[Ip-health] MSF letter to the Lancet on access to ARVs

[Michelle Childs]

MSF responds to the recent Lancet special on AIDS; the graph on pricing of
ARVs
could not be reproduced; see Untangling the web at
http://www.accessmedmsf.org/documents/untanglingtheweb%209.pdf or the
original
lancet article. Copied as fair use.

The Lancet, Vol 368 September 23, 2006

A missed opportunity?

The past 5 years have been essential to increasing access to antiretroviral
treatment in resource-poor countries, and this experience has raised many
challenges. The first was simply to start treating patients in the face of
criticism and doubts expressed by the scientific community1 and major
donors,2 with little support from UN agencies.

 Although we welcome The Lancet's initiative to devote an issue to
HIV/AIDS, we are disappointed that so much space was devoted to
uncontroversial and apolitical statements by UN agencies. Behind the
self-congratulation of multilateral agencies lies the fact that universal
access is far from within reach, and strategies to ensure longterm quality
care in resource-limited settings hardly exist. Ensuring free, long-term
treatment access will require more than goodwill, and affordable medicines
do not suddenly appear with the publication of new formularies. WHO's
public-health approach to antiretroviral therapy focuses on the "Fours
Ss": when to Start, when to Substitute, when to Switch, and when to Stop.3
But who will pay the price of this strategy? Most countries are barely
managing with the first and last S (starting and stopping).

Although basic first-line therapy costs are as low as US$132 per patient
per year, the main substitution for toxicity requires tenofovir, which is
rarely registered, at least 2.5 times more costly, and not available as a
triple fixed-dose combination. Basic second-line regimens currently cost
at least ten times more (figure).4 At these prices, 10% of patients on
second-line therapy would represent over 60% of the national drug budget.
What is WHO doing to address this issue? Price is only a part of the
problem. Of the 13 drugs recommended by WHO, only six have
been prequalified. There are no generic prequalified versions of any of
the five antiretrovirals specifically recommended for second-line
treatment (didanosine,atazanavir, lopinavir/ritonavir, saquinavir, and
ritonavir), and only two originator companies offer a differential price
for these pro now in full force in major generic-producing countries such
as India-on whose generic medicines around half of those receiving
antiretroviral treatment in the developing world currently depend-it is
unlikely that generic versions of these and other new drugs will be
produced without a serious political struggle.

The recent removal of the WHO representative in Thailand for suggesting
that compulsory licensing should be considered an option for securing
affordable second-line medicines shows how little progress has been made
to confront these major political barriers.5 That none of these issues
were addressed by the major multilateral agencies who dominated The
Lancet's special issue provides further confirmation of the lack of
political courage where it is needed most.

We declare that we have no conflict of interest.

*Alexandra Calmy, Fernando Pascual, Sheila Shettle, Felipe Garcia de la
Vega, Nathan
Ford
acalmy@stvincents.com.au
MSF Campaign for Access to Essential Medicines, 78 rue de Lausanne, 1202
Geneva,
Switzerland; and Medecins sans Frontieres, Bangkok, Thailand

1 Marseille E, Hofmann P, Kahn J. HIV prevention before HAART in
sub-Saharan Africa.
Lancet 2002; 359: 1851-56.

2 Donnelly J. Natsios called racist; firing sought. Boston Globe Sept 6,
2001.

3 Gilks C, Crowley S, Ekpini R, et al. The WHO public health approach to
antiretroviral treatment against HIV in resource-limited settings. Lancet
2006; 268:
505-10.

4 Campaign for Access to Essential Medicines. Untangling the web of price
reductions: a pricing guide for the purchase of ARVs for developing
countries, 9th
edn. Geneva: Medecins sans Frontieres, 2006.
http://www.accessmedmsf.org/documents/untanglingtheweb%209.pdf (accessed
Sept 12,
2006).

5 Williams D. World health: a lethal dose of US politics. Asia Times June
17, 2006.
http://www.atimes.com/atimes/Southeast_Asia/HF17Ae01.html (accessed Aug
31, 2006).


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--
Michelle Childs -Head of European Affairs
Consumer Project on Technology in London
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http://www.cptech.org

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