How do intellectual property law and international trade agreements affect access to antiretroviral therapy?

Trade, intellectual property, and the public health bearing

The objective of this article is to describe the current fracture between global trade and public health priorities, as well as examine opportunities for harmonisation. A literature review of public health, global trade, and intellectual property articles describes several issues with recommendations. Currently, there is mixed quality of research and a lack of health impact assessments to accompany the global trade agenda. Human rights concepts continue in debate as flexibilities to trade laws remain without organised surveillance or evaluation. There are specific, relevant recommendations to implement a trade agenda inclusive of public health leadership. Recent trade and intellctual property advances in public health collaborations should be supported and continued. Trade groups should produce impact assessments before decisions on policies are made, with quality to the research. Lastly, a global research and development treaty should be an open, accessed path.

Likely impact of pre-exposure prophylaxis on HIV epidemics among men who have sex with men

Rapid developments in the field of HIV pre-exposure prophylaxis (PrEP) with antiretrovirals offer a promise to bring HIV transmission among gay and other men who have sex with men (MSM) to zero by 2030. This review evaluates studies, which modelled the impact of PrEP on HIV diagnoses, and discusses the progress towards PrEP implementation. Studies in English, conducted after 2010 among MSM in countries of the Organization for Economic Cooperation and Development (OECD) were reviewed. Six modelling studies were included, three of which had been conducted outside the US. None of the published models showed that PrEP alone can reduce HIV diagnoses to zero and eliminate HIV transmission by 2030. However, PrEP in combination with other biomedical interventions can reduce HIV diagnoses on the population level by ~95%. Other upcoming biomedical prevention strategies may strengthen combination prevention. Access to PrEP remains limited, even in the OECD countries. Modelling studies can assist governments with decision-making about PrEP implementation and add urgency to the implementation of PrEP. More work is needed on modelling of the impact of PrEP on HIV diagnoses trends outside the US where PrEP implementation is in its early stages.

Preexposure Prophylaxis of HIV Infection: the Role of Clinical Practices in Ending the HIV Epidemic

PURPOSE OF REVIEW

The aim of this study is to summarise the recent evidence from high-income settings about providers' ability to deliver on the UNAIDS goal of at least three million people at substantial risk of HIV infection with PrEP by 2020, including awareness and knowledge about PrEP, willingness to prescribe PrEP, current levels of prescribing and service delivery models and issues.

RECENT FINDINGS

Awareness about PrEP among health providers is growing, but at different pace depending on provider type. HIV and sexual health specialists are more likely to have knowledge about PrEP than generalists, and to be willing to prescribe it, mainly because of their closer contact with people at high risk for HIV and better risk assessment skills. There is still no consensus as to who should be responsible for providing PrEP, but clearly all hands on deck will be useful in delivering on the international target of three million people at substantial risk for HIV on PrEP by 2020. Only about 5% of the target has been reached so far. Local guidance and large-scale education and information programs for clinicians will be necessary to upskill health providers. High cost of PrEP is still a major barrier for its broad implementation, even in countries were PrEP roll-out has started. Health services are facing major structural challenges due to implementation of PrEP services to a substantial volume of patients. The early implementation experiences demonstrated that PrEP can be successfully delivered across a variety of settings, and a broad range of strategies and models of care can streamline PrEP delivery. Education of the providers and PrEP cost solutions will be essential for rapid roll-out of PrEP.

PrEP implementation in the Asia-Pacific region: opportunities, implementation and barriers

INTRODUCTION

HIV epidemics in the Asia-Pacific region are concentrated among men who have sex with men (MSM) and other key populations. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention and could be a potential game changer in the region. We discuss the progress towards PrEP implementation in the Asia-Pacific region, including opportunities and barriers.

DISCUSSION

Awareness about PrEP in the Asia-Pacific is still low and so are its levels of use. A high proportion of MSM who are aware of PrEP are willing to use it. Key PrEP implementation barriers include poor knowledge about PrEP, limited access to PrEP, weak or non-existent HIV prevention programmes for MSM and other key populations, high cost of PrEP, stigma and discrimination against key populations and restrictive laws in some countries. Only several clinical trials, demonstration projects and a few larger-scale implementation studies have been implemented so far in Thailand and Australia. However, novel approaches to PrEP implementation have emerged: researcher-, facility- and community-led models of care, with PrEP services for fee and for free. The WHO consolidated guidelines on HIV testing, treatment and prevention call for an expanded access to PrEP worldwide and have provided guidance on PrEP implementation in the region. Some countries like Australia have released national PrEP guidelines. There are growing community leadership and consultation processes to initiate PrEP implementation in Asia and the Pacific.

CONCLUSIONS

Countries of the Asia-Pacific region will benefit from adding PrEP to their HIV prevention packages, but for many this is a critical step that requires resourcing. Having an impact on the HIV epidemic requires investment. The next years should see the region transitioning from limited PrEP implementation projects to growing access to PrEP and expansion of HIV prevention programmes.

The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention

INTRODUCTION

Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework.

DISCUSSION

After a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers.

CONCLUSIONS

The strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.

