The challenges of switching to improved first-line HIV/AIDS treatments
Today, about one third of the ten million people in urgent need of AIDS treatment are receiving it. Although still far short of universal access, these figures do represent a massive scale-up from the dark days of the late 1990s when the mainstream perception was that HIV treatment was too expensive and complicated to be used in developing countries.
The cost of treatment has dropped from more than 10K pppy just eight years ago to 87 pppy today, due to the market competition generated by generic pharmaceutical companies. Simplified treatments through combining several drugs into one tablet in fixed-dose combinations has also contributed to theability to scale-up treatment programmes.
But HIV is a life-long disease, which means that people over time need access to newer medicines when they experience serious side effects or resistance to their drugs. However, increased patenting due to World Trade Organization rules in key generics producing countries is keeping the price for these newer medicines very high. This in turn is putting a major strain on treatment programmes. MSF’s experience treating HIV/AIDS reflects these dilemmas. The most commonly used first-line AIDS treatment in developing countriesincludes the drug stavudine or d4t This drug can cause a variety of side-effects in patients, including neuropathy and lipoatrophy, and patients need to be taken off the drug. A study carried out in MSF’s HIV project in Kigali, Rwanda, and presented at the IAC in Mexico City in August 2008 shows that 16.6% of patients needed to switch to an alternative regimen due to the side effects related to stavudine.
In recognition of the problems associated with stavudine, in 2006, the World Health Organization in its guidelines on HIV treatment, recommended a move away from stavudine to less toxic drug combinations, containing either zidovudine (AZT) or tenofovir (TDF). However, such a switch comes with a considerable price tag. For example, substituting zidovudine for stavudine doubles the cost of a treatment. Switching to a tenofovir-based treatment leads to even more dramatic price increases – ranging from 4 to 11 times the cost of the most affordable treatment A forecasting pricing model applied to MSF’s HIV project in Epworth, Zimbabwe estimates that replacing stavudinewith a TDF-based regimen for all patients from 2008 to 2014 (based on today’s prices) would increase costs from $2 million to $8.5 million. This means national treatment programs will be faced with uncomfortable choices about whether to treat a greater number of patients on more affordable ARV combinations, or fewer patients on less toxic but more expensive combinations. At the same time, the need for access to newer drugs for patients who have developed resistance to their first set of medications is growing at a rapid pace. In MSF’s longest-running AIDS project, in Khayelitsha, South Africa, approximately 22% of patients on treatment.