Injustice In the Price System for Second Generation AIDS Drugs

Around the turn of the century, a wave of activism combined with the generic production of AIDS-combating drugs significantly lowered the price of first-line treatment for HIV. Now, because the price of a standard antiretroviral (ARV) regimen hovers around $160 per person per year, the majority of AIDS victims around the world have access to this baseline version of ARV. This is an amazing reduction from the $10,000-15,000 range of the late 1990s. However, even the lowered price is prohibitively expensive for many developing countries, and unfortunately, international trade law still prevents a straightforward price reduction of ALL types of ARV.

Second-line ARV drugs, developed after the less sophisticated first-line medications, have less potential for toxic side-effects and will defeat strains of HIV that have become immune to baseline ARV. Though they are less critical than first-line ARV, they are needed in the fight against AIDS for those victims for whom first-line treatment won’t work. The WTO’s 1994 Agreement on Trade-Related Aspects of International Property Rights (TRIPS) granted protection to all antiretroviral medications for twenty years after they are patented. The first-line medications’ protections have already expired, and even before they had, foreign companies and governments had broken the rules of TRIPS and produced generic first-line ARV.

The better performing, second-line drugs don’t have the same protection, causing a great disparity between the price of baseline and second-line ARV. The days of $10,000-yr ARV are over, but because under TRIPS patents still protect the later medications, a second-line regimen costs $550 per year in low-income countries. The price is only this low because the international wave of advocacy which accompanied the production of generic first-line medication in the early 2000s induced the major pharmaceutical giants to operate with a tiered price system—that is, it offers prices to countries on the basis of per capita income. Drugs are cheaper in poor countries than in rich countries, but not cheap enough to be affordable. Considering that a billion people around the world earn less than a dollar a day, and that HIV is concentrated among these people, pricing drugs at $550 is little different from a death sentence for thousands of HIV+ poor people for whom first-line ARV doesn’t work. Considering also that middle-income countries with vast income inequality, such as India, China, and most importantly South Africa, must pay an even higher price, the poor in those countries are even less able to receive second-line treatment.

Governments can legally issue compulsory licenses domestically for generic drug production, so that a limited number of non-brand second-line ARV can be produced, but doing so comes with severe diplomatic consequences, usually from the United States. In 2007, Thailand allowed the generic production of pharmaceutical giant Abbott’s brand medicine Kaletra, a second-line ARV drug. The US retaliated by placing Thailand on the “priority watch list” for trade, and Abbott removed seven other very valuable ARV products from Thailand. This was detrimental to Thailand’s national health and economy, but the country’s bravery did lower the price of this particular type of second-line ARV for the rest of the world.

Much more international advocacy is needed to give all variations of ARV a just price. All people deserve proper treatment for their medical conditions. For more details about the history of antiretroviral drugs, read the a fuller account at http://www.avert.org/generic.htm. And find out more about how you can help on the AFCA website!

Masvingo Bound

tran June 19, 2012 – Masvingo, Zimbabwe



Juju's lemon eyes

The morning starts at 5:30am, getting ready for a new adventure to give out sixty goats to children and their guardians.  We pluck the kids out of bed while it is still dark and join Ncube, who is driving us.  Boiled eggs, peanut butter sandwiches and water accompany us for the long trip ahead.  Eric, Ncube and I are in charge of delivering, vaccinating and tagging the goats and I can’t wait.

We arrive at a dusty, dry, forlorn, tiny grouping of houses and hear signing in the distance. Up ahead just a little bit, we see colorful figures swaying and dancing as they sing a welcome song to our little truck as we whip up dust all around us.  Before I know it, I am swaddled in hugs and kisses and pats and “welcomes!”.  It is a beautiful welcome and I am so happy my family is with me.  Eric has not seen a distribution of goats before and I am excited for him to see this joyous welcome and to see the joy that is to come.

Aiden drumming

We are ushered into a tiny church, complete with four hand-hewn benches and a small table on the front.  There, more singing washes over us, with clapping added in and the beating of drums.  Aiden boldly walks up to one of the drums and adds his piece alongside the drummer.  He concentrates on what he is doing and enjoys every minute of it.  After a short speech from the village goat project coordinator, we hand out the ear tags to each guardian in preparation for the distribution.  We traipse back outdoors into the dust in order to meet the goats and more singing follows and envelopes us.

