Sunday, March 20, 2011

What if HIV Drug Pricing Depended on 'the Market', Rather Than Subsidy?

Are HIV programs in developing countries really in danger of collapsing because donor funding is being cut? This would result in the HIV drug subsector suddenly having to do without public money, which has supported it almost entirely so far.

Antiretroviral drug (ARV) research and development was carried out by publicly funded institutions. And the bulk of the finished products have always been bought and paid for by public money, so called foreign aid.

The price of ARVs has so far stayed too high to rely on any 'market'. The majority of HIV positive people live in developing countries and would never be able to afford to pay for ARVs for the rest of their lives, even if they were a fraction of the current price.

I doubt if the ARV industry, that has been built up so carefully, will be allowed to collapse. Like the financial institutions around the world that have been propped up with public money, this industry is also 'too big to fail'.

The ARV market is also changing. Up to now, the drugs are usually given to HIV positive people who have reached a certain stage of disease progression. As part of a larger care program, ARVs can keep people alive and healthy for many years.

But more recently, there has been talk about putting people on ARVs regardless of what stage of disease progression they have reached. This could increase the number of potential customers by several hundred percent.

And there are plans to put as many HIV negative people as possible on ARVs of some kind. Of course, the potential recipients of these drugs for prophylactic uses are referred to as 'most at risk' or something similar. As if the HIV industry have any idea who is at risk; as if they give a damn.

If you ask UNAIDS who is most at risk of being infected in African countries, they will say that anyone who is sexually active is at risk, and those who are most sexually active are most at risk. But who is most sexually active, and are they really more at risk than those who are not particularly sexually active, or who are not sexually active at all?

Surprisingly, the answers to these rather obvious sounding questions is not so clear. Because UNAIDS then point to those who are most infected by HIV and conclude that it is because they are most sexually active. The circularity of this argument has very serious consequences.

So as the pharmaceutical lobbyists want more HIV positive people to be put on ARVs earlier, and also want more HIV negative people to be put on them as well, much of the work will be completely misdirected. Rates of drug resistance will be rife and death rates will probably also rise.

But a hell of a lot of drugs will be sold. And resistance will mean many tens, perhaps even hundreds of times more money per patient. Developing countries will be drowning in a sea of drugs, yet most of them will be of little benefit and many could be doing a lot of harm.

A recent IPS article asks when national governments of countries with serious HIV epidemics will become major funders in HIV treatment and prevention programs. But were they ever intended to become involved? What exactly could they do?

It would be interesting if these countries could have a say in how HIV positive people were treated and in how HIV prevention policies characterized risk. Would they reject the current racist and sexist assumptions about African sexuality, or would they simply play along?

There would certainly be no incentive to play along if they had to pay for treatment and prevention themselves, if any of these countries were even able to do so. But if they were allowed to play a part in HIV programming, perhaps they would do what no Western country or institution has yet done: question the assumption that all Africans are sex maniacs.

The article concludes with some rather trite nonsense about negotiating through the World Trade Organization (WTO) to get a better price, using the TRIPS (Trade Related Aspectes of Intellectual Property Rights) agreement, but these were never developed to benefit developing countries. On the contrary, they were developed to support the pharmaceutical industry and others based in rich countries.

If a reduction in donor funding means that people currently being kept alive by ARVs will just be allowed to die, this would be a humanitarian disaster. But if it means that countries with the worst epidemics, all African, get to decide what would really have an impact on HIV transmission, this might be the first step in turning around the pandemic. This could avert the even bigger disaster that is the status quo, which condemns millions of people to HIV infection, illness and premature death.


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