit from preferential pricing when buying antiviral drugs from large pharmaceutical companies, according to the annual Médecins Sans Frontières (MSF) drug pricing report, Untangling the Web of ARV Price Reductions.

"The main bad news in the study is the fact that a number of pharmaceutical companies will no longer be providing preferential pricing to middle-income countries like Brazil, China, India and Thailand," Nathan Ford, medical director at MSF's Campaign for Access to Affordable Medicines, said at the launch of the report at the sixth International AIDS Society conference on HIV pathogenesis, treatment and prevention in Rome.

According to the report, pharmaceutical firm ViiV Healthcare – owned by Pfizer and GlaxoSmithKline – no longer offers reduced prices to middle-income countries, even when their programmers are fully funded by the Global Fund to fight Aids, Tuberculosis and Malaria.

Merck has also ceased to offer discounted prices to all lower middle- and upper middle-income countries, proposing instead to negotiate discounts on a case-by-case basis. Previously, Merck offered middle-income countries discounts that were still up to 10 times the price of generic versions. Of particular concern is the price of the UN World Health Organization-recommended third-line drug raltegravir – an integrate inhibitor that blocks retroviral replication – which costs up to US $5,870 per person per year in Brazil, compared with $675 in sub-Saharan Africa.

Janice Lee, pharmacist at MSF's Campaign for Access to Essential Medicine, noted that drug company discount programmers were not a long-term solution, and governments would have to start using trade-related aspects of intellectual property rights (Trips) measures to override patents. In the past, Brazil and Thailand have used compulsory licenses – when a government allows someone else to produce the patented product or process without the consent of the patent owner – to lower prices in their countries.

The report notes that Abbott excludes low- and middle-income countries from differential prices for the standalone heat-stable ritonavir 100mg tablet. It blocks the enzyme protease, required by HIV to make new viruses. A spokesman for Abbott said the company's long-standing pricing policy would protect the poorest people living with HIV.

"Abbott's preferential pricing policy for ritonavir has been in place, unchanged, for a decade," Dirk van Eeden, director of HIV communication and policy at Abbott, told IRIN/PlusNews via email. "It includes all African and least developed countries, where the outright majority of patients with HIV live."

ViiV Healthcare also defended its pricing policy, saying it was committed to ensuring access to its medicines.

"For least developed countries, low-income countries, and sub-Saharan Africa we offer not-for-profit prices and royalty-free voluntary licenses. In middle-income countries we have a clear tiered pricing approach, where prices are based on the GDP of the country and the burden of the epidemic," said Rebecca Hunt, ViiV spokeswoman, via email. "This approach means that our medicines are available to those who need them the most and that ViiV Healthcare can generate a sustainable return to research and develop the HIV medicines of the future."

The recent decision by Gilead Science to sign a licensing agreement with the Medicines Patent Pool to increase access to HIV and Hepatitis B treatment in developing countries also excludes middle-income countries.

The good news

There is some good news, though. A once-daily combination pill containing tenofovir – a WHO-recommended first- and second-line drug – costs $173 per person per year, compared with $613 five years ago.

"We're seeing drug prices continue to decline when patents do not form a barrier to generic production," said Lee. "These reductions increase the feasibility of reaching the new UN goal of getting 15 million people on treatment by 2015."

The reductions in price for less toxic medications such as tenofovir also ease the pressure on over-burdened health systems.

"Tenofovir is much less toxic than Stavudine [no longer recommended by WHO due to its toxicity], which now allows us to put more people on it and ease the pressure on our health services; we can get patients into self-management without worrying about the effects of drug toxicity," said Eric Goemaere, medical director for MSF in South Africa.

He noted that there was an urgent need for the price of second- and third-line ARVs to fall to make them more accessible to HIV-positive people in poor countries. Drugs such as Johnson & Johnson's darunavir - which, when boosted by ritonavir, is listed by WHO as a potential third-line drug - are not free in most ARV programmes, and cost as much as $1,095 per person per year in sub-Saharan Africa.

"We have a few patients who need third-line treatments, but we are forced to tell them: 'We have no option for you'. They have to go to the private sector to access drugs like darunavir," Goemaere added.