Eric tagging ears

A para-vet does the vaccinations while Eric and then, I, do the tagging of the ears.  This group is incredibly organized and we are done with the tagging in no time.  Contracts are signed and we are invited back to the little church for a lunch of rice, sadza and some yummy sauce.  We eat with our hands and quickly get full as the sadza hits our bellies.  It is so sweet to sit with these brothers and sisters who are so grateful for the goats given to them.  When I tell them that I’ve prayed for them and won’t stop doing so, they clap and smile.  I love their huge smiles!

Juju and Morgan

One thing they repeat over and over again, in different ways, is their gratitude for the porridge AFCA sent in the past.  They are hungry and they miss it.  Their children walk 20 kilometers to school (each way) and it is hard for them to do this with no food in their bellies.  They can’t concentrate and they fall sick often.  The porridge was a life-saver, they say.  They even act out a drama about the porridge and how it helps them.  I tell them I’ll try to get them more, but I can’t promise.  I don’t know if I can provide it or if it is even available for me to send.  Shipping costs are extraordinary.  Yet, I, like them, pray for a miracle and hold on to hope that we will be able to send porridge once again.

Aiden learning

I am so proud of my children and of Morgan!  They integrate so well with all the folks we meet.  They share stories. They eat the food given to them. They smile, they clap, they sway to the music.  Aiden is so curious – he leans into the man who holds the goats while they are tagged because he doesn’t want to miss anything.  Everyone is patient with him and they give him room and allow his little eyes to see all they want to see.   As I turn around after tagging a goat, I spy Juju telling a young lady a story of some sort.  The girl is laughing and Juju is in her glory.  They swap stories and I turn back to tag another goat.

Jodi teaching and Q translating

He has a future!!

Throughout the day, we think of Jodi, who is conducting a workshop in another village, where we delivered goats last week.  She is surprised to meet not only the families who received goats last week, but to have sixty five people show up for the training.  Apparently, the entire village is out to listen to Jodi!  The talk goes really well, with Q translating and people asking many questions and taking notes. They are hungry for knowledge and as Jodi teaches in one village, our own folks ask for more training and workshops.  Everyone wants their goats to do well, for their milk to help the children and the elderly, for baby goats to be born safely and to grow up strong and well.

So do I.

Matopos National Park

June 16, 2012 - Matopos, Zimbabwe

Today is sunny and we are planning on having a fabulous day at the Matopos National Park.  With John driving the big LandRover, the rest of us pile into the back of the truck and take off with a picnic lunch packed.  We are dressed warmly because there are no windows on the truck and while it is sunny, the breeze is still chilly at this time of the morning.  About an hour into the drive, we stop to allow Aiden, Eric and AJ to sit in the top of truck.  Aiden is so excited!! His eyes are shining like little olives and he has the biggest smile on his face.  He is loving this time of freedom from car seats and let us know that he doesn’t want to use car seats ever again.

After a bit, we change positions and Juju, Morgan and I sit on the top and we feel the wind whipping through our hair as we dodge branches that threaten to knock us off the top.  We laugh and enjoy the bumps in the road, hanging on to the grill around the top of the truck, which keeps us safe.

We arrive at a gorgeous location, named a World Heritage Site three times over: topography, culture, and something else having to do with the animals there.  There are eagles of all sorts there…a veritable United Nations of eagles. Monkeys and baboons about and they visit us during our lunch time.  We join a group of other Zimbabwean families and soon, the kids are all playing together, climbing huge boulders and rocks, trees and anything that they can get on.  They chase each other and have an absolutely blast.  Morgan, Aiden and I try our hand at canoeing and we laugh uproariously as we get stuck in huge weeds and as Momo gets soaked trying to paddle.  She tells me this might be the first time she’s canoed and we are excited that it has happened here in Zimbabwe.

After a communal lunch of boersworst (beef sausage), peanut butter and jelly sandwiches (our contribution), salad, all sorts of cookies, tea, and water, AJ and Juju race Momo, Aiden and I in the canoes.  My team loses but we have the most fun, I think.  Eric is having a great time hiking with some men and he comes back full of information about what is happening in the area and with the folks we are meeting. 

