Amy Nunn

Evolution of Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to AIDS Treatment

Background Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazils AIDS treatment program has been cited widely as the developing worlds largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005. Methods and Findings We compared Brazils ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazils reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir–ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US

Low Perceived Risk and High HIV Prevalence Among a Predominantly African American Population Participating in Philadelphia's Rapid HIV Testing Program

200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US

Linking HIV-positive Jail Inmates to Treatment, Care, and Social Services After Release: Results from a Qualitative Assessment of the COMPASS Program

414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US

Keeping the Faith: African American Faith Leaders’ Perspectives and Recommendations for Reducing Racial Disparities in HIV/AIDS Infection

7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US

Preventive Healthcare for Underserved Women: Results of a Prison Survey

2 billion on drugs for HAART between 2001 and 2005, implying a savings of US

Geography Should Not Be Destiny: Focusing HIV/AIDS Implementation Research and Programs on Microepidemics in US Neighborhoods

1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazils locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazils locally produced generics totaled US

The HIV Care Cascade: Models, Measures and Moving Forward

110 million from 2001 to 2005. Conclusions Despite Brazils more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US

Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities.

1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.

Changing global essential medicines norms to improve access to AIDS treatment: Lessons from Brazil

African Americans are disproportionately infected with HIV/AIDS. Despite Centers for Disease Control and Prevention (CDC) guidelines recommending routine opt-out testing for HIV, most HIV screening is based on self-perceived HIV risks. Philadelphia launched a rapid HIV testing program in seven public health clinics in 2007. The program provides free rapid oral HIV tests to all patients presenting for health services who provide informed consent. We analyzed demographic, risk behavior, and HIV serostatus data collected during the program between September 2007 and January 2009. We used multivariable logistic regression to estimate the association between behavioral and demographic factors and newly diagnosed HIV infection. Of the 5871 individuals testing for HIV, 47% were male, 88% were African American, and the mean age was 34.7 years. Overall HIV prevalence was 1.1%. All positive tests represented new HIV diagnoses, and 72% of individuals reported testing previously. Approximately 90% of HIV-positive individuals and 92% of individuals with more than five recent sex partners never, or only sometimes, used condoms. Two thirds of individuals testing positive and 87% of individuals testing negative assessed their own HIV risk as zero or low. Individuals reporting cocaine use and ever having a same sex partner both had 2.6 times greater odds of testing positive. Condom use in this population was low, even among high-risk individuals. Philadelphias program successfully provided HIV testing to many underserved African Americans who underestimate their HIV risk. Our results nevertheless suggest greater efforts are needed to encourage more individuals to undergo HIV testing in Philadelphia, particularly those who have never tested.

Commentary on Boyd et al. (2012): Debunking myths about methadone and crime

Approximately 17% of individuals living with HIV/AIDS pass through the correctional system each year. Jails provide a unique opportunity to diagnose and treat HIV infection among high-risk, transient populations with limited access to medical services. In 2007, the US Health Resources and Services Administration funded a multi-site demonstration project entitled Enhancing Linkages to HIV Primary Care in Jail Settings that aims to improve diagnosis and treatment services for HIV-positive jail detainees and link them to community-based medical care and social services upon release. We performed an evaluation of the Rhode Island demonstration site entitled Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS). Through in-depth qualitative interviews among 20 HIV-positive COMPASS participants in Rhode Island, we assessed how COMPASS impacted access to health care and social services utilization. Most individuals were receiving HIV treatment and care services upon enrollment, but COMPASS enhanced linkage to medical care and follow-up visits for HIV and other co-morbidities for most participants. Several participants were successfully linked to new medical services as a result of COMPASS, including one individual newly diagnosed with HIV and another who had been living with HIV for many years and was able to commence highly active antiretroviral therapy (HAART). While many individuals reported that COMPASS support prevented substance abuse relapse, ongoing substance abuse nevertheless remained a challenge for several participants. Most participants enrolled in one or more new social services as a result of COMPASS, including Medicaid, Supplemental Security Income, food assistance, and housing programs. The primary unmet needs of COMPASS participants were access to mental health services and stable housing. Intensive case management of HIV-positive jail detainees enhances access to medical and social support services and helps prevent relapse to substance abuse. Expanding intensive case management programs, public housing, and mental health services for recently released HIV-positive detainees should be public health priorities.