Andrew Hill, Pharmacology and Therapeutics, Liverpool University, UK

1. 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 YoudingChen IAS Conference, Kuala Lumpur, Malaysia, July 2013 (late-breaker WELBD05)

2. 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?

3. Methods HIV drug prices used in national programmes (2010-2012) 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.

4. Low income countries

5. Lower-middle incomecountries

6. Higher-middle income countries

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

8. LOW LOWER-MIDDLE Malaysia Ukraine India Thailand Cambodia Uganda Ethiopia Botswana Nigeria Kenya Philippines Malawi South Africa Vietnam Namibia Tanzania

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

10. LOW LOWER-MIDDLE Malaysia Ukraine Thailand Uganda Nigeria Botswana Indonesia Tanzania South Africa Kenya

11. LOW LOWER-MIDDLE Malaysia Thailand Uganda Vietnam Ukraine Cambodia Malawi Nigeria Botswana Ethiopia Namibia Tanzania Kenya Philippines South Africa India

12. LOW LOWER-MIDDLE Malaysia Vietnam China Ukraine Russia Thailand Brazil Tanzania Indonesia India Uganda Malawi Namibia Botswana Kenya Nigeria Philippines South Africa Ethiopia Cambodia

13. Median cost of treatment (US$ per person-year) in higher-middle income countries by location (+ range)

14. 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 antiretroviralsfor all middle-income countries with large HIV epidemics.

15. Median cost of treatment (US$ per person-year) by income classification, according to GNI per capita (+ range)