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Cheaper antiretrovirals to treat AIDS in South Africa
Karen Zwi, Neil Soderlund, and Helen Schneider
2000-06-12

What would reducing the price of antiretrovirals mean for South Africa in its battle against HIV and AIDS? It is important to distinguish between using antiretroviral drugs to prevent mother to child transmission and to treat adults infected with HIV. The authors deduces that they are at their most cost effective in preventing mother to child transmission.

Many countries in sub-Saharan Africa are overwhelmed by a pandemic of HIV and AIDS that is reducing life expectancy by two decades, reversing gains made in infant mortality and increasing the burden on health resources that are already overstretched. South Africa is no exception. The government, AIDS activists, healthcare professionals, and communities are desperate to find a universal solution or magic bullet. Triple combination therapy has dramatically widened the gulf in people's experience of HIV and AIDS, depending on whether they live in the North or the South. Not surprisingly, activists, both local and international, have persistently called for a substantial lowering of the prices of antiretroviral and other expensive drugs needed to treat people with AIDS.

What would reducing the price of antiretrovirals mean for South Africa in its battle against HIV and AIDS? It is important to distinguish between using antiretroviral drugs to prevent mother to child transmission and to treat adults infected with HIV. Interventions to reduce vertical transmission are highly effective in preventing primary HIV infection in babies and would probably save at least 15 000 lives per year in South Africa. The costs of such programmes are located in the setting up of accessible antenatal services, counselling and testing, and training of staff. Drawing on cost data from previously published work, we have calculated that the antiretroviral component would constitute only an estimated 7% of the total costs of setting up a programme in South Africa to prevent vertical transmission based on using nevirapine. The entire programme would cost less than 1% of current spending on public health care. Even at current market prices, therefore, this seems a highly cost effective intervention in South Africa and elsewhere. There is widespread support within the healthcare community in South Africa for piloting these interventions as soon as possible. ... In common with many developing and developed countries, South Africa has tried to implement policies such as parallel importation and compulsory licenses, which would reduce drug prices generally. However, the issue of affordable drugs has been complicated by a somewhat inexplicable position on drugs for HIV and AIDS specifically, originating in President Mbeki's office. The South African government seems ill disposed to the use of antiretrovirals for any purpose. The reasons given are not currently cost concerns, but rather doubts about the safety and efficacy of antiretroviral drugs, and even doubts about the scientific basis of AIDS causation and treatment. This is shown by the invitation to Peter Duesberg, who is known as an AIDS dissident, to sit on a government advisory panel in South Africa. The rather controversial approach is somewhat difficult to understand but may be located in a need to find a unique `African' solution to the problem of HIV and AIDS.

The government is probably right about the secondary importance of antiretrovirals, but for the wrong reasons. Real solutions to the AIDS epidemic in South Africa are a lot less glamorous. They consist of incremental improvement in basic health services, including antenatal care, prophylaxis and treatment of opportunistic infections, and tuberculosis and sexually transmitted disease care, improved status for women in society, support to community based palliative care providers, and improved cooperation between government and non-governmental organisations. Lowering the price of antiretrovirals has a role to play, but is not in itself a solution.

For the full text and references please see BMJ 2000;320 1551-1552
http://bmj.com/cgi/content/full/320/7249/1551

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