MSF and AIDS

Delivered by Joelle Tanguy, U.S. Executive Director, MSF, at the Global Health Council HHS Consultations, Washington D.C.

Doctors Without Borders/Médecins Sans Frontières is an international humanitarian medical organization working around the world in over 80 countries, assisting the most vulnerable. Our experience with HIV/AIDS started in the late 80’s.For a decade, we focused exclusively on prevention programs, constrained by the unavailability of treatment options. In 1997 we were running 30 projects, in majority aimed at prevention, only 4 countries with a curative component. This was the public health thing to do, given the need to slow down the epidemic and to accommodate the constraint of the unreasonable costs of curative options. But it become progressively an untenable position, humanly, socially, and in medical ethics terms.

We know now that we must recognize the limits of public health reasoning, in particular for this pathology. We have patients before us and their numbers are crying out to us. These are patients who do not have access to effective treatments established here or in Europe. The logic of cost-effectiveness is too often is put first in the fight against Aids in developing countries – placing emphasis on prevention rather than curative care. But hospital beds in sub-Saharan Africa are filled with patients considered incurable for whom treatments nevertheless exist! We support the arguments of cost effectiveness when it is a question of proving that a measles vaccination is ultimately less expensive than the response to an epidemic. But in the case of AIDS we have to understand that this type of reasoning is simply inhuman, especially when it reinforces the total indifference of the rich countries with respect to the 30 million people currently infected in the economically disadvantaged world.

We are now focusing on the curative challenge in East and Southern Africa, South East Asia, and Central America. And rather than accept the constraints, we’re challenging them.

THE ISSUE OF INFRASTRUCTURE

Many, and especially the industry, argue that the worst affected countries do not have the infrastructure or medical expertise to adequately administer the complex regimen of HIV/AIDs drugs. This is true… to some extent. Our response to this issue is several folds.

1. Even without ARVT, there is a lot of work to be done around the treatment of opportunistic diseases of Aids, such as cryptococcal meningitis, a common systemic fungal infection that can be deadly to people whose immune systems have been crippled by HIV. The fungal infection can kill within a month or so, but daily Fluconazole/Diflucan treatments can keep the fungal infection at bay. And there’s plenty of room for improvement as Pfizer has priced the drug worldwide beyond the reach of most patients. Many people are needlessly dying in hospital beds in sub-Saharan Africa or poor parts of Asia, when simple drugs are available that would cure their ailment, prevent relapse, increase their comfort, and restore their capacities.
    
2. ARVT is more complex. But we take issue with the standard denial of care arguing the complexity of ARVT and the lack of infrastructures. While this may be true in some Sub-Saharan countries, it is not true of all developing countries. Public health systems in economies in transition such as Thailand have the capacity and the will to deal with complex regimen. The problem is more that prohibitive pricing and strict enforcement of trade and patent laws have made it virtually impossible for governments in developing countries to cheaply produce or grant licenses for the generic production of the most basic anti-retroviral medicine.
    
3. And for those countries who do not have the lab and health infrastructures required by the most complex regimen of ARV, what are we supposed to do? Abandon the patients to their fate? We cannot accept that, and must look again and again for a solution to their plight.

THE MSF ACCESS TO ESSENTIAL MEDICINES CAMPAIGN

To address the crisis in access to critical drugs for communicable diseases including HIV/AIDS but also such neglected diseases as Sleeping Sickness, Kala Azar and others, MSF has launched the Access to Essential Medicines Campaign.

The first issue is ensuring there is adequate research efforts around neglected diseases. Research for such communicable diseases as tuberculosis and malaria has ground to a halt. Between 1975 and 1997 out of 1,223 new drugs developed only 13 (1%) were to treat tropical diseases. Only four of these were the result of human R&D activities of the pharmaceutical industry.

Even when effective treatments exist, as they do for diseases like multidrug-resistant tuberculosis and many AIDS-related infections, when lifesaving medicines are available, they are simply too expensive, due in large part to patent protection and pricing strategies aligning on the wealthiest markets. A lucrative market for lifesaving drugs addressing infectious diseases simply does not exist in the developing world despite the fact that more than 90 percent of all deaths and suffering from infectious diseases occurs there.

