Fabiana Frayssinet*
RIO DE JANEIRO, Jun 27 2007 (IPS) – In under a decade, programmes providing universal free access to antiretroviral medicines have greatly decreased AIDS mortality in countries like Argentina and Brazil, but this progress is now threatened by the rising prices of new formulas patented by the big pharmaceutical companies.
Credit: World Health Organisation
The Brazilian Health Ministry guarantees access to antiretroviral medications for all people with HIV/AIDS.
According to the National Programme on Sexually Transmitted Diseases and AIDS (PN-DST/AIDS), 180,000 people in Brazil are regularly taking these drugs, which reduce the HIV (human immunodeficiency virus) load in the body, improving quality of life and preventing opportunistic infections.
Between 1996 and 2004, antiretrovirals contributed to lowering AIDS mortality by 27.5 percent, and between 1996 and 2003, AIDS-related hospital admissions fell by 80 percent. This saved the health services 635,000 hospital admissions and an estimated 1.7 billion dollars in health costs, according to official figures.
The same trend is seen in Chile, which achieved universal antiretroviral coverage in the public health sector in 2003. The effects of widespread use of these drugs can already be clearly seen, and AIDS-related health indicators have improved, Patricio Novoa, coordinator of the holistic healthcare department at Vivo Positivo (Living Positive), an umbrella group of Chilean organisations for people living with HIV, told IPS.
In Argentina, the Health Ministry says that in 1996 before antiretroviral treatment was available AIDS mortality stood at 60 percent, while by 2004 mortality had dropped to 38 percent, and the figure is doubtless even lower now, the executive director of the non-governmental Fundación Huésped, Kart Frieder, told IPS.
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These indicators are accompanied by other non-quantifiable benefits, says Veriano Terto, coordinator of the Brazilian Interdisciplinary AIDS Association (ABIA).
The big change that has occurred since antiretroviral meds became available is that as patients quality of life has improved, the link between being HIV-positive and death has been broken, the idea that because one has AIDS one is doomed to die. AIDS and the stigma of death have been separated, Terto said.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) considers Brazil s programme one of the best and most successful in the world. Seventeen drugs are included in the anti-HIV cocktail used in this country: eight of these are imported and nine are produced locally, in government laboratories like Fiocruz.
Production of generic drugs, which have the same active ingredients as patented medicines but are far cheaper, knocked down the average cost of treating one patient for one year from 6,240 dollars in 1997 to 1,336 dollars in late 2004, said Mariangela Simao, the director of PN-DST/AIDS.
These savings were achieved by a combined policy of government funding for manufacturing generic medicines, and vigorous negotiation with the big transnational pharmaceutical companies to bring prices down.
The negotiations were successful, for instance, when Brasilia threatened to impose obligatory licensing, a mechanism under international trade rules that in effect annuls the patent in the country where it is enacted. This persuaded Roche to reduce the price of Nelfinavir by 40 percent, leading to savings of 40 million dollars a year, and Merck to accept a 60 percent price cut for Efavirenz, saving the Brazilian state another 43 million dollars a year.
The most publicised case came earlier this year, when the failure of new negotiations to cut the price of Efavirenz prompted the Brazilian government, for the first time ever, to require obligatory licensing for public, non-commercial use of the drug, a pioneering step in Latin America.
Brazil based its action on the intellectual property agreements adopted by the World Trade Organisation (WTO), which established the priority of public health over patenting rights, in order to allow countries to take such measures when facing health emergencies.
Buying the generic version of Efavirenz, at first from laboratories in India, will lead to savings of 30 million dollars a year in health spending, said Simao, and this money can be invested in other measures to improve health care for people living with AIDS, she added.
UNAIDS takes a positive view of measures taken by a country to ensure universal access to medicines by its population, the agency s representative for South America s Southern Cone region, Laurent Zessler, told IPS.
Brazil, a middle-income country, has shown that it is possible to implement free distribution of medicine nationwide, and that this is associated with treatment compliance by people living with HIV, he added.
The bad news, according to Simao, began in 1995 when more patients were gradually coming forward for treatment. Then when new medicines came on the market, individual treatment costs began to rise.
The greatest challenge now is not only to maintain the good results achieved so far, but to extend them further, and guarantee that they will be sustainable in future, warn non-governmental organisations like ABIA, represented by Terto.
The new medicines are increasingly expensive and increasingly heavily protected by patents, and as the number of treatment cases rises, it will be difficult for the government to maintain its programme, Terto said.
The same obstacles may affect the Argentine programme, Frieder said.
New medicines have begun to appear, for which no generic versions exist, nor are they listed in pharmacopoeias. They are used to improve the patients quality of life, for example, they involve taking one pill a day instead of six, and access to them will be more difficult, Frieder said.
The price hikes are also causing concern at the international humanitarian organisation Médecins Sans Frontières (MSF Doctors Without Borders), which treats more than 80,000 HIV-positive patients in more than 30 countries.
An article published on the MSF website called attention to the cost explosion of antiretrovirals and said its spending on these drugs will double in the next two years, as more and more patients have to move on to more modern, second-line treatments.
Around 50 pharmaceutical companies throughout the world are producing these medicines, MSF said, and new treatments and potential vaccines are being developed because they have a market in Western countries.
However, the article points out that of the 40 million people infected with HIV/AIDS, 90 percent live in the developing world, and out of the six million people in developing countries who need antiretroviral drug therapy, only 440,000 are receiving it, based on UNAIDS figures from 2005.
Solutions for the future, whether initiated by UNAIDS, MSF or the William J. Clinton Foundation, will have to be based on antiretroviral donations, production and technical training networks.
Brazil, for instance, donates locally produced antiretroviral drugs to 11 countries: Bolivia, Burkina Faso, Cape Verde, Colombia, East Timor, El Salvador, Guinea Bissau, Mozambique, Nicaragua, Paraguay, and Sao Tomé and Príncipe, according to Simao.
In January 2006, Brazil and Argentina signed a cooperation agreement for the building of a pharmaceutical plant to manufacture medicines and diagnostic tests for several diseases, including AIDS.
The plant is to be built in Argentina and will be financed by investments from both countries.
Brazil coordinates an International Technical Cooperation Network on HIV/AIDS to which Argentina, China, Cuba, Nigeria, Russia, Thailand and Ukraine also belong. Its primary purpose is technology transfer for antiretroviral production.
These initiatives have contributed to the sustainability of antiretroviral distribution programmes in countries like Bolivia, where for the past four years AIDS victims have had access to the medicines through departmental (provincial) health services. Brazil has donated antiretrovirals to Bolivia since 2003.
In Venezuela, all HIV/AIDS patients registered with the Health Ministry have had access to the drugs free of charge since the year 2000.
Between 20 and 30 million dollars a year are spent on this programme. The 17 medicines used are bought from Cuba and India, among other manufacturing countries, and Caracas supports Latin American negotiations with the big international pharmaceutical companies to secure price reductions.
The cooperation network is beginning to take shape in Paraguay, too, where 1,184 people receive the drug cocktail through the National Programme on AIDS. The mortality rate has been cut by 30 percent since 1996, programme director Nicolás Aguayo told IPS.
Paraguay also participates in a Brazilian government initiative called South-South Links, under which 300 people, including 21 children, receive antiretroviral medication.
(*With additional reporting from Marcela Valente in Argentina, Bernarda Claure in Bolivia, Daniela Estrada in Chile, David Vargas in Paraguay and Humberto Márquez in Venezuela.)