improving access to drugs for...

Towards the creationof strategic partnerships:Improving access to drugsfor HIV/AIDS

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Towards the creation of strategic partnerships:Improving access to drugs

for HIV/AIDS

RReeppoorrtt ooff aa ccoonnssuullttaattiivvee mmeeeettiinngg

30 Juunnee–2 Juully 1997Saallllee C, WHO, Geenneevvaa

B E S T P R A C T I C E C O L L E C T I O NU N A I D S

UNAIDS/98.40 ©Joint United Nations Programme on HIV/AIDS, 1998. All rights reserved. This publication may befreely reviewed, quoted, reproduced or translated, in part or in full, provided the source is acknowledged.It may not be sold or used in conjunction with commercial purposes without prior written approval fromUNAIDS (contact: UNAIDS Information Centre – 20, avenue Appia – 1211 Geneva 27 – Switzerlandor e-mail: [email protected]).

List of abbreviations

WHO World Health OrganizationWB World BankUNICEF United Nation Children's FundUNESCO United Nations Educational, Scientific and Cultural OrganizationUNDP United Nations Development ProgrammeUNFPA United Nations Population Fund NGO Nongovernmental Organization

I. Meaning of terms as used in the meeting ..................................................................................................................................5

Executive summary.....................................................................................................................................................................................................6

Chile, Argentina, Brazil—Recommendations.....................................................................................................................................6

Côte d'Ivoire, Senegal,Togo, Morocco—Recommendations..............................................................................................6

Zimbabwe, Zambia—Recommendations ...............................................................................................................................................7

Philippines,Thailand—Recommendations..............................................................................................................................................7

Perspectives of NGOs and people living with HIV—Recommendations ............................................................8

II. Introduction............................................................................................................................................................................................................................9

III. The objectives of the consultative meeting .............................................................................................................................9

IV. Method of work..............................................................................................................................................................................................................10

IV.1 The process—The sequencing of activities for the consultative meeting....................................................10

IV.2 Major observations on the process.....................................................................................................................................................11

IV.3 Content of groupwork I—Identifying issues and responses......................................................................................11

IV.4 Content of groupwork II—Partnership creation at country level and UN collaboration .........11

IV.5 Actors—Participants in the consultative meeting.................................................................................................................12

V. Summary of outcomes .......................................................................................................................................................................................12

V.1 Summary of introductory session...........................................................................................................................................................12

V.2 Summary—UN perspectives........................................................................................................................................................................14

V.3 Summary—Country perspectives...........................................................................................................................................................15V.3.1 Chile, Argentina and Brazil.............................................................................................................................................................15V.3.2 Côte d'Ivoire, Senegal,Togo and Morocco......................................................................................................................16V.3.3 Zimbabwe and Zambia........................................................................................................................................................................17V.3.4 Philippines and Thailand......................................................................................................................................................................17V.3.5 Community/NGO perspective...................................................................................................................................................18

VI. Follow-up of actions.................................................................................................................................................................................................18

Annex 1: List of participants ....................................................................................................................................................................................19

Contents

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Refers to the following:

• Class I Drugs for palliative treatment (e.g. painkillers, sedatives, anti-pyretic, anti-diarrhoea);

• Class II Drugs for treating opportunistic infections (e.g. anti-tuberculosis drugs,anti-fungal agents, and anti-protozoal drugs);

• Class III Drugs for malignancies related to HIV/AIDS (e.g. vincristine);

• Class IV Drugs that have specific action on the virus (e.g. zidovudine, proteaseinhibitors, non-nucleoside reverse transcriptase inhibitors).

Combines two main concepts:

• (a) availability—geographical access,

• (b) affordability—economic access.

Means the form of governance, participation, the role of the state or public affairs,issues of equity, power and interest groups. It includes how decisions are made con-cerning resource allocation. As much as one would consider current public sector reformas making economic sense, its design and implementation reflect predominant politicalpowers.

Is about making decisions on resource allocation in conditions of scarcity, which are in turn influenced by macro-economic factors and the general economy of the countryin terms of production and consumption. Financing of health in general and drugs inparticular are usually linked to the political decision-making process. Economic analysisprovides an opportunity to examine the various options given the existing resources,especially when the bulk of resources are from the public sector. Economic reforms suchas structural adjustment programmes influence resource allocation considerably, and itseffects go beyond mere budget deficit reductions.