We soak in the sun on lawn chairs, chat with new friends, munch on snacks, and watch the monkeys play on the rocks while our children (resembling monkeys now that they are muddy and dusty and dirty) chase them and scamper around.

June 17, 2012 – Bulawayo, Zimbabwe

Church this morning was really nice, where we met up with folks we met yesterday and met some new people, too.  When we were about to leave church, I looked around for Aiden and not finding him, started looking around.  Momo found him sipping hot tea with a bunch of people, sitting in the middle of all of them and having the time of his life.  I am so grateful that these kids are so ready to try new things, to make new friends, and to have fun.  Momo has been great, too, helping out at a youth group meeting on Friday night with AJ and making friends all around.  These three are really doing a great job at assimilating and making the best of everything. 

One of the things we are getting used to is the power cuts. Wednesday is the only day we’ll usually have electricity all day long.  Otherwise, we won’t have it on Monday morning, but will in the afternoon. We won’t have any on Tuesday. We won’t have any on Thursday morning, but will in the afternoon.  Then, Friday morning we will, but none on Friday afternoon until Saturday afternoon.  Sunday morning, we don’t have and we will on Sunday afternoon.  And, no electricity means no water.  So, we have to plan our baths and flushing of the toilet carefully. We are getting into a rhythm bit by bit.

This afternoon, we will be going to the animal orphanage to check out lions at feeding time and to have monkeys walk on us.  I think the kids will love it!

Goats and Sadza

June 14, 2012 – Bulawayo, Zimbabwe

After a breakfast of rice and a fried egg, Jodi, Morgan, Juju and I head out to distribute fifty-six goats to beneficiaries approximately three hours away.  Q takes us in a pick-up truck and what starts out as a ride on an asphalt road ends up on a narrow dirt road with small villages suddenly appearing on the side of the road.

Q tells us that we should be able to spot a giraffe and that keeps us looking out the windows.  While no giraffe materializes, we do see a group of baboons on the side of road and we go wild with excitement, taking photos of the monkeys.  We also spot impalas, which makes us happy, too.  We never do see the giraffe, but we have a fun time looking anyway.

Jodi getting ready to tag ears

Three hours later, when we reach the delivery place, we are greeted by nineteen grandmothers and grandfathers who are raising orphaned children.  We are welcomed with great smiles and a song, which is always such a welcoming sound and one with I treasure for months and years afterwards.  The goats are brought in by the chief of the village and everyone’s smiles grow even larger, if that is possible.  The para-vet vaccinates the goats.  I am given the task of marking ear tags with family names and “AFCA”, Jodi is given the task of tagging ears, Morgan and Juju take photos and video the whole process.  We are busy for quite a while and it is exciting to see how happy everyone is.  When we name one goat “Darryl”, the owner keeps repeating “I am so happy, I am soooo happy!”  She is thrilled to take three goats home with her, knowing that the orphaned children she cares for will be able to become self-sufficient if they stick to the program. 

Morgan getting a hug

When all the goats are vaccinated, tagged and distributed, a song starts.  A bit of clapping joins in and finally, foot stomping as the song changes from Shona to English and we clearly hear words in the song – “thank you very much”.  It is so sweet, this thanking for a simple gesture.  They are indeed grateful for the animals and they show it in their smiles, their hugs, their music. 

Some goats are tied together with twine. Some with plastic. Some with rope. Six are put on the back of a cart and are taken away by a team of four cute donkeys.  Everyone is in a celebratory mood and we are invited to join them for lunch.  Q is unsure how we’ll react to this, which is just silly, since I’ll try just about anything.  I sit in the round kitchen hut with the chief, the pastor, Q and the para-vet who’s been trained through this project.   A huge plate of sadza 'n chicken is placed in front of me and I eat with my right hand, making a ball with the sadsza (corn meal cooked with water) with my fingers and thumb and dipping it into the sauce to grab a piece of chicken with it. I pop it in my mouth and find it delicious.  Because people only eat once a day, they are hungry and they are happy to eat the big portion of sadsza.  I, on the other hand, am trying to figure out how I am going to eat it all.  Q notices that I cannot possibly eat it and kindly, lets me know I don’t have to finish it up.  I do my best and when I am quite done, a plate of melon, maize and squash soup is placed in front of me.  Yikes!  There is no way I can make this happen, so I ask for a small portion and eat that. 

