Cheaper drugs page 2

For the majority of people in African countries the healthcare they receive is mainly provided by the government via health facilities comprising main / referral hospitals, district hospitals, health clinics, and dispensaries. In order for the HIV drug distribution program to succeed there has to be increased investment for development of the health infrastructure. This will also include the development of roads, providing transport, secure stores, warehouses etc. It may also require innovative ideas, such as using churches, schools and other public buildings as a means of expanding the number of outlets for the distribution of medicines. The table below illustrates the wide range in difference of the number of persons who would have access to HIV drugs if existing systems were to be utilised.

Estimated number of HIV infected people and their access to Essential Drugs treatment in selected countries

Country	Number of HIV infected people in 1999	Access to essential drugs*
Burkina Faso	350,000	60%
Cote D’Ivoire	760,000	80%
Kenya	2,100,000	35%
Nigeria	2,600,000	10%
South Africa	4,200,000	80%
Uganda	820,000	70%
Zimbabwe	1,500,000	70%
*Access to minimum of 20 most essential drugs continuously available at public or private health facilities within 1 hr walk. Source: Adapted from UNAIDS Update 2000 & World Bank 2000

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A timetable of distribution

This will probably be easier to start in urban areas, and at this stage the numbers and concentration of HIV infected people is much greater in urban areas. But health planners should remember that the majority of the population lives in the rural areas, and while this may give them some breathing space, it will not last long. It should not be used as an excuse to delay the development of health infrastructure and distribution networks in rural areas.

A comprehensive well thought out program outlining how patients will receive their drugs will have to be formulated. This will be critical to the success of the whole exercise. Some questions that need to be answered are:

Will there be a registration scheme for HIV positive people showing they are entitled to HIV drugs?
Will patients be able to receive treatment from anywhere, or will it only be at a health facility they are registered at?
How often will patients be expected to get their medicines? Will they receive a weeks or months supply each time they visit a health facility or will they have to do as best they can?

The list of questions and possible solutions are by no means exhaustive and there are surely many other issues that will have to be dealt with. Below are listed a few benefits and problems a program of registration may have.

Benefits of a registration program	Problems of a registration program
More accurate data on the actual number of infected people allowing better calculation of demand for drug	May act as a barrier for people coming forward, especially if it is perceived as a means of discrimination by marking them out.
More accurate data means better epidemiological monitoring of the progress of the epidemic, and better forecasting of future demand for treatment	If people are restricted to receiving drugs only at the clinic or within the area they were registered, it may limit the ability to receive treatment, especially for people who are mobile such as truck drivers, or migrant workers.
It will be easier to set up regular timetables for a drug distribution system. Patients can be called in on certain days and dates based on their registration number. The attraction for the patient is that they do not have to make expensive fruitless journeys to the health clinic because they can be assured of receiving a sufficient amount of drugs when they visit the health clinic at the appointed time. They can then plan their journeys and activities better. From the clinic point of view knowing the expected number of people on any day means better control of the supply and availability of drugs.	Potential for fraud. Uninfected people may pose as HIV infected people. This is especially where unscrupulous persons may perceive there is some profit or gain to be made from HIV drugs, perhaps to sell them in areas where supply is poor. They may procure access to drugs by registering at multiple health clinics. It is also possible the personnel at the clinics, or even HIV infected people could be involved in such corrupt activities.
Standard registration forms or cards means better coordination between different organizations involved in HIV drug distribution.	Insufficient number or availability of registration cards or forms will interfere with the distribution and monitoring of drug distribution.

The frequency with which patients receive drugs will also be an important factor. For example drugs given at weekly appointments may be more affordable in terms of the cost of the drugs, but would be more inconvenient in terms of the time and cost of transporting for the patient to attend the health clinic at such short intervals on a regular basis. Monthly appointments would require fewer appointments, but the drugs would cost a proportionally greater amount. A balance would have to be found, for example patients living closer to the health clinic attending on a weekly basis, those living further away on a monthly basis.

Different approaches will be needed in the rural areas that contain the majority of the population, have a relatively smaller number of health facilities in a more geographically wide area when compared to urban areas that have a smaller more densely located population served by more health facilities. The type of distribution plan adopted will vary from country to country depending on local conditions and many other factors. But one factor that will surely affect the ultimate success of the drug distribution program will depend on the patient's ability to pay for treatment, which ultimately depends on the price of HIV drugs. The cost of distributing the drugs will also affect the government’s ability, willingness and commitment to sustaining the program.