Relates to emerging technologies in general, as well as more specifically changes in drugsand new treatment guidelines to enhance the rational use of drugs.

Indicates beliefs, lay perception and their influence on the use of drugs, as well as beliefsthat influence delivery of service in organizations such as corporate culture.

The law of the land (i.e. regulatory frameworks for drugs, constitutional rights in termsof access to care, laws relating to drug dispensation, etc).

HIV/AIDS drugs

Access

Political

Economical

Technological

Socio-cultural

Legal/Ethics

1. Meaning of terms as used in the meeting

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The efforts of governments to improve access to drugs have been compromised by general economic problems during the past 10 years, to such an extent that evendrugs for opportunistic infections are not readily available in many of the public healthinstitutions. Given the current economic situation, these countries would need bothfinancial and technical support to introduce antiretroviral therapy in a systematic fashion.The use of government resources to finance the purchase of antiretrovirals was exten-sively discussed with various options being suggested.

From January 1996, the UNAIDS Secretariat has been in consultation with key playersin the pharmaceutical industry, NGOs, people living with HIV, UN, major bilateraldonors, country representatives and National AIDS Programme Managers on issuesrelating to access to drugs for HIV/AIDS. This meeting, held on 30 June to 2 July 1997,was the climax of this consultative process. The meeting brought together people living with HIV/AIDS, NGO representatives, National AIDS Programme Managers andUN representatives. With a modified version of the Search Conference approach, thefollowing questions were raised:

• What are the current and future issues on access to drugs for HIV/AIDS at countryand global levels?

• What partnerships should be created at country level to address these issues?

• What should be the content of these partnerships at country level?

• What should the UN do at global and country level to support these partnerships?

To foster regional exchange of experience as well as enhance regional specificity, participants were assigned groups on a regional basis.

Health, social security systems and level of economic development differ greatly withinLatin America. Community groups, individuals and media have mainly been responsiblefor making antiretroviral therapy available in the public sector in a number of countries.However, the current prices of antiretroviral drugs and the available resources raise thechallenge of long-term sustainability. The introduction of antiretrovirals provides anopportunity to revisit the concept of care for people living with HIV. The appropriateprovision of antiretroviral therapy will require a systematic development of additionallaboratory services, social support, reorienting the delivery of health services and thedevelopment of new treatment guidelines for people living with HIV. In the view of participants the availability of drugs for treatment of opportunistic diseases is generallyof acceptable level in the region.

ChileArgentina

Brazil

Côte d’IvoireSenegal

TogoMorocco

Executive summary

Towards the creation of strategic partnerships: Improving access to drugs for HIV/AIDS

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Recommendations

The UN should facilitate governments to systematically examine the various options for providingcare for people living with HIV. At the same time the UN should assist governments in (a) negotiating with pharmaceutical companies for better pricing of drugs; (b) promoting rational useof drugs by helping countries in the development of technical guidelines; (c) assisting countriesin the monitoring and evaluation of the new treatment therapy; and (d) assisting countries in thepolicy dialogue on options on care.

One such innovative financing option for antiretrovirals is the one that has been takenby the Togolese government which allows them to facilitate the private sector's purchasing of antiretroviral therapy, while the government focuses on the monitoringof quality within an appropriate regulatory framework. This policy approach is partly inresponse to the need to provide regulatory and monitoring frameworks for the privatesector.

Zimbabwe and Zambia have developed the drug system on the essential drug princi-ples with the support of WHO with varying levels of success. Extensive experienceexists on home-based care for people living with HIV in the two countries.Governments of both countries are engaged in health sector reforms as a means ofimproving the effectiveness and efficiency of the health services. Zambia takes the moreradical approach while Zimbabwe takes the incremental approach to reforming thehealth system. Therefore, access to drugs is being considered within the context ofhealth sector reforms. This group did not see the introduction of antiretroviral therapyas mutually exclusive from improving treatment for opportunistic diseases, but ratheran opportunity to increase the resource base for care for HIV/AIDS in general. Thisbeing the case the group saw the need for preparatory actions to start now for the systematic introduction of antiretroviral therapy, so that operational issues are identifiedand dealt with. The private sectors in both Zambia and Zimbabwe are already prescribingantiretroviral therapy to patients who can afford to pay. In as far as the improvementof access to drugs for treating opportunistic diseases is concerned, Zimbabwe andZambia have used the following mechanisms with varying levels of success: (i) cost-shar-ing schemes and exempting drugs for HIV and TB from import taxes; and (ii) encouraginglocal production of generics.