Gertrude, Juju and a goat named Juju

This time around, I tell Morgan and Juju that they can eat the sandwiches we brought, giving them time to get more accustomed to the food and way of eating.  I want their bellies to be ready.  Because the soup was boiled hard, for a long time, I thought it was ok for them to taste it and they both did. Now, they are so curious to try other foods and that makes me happy.  Little by little, though…don’t want their bellies rebelling.

Lunch is done and I wash my hand in a bowl of water.  We say our goodbyes and hear the beginnings of a song.  It is so beautiful, it brings tears to my eyes and I notice that I am not the only one affected.  Morgan and Jodi are all emotional, too, and I think to myself, “welcome to Africa”. 

Success in the International Antiretroviral Therapy Market!

One of the coolest success stories in the 25-year history of HIV/AIDS is the dramatic price drop of baseline antiretroviral drugs (ARV therapy, or ART) since the turn of the 21st century. These drugs are pivotal in the fight against AIDS, granting a healthy and productive life to HIV patients who adhere faithfully to a strict therapy regimen. And these drugs’ new affordability on the international market has allowed a 16-fold increase in the number of poor-country citizens receiving ARV drugs from 2003 to 2010 alone. At the end of 2010, 6.6 million people in the developing world were benefiting from them. 47% of the world’s citizens had access to ART; by now, that proportion is over half.

Here’s how the price decrease happened. In a nutshell, a combination of activism and generic drug production loosened the patent-protected monopolies surrounding the first kinds of antiretroviral medication ever developed, thereby breaking down the control that pharmaceutical companies had over their sale. In 1994, the World Trade Organization’s Agreement on Trade-Related Aspects of Property Rights (TRIPS) prohibited the production or sale of antiretroviral drugs except by the large pharmaceutical companies that developed them. This meant that treatment for AIDS, priced at $10,000-15,000, was prohibitively expensive in developing countries. Fewer than 2% of the HIV+ population in these countries acquired ART. In 2000, despite these regulations, Brazil began producing generic versions of the protected drugs, selling them at a fifth of the brand price. The same year, an Indian company, Cipla, followed suit, pricing their drugs at a mere $350 per person per year by early 2001. The competition from the generic producers angered the pharmaceutical companies but forcefully drove down the price of brand-name ARV to match Cipla’s price. Throughout the early 2000s, the downward price trend continued—now, basic, first-line ARV is available for $160-200 per person per year, and to this day, India supplies 80% of donor-funded ARV. Generic drugs are very much responsible for the expansion of treatment access around the developing world, especially in sub-Saharan Africa, where the AFCA works.

The entrance of generic drugs into the ARV market coincided with a lot of advocacy work, putting political pressure on pharmaceutical companies to loosen their hold on their monopolies. For example, the Clinton Foundation formed after President Clinton exited office, and it has lobbied for the availability of generic AIDS drugs ever since. Furthermore, in 2001, the international community reacted indignantly when 39 major pharmaceutical companies attempted to sue the South African government for passing a law that would facilitate the production and importation of generic ARVs. After several global petitions were drawn up against them, these companies were forced to back down. Though activists’ efforts have never formally changed TRIPS’ patent protection rules, they did produce a 2001 WTO resolution called the Doha Round Agreement, which declared that TRIPS would be interpreted with the intended goal of global expanding treatment access. The pharmaceutical companies have been semi-compliant; in 2006, UNITAID, an organization which funds ARV distribution and lobbies for further price reductions, began operations with moderate success. These steps represent progress and provide hope that one day ARV’s may be available to all who need them.

Today’s legal and economic picture of ARV access is still far from ideal. Much more activism is needed to dissolve the monopolies on the more effective second-line ARV medication. More information on the challenges of expanding access to come in the next few days! A more detailed account of the story of the ARV market is available at http://www.avert.org/generic.htm. In the meantime, find out how you can get directly involved and make a concrete difference by exploring our website!

