Is the pricing of antiretrovirals equitable? Analysis of antiretroviral drug prices in 20 low and middle income countries Andrew Hill, Pharmacology and Therapeutics, Liverpool University, UK Jintanat Ananworanich, HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand Kiat Ruxrungtham, HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand Bryony Simmons, MetaVirology Ltd, London, UK Nathan Ford, University of Cape Town, South Africa Thanks to: Paul Cawthorne, Edward Low, and Youding Chen IAS Conference, Kuala Lumpur, Malaysia, July 2013 (late-breaker WELBD05)

Background Antiretroviral treatment is available at very low prices in the lowest income countries, defined by Gross National Income (GNI) less than $1025/person-year. However there are many middle-income countries with large HIV epidemics – there is no established system for fair pricing of antiretrovirals across these countries. We could expect the prices of HIV drugs in these countries to rise gradually, as the national income levels rise – does this happen in real-life?

Methods HIV drug prices used in national programmes ( ) were extracted from the WHO Global Price Reporting Mechanism (GPRM) database. Treatment costs (branded and generic) were compared with per capita annual gross national income (GNI), using the World Bank database. Six key ARV drugs were analysed: NVP, EFV, TDF, ZDV/3TC, TDF/FTC, LPV/r Countries were classified as: 1. Low income (GNI ≤ $1025/person): Ethiopia, Malawi, Uganda, Tanzania, Kenya, Cambodia, 2. Low-middle income (GNI $1026-$4035): Nigeria, Vietnam, India, Philippines, Indonesia, Ukraine, 3. Upper-middle income (GNI $4036-$12,475): Namibia, South Africa, Botswana, Thailand, China, Malaysia, Brazil, Russia.

Low income countries Country GNI (per capita, US$) n(HIV) Estimated HIV Prevalence (%) Tanzania$5401,600, Kenya$8201,600, Uganda$5101,400, Malawi$360910,00010 Ethiopia$370790, Cambodia$82064,0000.6

Country GNI (per capita, US$) n(HIV) Estimated HIV Prevalence (%) Nigeria$1,2803,400, Indonesia$2,940380, Vietnam$1,270250, Ukraine$3,130230, Philippines$2,21019,000<0.1 Lower-middle income countries

Country GNI (per capita, US$) n(HIV) Estimated HIV Prevalence (%) South Africa$6,9605,600, Russia$10,6501,015, China$4,940780,000<0.1 Thailand$4,440490, Brazil$10,720490, Botswana$8,533300, Namibia$4,700190, Malaysia$8,77081, Higher-middle income countries

LOWER-MIDDLELOW Malawi Philippines Indonesia Ukraine Thailand Malaysia South Africa Brazil Russia Uganda Vietnam Nigeria India Tanzania Kenya Cambodia Ethiopia Namibia China

LOWER-MIDDLELOW Malawi Philippines Ukraine Thailand Malaysia South Africa Uganda Vietnam Nigeria India Tanzania Kenya Cambodia Ethiopia Namibia Botswana

LOWER-MIDDLELOW Malawi Philippines Indonesia Ukraine Thailand Malaysia South Africa Brazil Uganda Vietnam Nigeria India Tanzania Kenya Cambodia Ethiopia China Namibia

LOWER-MIDDLELOW Indonesia Ukraine Thailand Malaysia South Africa Uganda Nigeria Tanzania Kenya Botswana

LOWER-MIDDLELOW Malawi Philippines Ukraine Malaysia South Africa Uganda Vietnam Nigeria India TanzaniaKenya Cambodia Namibia Botswana Ethiopia Thailand

LOWER-MIDDLELOW Malawi Philippines Indonesia Ukraine Thailand Malaysia South Africa Brazil Uganda Vietnam Nigeria India Tanzania Kenya Cambodia Ethiopia Russia China NamibiaBotswana

Median cost of treatment (US$ per person-year) in higher-middle income countries by location (+ range) FormulationAfrican countriesNon-African countries Ratio of costs EFV (600mg OD)60 (51-69)241 (57-784)4.0 NVP (200mg BID)30 (29-35)97 (32-162)3.2 TDF (300mg OD)107 (79-135)477 ( )4.5 TDF/FTC (300/200mg OD)122 ( )468 ( )3.8 ZDV/3TC (300/150mg BID)98 (97-113)562 ( )5.7 LPV/r (400/100mg OD)425 ( )1000 ( )2.4

Conclusions Middle-income countries outside of Africa are paying, on average, four times higher prices for antiretrovirals than African countries with similar Gross National Incomes. Among the middle-income countries, there is no consistent correlation between drug prices and Gross National Income. This analysis will be repeated, dividing the costs by branded and generic suppliers. 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.

Median cost of treatment (US$ per person-year) by income classification, according to GNI per capita (+ range) Formulation Low income (≤$1025) Low-middle income ($ ) Upper-middle income ($ ,475) EFV (600mg OD)51 (48-53)53 (50-86)232 (51-784) NVP (200mg BID)31 (30-31)31 (31-41)32 (29-162) TDF (300mg OD)71 (66-84)80 (52-106)345 (79-715) LPV/r (400/100mg OD)407 ( )585 ( )878 ( ) ZDV (300mg BID)86 (72-89)88 (88-99)102 (80-743) TDF/FTC (300/200mg OD)87 (85-143)133 ( )150 ( ) ZDV/3TC (300/150mg BID)97 (95-99)100 (82-103)106 (97-752)