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Current experience with differential pricing of HIV/AIDS
related drugs in Uganda
Dorothy Ochola M.D.-Muyingo Sowedi - Malamba S. Paul J. Weidle, Pharm.D.,MPH, -
Joseph Saba, MD.
10 April 2001 – Høsbjør, Norway
Based on experience from UNAIDS Drug Access Initiative
Background (1)
• Estimated population of 21 million people (1998)
• Average HIV prevalence is 7%.• An estimated cumulative number of
2,276,000 to have been infected since the onset of the epidemic in 1982
• 1,438,000 estimated to have died.• GNP per capita: $310 (1998).
Background (2)
• HIV-related drugs in several categories– STI drugs provided to patients through STIP– Basic drugs for treatment of opportunistic
infections– TB drugs– Basic drugs for pain relief & symptom control– Antiretrovirals & sophisticated drugs for
opportunistic infections – patient meets full cost
The UNAIDS/MOH D.A.I.
UNAIDS/MOH HIV Drug Access Initiative.• Goal: to increase access to HIV-related drugs
and care.
Two major mechanisms:• Adequate healthcare infrastructures• Differential pricing and responsive distribution
system
D.A.I.: Implementation
Pilot Program initiated in June 1998.– Access to antiretroviral drugs initiated 1 Aug.1998.– National Advisory Board to oversee activities.– Mechanism for negotiations, procurement and
distribution for ARVs established– Treatment centres for access to ARVs accredited.– Training of health providers in correct use of drugs
conducted– Patients pay for ARV medications and medical visits
ARV Price Analysis - Objectives
Carried out in December 2000 with the following objectives:– Describe the cost of ARV drug combinations to
patients in Uganda.– Describe reasons for price fluctuations of ARV to
patients in Uganda.– Quantify the price reductions as at end of 2000.
Method
• Information on cost of ARV gathered from medical Access (U) Ltd.– From August 1998 – December 2000.– Costs of drugs purchased in foreign currency 7
converted to Ugandan shillings
• Information on costs of drugs to patients gathered from treatment centres.– = cost of drug to medical access plus small
mark-up
ARV price reduction in Uganda
$284
$113
$221
$131
$230
$144
$270
$82$86
$350
$0
$100
$200
$300
$400
Pri
or t
oD
AI
Init
iati
onof
DA
I
Retrovir Videx Zerit Epivir Crixivan
5 - 49% reduction
at initiation of DAI – August 1998
Cumulative enrollment - DAI
137
273359
428
607
740
872 912
512
0100200300400500600700800900
1000
Aug-Sep98
Oct-Dec98
Jan-Mar99
Apr-Jun99
Jul-Sep99
Oct-Dec99
Jan-Mar00
Apr-Jun00
Jul-00
N
All Nsambya Mildmay Mulago JCRC Mengo
ARV costs in response to Currency Valuation & Price Changes
0
200000
400000
600000
800000
1000000Ja
n-99
Jul-
99
Jan-
00
Jul-
00
Uga
nda
Shil
ling
s
Combivir/Indinavir Combivir/Nelfinavir
Uganda, 1999-2000
Reasons for recent price reductions
• Negotiated reductions in the prices of some drugs from multinational phamaceutical manufacturers
• Pressure from Governments, PWAs and other activists in developed countries on multinational companies
May 2000 announcement: Further Price Reductions
• 5 pharmaceutical companies/5 UN Agencies pledged to substancially reduce prices for developing countries.
• Effected in Uganda – November-December 2000.
• Price reductions for individual products 0-83% compared to Feb 2000 prices.
• Price reduction not same for all drugs (>50% for 6 drugs, 25-50% for 2 and <5% for 6 drugs).
Cost of 30 days supply of Combinations of ARVs in Uganda
$0
$250
$500
$750
ZD
V/D
DI
DD
I/D
4T
CO
M
CO
M/N
EV
ZD
V/D
DI/
EF
V
DD
I/D
4T/E
FV
CO
M/E
FV
ZD
V/D
DI/
IDV
DD
I/D
4T/I
DV
CO
M/I
DV
ZD
V/D
DI/
NF
V
DD
I/D
4T/N
FV
CO
M/N
FV
ZD
V/D
DI/
RIT
/SA
Q
DD
I/D
4T/R
IT/S
AQ
CO
M/R
IT/S
AQ
Feb-00 Dec-00
Feb Dec 2000
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000zd
v/D
DI
DD
I/d
4t
com
com
/nev
zdv/
DD
I/E
FV
DD
I/d
4t/E
FV
com
/EF
V
zdv/
DD
I/ID
V
DD
I/d
4t/I
DV
com
/ID
V
zdv/
DD
I/N
FV
DD
I/d
4t/N
FV
com
/NF
V
zdv/
DD
I/R
IT/S
AQ
DD
I/d
4t/R
IT/S
AQ
com
/RIT
/SA
Q
Uga
nda
Shi
lling
s
Brand name drugs onlyGeneric drugs where possible
Cost of 30 days supply of Combinations of ARVs in Uganda
using Generic Vs. Brand Name Drugs - Dec 2000
CENTER START DATE
JUL-2000 DEC-2000 JAN 01
*JCRC 01-Aug-98 423 (46%) 452 512
Nsambya 06-Aug-98 286 (31%) 305 345
Mildmay 05-Oct-98 158 (17%) 167 189
Mulago 21-Jun-99 33 ( 4%) 41 41
Mengo 02-Jan-00 12 ( 1%) 12 12
Total 912 977 1099
* Additional 536 patients started purchasing ARVs before August 1998 or had no clinical records at the center
ENROLMENT AFTER NEW PRICE REDUCTIONS
Lessons learned (1)
• The cost of ARVs is only one aspect of total cost of providing HIV/AIDS care.
• Few HIV/AIDS individuals have adequate financial resources to purchase ARVs – majority cannot afford even at current reduced costs.
Lessons learned (2)
• Need more public funding to enhance healthcare infrastructure and subsidize further drug costs.
• Depreciation of local currency may affect patients purchasing power, and therefore quality of care.
• Further price reductions will enable more of those previously on dual therapy to access HAART.
Conclusions• Differential pricing can be looked at from two
perspectives: the health care provider and the care seeker.
• In developing countries most care seekers cannot meet the costs. The provider to some extent is under obligation to fill the gap.
• We have recently seen important efforts for differential pricing. What are care providers prepared to do?