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IAS 2013: Middle-income Countries Outside Africa Pay Four Times More for Antiretroviral Drugs


Middle-income countries outside Africa are paying, on average, 4 times more for antiretrovirals than African countries with similar gross national incomes (GNI), according to a study presented recently at the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur.

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Antiretroviral treatment is available at very low prices in the lowest-income countries, defined as having a GNI of less than USD $1025 per person per year. However, there are many middle-income countries with large HIV epidemics, such as South Africa and Russia. There is no established system for fair pricing of antiretrovirals across these countries. It could be expected that the prices of antiretrovirals in these countries would rise gradually, as national income levels rise. However, the study also found that there is no consistent correlation between drug prices and GNI among middle-income countries.

Overall, median treatment costs increased through income categories. However, prices remained stable in African countries with rising GNI, but outside Africa there were large price rises in some middle-income countries, not clearly correlated with higher GNI.

The study, by Andrew Hill from the University of Liverpool and colleagues, compared the treatment cost of 6 key antiretroviral products with the per capita annual GNI of countries in 3 income bands.

The 6 low-income countries (GNI < $1025 per person) included in the comparison were Ethiopia, Malawi, Uganda, Tanzania, Kenya, and Cambodia. The 6 low-middle countries (GNI $1026-$4035 per person) were Nigeria, Vietnam, India, the Philippines, Indonesia, and Ukraine. Also 8 upper-middle income countries (GNI $4036-$12,475 per person) were included, namely Namibia, South Africa, Botswana, Thailand, China, Malaysia, Brazil, and Russia.

The products used were nevirapine (Viramune), efavirenz (Sustiva or Stocrin), tenofovir (Viread), zidovudine/lamivudine (Combivir), tenofovir/emtricitabine (Truvada), and lopinavir/ritonavir (Kaletra or Aluvia), including branded and generic versions.

The median cost of treatment per person per year in African upper-middle income countries for efavirenz (600 mg, once-daily) was found to be $60 (range $51-$69) compared to $241 in non-African countries -- a 4-fold increase. The price of efavirenz in non-African countries ranged from $57 in Brazil to $784 in Malaysia.

This trend was repeated for across all the other antiretrovirals examined:

  • Nevirapine (200 mg twice-daily) cost $30 (range $29-$35) in African countries compared to $97 (range $32-$162) in non-African countries.
  • Tenofovir (300 mg once-daily) cost $107 (range $79-$135) in African countries compared to $477 (range $262-$715) outside Africa.
  • Lamivudine (150 mg twice-daily) cost $98 (range $97-$113) in Africa compared to $562 (range $372-$752) outside Africa.
  • Lopinavir/ritonavir (400/100 mg once-daily) cost $425 (range $397-$490) compared in Africa to $1000 (range $793-$3794) in non-African countries.

Across all the in Africans, Malaysia (the country with the third highest GNI of the middle-income counties) was paying the highest price, except for tenofovir, where Brazil was paying the highest price.

While it is expected for upper-middle income countries to pay higher prices for antiretrovirals, it is the range in price across upper-middle income countries which highlights the discrepancy in the pricing system.

Antiretroviral Cost Comparison

  • The median cost of efavirenz for low-income countries was $51, compared to $53 for low-middle income countries and $232 (range $51-$784) for upper-middle income countries.
  • The median cost of nevirapine was $31 for both low-income and low-middle income countries, compared to $32 (range $29-$162) for upper-middle income countries.
  • The median cost of tenofovir was $71, $80, and $345 (range $79-$715) for low, low-middle, and upper-middle income countries, respectively.
  • The median cost of lamivudine was $97, $100, and $106 (range $97-$752), respectively.
  • The median cost for lopinavir/ritonavir was $407, $585, and $878 (range $397-$3794), respectively.

This analysis will be repeated, dividing the costs by branded and generic products. Patent restrictions on some drugs may be causing higher prices in some middle-income countries.

"We need a new system of fair pricing for antiretrovirals for all middle-income countries with large HIV epidemics," said Hill.

See also: IAS 2013: Cost of HIV Drugs in Resource-limited Settings [VIDEO]



N Ford, J Ananworanich, B Simmons, and A Hill. Is the pricing of antiretrovirals equitable? Analysis of antiretroviral drug prices in 20 low and middle income countries. 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013). Kuala Lumpur, June 30-July 3, 2013.  Abstract WELBD05