In summary, our patients are dying, not because their diseases are incurable, but because as consumers, they do not provide a viable market for pharmaceutical products. Clearly, market forces alone are not enough to address the need for affordable medicines or to stimulate research and development for neglected diseases.

Our intuition was that progress would come from a confluence of efforts: public mobilization, public-private partnerships and regulation. Two years ago, we initiated a campaign to develop “Access to Essential Medicine”, partnering with activists groups, academics, philanthropic institutions, corporate interest groups (drug manufacturers and associations), the media and governmental institutions such as the World Bank to stimulate development and appropriate pricing of drugs for the developing world. Together we must ensure that trade of essential medicines is regulated in the interest of public health. We are not questioning the importance of patents in stimulating research and development, but rather we are insisting that a balance be found between protecting intellectual property and ensuring individuals’ access to medicines. And we are seeking to provide an impetus for both policy development and practical solutions to specific access problems.

Our campaign is developed around three key directions:

• Stimulating research
• Overcoming access barriers
• Humanizing trade agreements

STIMULATING RESEARCH

The reason for the research gap is clear: drugs for tropical diseases are not profitable for drug companies. The pharmaceutical industry is focusing investment to meet the needs of people living in wealthy countries and increasingly funds research devoted to lifestyle diseases.

Our campaign seeks to communicate the urgent need for new treatments for communicable diseases ignored by industry. We are challenging the drug industry’s attitude, at most charitable (donations programs) but not yet responsible, and we are inviting developed countries, international organisations and non-governmental organisations to help fill the void.

OVERCOMING ACCESS BARRIERS

Many drugs are too expensive for those in the developing world to buy. Other life-saving treatments are not available because manufacturers have abandoned production in favour of making more profitable drugs for customers in wealthy countries.

This second effort of our campaign is attempting to increase accessibility to specific treatments.

To achieve this, we:

• Conduct global price analyses of selected essential drugs that are too expensive. This pricing information can be used to negotiate better prices and demonstrate price differences from different manufacturers around the world.
• Study the quality of all sources of select expensive essential drugs to identify high-quality low-cost producers.
• Support health ministries that are working to increase access to essential drugs.
• Work with the WHO and industry to restart the manufacture of abandoned drugs such as DFMO for sleeping sickness.

HUMANIZING TRADE AGREEMENTS

The emerging global trade system, which sets the rules for how products are sold within and between countries, treats medicines like all other products. This needs to change. The patenting of medicines confers a market monopoly to pharmaceutical companies who often charge the same high price worldwide. The result is that people in the developing world cannot afford treatments and die from curable diseases.

Imagine if food prices were the same in Nairobi, Guatemala City and Brussels. Would we accept that people would die because they could not afford the price of food?

Our goal is to support the implementation of existing international trade provisions that were designed to protect people’s access to essential goods such as life-saving medicines.

• Compulsory licensing: the legal right (in certain circumstances) for companies to produce patented medicines in exchange for a royalty payment to the patent holder.
• Parallel imports: the legal right to import patented drugs, when the drugs are sold more cheaply in other countries.

To achieve the above, we work closely with local partners, medical teams and associations, organisations of people living with HIV-Aids such as South Africa’s Treatment Action Campaign, the National Thai Network of People Living with HIV/AIDS in Bangkok, HealthGap and ACT Up and others here. We also work with consumer activist groups such as the Thai Federation for Consumers and here with Jamie’s Consumer Project on Technology. We seek to actively contribute to a civil society movement that will, if we are successful, challenge the neglect of a major global health and equity issue.

We are also calling on pharmaceutical companies to use sustainable mechanisms (thus other than charity) to make life-saving drugs available to people in poor countries. This could be done most effectively by lowering prices to affordable levels - through tiered pricing - or by issuing voluntary licenses that would allow for the importation or production of generic versions of treatments.

Some of our efforts focus on inviting drug makers to reduce the prices of AIDS drugs or allow for the marketing of generic versions of the medicines in poorer nations. The challenge ahead is daunting.

Pharmaceutical products responding to dramatic public health crises should be looked at differently from other goods and services. Health is not a commodity; it is a human right.