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Access to Treatment

This section looks at issues concerning the access of children with HIV to effective treatment. Other sections look at which antiretroviral drugs should be used and provide practical treatment tips.

Key points about access to treatment for HIV are:

1. Effective antiretroviral drugs have been available since 1996. Using several of these drugs together in combination has greatly increased survival of people with HIV in developed countries.

2. WHO estimate that more than 6 million people in developing countries need antiretroviral treatment now. However, only around 400 000 people were receiving this treatment at the end of 2003.

3. One of the main barriers to treatment has been its cost. This has been particularly high because of the high costs of the drugs and the fact that a person needs to take several of these over a long period. However, prices of antiretroviral drugs have fallen dramatically since 2000.

4. There are other barriers to treatment in developing countries. These include the lack of sufficient health infrastructure, lack of sufficient trained staff and lack of national policies which promote antiretroviral treatment from a public health approach.

Access to Antiretroviral Drugs

Effective antiretroviral drugs have been available since 1996. Using several of these drugs together in combination has greatly increased survival of people with HIV in developed countries. These drugs do not 'cure' HIV. They do control the disease which means that people living with HIV live longer and have a better quality of life. They do have to be taken for life and can have severe side-effects.

Unfortunately, very few people in developing countries currently receive these drugs. It is estimated that more than 6 million people in developing countries need antiretroviral treatment. However, only around 400 000 people were receiving this treatment. More than one third of these live in one country, Brazil. The World Health Organisation has set a target that more than 3 million people in developing countries should be receiving these drugs by 2005.

Barriers to Access - Cost

The main barrier to access to this treatment has been its cost. Prior to 2000, this was estimated at $10-15 000 per year. This was not only because of the high cost of the drugs but also because a person needs to take more than one drug for a long period. However, drug prices have fallen dramatically. Treatment may now cost as little as $350 per year. This has occurred for several reasons. Documents which explain these reasons use a number of technical terms. These are explained briefly here:

• Generic Production - Many of the antiretroviral drugs that are available are produced by international drug companies. These companies seek to protect their new drugs through a system of 'patents'. These patents are laws which prevent other companies 'copying' the drug. Drugs protected by patents are sometimes called proprietary drugs. Drugs that are not protected by patents are called 'generic'. Some countries (Brazil, India, Thailand) have produced 'generic' versions of antiretroviral drugs at much lower prices than the proprietary drugs. As a result of this competition, drug companies have greatly reduced prices of their proprietary drugs.
• Differential Pricing/Discounting - This involves companies selling their drugs at a lower price in developing countries than in developed ones. This only works if the markets can be kept separate. It relies on the good will of drug companies. They may only agree to this if countries agree to stricter rules on patents and other forms of 'intellectual protection'.
• TRIPS Safeguards - TRIPS (Trade-related aspects of Intellectual Property Rights) is one of the rules of the World Trade Organisation (WTO). Its aim is to ensure that rules on intellectual property rights are applied throughout the world. Many countries are currently able to produce and use generic antiretroviral drugs because their national laws do not recognise patents on these drugs. There is international pressure for countries to adopt the provisions of TRIPS which would make these patents apply in all countries. However, TRIPS allows for countries to overrule these patents when it is needed to promote 'public health'. This can be done through 'compulsory licencing' which allows a country to make or buy a generic version of a proprietary drug when it is needed for public health reasons. Buying such a generic drug from another country is called 'parallel importing'.
• Regional/International Procurement - Drug costs can be reduced when they are purchased in bulk. This can be done where countries purchase jointly with other countries in their region. International arrangements have been used for other medicines, such as vaccines. Currently, there is no international system for purchasing antiretroviral drugs.
• Local Production through Voluntary Licencing - This involves a country and a drug company agreeing to allow the drug to be manufactured in that country. This will require the transfer of technology from the drug company to the country.
• Drug Donations - These may improve short-term access to a drug. However, they may hinder changes needed to ensure these drugs remain available over time. They may stop countries producing their own medicines. In addition, such donations usually only benefit a few people in a few countries.

Other Barriers to Access

Other major barriers to access to antiretroviral drugs include the lack of health infrastructure and adequately trained staff in developing countries. This is particularly important with antiretroviral drugs because they are complex and difficult to take, it is difficult to select and monitor patients and there is a risk of resistance developing.

One major part of health infrastructure is the availability of laboratory facilities. The World Health Organisation has identified four levels of such facilities - minimum, basic, desirable and optional. The minimum level requires the ability to measure haemoglobin and to test for HIV antibodies. Currently, only the minimum level is required to be able to start antiretroviral treatment programmes.

Expanding Access to Treatment

The following steps will be helpful in expanding treatment with antiretroviral drugs:

• Starting small and gradually expanding.
• Securing additional resources so that funds are not diverted away from other parts of the health service.
• Adopting national policies which have a public health approach. These include having an agreed, simplified first line treatment regime and ensuring a continuous drug supply.
• Training health staff at all levels in how to provide this treatment.
• Ensuring that work is carried out in both public and private sectors.
• Developing a national system for monitoring drug resistance.

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