Ahnu Boots Are a Girl's Best Friend

I want to thank our friends at Ahnu for providing me with the absolute best boots ever.  I have worn them to the top of Kilimanjaro, through the streets of Harrisburg, PA and everywhere in between. Here they are, in the Democratic Republic of Congo, looking dirtier than usual.  I am resting my feet on the truck window, as we wait for help on our 11th breakdown of the trip.

Ahnu has been a generous supporter of our work, giving us certificates for Kilimanjaro climbers and winners in our recent 5k.  I believe we host the 5k with the absolute best prizes, thanks to sposnors like Ahnu!

I've also uploaded some photos of them on a road in Congo (yes, I am the height of fashion, wearing them with a skirt), in Kenya (with baby Juma and little Rama).  Right now, they are with me in Zimbabwe, after being worn in Bangui, Central African Republic and in Johannesburg, South Africa.  They are definitely looking like they need a good cleaning right now, but they are still as comfortable as always!

We Made It!

June 12, 2012 – Johannesburg, South Africa – Bulawayo, Zimbabwe

I spy them from the top of the tall escalator.  I am on the third floor and they are in a terminal on the ground floor.  I see her first, tall and elegant, fifteen years old, my niece Morgan.  She is laughing at something one of the small ones said or did.  I scan a bit and see Juju and Aiden playing in front of her, acting funny to see her laugh again.  Eric is on the right of them, Jodi on the left of her.  My heart beat picks up and I feel it change pace.  I start walking down the escalator to get there faster and the youngest, A, looks up and stares for the span of one second or less.  I see him trying to figure it out…is this who he feels it is, in this strange airport far from home.  Suddenly, whether it is his eyes or his heart that make the decision, he leaves what he is doing and screams “mommy” over and over again as he runs towards me.  J joins in and passengers in ten terminals turn to look.  It is sweet – we are together again.  My small family that has grown to six with M and Jodi joining the group.

We fly away to our summer place in Bulawayo.

The visa process takes a long time so I take care of customs while M plays with the kids and E and Jodi take care of visas.  I chat with customs officials I’ve known in the past, those who’ve seen me through the process before and who’ve harassed me years ago, but who defended me from then on.  Not a single bag is looked at and we get through easily, with water filters and powdered milk intact.

Ncube (pronounced “click” +beh”) picks us up and brings us to our home, a cottage that the three little bears would be proud of.  One bedroom (E&T), living room/kitchen (Jodi in LR), bathroom (with flushing toilet and bathtub when water is available), and a loft (three kids) is the sum of it.  This cottage belongs to Helene and John Stambolie, our gracious hosts, and their four children.

There is no electricity on Tuesdays and therefore, no water, as the water is pumped from a borehole.  AJ, the eldest and only son of the big house, takes E to the grocery store from where we receive a bag of rice, a bag of beans, milk, eggs, bread and butter.  I start soaking the beans for tomorrow and we set about the business of settling in before it gets too dark.  M makes chocolate milk with some Milo I brought from Kenya and the kids drink that while I make some grilled cheese sandwiches with cheese given to us by the Stambolies.  With full bellies, J arranges games we brought, M unpacks loads of crafts for the summer, Jodi arranges her corner, and I organize the kitchen and our things.  A is busy checking out the yard and asks anyone who will listen if we’ll hop with him.  E is back at the market, scoping out lanterns, a fridge the Stambolies ordered (just don’t open it much on days with no electricity), and anything else we might need.

We are invited to go to the big house for a proper dinner, but A refuses to go.  He says he is too tired and just wants sleep.  This from the child that didn’t stop hopping around outside while we set things up and who has already fallen in love with the large yard in which he is free to play as long as he pleases.  I bathe him out of a bucket of water we pilfer.  The second half of the bucket is enough to bathe J.  Snuggled in clean, warm pajamas, A is asleep in thirty seconds, not caring that the bed, pillow, house, surroundings are new.  The rest of us take five steps and find ourselves in the big house where a dinner of spaghetti and salad await us.  With easy conversation and a dinner followed by tea, I know, I just know, that this is going to be a good summer.  M feels it too, my beautiful niece.