E-drug: After ARV price reductions what else?
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I would like to respond to NN's comments on the WSJ about ARV
becoming more affordable. He says quite correctly:
"One would expect the private sector, insurance companies and
companies with AIDS programmes to take up these cheaper drugs first.
At USD 600 per year, it is probably cost-effective to treat your
skilled workforce as they then live many years longer, and fewer
people have to be trained."
He also says "The message is clear: Ministries of Health should start
considering ARV policies similar to Brazil, and prepare for a future where
ARVs are available at USD 200 pp/year or so (MSF prediction by end 2002).
There is no excuse anymore for writing ARVs off as "impossible,
unaffordable" treatments in developing countries."
I think both points should be looked at with a time perspective. In most of
the high HIV load most drugs by value are purchased in the private sector.
The public sector struggles to spend US$2 per year per head. Tuberculosis,
an eminently curable condition costs between $20-30 in drug costs and yet
many poor countries public sectors cannot afford this cost.
So in the short term in these countries, ARV's are likely to be purchased in
the private sector by companies for their employees and by those with
private insurance and those who are rich enough to afford the reduced price
drugs.
The key responsibility on governments is to remove barriers to the
availability of these cheaper ARV's. This means removing duties and tariffs,
exempting these drugs from sales and VAT taxes and waiving
registration fees for these drugs. It also means that Drug regulatory
authorities will need to register products from multiple suppliers
even if the drugs are still
patented. Professional associations of pharmacists will also have to induce
their members to reduce markups on these drugs to make them more
available. If they do not governments will need to apply price
control (mark-up) regulations.
Another area of prices which will need to be addressed is that of laboratory
monitoring tests. There may be a case for compulsory licensing of these
technologies and the measures described above may need to be applied to
reduce the cost of these tests. Clinical trials to evaluate how necessary
these tests are and to evaluate clinical regimens will also be needed. Such
trials could be funded or undertaken by ministries of health. Finally I
would advocate that ministries may want to arrange for a confidential
register of the patients using these drugs to determine outcomes under
differing circumstances.
Having lower cost drugs available is a crucial first step and the work of
MSF and the many activists involved must be commended. But it is only the
first step! The next steps will involve identifying the barriers to
effective use initially in the private sector, later in the public sector,
and breaking down these barriers. Much more needs to be done to make ARVs
effectively available!
Richard Laing
Boston University School of Public Health
richardl@bu.edu
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