On the current trajectory, most people who need them will not be able to get them any time soon, because high prices and monopolies will keep people in low- and middle-income countries locked out.
By Matthew Kavanagh and Eamonn Murphy
Here’s the good news: there are a new set of breakthrough medicines to prevent and treat HIV, known as “long actings” because they can be taken every few months instead of every day, and they are coming on-stream. If, as they are rolled out, they are made available at scale, they could help save many lives and help end the AIDS pandemic.
But here’s the bad news: on the current trajectory, most people who need them will not be able to get them any time soon, because high prices and monopolies will keep people in low- and middle-income countries locked out. That’s where we are heading – again.
UNAIDS has been convening some of the world’s leading scientists and researchers. They have emphasised to us that long-acting drugs for prevention are available now – an injection every few months that very effectively protects against HIV transmission. It has been approved in the U.S. and the World Health Organization (WHO) is reviewing it now.
And in the near term, there are in addition exciting medicines in development for long-acting treatment – which could make it far easier for people to stay on life-long HIV treatment, even when their lives make getting pills every day difficult.
New HIV prevention tools like long-acting pre-exposure prophylactic (PrEP) are particularly needed to fight the ongoing pandemic. In 2020, a year for which the world had set a collective goal of reducing new infections below 500,000, there were, in fact, 1.5 million; and in too many communities new HIV infections are rising.
Critical prevention needs
Long-acting injectable PrEP could help fill critical HIV prevention needs for those facing the worlds’ highest HIV risks – particularly those whose lives, logistics, and legal contexts make accessing and taking oral prep challenging.
This includes people facing discrimination, including gay men, transgender people, sex workers, and people who use drugs in Africa, Asia, Latin America and the Caribbean, and Eastern Europe. Young African women, facing far higher risks than young men of their age, also need new HIV prevention options.
Studies have shown many people want a long-acting option, and indeed an estimated 74 million people around the world use long-acting injections to prevent pregnancy. Carefully done studies presented at the Conference on Retroviruses and Opportunistic Infections (CROI) showed long-acting PrEP can prevent more new infections than taking a pill every day.
If and when WHO endorses its use, the world should move fast to make it available at scale. The best way to ensure this breakthrough science translates into a global game-changer it is to make it available free to all who choose it.
UN member states agreed a new Political Declaration on HIV/AIDS last year that sets an ambitious goal of getting access to PrEP for 11 million people by 2025. For this to be possible, the governments and institutions who will need to make large scale purchases will need to be able to do so at a price that they can afford.
Right now, in the US long-acting PrEP costs tens of thousands of dollars. But members of UNAIDS’s Scientific and Technical Advisory Committee (STAC) assess that long-acting prep can be manufactured affordably – tens of dollars instead of tens of thousands. It would be possible for prices to come down whilst ensuring continued profitability for producers.
Exclusionary, deadly approach
For treatment, the science is also moving rapidly and promising technologies on the way could be transformative. As of last year, 28.2 million people were on HIV treatment – that’s over 10 billion times every year people living with HIV take a pill.
But 10 million more people still need access to HIV treatment. If people could choose a pill that lasted a week or an injection that lasted months it would make it easier for many to start and sustain treatment – saving lives and stopping HIV transmission.
One key structural barrier that jeopardizes widespread access is the fact that production of these medicines is so far monopolized by a tiny number of companies based in a tiny number of countries, keeping prices high and limiting (and concentrating) supply. We know from experience (on the first ARVs, on the second generation of ARVs, and with COVID-19 vaccines and medicines) that this barrier can only be overcome through intervention.
When treatment for HIV first became available in the late 1990s, ARV monopolies meant the price was over $10,000 per person per year, a price far out of reach for the millions of people living with HIV.
As a consequence,12 million Africans died. Mass use of antiretrovirals to stop AIDS came only when low- and middle-income countries defied pressure and triggered generic competition, and when global civil society pressured Western governments and companies to stop working to block them.
That experience led the world to say never again to allowing people in developing countries to be locked out access to life-saving medical technology. But the same exclusionary and deadly approach has denied Africa access to sufficient vaccines in the COVID-19 crisis.
Sharing, not monopolising knowledge
And on the current trajectory we are on course to repeat the story with new HIV medicines. It could be years before new drugs becoming available in New York or London ever reach those who need them most in Manila, Freetown, Maputo, Sao Paolo and Port-au-Prince.
An alternative approach is available, that ensures the translation of science into impact. Manufacturers of HIV drugs can set prices at affordable levels for low- and middle-income countries. To secure this for the long term, generic production in low- and middle-income countries is essential.
To do that we have to overcome monopolies. Pooling patents and pro-actively transferring technology can make it possible for a wider set of manufacturers in Africa, Asia, and Latin America to make long-acting ARVs at low costs. This must be standard practice – and the sharing of information can start even before regulatory approval for use.
Of course, price and local production are not the only barriers to ensuring effective use. Some public health systems may require global solidarity and support to purchase commodities, with logistics and storage, training for effective provision, and engaging communities to ensure demand and treatment literacy for retention. The joint United Nations Programme on HIV/AIDS, and our partners, are providing support on all of these.
Building from emergency action on COVID-19, we need to end inequalities in access right across health technologies, by spurring the best science and getting it to everyone, investing in all health innovations as global public goods.
To stop today’s pandemics and to prevent future pandemics, it is vital to move from monopolizing knowledge about lifesaving health technologies to sharing it worldwide. We need to reform rules on the protection of intellectual property that have failed us in these pandemics, so that access to life-saving science is no longer dependent on the passport you hold or the money in your pocket.
Not on track
We need governments to use their powers to compel sharing of pandemic science and technology and ways to compel companies and countries to use WHO-led mechanisms. We need to separate incentives for innovation from monopolies on manufacturing. Monopolies constrain supply, perpetuate unaffordable prices, widen inequalities, and have proven an unreliable driver of innovation, especially for those health issues that disproportionately impact people living in poverty.
We need to invest now in building health production capacity all over the world. We need to prioritise investment in universities and other public research institutions to enhance our technical capacity to develop medical technologies for all.
We can end the AIDS pandemic. And the COVID-19 pandemic. And stop the pandemics of the future. But we are not on track – in part because biomedical breakthroughs are not getting to those who need them most. If we act on long-acting ARVs, many people who would otherwise have acquired HIV will not. People living with HIV who would otherwise have died of AIDS will not. And the well-being and dignity of people at risk of or living with HIV can be enhanced.
Equitable global access to pandemic-fighting technologies cannot be achieved through the default operation of the market alone. It is policy and practice dependent. Work on those policies cannot wait until all those technologies have been rolled out at scale in rich countries, but needs to be accelerated now.
Leaders from civil society networks, especially those led by people living with HIV and by key populations, are calling for us to act now to ensure global access to new HIV technologies. We can and we should.
Shared science will save lives and stop pandemics.
This piece has been sourced from Inter Press Service
The writers are Deputy Executive Directors of the United Nations Joint Programme on HIV/AIDS (UNAIDS)