1. 2 nd line and recent ARVs prices and access issues Carmen Pérez Casas Access Campaign MSF May 2006

2. Measuring prices of ARVS in pilot surveys -Very few ARV drugs available in surveys using WHO/HAI manual - some core list ARVs are rarely used now - sampling method inappropriate -In some countries ARVs are free or subsidized, - international reference prices not always not always available

3. Fluconazole price differences: example from pilot surveys Only data for some OIs available from pilot surveys

4. Mea -There is some information on prices for procurement purposes (UNICEF/WHO/UNAIDS/MSF Sources & Prices, MSF Untangling the Web) -Website data bases (WHO GPRM, Gfund ) -Some studies -Need more information about the end user prices -HAI/WHO hope to develop a separate method for measuring total treatment cost of AIDS (and other chronic diseases). What kind of information on prices of ARVS is available?

5. Prices and acces issues in 2nd line ARVS : Lessons from the past (older ARVs) Generic competition (most existing patents before 1995) : –lower prices, to US$132 –And FDCs (3-in-1 pill) to improve adherence Quality sources -- many WHO prequalified generics Affordability and availability allowing more rapid scale-up

6. Older ARVs: competition lowering prices ( Lowest offered prices US$ for yearly triple- d4T + 3TC + NVP) June 2006, $132 Cipla

7. Are these lowprices still a barrier in access to ARVs? Example: MSF Survey in Nigeria to measure how affordable are the current user fees for a Nigerian patient in need of ART Income : nearly 50 % of the interviewed MSF patients (n= 89) live on < 36US$ monthly Monthly ART cost before enrollment in the free MSF-program: 40 US$ for ARVs

8. Answers to sources of financing ART (n=89)

9. 61% 14% 17% 1% FINANCE out of govt.stock SIDE EFFECTS SOCIAL HEALTH OK FAILURE TO IMPROVE OTHER 72% of all ARV experienced interviewed people (n= 122) had ART interruption : causes? 1% 6%

10. Source: DST/AIDS

11. 11 Current Prices of 2 nd -Line ARVs Price of 2 nd -Line treatment as average of the 12 combinations recommended in the new draft WHO guidelines Source: CHAI (average annual cost in US$ reported by GPRM) $6, 000 $1,400 10x $140 40x 1 st Line (Africa) 2 nd Line (Africa) 2 nd Line ( Middle Income)

12. Abbott price for LPV/r ( yearly,US$, in 2005)

13. How to decrease recent ARVs prices? Enabling Factors for Starting & Scaling Up ARV Treatment were: Reductions in prices of 1 st line treatments through generic competition Simplification of treatment (esp. development and use of FDCs) WHO prequalification

14. Situation post-2005... unless IP flexibilities used

15. ADULT JUNIOR BABY Fixed-Dose Combination of d4T/3TC/NVP FDC for adult and children

16. No adapted formulations..... or some adapted R&D but not accesible « Now you can take KALETRA in.. 4 tablets, with or without food, and with no refrigeration requirements ». Keep at –2 to 8 Cº. <25ºC during two months

17. Post-2005... unless IP flexibilities used ADULT JUNIOR BABY Fixed-Dose Combination of d4T/3TC/NVP

18. New drugs for chronic diseases …. we will face same challenges in other chronic diseases as new medicines are developed for richer nations chronic patients. Will they be affordable and adapted for developing nations??

19. AIDS IS ONE CHRONIC DISEASE. ACCESS TO NEWER AND ADAPTED TREATMENTS WILL BE NECESSARY EVERYWHERE Since more patients in the future will need them, we need to start thinking about getting affordable and available second line drugs now.