Cutting The Cost Of HIV Treatment. 31/10/09

TAMAR KAHN

2009/10/31

The Department of H ealth is finalising new guidelines that will see patients starting treatment earlier. It is also considering whether to provide more patients with an expensive drug, tenofovir, which has fewer side effects than the much cheaper and more commonly prescribed stavudine.

The price tags for personnel, laboratory tests and drugs are all under the microscope.

Finance Minister Pravin Gordhan hinted at the potential savings to be made earlier this week, when he released his midterm budget. “If we use a different approach … we can get the drugs at one sixth of the cost, which frees up money for other priorities,” he said.

Industry sources and analysts are sceptical that costs could be reduced so much, but it is clear SA could be getting its AIDS drugs much cheaper than it does through the R3,6bn tender it awarded last June.

A rough calculation based on the Clinton Foundation AIDS Initiative’s August price list, making allowances for VAT, transport costs, warehousing and distribution, shows SA is paying 27% more for efavirenz than it could be, and double its rate for tenofovir .

These are the two most expensive drugs provided at state facilities. Efavirenz is prescribed to most adults as first-line therapy, along with stavudine and lamivudine. Patients who get dangerous side-effects from stavudine are switched to tenofovir.

“D4T (stavudine) is one of the biggest obstacles to providing ARVs at primary level. It has a host of common, disfiguring and dangerous side-effects ,” president of the Southern African HIV/AIDS Clinicians Society Dr Francois Venter says .

“If we could replace it with tenofovir, it would be a huge step forward, and the only obstacle appears to be cost.”

Aspen Pharmacare, which won 60% of the AIDS drug tender, says its prices are higher than the Clinton Foundation’s because of the high cost of imported active pharmaceutical ingredients, and because it did not have the licence to produce generic tenofovir or efavirenz when the tender was issued. Aspen is waiting for its application to the Medicines Control Council to register generic tenofovir , without which it cannot distribute the drug in SA.

The H ealth D epartment’s Yogan Pillay says the government is looking at ways to reduce the cost of its HIV/AIDS programmes.

Officials are exploring “task- shifting” — training nurses to provide services traditionally performed by doctors — and talking to the National Health Laboratory Services about cutting the cost of the regular blood tests required to monitor AIDS patients’ progress.

But most significantly for the industry, the department is also talking to its suppliers about how to cut medicine prices, including those in the current contract, which expires in May. “One of the biggest challenges facing our (local) drug companies is that 70% of their prices come from the active pharmaceutical ingredient , which is imported,” says Pillay. “The g overnment could look at buying them in bulk, or SA could produce them in the country in the state or private sector or in a public-private partnership.”

The D epartment of T rade and I ndustry has set up a task team to investigate the feasibility of establishing a local active pharmaceutical ingredient industry.

“Alongside that, we’ve started discussions with the Clinton Foundation. We’ve compared prices and found that in some areas we could make savings … and we’ve started to think about how we could do the next tender (differently),” says Pillay.

The AIDS Law Project’s Jonathan Berger says the government is not legally obliged to use the tender system and could procure drugs via the Clinton Foundation if it chose to.

“The constitution requires processes that are fair, equitable, transparent, competitive and cost- effective. The legal framework to give effect to this does not necessarily require a tender process,” he says. “But you’d probably want to give local companies a chance to at least match or better them (the Clinton Foundation).”