Thailand has had extensive experience in the use of antiretroviral therapy for people livingwith HIV. The Thai government has developed a system that includes policy research onaccess to antiretroviral drugs within the local context, and as a result has elaborated current policy measures relating to improving access to antiretrovirals in Thailand a prod-uct of a more systematic way of policy development in care in general and antiretroviralspecifically. This has become increasingly important, as the numbers of people living withHIV increased at the same time as the economy showed slow growth.

The Thai government has responded in two ways: first, they have developed a mecha-nism for providing antiretroviral therapy only to patients with potential good compliance

Recommendations

The UN should facilitate governments to systematically examine the various options for providingcare for people living with HIV. At the same time the UN should assist governments in negoti-ating with pharmaceuticals companies for better pricing of drugs.

Recommendations

In their view the UN role should be the provision of technical support for: (a) policy and technicalguidelines; (b) provide best practice examples in improving access to drugs; and (c) assist countriesin negotiating price reductions with pharmaceutical companies.

PhilippinesThailand

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ZimbabweZambia


in a network of reference medical centres; second, by integrating HIV/AIDS care costs inall the other divisions of the Ministry of Health dealing with care. The net effect of thesemeasures has been the broadening of the resource base for care for HIV/AIDS in Thailand.

On the social level stigma associated with HIV/AIDS adversely affects people's accessto drugs in Thailand and the Philippines. Stigma is a social cost that prevents people livingwith HIV from seeking treatment even when needed. It can cause people to foregotheir right to reimbursement of expenditures on drugs that have been bought for HIV-related conditions so as to avoid identification of their HIV-status. The NGO represen-tative from Philippines indicated that there is no access to antiretroviral drugs in thepublic sector and access to drugs for opportunistic diseases outside the capital city is limited. The nearest to provision of antiretroviral therapy was a 6 weeks study, with littleassurance for continuity, hence raising the guineapig feeling within NGO circles inPhilippines.

On the whole NGOs and people living with HIV were very supportive of the UNAIDSfocus on access to drugs taking into account the political, social, economic, legal/ethicaland technological issues. A number of them raised the need to locate the initiative withinthe overall context of providing care for people living with HIV. In their view commu-nities must be involved in the design and implementation of effectiveness studies atcountry level to avoid the guineapig feeling. In many developing countries drugs forpalliation and treatment of opportunistic diseases are still lacking. It is therefore impor-tant that the focus of the strategy takes into account the whole range of drugs frompalliation right up to antiretroviral therapy. A process of negotiation and prioritizationcan only take place at the local context. The barriers to access to care in general andaccess to drugs in particular include issues such as stigma, so access strategy shouldaddress even socio-cultural issues.

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Recommendations

The UN role should be the provision of technical support for: (a) policy and technical guidelines;(b) provide best practice examples in improving access to drugs; (c) assist countries in negotiat-ing price reductions with pharmaceutical companies; (d) assist countries to look at issues foraccess drugs in a systematic manner using operational research strategy; (e) assist countries inthe monitoring and evaluation of the new treatment therapies using the operational researchapproach; (f) assist countries in the development of provider and user default prevention strate-gies for antiretroviral therapy; and (g) for countries such as the Philippines, assistance in the areaof legal ethical issues as it relates to new treatment studies.

Recommendations

The UN should: (a) assist countries in the greater involvement of people living with HIV/AIDSin issues of research design, access to drugs and care; (b) continue to advocate and support ini-tiatives for access to care in general and drugs in particular; and (c) carry out anthropologicalresearch to identify socio-cultural barriers to access to care in general and drugs for HIV/AIDSin particular.

