Large disparities in costs of antiretrovirals between low- and middle-income countries

AIDS 2016 combined logoPolly Clayden, HIV i-Base

There are still vast differences in antiretroviral prices between countries with similar Gross National Income, according to data shown at AIDS 2016.

Dzintars Gotham and colleagues from Imperial College and St Stephens AIDS Trust, London, took a further look at disparities in global HIV drug pricing. [1] Early findings from this study were presented at IAS 2013 and found that middle-income countries outside Africa paid, on average, four times more for antiretrovirals than African countries with similar Gross National Incomes (GNI). [2, 3]

There have been substantial drops in the prices for antiretrovirals in low-income countries 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 patent protected.

The investigators extracted prices and transactions for originator and generic antiretrovirals used in national treatment programmes from the WHO Global Price Reporting Mechanism database (over 100 countries), and a Russian government database. They calculated median prices for each country from 2013-2015 – presented as US$ per person per year. For each drug they calculated price differences as percentage increases relative to the lowest median price for that drug.

Two originator PIs had significantly higher median prices outside sub-Saharan Africa (SSA): lopinavir/ritonavir US $360 (non-SSA) vs $232 (SSA); and darunavir US $5760 (non-SSA) vs US$ 657 (SSA).

In Russia, which, the investigators noted, was re-classified as a high-income country in 2013 but has a large untreated HIV positive population, antiretroviral prices were much higher than in SSA: TDF/FTC cost US$ 2, 313 vs US$ 39 for the NTRI co-formulation in Botswana (+5930%).

The Russian price for darunavir was US $4, 695 (rising to a shocking $ 8,675 in Azerbaijan) vs US $ 379 in South Africa (+1239%); atazanavir/ritonavir was US$ 1, 204 vs US$ 123 in Togo (+647%) and lopinavir/ritonavir US$ 1, 434 vs Central African Republic US$ 214 (+581%).

The analysis also revealed Senegal and Moldova had significantly increased prices compared with other countries from the same and outside their respective regions.

In Moldova prices ranged from +2250% to +210% of the minimum lowest prices: darunavir/ritonavir was US$ 8, 535 compared with the South African price of US$ 379; and TDF/FTC was US$ 82 compared with US$ 39 in Botswana.

In Senegal the percentage increase compared with the minimum lowest prices ranged from +387% to +180%: TDF/FTC US$ 151 compared with US$ 39 in Botswana; and abacavir US$ 203 compared with US$ 113 in Botswana.


Non-African countries continue to fare badly for low-cost antiretrovirals and once again this research group reveals stark contrasts in pricing even across countries in Africa.

Aggressive intellectual property rules could make new priority drugs like dolutegravir (although the recently announced price for the ViiV dolutegravir of US$ 400 per-person year sets a good precedence for middle-income countries) and tenofovir alafenamide completely out of reach for many people with HIV living in countries that do not bene t from low generic prices.


  1. Gotham D et al. Differences in antiretroviral drug prices between countries within and outside sub-Saharan Africa. AIDS2016. Poster abstract TUPEE624. (abstract) (poster)
  2. 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. (abstract) (webcast)
  3. Clayden P. High prices for antiretrovirals in middle-income countries outside Africa. HTB. 1 October 2013.

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