Middle-income countries outside Africa are paying four times as much, on average, for HIV drugs as middle-income countries in Africa, according to a study from the University of Liverpool, reported by NAM’s aidsmap site.

You might have missed Dr Andrew Hill’s presentation at the International AIDS Society meeting in Kuala Lumpur but it’s worth looking at because he so comprehensively misses the real point. His findings are interesting; his conclusions are symptomatic of the muddled thinking in international health over drug prices. His team studied six low income countries, six with lower middle income status and six with upper middle income status and concluded that the non-African middle income countries pay more for AIDS drugs than the middle-income countries in Africa. This is easily explained by the distortions (some good, some bad) created by the Global Fund and by the fact that there is far more HIV in Africa than in the rest of the developing world.

However, Dr Hill misses some real issues (at least according to the report). Here are two examples

  • Lower middle income countries (e.g. Nigeria) were paying about the same as the very poorest countries (e.g. Malawi) for anti-retroviral drugs. Dr Hill does not seem to have noticed it but this reflects a fundamental inequity: Nigeria (with $2700 of income for each Nigeria — its “per capita GDP”) chooses to spend US$46 of government money per person per year on health. Malawi (per capita GDP about $900) spends almost the same cash amount ($39). Nigeria, a country that is three time richer than Malawi, prefers to spend its money on things other than health. That is the right of a democratic government. It’s just not the job of the international community to fix it.
  • One medicine, efavirenz, cost $57 in Brazil but $784 in Malaysia. This, the researchers said was “unfair”. Maybe but probably not for the reasons they have in mind. Brazil has an admirable record in HIV treatment and therefore uses a lot more HIV medicine than other countries – it got a first mover advantage (everyone wanted to help a country doing well) . However, the biggest factor of all is that Brazil uses the threat of confiscation of patents to secure low prices. Is this a fair way of playing the international system? (Brazil is just as aggressive in other treatment areas but often uses the threats to secure tech transfer or other concessions). Now Brazil (with a per capita GDP of about $12,000) pays about a twelfth of the price for efavirenz that Bulgaria (with a per capita GDP of about $14,000) pays. Future drug research is funded by Bulgaria while Brazil gets shiny new football stadiums and slick new navy ships.

As Professor Hill says, “we need a fairer system”. I’m just not sure that my two examples were top of his mind, we’ll have to wait for the full paper to find out

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