Affordable Treatment

Treatment may now be within reach for millions of AIDS sufferers. Bush administration take note.

| Wed Apr. 7, 2004 2:00 AM EDT

Bill Clinton has helped craft an agreement that will make treatment available for millions of HIV/AIDS patients in 122 countries served by the Global Fund to Fight AIDS, Tuberculosis and Malaria. If it sticks, the deal will amount to a major expansion of the agreement to distribute the more affordable fixed-dose combination (FDC) pills that the Clinton Foundation brokered for 16 African and the Caribbean countries last year.

According to the deal, co-sponsored by the Global Fund, the World Bank, UNICEF and the Clinton Foundation, Indian and South African companies will supply the medicines at one-third the price of the cheapest ones available in the West, while U.S. companies will provide diagnostic tests at one-fifth the market price. The Bush administration, which organized a meeting last week in Botswana to discuss the safety of the generic FDCs -- a meeting some AIDS activists criticized as an attempt to discredit their use -- has so far resisted pressure to purchase the drugs using the $15 billion it pledged for AIDS aid for Africa.

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As the United Nations Special Envoy for HIV/AIDS in Africa Stephen Lewis explained in a press release:

"…the Clinton Foundation will negotiate the drug prices, UNICEF will employ its procurement capacity and the Global Fund and World Bank will provide the funding.

We're talking of fixed-dose combinations of generic drugs, pre-qualified by the World Health Organization, to be purchased overwhelmingly from generic companies based in India, at prices as low as $140 per person per year."

In an interview with the New York Times, a representative of the Clinton Foundation conceded that not all the companies mentioned in the announcement had indeed signed on to its terms -- indeed, to judge from the Times' interviews with the companies in question, there's a lot of finalizing to be done. Anil Soni, Chief Adviser to the Global Fund's Executive Director, nevertheless said that the groups proceeded with the announcement because:

"We want to make clear to our recipients that it is possible to purchase generics that are up to the W.H.O. quality standard."

The FDCs combine several anti-retroviral (ARV) pills that are currently administered to HIV/AIDS patients. This week's announcement is a major boost for generic FDCs and is also significant because the Chairman of the Global Fund Board is Tommy Thomson, Bush's Secretary for Health and Human Services. It remains to be seen if the move will make the Bush administration rethink its opposition to FDCs. (It prefers that groups purchase the more expensive ARV treatments from Western pharmatheutical companies -- a policy criticized for boosting those companies' patent rights and coffers while millions of sufferers go untreated.

Critics of generic FDCs argue that they have not been sufficiently tested and that the success of the ARV combinations rests on the fact that they can be tailored to the needs of the particular patient. Though the effort to provide affordable treatment to Africa's HIV/AIDs population is admirable, they say, cutting corners on safety as a trade-off for price is not -- and may lead to higher costs in the long-run. As Thompson Ayodele, the coordinator of the Institute of Public Policy Analysis in Lagos says:

"Some suspect that the WHO's main reason for promoting FDCs is that they are cheaper: two fixed-dose combination pills costs $140 per patient compared to about $600 per year for six pills per day. But the cost of the pills must not be the sole deciding factor in their use. Many are concerned that the WHO, in its attempt to provide anti-retroviral drugs to millions of AIDS victims, is glossing over safety and downplaying efficacy. Indeed, FDCs may well offer false economy: if the pills lead to increased resistance, then they will not be cost-effective because in the future more money will have to be spent on second-line therapies to treat resistant strains."

Controversy over the FDCs aside, the project's implementation will be complicated by poor health infrastructure and corruption in the recipient countries. One fear, as Chairman of the Clinton Foundation's AIDS Initiative Ira Magaziner points out, is that:

"The program could fall apart if black marketeers get in and start diverting medicines."

The joint project should meet World Health Organization's goal of providing treatment to 3 million HIV/AIDS patients in poor countries (minus Brazil, which provides free treatment) by 2005; it is estimated that less than 200,000 of the 6 million patients who need the treatment actually receive it. The Global Fund has committed $1.25 billion for AIDS projects over two years, while the World Bank has pledged $1.6 billion.

This week's announcement is an important step in making HIV/AIDS treatment accessible to the world's poor. The Gates Foundation, which has devoted much of its AIDS aid to Botswana, has experienced success with ARV treatments as a result of a collaborative effort with a pharmaceutical company and an aggressive government campaign. It is hoped that generic FDCs will prove to be a safe and more affordable alternative that will help achieve similar results elsewhere. The Bush administration should support this effort and purchase generic FDCs as part of its aid to Africa, as well as scrap its policy of denying funding to clinics that treat HIV/AIDS patients if these clinics perform abortions.

Africa's AIDS epidemic is inextricably tied with its economic underdevelopment and these problems won't be solved until the AIDS crisis is under control. As World Bank President James Wolfensohn said:

"We regard AIDS as being the single most important issue at the moment in Africa because of the devastating effect that it has had throughout the continent, and it is not something that is deferrable to discussions of economic or other issues."