International Seminar on Access to Treatment for HIV in Developing Countries  5-6 June 1998 London, UK

Ben Plumley of Glaxo Wellcome said a multipartite way forward is needed among all the relevant groups, including industry, governments, international agencies and affected communities. The issue is to develop effective programmes which incorporate realistic expectations about the use and value of all treatments, not only antiretrovirals, but also treatments for opportunistic infections. While new simplified and highly potent treatment regimens are being developed, there remain issues around the use of antiretrovirals, long-term and short-term, in the developed world, such as compliance and the emergence of resistance, and these issues need to be taken into account when considering programmes in developing countries. The actual cost of a drug may be viewed as the last piece in the equation. The primary issue is the public health context in which treatment is being considered, and the existing levels of health and social infrastructure needed to support these interventions. One critical infrastructure issue is the need for reliable distribution mechanisms. Prices of treatments can be reduced to levels that meet WHO requirements for cost-effective interventions. Earlier this year, Glaxo Wellcome announced a programme of preferential public sector pricing of Retrovir (AZT) for reduction of mother to child transmission of HIV.

The starting point is that that care and treatment has to be placed in the broader HIV public health context. Secondly, the concept of treatment needs to be defined and should include the management of opportunistic infections, good nutrition and diet, and the appropriate use of local medicines. Above all, the international community must continue to recognise the important contribution that can be made by the affected communities themselves, and efforts to develop the capacity of community groups and organisations must continue.

Jorge Saavedra from Mexico expressed concern that countries labelled as developing countries are often grouped together when there are large differences between them regarding both the epidemiology of HIV and the economic situation. For example, in sub-Saharan Africa there are 14 million cases of HIV/AIDS compared to 1.3 million in Latin America (UNAIDS 1997) but the GDPs in these regions in 1995 was estimated at US$296,748,000 and US$1,688,195 respectively (World Bank 1997). He stressed the need for economic aid for Africa to achieve the ARV goals, and in Latin America, the need for political will to improve coverage. (See chart)

The issue of indigenous pharmaceutical production was raised, with the comment that companies like Glaxo Wellcome are crippling the indigenous capacity in many developing countries to evolve ARVs and to produce AZT. It was asked that the seminar give some scope for discussion about ways to facilitate local production of ARVs and local capacity of indigenous pharmaceutical companies.

In response, Ben Plumley from Glaxo Wellcome, said that patent protection was not at odds with finding ways of incorporating therapies into public health contexts in developing countries. Rather, differential pricing is the way forward. Indeed it could be argued that in those countries where intellectual property is not respected, and generic manufacture of drugs exist, there is less incentive for companies who had legitimately researched and developed new medicines to find ways of bringing these new treatments to these countries. The way forward lies in genuine a multipartite response, in which the role of industry is recognised, but in which the international community and the governments themselves work concurrently to develop the public health context in which treatments can be optimised.

The reality of treating diseases in many developing countries where the health infrastructure was weak was brought up. Two disease models already exist for which effective treatments are available at low cost. One is TB, a chronic disease which can be cured in six months with daily treatment and at low cost. The price of the drugs for a complete course of therapy for TB has been reduced considerably to US$11 in China and US$16 in India.

However, in India only about 45% of TB patients are cured because the necessary health infrastructure is not in place. Another disease is syphilis, which can be diagnosed in the smallest health centre and cured by one injection. However most developing countries are not treating or screening for syphilis. If these two diseases, TB and syphilis, can not be treated adequately with the existing health infrastructures, how can ARVs be provided through pilot projects in these same environments?
 

UNAIDS, Report on the Global HIV/AIDS Epidemic 1997. Geneva
World Bank Development Report, 1997 Washington, DC.