Cheaper antiretrovirals to treat AIDS in South AfricaBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7249.1551 (Published 10 June 2000) Cite this as: BMJ 2000;320:1551
They are at their most cost effective in preventing mother to child transmission
- Karen Zwi, senior lecturer,
- Neil Söderlund, senior researcher,
- Helen Schneider, director
- Division of Community Paediatrics, University of the Witwatersrand
- Centre for Health Policy, University of the Witwatersrand
- Centre for Health Policy, PO Box 1038, Johannesburg 2000, South Africa
Many countries in sub-Saharan Africa are overwhelmed by a pandemic of HIV and AIDS that is reducing life expectancy by two decades, reversing gains made in infant mortality and increasing the burden on health resources that are already overstretched. South Africa is no exception. The government, AIDS activists, healthcare professionals, and communities are desperate to find a universal solution or “magic bullet.” Triple combination therapy has dramatically widened the gulf in people's experience of HIV and AIDS, depending on whether they live in the North or the South. Not surprisingly, activists, both local and international, have persistently called for a substantial lowering of the prices of antiretroviral and other expensive drugs needed to treat people with AIDS.
What would reducing the price of antiretrovirals mean for South Africa in its battle against HIV and AIDS? It is important to distinguish between using antiretroviral drugs to prevent mother to child transmission and to treat adults infected with HIV. Interventions to reduce vertical transmission are highly effective in preventing primary HIV infection in babies and would probably save at least 15 000 lives per year in South Africa.1 2 The costs of such programmes are located in the setting up of accessible antenatal services, counselling and testing, and training of staff.3 Drawing on cost data from previously published work, we have calculated that the antiretroviral component would constitute only an estimated 7% of the total costs of setting up a programme in South Africa to prevent vertical transmission based on using nevirapine.3 The entire programme would cost less than 1% of current spending on public health care. Even at current market prices, therefore, this seems a highly cost effective intervention in South Africa and elsewhere.3 4 There is widespread support within the healthcare community in South Africa for piloting these interventions as soon as possible.5
It is more difficult to promote the case for antiretroviral medication to adults with HIV. Here drugs are a major component of the cost, since high doses are given indefinitely to patients. Even though some savings would be made in preventing admission to hospital, this intervention is unlikely to pay for itself. If the costs of triple antiretroviral therapy were reduced to one quarter of current levels, this would still require a more than 50% real increase in the public health budget by 2010.6 Glaxo Wellcome's recently announced proposal to reduce the price of the combination drug Combivir (fixed dose combination of zidovudine and lamivudine) to $700 (£440) per year will no doubt increase the market for antiretrovirals in South Africa. It would make little difference to most poor people, however, who rely on the state healthcare system with budget constraints too tight to accommodate more than marginal extra costs. Furthermore, for the public sector there would seem to be more pressing priorities in terms of HIV care. Isoniazid and co-trimoxazole prophylaxis against tuberculosis and pneumonia respectively has been shown to be highly effective but is rarely used outside of specialist care centres in South Africa.7 8
Cure rates of tuberculosis are poor even by the standards of developing countries (57% for patients with newly positive smears) and the whole infrastructure for treatment needs substantial overhaul.9 Drugs such as fluconazole and ganciclovir for the management of severe opportunistic infections remain inaccessible to most South Africans. Finally, to take advantage of accessible antiretroviral drugs, people need to be comfortable with finding out and declaring their HIV status; most evidence shows this is not yet the case.
In common with many developing and developed countries, South Africa has tried to implement policies such as parallel importation and compulsory licenses, which would reduce drug prices generally.10 However, the issue of affordable drugs has been complicated by a somewhat inexplicable position on drugs for HIV and AIDS specifically, originating in President Mbeki's office. The South African government seems ill disposed to the use of antiretrovirals for any purpose. The reasons given are not currently cost concerns, but rather doubts about the safety and efficacy of antiretroviral drugs, and even doubts about the scientific basis of AIDS causation and treatment. This is shown by the invitation to Peter Duesberg, who is known as an AIDS dissident, to sit on a government advisory panel in South Africa. The rather controversial approach is somewhat difficult to understand but may be located in a need to find a unique ‘African’ solution to the problem of HIV and AIDS.
The government is probably right about the secondary importance of antiretrovirals, but for the wrong reasons. Real solutions to the AIDS epidemic in South Africa are a lot less glamorous. They consist of incremental improvement in basic health services, including antenatal care, prophylaxis and treatment of opportunistic infections, and tuberculosis and sexually transmitted disease care, improved status for women in society, support to community based palliative care providers, and improved cooperation between government and non-governmental organisations. Lowering the price of antiretrovirals has a role to play, but is not in itself a solution.