Access to generic antiretrovirals: inequality, intellectual property law, and international trade agreements

The governments of numerous low- and middle-income countries are currently instituting rules that strengthen changes in domestic intellectual property legislation, often made to conform to the mandates of "free" trade agreements signed with the United States. These measures frequently include intellectual property provisions that extend beyond the patent law standards agreed upon in recent World Trade Organization negotiations, which promised to balance the exigencies of public health and patent holders. In this paper, we analyze the concern that this augmentation of patent law standards will curtail access to essential medicines, particularly as they relate to the AIDS pandemic. We critically examine the potential threats posed by trade agreements vis-à-vis efforts to provide universal access to antiretroviral medications and contend that the conditioning of economic development upon the strengthening of intellectual property law demands careful attention when public health is at stake. Finally, we examine advocacy successes in challenging patent law and conclude that greater advocacy and policy strategies are needed to ensure the protection of global health in trade negotiations.

Globalization and social determinants of health: Promoting health equity in global governance (part 3 of 3)

This article is the third in a three-part review of research on globalization and the social determinants of health (SDH). In the first article of the series, we identified and defended an economically oriented definition of globalization and addressed a number of important conceptual and metholodogical issues. In the second article, we identified and described seven key clusters of pathways relevant to globalization's influence on SDH. This discussion provided the basis for the premise from which we begin this article: interventions to reduce health inequities by way of SDH are inextricably linked with social protection, economic management and development strategy.

Reflecting this insight, and against the background of the Millennium Development Goals (MDGs), we focus on the asymmetrical distribution of gains, losses and power that is characteristic of globalization in its current form and identify a number of areas for innovation on the part of the international community: making more resources available for health systems, as part of the more general task of expanding and improving development assistance; expanding debt relief and taking poverty reduction more seriously; reforming the international trade regime; considering the implications of health as a human right; and protecting the policy space available to national governments to address social determinants of health, notably with respect to the hypermobility of financial capital. We conclude by suggesting that responses to globalization's effects on social determinants of health can be classified with reference to two contrasting visions of the future, reflecting quite distinct values.

HIV/AIDS drugs for Sub-Saharan Africa: how do brand and generic supply compare?

Background

Significant quantities of antiretroviral drugs (ARVs) to treat HIV/AIDS have been procured for Sub-Saharan Africa for the first time in their 20-year history. This presents a novel opportunity to empirically study the roles of brand and generic suppliers in providing access to ARVs.

Methodology/Principal Findings

An observational study of brand and generic supply based on a dataset of 2,162 orders of AIDS drugs for Sub-Saharan Africa reported to the Global Price Reporting Mechanism at the World Health Organization from January 2004-March 2006 was performed. Generic companies supplied 63% of the drugs studied, at prices that were on average about a third of the prices charged by brand companies. 96% of the procurement was of first line drugs, which were provided mostly by generic firms, while the remaining 4%, of second line drugs, was sourced primarily from brand companies. 85% of the generic drugs in the sample were manufactured in India, where the majority of the drugs procured were ineligible for patent protection. The remaining 15% was manufactured in South Africa, mostly under voluntary licenses provided by brand companies to a single generic company. In Sub-Saharan African countries, four first line drugs in the dataset were widely patented, however no general deterrent to generic purchasing based on a patent was detected.

Conclusions/Significance

Generic and brand companies have played distinct roles in increasing the availability of ARVs in Sub-Saharan Africa. Generic companies provided most of the drugs studied, at prices below those charged by brand companies, and until now, almost exclusively supplied several fixed-dose combination drugs. Brand companies have supplied almost all second line drugs, signed voluntary licenses with generic companies, and are not strictly enforcing patents in certain countries. Further investigation into how price reductions in second line drugs can be achieved and the cheapest drugs can actually be procured is warranted.

Closing the access gap for health innovations: an open licensing proposal for universities

BACKGROUND

This article centers around a proposal outlining how research universities could leverage their intellectual property to help close the access gap for health innovations in poor countries. A recent deal between Emory University, Gilead Sciences, and Royalty Pharma is used as an example to illustrate how 'equitable access licensing' could be put into practice.

DISCUSSION

While the crisis of access to medicines in poor countries has multiple determinants, intellectual property protection leading to high prices is well-established as one critical element of the access gap. Given the current international political climate, systemic, government-driven reform of intellectual property protection seems unlikely in the near term. Therefore, we propose that public sector institutions, universities chief among them, adopt a modest intervention--an Equitable Access License (EAL)--that works within existing trade-law and drug-development paradigms in order to proactively circumvent both national and international obstacles to generic medicine production. Our proposal has three key features: (1) it is prospective in scope, (2) it facilitates unfettered generic competition in poor countries, and (3) it centers around universities and their role in the biomedical research enterprise. Two characteristics make universities ideal agents of the type of open licensing proposal described. First, universities, because they are upstream in the development pipeline, are likely to hold rights to the key components of a wide variety of end products. Second, universities acting collectively have a strong negotiating position with respect to other players in the biomedical research arena. Finally, counterarguments are anticipated and addressed and conclusions are drawn based on how application of the Equitable Access License would have changed the effects of the licensing deal between Emory and Gilead.

Why should medical students care about health policy?

Gupta argues that medicine has become increasingly influenced by political, economic and social policies, and that medical students should become well-versed in these policies.