The 15th International AIDS Conference was held July 11-16 in Bangkok, Thailand. At the end of the conference, almost all the 17,000 delegates, including government representatives, non-governmental organizations (NGOs), activists, pharmaceutical companies, and scientists, were in agreement on one issue: that HIV/AIDS is real and needs to be tackled as a matter of urgency. However, there wasn’t much agreement on how best to tackle the problem.
There was much debate on what really are the obstacles to access of HIV/AIDS drugs and treatment: To patent or not to patent? That seemed to be the question. There was also a continuous wrangling as to whether the much-heralded Ugandan model ABC–Abstain, Be faithful and Condomize–should be the most appropriate way to prevent its spread.
For those not infected, it stands to reason that the best way to reduce the risk is abstinence or, failing that, the use of condoms. The latter will not be as effective as the former. Abstinence is "cost free," an important consideration in a poor country. The use of condoms is not "cost free" or 100 percent fool-proof against infection. Exposure of condoms to ultraviolet light, heat, and humidity weakens condoms and reduces their efficacy. There are numerous cases of people contracting HIV/AIDS even though condoms were used.
The widely accepted success of the Ugandan approach is based on its broad approach, taking account of the realities faced by its people and speaking their language. The ABC model promotes abstinence, fidelity, and condoms. Failure to promote all of these simple steps–wearing a condom probably being the most complicated step in such a poor country–would mean more deaths.
Right now the administration has even set aside 33 percent of its funds for prevention by promoting abstinence. Promoting abstinence may well be a futile gesture in rich, urban, western countries, but in poor countries, where the only defense against HIV/AIDS is a change in behavior, messages of abstinence and fidelity save millions of lives.
Another contentious issue in Bangkok was the provision of cheap antiretroviral drugs to victims. Many of the "serial activists" present at the conference regard research-and-development-based drug companies as the ultimate villains preventing access to cheap drugs. They were therefore happy to unleash their campaign of violence, vandalism, and simplistic slogans, doing nothing to help sufferers of HIV/AIDS and detracting from the real causes of poor access to treatment. These activists blame patents for blocking access to generic drugs. On the contrary, a combination of several factors, not necessarily patents, is responsible for blocking access to medicines.
Patents Not to Blame
In many poor countries, where annual spending on health per person is less than $2, the cost of registering a patent is too great. A recent study by Dr. Amir Attaran, fellow at the Royal Institute of International Affairs in London, evaluates the relationship between patents and access to essential medicines in 65 countries, covering a total population of four billion people–almost two-thirds of the world’s population.
Of the 319 drugs on the World Health Organization’s (WHO) Essential Medicines List, just 19 are on patent. In the world’s poorest countries, then, less than 2 percent of drugs are on patent. One of those 19 drugs, eflornithine, has been donated by its inventor; another, tamoxifen, is off-patent in most countries. In reality, only 17 essential medicines are on patent.
What prevents access to essential medicines in Africa in most cases are excessive bureaucracy, poverty, and poor health infrastructure. Six countries, including Nigeria, have recently signed a Brazil-initiated pact to manufacture generic drugs in the fight against the HIV/AIDS pandemic. It will be interesting to see how each of these countries will make the drugs available in the remotest areas. Merely producing generic drugs does not translate into actual delivery. If drugs for malaria, which kills more people than AIDS, are not available in hospitals and clinics, particularly in rural areas in Nigeria, what guarantees are there that antiretroviral drugs will be?
Simply supplying or producing medicines does not solve the realities of the health care crisis in Africa, where the basic health care systems are simply not in place to provide effective treatment programs, even when the drugs are available.
Take Malawi for instance, where an organization called the European Coalition of Positive People can import HIV drugs cheaply but doesn’t know what they would do with the drugs once they got them there. Throughout Malawi, there are less than 35 hospitals, one doctor for every 32,000 patients, and other health care personnel simply do not exist. The lack of good roads prevents the delivery of medicines in rural areas. Clinics are few, and there are inadequate storage and refrigeration facilities once the drugs are delivered.
The real problem is not merely the supply of medicines. For instance, the Nigeria National ARV Treatment Programme has less than 40 centers. It is estimated that 14,730 AIDS patients had registered for government ARV pilot programs meant for 10,000 people. Because of bureaucracy and stigmatization in government hospitals, others simply avoid these centers and get their drugs elsewhere.
Counterproductive Activism
The intention of those who focus on allowing countries to make generic drugs or giving cheap drugs to countries that have no way of delivering them safely to patients in all nooks and crannies will be counterproductive.
Complex antiretroviral therapies require strict adherence. The income of most people across Africa is less than $2 per day. AIDS patients, because of their level of income, cannot afford these generic drugs even when sold at rock-bottom prices. When they do get the drugs, patients must do a number of tests mostly on regular basis to determine whether the drugs are working. Failing to do so greatly increases the risk of developing drug-resistant viral strains. Even though the generic drugs are almost free, patients cannot afford to pay for the tests.
Blaming patents for blocking access to medicines is off target. The priority should be on increasing the economic well being of the people on the continent, through increases in trade and economic freedom, not through foreign aid. Only then can they upgrade their infrastructure and invest in health care and prevention, and people will be able to pay for their health costs.
Part of the AIDS funds should be used not only in AIDS prevention campaigns but also for preventing other opportunistic infections that prey on AIDS sufferers and are the ultimate cause of death. Clean and safe drinking water should be provided, and improvement in sanitation and spraying with insecticides for prevention of vector-borne diseases such as malaria is needed. This is the surest way to halt the pandemic–not by throwing darts at pharmaceutical companies.
Thompson Ayodele ( thompson@ippanigeria.org ) is coordinator/director of the Institute of Public Policy Analysis in Lagos, Nigeria. An earlier version of this essay was published on July 31, 2004 on thisdayonline.com.
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