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What will be the actual cost the HIV/AIDS drugs to the customers and the government?

At the moment the proposed price of HIV drugs is being put at $1.00 per day. But even at this low price the drugs will still be out of the reach of the majority of PHAs in African countries. But this is not the only cost that is involved in AIDS. The table below shows a list of the cost of AIDS treatments a PHA is likely to incur in the course of the disease. Even in the absence of antiretroviral drug treatment the cost was already between $300 – 500 dollars per year.

Cost of AIDS Treatments

Type of treatment	Cost per patient per year in Sub-Saharan Africa
Palliative care * (drugs only)	$19
Palliative care plus treatment of low cost opportunistic infections**	$299
Palliative care plus treatment of all opportunistic infections	$490
Highly active antiretroviral therapy (HIV drugs)	$400-700
Diarrhoea, skin rashes, pain nausea, cough, headaches, fever, shortness of breath * TB, Toxoplasmosis, oral and oesophageal thrush, pneumonia / septicemia Source: Adapted from World Bank 1999

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Subsidising HIV drugs even further

A case can be made for subsidizing the cost of HIV drugs even further. Lowering the price to $0.50 per day or less would be more affordable for the majority of the population. By doing this more people are likely to be able to afford treatment. Governments could apply a differential pricing mechanisms that will depend on the patients ability to pay i.e. a poverty index. This will keep the cost low for the poorest of the poor pay who will the least while better of pay more. The example below compares the effect of a subsidy on the total cost of 1 month treatment at an official price of $1.00 per day:

Subsidy	Daily cost to consumer	Monthly cost to consumer
$0.00	$1.00	$30.00
$0.50	$0.50	$15.00
$0.75	$0.25	$7.50

Which price structure is more likely to be affordable to the consumer?

Consider the following scenario: due to the high price of drugs, rather than getting a full dose of drugs, the patient buys drugs that will last for only a few days. They then stretch them drugs out until they can next afford to buy more. Such a disastrous scenario resulting in frequent breaks of treatment is very common in situations where the sustained affordability of drugs is beyond the means of the consumer. The potential for developing resistance to the drugs becomes extremely high and can become widespread very quickly.

By keeping the price of drugs low, the government will ensure that people will be able to afford continued treatment and are more likely to stick to the recommended treatment. The long term saving made by the government far outweigh the cost of such subsidies. The reason being PHAs who undergo treatment with HIV drugs remain healthier for a lot longer and in the long run use fewer resources. The overall savings to the individuals, their family, society and the government is immense.

By remaining healthier, PHAs will require fewer instances of hospitalization thereby reducing the demand on already overburdened health care systems
By staying healthy PHAs will continue to be able to work and make a contribution to the economy.
By staying healthy PHAs will require less care from friends and relatives reducing the social, emotional and financial burden.
The PHAs will be able to continue to provide and care for their families.
By living longer the family unit remains together for longer and slowing down the increase in numbers of AIDS orphans, thereby reducing the social burden on the state.

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Prevention Strategies - the dual approach

Without effective prevention strategies no matter how widely available cheap HIV drugs become, treatment alone will not slow down the HIV epidemic, the growth in numbers of people infected with HIV will continue unabated. A dual approach that combines treatment programs with education and prevention programs is needed. At the same time urgent changes in the policy and attitude of many governments to the HIV/AIDS epidemic is needed. Examples such as Heads of State taking the lead in calling for changes in sexual behavior have proved very effective, as most recently seen in Botswana.

Governments must continue to vigorously promote Education and Prevention programs that keep on reinforcing the message about the need for safe protected sex, refraining from risk taking behavior and continued vigilance if there is to be a realistic chance of defeating HIV/AIDS. Widespread changes in sexual behavior will be needed.

For their part International donors should give greater support in the form of low interest loans to aid African governments provide treatment for HIV/AIDS sufferers. International donors should also be more committed to providing resources for prevention strategies if there is ever to be any hope of defeating the HIV/AIDS epidemic. The burden is just to great for African nations to shoulder alone.

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