Perspectives of NGOsand people living

with HIV

The recent introduction of proteaseinhibitor therapy has brought to the forenew political and ethical challengesabout access to medical care for HIV.These need to be reconciled with thetechnical, financial and social capacitiesof the health system and the society indiverse settings. These new inter-relatedproblems call for a holistic and systemicview of the issue of access to drugs forpeople living with HIV to avoid the intro-duction of solutions that would bankruptsocial security systems, health systemsand governments in the long term.

The most frequently cited constraints foraccess to drugs for HIV/AIDS relate tolimited funding, but economic argumentsalone should not be sufficient reason todeny care to those who need it.Economic arguments need to be consid-ered together with issues of social justiceand equity, which can be resolved onlythrough negotiations among variousstakeholders. This should ideally result inthe creation of strategic alliances in theprevention of HIV infection. The creation

of UNAIDS is in part a recognition of theimportance of bringing together theactions of the UN system with respect toAIDS prevention and control. Access todrugs for people living with HIV has beenon the agenda of UNAIDS Cosponsorsbefore, but this issue has acquired higherpriority since UNAIDS was founded andhas gained more importance since theVancouver AIDS Conference in July1996. Since then, the UNAIDS Secretariathas been in consultation with several key players namely: UN and country representatives, people living with HIV,NGOs, pharmaceutical companies andProgramme Managers. Further informa-tion was obtained during the followingmeetings:

• The WHO meeting organized with theUNAIDS collaboration on the publichealth implications of the introduction ofantiretroviral therapy held in April 1997;

• The UNAIDS meeting on partnershipwith the pharmaceutical industry held16–18 June 1997.

The objective of this consultative meet-ing was to determine the drug situationfor HIV/AIDS as perceived by the variousactors at global, regional and countrylevel. To ensure that discussions weregrounded in reality, selected countriesand NGOs were asked to present theirviews before the actual group discus-sions. To allow participants to reflect onthe complexity of the issue, the followingquestions were asked:• Which class of drugs would you like to

focus on?

• Why this particular class of drugs?• What are the key issues on access to

drugs for HIV/AIDS and related illnessesat country and global levels?

• What partnerships should be createdat country level to address the issue ofaccess to drugs for HIV/AIDS andrelated illnesses?

• What should be the content of thesepartnerships at country level?

• What should the UN do at global andcountry levels to support these part-nerships?

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II. Introduction

III.The objectives of the consultative meeting

To facilitate optimal participation by the var-ious participants the consultative meeting was sequenced as shown in figure 1. Theapproach used in this consultative meeting isthe modified Search Conferencing that hasbeen used successfully in dealing with issuesof difficulty in the private and public sector.The Search Conference method1 as popular-ized by Merrelyn Emery and Ronald E. Pursertakes an open system planning method as thebasis for participatory planning and partnershipcreation. It provides an opportunity for thevarious actors to bring to the table their var-

ious perspectives of the present and futureand, through a process of dialogue, a sharedvision emerges with the commitment of eachof the groups taking responsibility to fulfilthis. For this meeting the process took thefollowing form:• introductory session;• country perspective;• community perspective;• UN perspective & partnership NGOs;• groupwork;• plenary sessions;• final recommendations.

I. Introductorysession

II. Countryperspective

III. Communityperspective

IV. UNperspective

V. PartnershipNGOs VI. Groupwork I

VII. Parallelplenaries

VIII. Synthesisdiscussions IX. Groupwork II

X. Synthesisdiscussions

XI. Finalrecommendations

IV. Method of work

IV.11 TThe pproccess——TThe seqquuencciingg of aacctiivviitiies for the cconsuulltaatiivve mmee--tiingg

FFiigguure 11. TThe pproccess

1 - The Search Conference – A powerful method for Planning Organizational Change and Community Action, Merrelyn Emery and Ronald E. Purser

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The participants appreciated the processas defined in the diagram. Early in theprocess, the UN group of representativessuggested that their discussions wouldbe more productive if they were heldwithin the framework of the realities ofcountries. The UN representatives there-

fore joined the discussions of the countrygroups rather than discussing in a groupof UN agencies only. This resulted in alively and stimulating exchange of viewson the needs of countries and the possi-ble responses of the UN system.

