World AIDS Day takes place on 1st December each year and one of this year's themes is #ItsNotOver – a reflection which prompts thoughts on what has been achieved in increasing access to anti-retrovirals, the scope for continued progress and the lessons that can be learned for access to other medicines.
It also begs a further question: can other killer viruses be tamed? And what would it take to achieve this?
Dr Rory Horner is a lecturer and researcher at the Global Development Institute – a flagship institute for the University of Manchester's addressing global inequalities research beacon.
His research explores the changing geographies of global development, with a specific focus on South-South trade and the pharmaceutical industry.
This World AIDS Day, he shares thinking rooted in his research experiences...
HIV equalled death
Patna, India
As part of my research in India, I interviewed an activist who had worked in a care home for people living with HIV/AIDS. He told me how in the late 1990s and early 2000s, he was going to the crematorium three to four times a month. Although anti-retroviral medicines had been available since the mid-1990s, he said:
"medicines were beyond our reach, beyond our dreams."
Yet when I interviewed him in 2012, he had only gone to a crematorium once for the same reasons in the previous three years:
“That's how powerful and effective this medicine is. We experience it with our own bodies. We are the living proof…... [Before] HIV equalled death….. But I don’t say they died because of HIV, but because of lack of access to medicine.”
A turning point for medicine access
Fire in the Blood film trailer
Fifteen years ago, Y.K. Hamied, made a dramatic announcement that would affect the lives of millions of people living with HIV/AIDS.
His company, Cipla, one of India's largest generic pharmaceutical manufacturers, would provide a year’s supply of anti-retroviral medicines for $350 a year.
Until that time - despite the AIDS virus spreading - the availability of anti-retrovirals (ARVs) which curtail the growth of the virus was extremely limited in much of the world. In many developing countries, the outbreak of AIDS had halted and even reversed the significant improvements in life expectancy which had been achieved in previous decades. However, in the United States, where the virus had grown so devastatingly in the 1980s, the number of deaths had already started dropping from 1996 onwards as ARV medicines became available.
Huge progress has since been made in access to ARVs thanks in part to considerable advocacy and international involvement. This includes, for example, the advocacy of ACT UP and the Treatment Action Campaign, as well as the work of Médecins Sans Frontières (MSF), the Global Fund to Fight AIDS, TB and Malaria, launched in 2002, and the US-backed President's Emergency Plan for AIDS Relief (PEPFAR) which launched in 2003.
Subsequent to Dr Hamied’s announcement in 2001, Cipla and other Indian companies have provided around 80% of the anti-retroviral medicines used by these influential health organisations.
Cipla even produces some anti-retroviral drugs in Uganda, a country hit particularly hard by HIV/AIDS. Many countries in eastern and southern Africa have increased their treatment coverage dramatically. Indeed 3.4 million people in South Africa, the worst-affected country, are on treatment.
By the end of 2015, global coverage of anti-retroviral therapy had reached 46% [43–50%] of those infected and involved 17 million people according to UNAIDS and demonstrated in the diagram below.
Source: UNAIDS (2016, 21).
The cost of a year's supply of ARVs is now less than $100 per year for first-line regimens and access has increased substantially. AIDS-related deaths peaked globally in the mid-2000s at an estimated 2 million per year and have since reduced to an estimated 1.5 million in 2010 and 1.1 million in 2015.
The global access to medicines campaign played a key role in the battle against HIV/AIDS, as vividly shown in the 2013 documentary Fire in the Blood. Generating momentum from controversies in relation to South Africa’s patent law provisions in the late 1990s, dubbed "Big Pharma vs. Nelson Mandela", the campaign played a key role in increasing international awareness of the barriers to access to medicines – especially the role of patent protection.
Yet the job is only half done. Approximately only half of people living with HIV/AIDS are receiving appropriate medication. Considerable progress is thus still required in increasing awareness of HIV and access to ARVs for people living with the virus. HIV/AIDS is still the leading cause of death among adolescents in Africa.
With the sense that the end of AIDS is achievable, development targets have become more ambitious. Millennium Development Goal 6 sought to “Combat HIV/AIDS, Malaria, and Other Diseases”.
Yet rather than just reverse the trend, Sustainable Development Goal 3 seeks to end the epidemic by 2030. A set of immediate, Fast-Track Commitments have been created for 2020 that seek to ensure those who are infected know they are infected, that they receive treatment and that the virus is suppressed.
· The pharmaceutical industry can (but doesn't always) play very positive roles for public health, including in the global South
· Providing generic medicines can dramatically increase access to medicines
· Overcoming patent barriers can play a key role in increasing access to medicines (as India's public health oriented patent laws have demonstrated), but are not the only barrier
· Global access to medicines advocacy to create political opportunities, combined with production capabilities of generic pharmaceutical companies, can be an extremely effective combination in increasing access
· Momentum – across advocacy groups, industry, governments and, very importantly, different parts of the world – has made significant progress, but needs to be continued
Generics for AIDS and Cancer too?
The "can opener" molecule may be our newest defense in the fight against HIV. Photo courtesy of Shutterstock
Lessons must be applied not just to the continued fight against HIV/AIDS but also to a range of other issues where gaps in access to medicines persist. Patent issues can continue to prevail for new regimens of treatment for HIV/AIDS. Yet restrictive patent clauses can continue to be proposed in new trade agreements, while elsewhere big pharma has continued its campaign against any reductions in scope or duration of patent protection.
Recently, it has been suggested that cancer is "worse than AIDS", killing more people than HIV/AIDS, TB and malaria combined. For example, hepatitis C virus, a liver disease infection, which can cause liver cirrhosis or liver cancer, is curable with antiviral medicines. Yet significant gaps remain in access. Many cancer medications are under patent. Like HIV/AIDS, cancer is also affecting populations in both global North and South and thus has potential for global action. It warrants considerable attention given much of the increase in burden is projected for low and middle-income countries where ability to purchase the relevant medicines is more limited.
On this World AIDS Day we must reflect on what life is like for those living with this illness and celebrate the progress made without becoming complacent about AIDS or ignoring other increasingly devastating illnesses.
The AIDS shift of taming this killer illness is well under way. It needs continued momentum to complete this transition and end the epidemic.
As the UN says, "AIDS is not over, but it can be".
Read more here about the research of Dr Rory Horner from the Global Development Institute – a flagship institute for the University of Manchester's addressing global inequalities research beacon.
