High prices for antiretrovirals in middle-income countries outside Africa

Polly Clayden, HIV i-Base

Middle-income countries outside of Africa are paying, on average, four times more for antiretrovirals than African countries with similar Gross National Incomes (GNI) according to an analysis presented at IAS 2013.

There have been substantial reductions in the prices for antiretrovirals in the lowest income countries –defined by a GNI less than US$1025/person-year – but these low prices are not consistent in middle-income countries with large HIV epidemics. There is no established mechanism for fair pricing in these countries and several key antiretrovirals are still on patent.

Andrew Hill from Liverpool University presented findings from an analysis of pricing of six key single agents and dual combinations used routinely in first and second line treatment, on behalf of colleagues from Thailand, South Africa and the UK.

The investigators looked at prices for nevirapine (NVP), efavirenz (EFV), tenofovir (TDF), AZT/3TC, TDF/FTC and lopinavir/ritonavir (LPV/r). Antiretroviral prices used in national programmes (2010-2012) were extracted from the WHO Global Price Reporting Mechanism (GPRM) database.

They then compared treatment costs – with both branded and generic antiretrovirals – with per capita annual GNI using the World Bank database.

The 20 countries were classified as:

  • Low income (GNI less than US$1025/person): Ethiopia, Malawi, Uganda, Tanzania, Kenya, Cambodia.
  • Low-middle income (GNI US$1026-$4035): Nigeria, Vietnam, India, Philippines, Indonesia, Ukraine.
  • Upper-middle income (GNI US$4036-$12,475): Namibia, South Africa, Botswana, Thailand, China, Malaysia, Brazil, Russia.

Dr Hill suggested that a gradual price rise as income increases might be expected but this analysis revealed huge disparities in prices between African and non-African upper-middle income countries not clearly correlated with rising GNI.

Overall median treatment costs were mostly uniformly low in low and low-middle income countries and prices remained stable in African countries as GNI increased. Antiretroviral drug prices in upper-middle income countries outside of Africa were significantly higher than African countries with similar GNIs (See Table 1). The highest prices of any country analysed were in Malaysia, which has a lower GNI than Russia or Brazil.

Table 1: Median cost of treatment (US$ per person per year and range) in higher-middle income countries by location
Formulation African countries Non-African countries Cost Ratio
EFV (600 mg OD) 60 (51-69) 241 (57-784) 4.0
NVP (200 mg BID) 30 (29-35) 97 (32-162) 3.2
TDF (300 mg OD) 107 (79-135) 477 (262-715) 4.5
TDF/FTC (300/200 mg OD) 122 (102-143) 468 (157-779) 3.8
AZT/3TC (300/150 mg BID) 98 (97-113) 562 (372-752) 5.7
LPV/r (400/100 mg OD) 425 (397-490) 1000 (793-3794) 2.4

The investigators will repeat the analysis dividing the costs by originator and generic suppliers. They will look at patent restrictions on some antiretrovirals that might be causing higher prices in some middle-income countries.

Dr Hill remarked there was “no rhyme or reason to prices”. He concluded: “We need a new system of fair pricing for antiretrovirals for all middle-income countries with large HIV epidemics”.


Non-African countries can get forgotten in mechanisms to aid fair pricing and rarely has an analysis shown this so starkly.

Aggressive intellectual property rules proposed in a free trade pact under negotiation by the US and 11 Asia-Pacific countries – the Trans Pacific Partnership – could prevent equitable access to affordable medicines further by extending patent protection for originators and restricting generic production. This could make promising new pipeline drugs like dolutegravir completely out of reach for many people with HIV.


Hill A et al. Is the pricing of antiretrovirals equitable? Analysis of antiretroviral drug prices in 20 low- and middle-income countries. 7th IAS Conference on HIV Pathogenesis Treatment and Prevention, 30 June – 3 July 2013, Kuala Lumpur, Malaysia. Oral abstract WELBDO.

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