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Brazil's policy of bargaining with drug companies over the cost of antiretrovirals—and flouting some international patents—saved the country $1bn (£0.5bn; €0.7bn) between 2001 and 2005, a study has found.
The researchers, from the Harvard School of Public Health, decided to carry out a detailed analysis of the cost of drugs for HIV in Brazil because they thought that little was known about the long term costs associated with providing highly active antiretrovirals to HIV patients in developing countries (PLoS Medicine 2007;4(11):e305 doi: 10.1371/journal.pmed.0040305). Brazil has free and universal access to antiretrovirals and is considered a model for other countries trying to boost their public treatment programmes.
Brazil's policy is credited with having helped reduce the prevalence of HIV in the country to 0.6% of the population, similar to that in the United States.
The researchers found that although the cost to Brazil of producing generic antiretrovirals locally grew between 2001 and 2005, overall the country still saved about $1bn in that period by using the threat of breaking patents on other expensive HIV drugs as a bargaining tool with drug multinationals.
The country has signed up to World Trade Organization agreements on patents but has cited WTO terms that allow countries facing a health emergency to produce patented drugs under licence without the owner's consent.
The drug industry has warned, however, that such actions could discourage companies from conducting the expensive research needed to develop new drugs.
A spokesman for the International Federation of Pharmaceutical Manufacturers and Associations said, “Brazil's overall campaign has to be applauded.” But he added: “Brazil used threats of compulsory licensing to obtain prices that the industry was voluntarily offering the poorest countries, and Brazil as one of the top 20 economies in the world is clearly not in the same category as Lesotho.”
However, Luiz Loures, an associate director of UNAIDS (the United Nations HIV and AIDS programme) who helped set up Brazil's ambitious AIDS treatment programme, said: “Brazil has shown that it is possible for a developing country to offer universal treatment.” He added that countries were right to break patents when they faced “a public health emergency” from HIV. “There is clearly provision within WTO rules for countries to do this,” he said.
Last May Brazil broke the patent on efavirenz (marketed as Stocrin in Brazil by Merck Sharp & Dohme), to import a cheaper generic version from India instead.
In July Brazil worked out an agreement with Abbott to cut the price of its drug lopinavir with ritonavir (Kaletra) by 30%.
Other countries, including Canada and Italy, have also used a clause in WTO rules to sidestep drug patents in the name of public health.
However, the Harvard researchers warn that, even with the savings, Brazil faces a tough time ahead.
“It faces significant challenges with the rising cost of providing universal access to AIDS treatment,” said the study's lead researcher, Amy Nunn.
She said that the costs of antiretroviral treatment in Brazil more than doubled from 2004 to 2005. The steep rise reflected the fact that more people with HIV were being treated and were living longer—and were increasingly requiring complex second line and third line treatments as a result of resistance to the first choice of antiretrovirals.
The World Health Organization estimates that only two million people in developing countries receive highly active antiretrovirals, just a quarter of those in need of such treatment in these countries (www.who.int/hiv/mediacentre/universal_access_progress_report_en.pdf).