Dr Richard Amenyah
One of the critical pathways to achieving universal health coverage and ending AIDS as a public health threat by 2030 is for governments to take advantage of the latest scientific innovations in medical technology and ensure these technologies are affordable, available, and accessible to all. Importantly, this includes access to essential medicines for the public good.
However, this pathway is proving very difficult and painful for people living with HIV in the Caribbean and Latin America regions because their governments are using their scarce resources to pay more for essential HIV medicines to keep them alive than governments in other regions.
The 2023 Global AIDS update highlighted that the average price per patient per year for durable antiretroviral drugs in the Caribbean and Latin America is $160, while the average price in West and Central Africa was just $67. This raises the question of fairness by persons living with HIV as to why countries in the Caribbean and Latin America are paying such a high price for lifesaving medicines for them in the region.
It is necessary to highlight this disparity because several Latin America and Caribbean countries are saddled with high debt and are sacrificing investment in social programmes for their people for debt servicing as stated in the recent report ‘’A world of debt: A growing burden to global prosperity’’ by the UN Global Crisis Response Group. The report puts the global public debt at $92 trillion, 30% of which is owed by developing countries.
To manage this unfair and unfortunate situation, it is important to explore potential strategies that Caribbean and Latin American countries could use to negotiate lower prices for essential HIV medicines and to ensure better access to life-saving treatments for their people as government workout more sustainable ways of dealing with inequalities in the international financial architecture to tackle the high cost of debt and mitigate the risk of external shocks and further debt distress as well as long-term development financing opportunities.
Most of the countries in the Caribbean and Latin America are classified economically as either middle-income or upper-middle-income countries. The COVID-19 pandemic—the high-cost-of-living crisis, the debt crisis, and climate change, has negatively impacted economic growth in the region.
Some governments are prioritizing debt services to avoid default and as such do not invest in the social sector as expected.
Countries have obligations to enforce patents of pharmaceutical products, as per their commitments as World Trade Organization members for a period of 20 years for the lifespan of patents. These international trade agreements and intellectual property Laws such as the Trade-Related Aspects of Intellectual Property Rights (TRIPS), can restrict the production and importation of generic drugs, thereby limiting competition and driving up prices.
These obligations most at times lead to limited competition in the pharmaceutical market in the region leading to higher prices for some essential medicines. The effect of these patent monopolies and stringent intellectual property laws is the lack of access to more affordable generic versions of antiretroviral drugs.
The patent for Dolutegravir would expire around 2026, which means that countries cannot purchase generic versions of the products while the patent from the originator is still valid. It is therefore not surprising that Latin America and Caribbean countries pay $160 per patient per year for dolutegravir-containing antiretroviral regimen than any other region.
Utilizing flexibilities in intellectual property laws helps countries to navigate around the strict TRIPS rules such as compulsory or voluntary licensing and parallel importation, to promote the production and importation of affordable generic drugs. These flexibilities have resulted in steep price reductions.
The recent consideration by Colombia to promote ‘’Health Justice’’ for people through patent authorization for the importation or production of generic forms of dolutegravir which is a key backbone drug for combination antiretroviral drugs for people living with HIV through compulsory licensing without permits from the patent holder, ViiV Healthcare, a joint venture of GlaxoSmithKline, Pfizer and Shionogi is a very bold step supported by several Civil Society Organizations to beat down the drug cost.
Even with compulsory licensing, however, it is important to note should this go through successfully, the Colombian government would still have to pay royalties to compensate for the innovation cost.
The reason for this move by Colombia is that even though generics of dolutegravir are available internationally at a much affordable cost and accessible through the Medicines Patent Pool.
However, countries like Colombia, Trinidad and Tobago and many other Caribbean and Latin American countries are not listed in the licensing agreement with ViiV/GSK and as such these countries cannot access dolutegravir at an affordable price. Such agreements are bad for public health and for ending the AIDS epidemic in the Caribbean and Latin America. Using effective and efficient procurement practices such as using pooled procurement may also yield efficiencies due to economies of scale and the power to negotiate better prices for HIV commodities for the region.
The Strategic Fund of the Pan American Health Organization (PAHO) is not perfect but a very good example of how to beat down drug prices for essential medicines. This regional technical cooperation mechanism involves pooling the procurement of essential medicines and strategic health supplies for countries that qualify.
Beneficiary countries leverage this Strategic Fund to strengthen their health supply management systems, access technical cooperation to plan demand, rational use and ensure commodity security by avoiding stock-outs.
The Strategic Fund signs long-term agreements with suppliers for selected health products essential for the countries and negotiates prices for a specific period. This process helps to improve efficiency, benchmarking predictable drug prices to ensure quick and timely delivery of high quality-assured health products.
Other ways governments in the Caribbean and Latin America can effectively lower the prices of HIV drugs is through local manufacturing of Antiretroviral drugs.
This would require scaling several critical steps including pre-qualification by WHO looking at Quality and Safety Standards from good pharmaceutical practices, regulatory approvals across the region’s skilled workforce, financing for infrastructure and equipment, sourcing raw materials, intellectual property and licensing issues as describe above, scale and production capacity for cost-effectiveness and affordability as well as long-term sustainability With strong regional and country political commitment it is possible to have local production of HIV drugs and other essential health productions for improved health responses in the region but it requires strategic planning and tactical and operational implementation for success.
Caribbean and Latin America countries should continue to advocate for price reductions to make these essential medicines affordable and accessible to their people. As governments in the region consider local production in the long term, they must in the meantime increase their negotiating power with pooled procurement and the leverage flexibilities in the TRIPS to make sure their HIV programs are high quality with improved health outcomes. It requires strong collaborative partnerships to support efforts to lower the prices of HIV drugs in the Caribbean and Latin America. Together, we can make a difference in the lives of people living with HIV in the region.
Dr Richard Amenyah is a medical doctor from Ghana and public health specialist. He is the director for the UNAIDS multi-country office in the Caribbean. You can reach him on Twitter at @RichardAmenyah or @UNAIDSCaribbean and [email protected]