Belinda Beresford The avalanche of Aids deaths flattening economies and smashing people’s lives is also rumbling at the heels of the pharmaceutical companies. Access to life-saving drugs, particularly anti- retrovirals, has been the cry of the Aids 2000 conference.
For many that meant lowering the costs of drugs so that not just those in the very top income bracket can afford to buy extra years of life. For others, including drug companies, it means first building an infrastructure from which to test and treat HIV-infected people. Then there are the demands for testing and distribution procedures to be implemented in accordance with best-practice protocols. The problem is that these can take years, while each year another 50E000 children are infected. Accusations of duplicitous behaviour abound, with governments, international organisations and pharmaceutical companies all accusing each other of communicating through the media, while piously asserting their interest in a “multi-sectoral approach”. But, as one speaker said, there seems to be a lot of debate where, in reality, there is agreement. The South African government, most researchers and NGOs agree that an infrastructure is needed to deliver medical care to people with the disease. Even if South Africa got free anti-retrovirals for all tomorrow, there are few doctors – and clinics – able to administer what are very complicated drug regimens.
With the possible exception of the pharmaceutical companies, most stakeholders are also in agreement that lowering drug prices is an important component in fighting the pandemic. Whether they truly feel that, the drug companies have implicitly agreed by announcing that they would be prepared to lower drug prices by up to 85% in certain circumstances. But the result seems to be inaction, as high court Judge Edwin Cameron said in his Jonathon Mann memorial lecture at the beginning of the Durban conference: “The drug companies and African governments seem to have become involved in a kind of collusive paralysis. “International agencies, national governments and especially those who have primary power to remedy the iniquity – the international drug companies – have failed us in the quest for accessible treatment.” Drug prices differ dramatically around the world, with World Health Organisation (WHO) and M’d’cins sans FrontiSres (MSF) just two bodies that have done price comparisons. Their figures back each other up. MSF has produced a report listing the costs of 10 drugs used in treating HIV/Aids. The report says the mini-mum price is on average 82% less than the United States price – a situation the agency attributes to the availability of generic products. Generic competition in Brazil means that the government there can treat 1E000 people with dual therapy for the same amount of money that the Uganda government would spend on treating just 228 people.
The problem for the drug companies is that they are under fire from all directions. They are facing increased pressure to allow developing countries cheaper and easier access to drugs to treat HIV and related infections. Simultaneously they are under constant pressure from shareholders. The implementation of compulsory licensing will mean they lose control over their intellectual property. There is concern about the mutability of HIV, which means that inappropriate use of medication can lead to it becoming resistant to the drugs. Even if drugs were given out free tomorrow it would be difficult to distribute them to people needing treatment, and to monitor how the treatment was going. Tests are also needed for the optimal use of drugs as anti-retroviral drugs can have very strong side effects and regimes need to be created and assessed carefully. This does not apply where the drugs are used for a short time – such as in preventing mother-to-child transmission.
US scientist John Mellors says drug resistance is not a serious problem in South Africa yet, although it is an increaing issue in areas such as the US where anti- retrovirals have been used for a long time. Meanwhile, reducing prices is just the first slippery step. Activists in the US are watching – cut prices of drugs on humanitarian grounds elsewhere and the question is going to be, why not do it in the US or Europe?
Drug companies have responded to the pressure by offering to make donations of drugs, or to offer reduced prices in certain circumstances. This too has come under attack, as having too many conditions attached.
A government official points out that the offer of free fluconazole from Pfizer applies to only HIV-positive patients who have a spinal tap to confirm they have cryptococcal meningitis. It will not be available for patients with other fungal infections who would also benefit from the drug. The offer also ends at the end of 2002 – six months after the patent on the drug expires. A WHO expert said that, whether true or not, it appears the offer is designed to keep the South African government from buying generic drugs for those six months after the patent ends. But privately aid workers point out that many countries in sub-Saharan Africa face no legal barrier to the production or import of generic drugs. Jeff Sturchio of Merck & Co pointed out that South Africa is one of the few countries in Africa in which patents are registered. “Why are generic manufacturers not already providing access in these country, where the patents are not there?” He also pointed out that the implementation of World Trade Organisation intellectual copyright agreements are not retrospective – countries producing generic drugs would not be prevented from doing so after joining the WTO. The development of anti-retroviral therapy, which hold the virus at bay, could be a pyrrhic discovery for drug companies. But hopefully it will lead to improved co-ordination on behalf of all involved so people with Aids can receive the best available medication.