MSF reports HIV salvage regimens remain 18 times more expensive than first-line treatment

Médecins Sans Frontières (MSF) has released the 18th edition of its HIV drug pricing report, which can be accessed here. The report provides key data on HIV treatment access, the latest HIV treatment guidelines from the World Health Organization (WHO), an overview on pricing for first-line, second-line, and salvage regimens, and a summary of the opportunities for – and threats to – expanding access to affordable anti-retroviral (ARV) therapy.

The report finds that prices of WHO-recommended, first- and second-line HIV regimens have continued to decline, while newer drugs – salvage treatments – remain highly priced. According to MSF, currently, the lowest available price for a quality-assured, WHO-recommended, first-line, one-pill-a-day combination is USD100 per person per year (tenofovir + emtricitabine + efavirenz). This is a decrease of 26% since MSF last recorded the lowest price for first-line treatment at USD136 in 2014.

For a WHO-recommended, second-line regimen, the lowest available price is now USD286 per person per year (zidovudine + lamivudine and atazanavir + ritonavir) – an 11% decrease from USD322 two years ago.

These prices continue to fall as a result of robust competition among generics manufacturers in key producing countries, such as India and Brazil. However, the prices of newer drugs – needed for people who lack other HIV treatment options – remain high, largely because of patent held by pharmaceutical corporations. The lowest price for salvage treatment at present is USD1,859 per person per year (raltegravir + darunavir and ritonavir + etravirine). This is more than 18 times the price of first-line therapy, and more than six times the price of the most affordable second-line combination at present. The price of this combination has reduced only by 7%, from USD2,006 per year in 2014.

These are the lowest global prices, but many countries, especially middle-income nations, pay much higher prices for these medicines because increasing patent-protection periods, with the incorporation of trade agreements, delay generics access (see Mexico: 9 February 2016: TPP to increase Mexico's medicine exports market share by up to 45% during 2016–21).

Outlook and implications

Treatment failure requires healthcare providers to use salvage therapy, and change the ARVs to a new combination that can reduce the HIV viral load despite resistance. Salvage therapy is often required when a patient is losing weight, their CD4 count is dropping, serious side effects are noted, and there is an increase in symptoms.

Although the number of people who require salvage therapy in developing countries is still relatively low at present, the increased use of gold-standard viral-load treatment monitoring is helping to identify more people who are failing on their first- or second-line treatment and need to be switched to another set of medicines. In MSF's HIV programmes, the number of people having moved to second-line therapy has already almost doubled since 2013.

UNAIDS has forecast that around 70% of all HIV-positive people would be living in middle-income countries by 2020, and several ARVs are still on patent in those countries. In some lower- and upper-middle-income countries, patents on key ARVs prevent production of generic versions, or buying of generics is outlawed. The drugs are not included in voluntary licensing agreements or have not used TRIPS flexibilities, such as compulsory licences.

However, the pharmaceutical industry has been more active in contributing to the affordability of ARV therapy in several ways, particularly through partnering, voluntary licensing, and differential pricing (see World: 4 April 2016: GSK will not seek patents for new drugs in low-income countries and Belgium: 4 December 2015: Janssen announces collaboration with non-profit organisation to tackle multi-drug-resistant TB).