For each of the issues defined above taking January–December 1997 as theplanning period. Each group wentthrough this exercise:

• Given the responses that you havedefined in group I, what are the

strengths of your current response?(These are activities you would like tocontinue.)

• What are the weaknesses in your cur-rent responses? (These are activitiesyou would like to change.) And what

The participants were then divided intofour regional groups. Each group thenwent through the following questions,taking 1996–1997 as the starting year.

• Which class of drugs would you like tofocus on as group? And why this par-ticular class of drugs?

• What major political events or issues (ifany) occurred at global or country levelthat are influencing the availability ofthe drugs chosen (class chosen in ques-tion 1) in your country? And what actionshave you carried out to respond tothese issues?

• What major economical events orissues (if any) occurred at global orcountry level that are influencing theavailability of drugs (class chosen inquestion 1) at country level? And theactions carried out to respond to theseissues?

• What major social/cultural issues inyour country influence the use of drugs(class chosen in question 1)? And whatactions (if any) have you carried out torespond to these issues?

• What major technological issues orevents (if any) at global level are influ-encing the availability of drugs (classchosen in question 1)? And what actionshave you carried out to respond to theseissues or events?

• What major legal/ethical issues orevents (if any) are influencing theavailability of drugs (class chosen inquestion 1)? And what actions if anydid you carry out to respond to theseissues or events?

• What indicators, if any, have you beenusing to monitor progress on theactions defined above?

IV.22 Maajjor obbservvaatiions on the pproccess

IV.33 Content of ggrouuppwork I——Identiifyyiingg iissuues aand respponses

IV.44 Content of ggrouuppwork II——PPaartnershiipp ccreaatiion aat ccouuntryy llevvell aandUUNN ccollllaabboraatiion

UNAIDS

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The following participated in this consul-tative meeting: • five focal points from UNAIDS co-

sponsoring agencies;• seven National AIDS Programme

Managers (Côte d'Ivoire, Argentina, Chile,Togo, Senegal, Zambia, and Zimbabwe);

• six people in charge of patient care(Chile, Senegal, Zimbabwe, Thailand,Zambia, and Morocco);

• one representative from an NGO;• five representatives of people living

with HIV/AIDS (Zambia–2 participants–,Philippines, Côte d'Ivoire, France);

• one representative of the HarvardAIDS Institute;

• UNAIDS Secretariat.

(Please refer to Annex 1 for list of participants)

changes would you like to make toimprove these responses?

• What obstacles do you see in theimplementation of your suggestedchanges? And how do you intend todeal with these obstacles?

• What opportunities do you see in theimplementation of changes? And howdo you intend to take advantage ofthese opportunities?

• Based on your analysis above, whatactivities would you implement for theplanning year?

• What actions would you expect fromthe UN to facilitate your actions atcountry level?

• What mechanisms should be devel-oped/strengthened at global level inthe UN to enhance your activities atcountry level?

• What mechanisms should be devel-oped/strengthened at country level toenhance the role of the UN at countrylevel?

• How would you monitor the progressof these activities?

Care and support for people living withHIV require far more than drugs, butthey are an essential component of care.The majority of the drugs in question arethose required to treat and relieveopportunistic diseases.

Many of these products, e.g. painkillers,palliatives, tranquillizers, anti-pyretic andanti-cancer drugs, can be found withinthe category of generics, and are there-fore available at relatively low cost. On

the other hand, all the drugs that aremeant to deal with HIV itself and sever-al newly developed drugs to treat oppor-tunistic diseases are still proprietary drugsand are more expensive. This basic facthas important implications for recom-mended approaches for improvingaccess to drugs for HIV/AIDS.

Evidence is emerging that successfulantiretroviral therapy requires that thedrugs be given as combination therapy

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IV.55 AAcctors——ppaartiicciippaants iin the cconsuulltaatiivve mmeetiingg

V. Suummmmaaryy of ouutccommes

V.11 Suummmmaaryy of iintroduucctoryy sessiion


(bi- or triple), but problems related tothese therapies are also being noted.These include difficulties that patientshave in adhering to, and tolerating, therapy regimens, antiviral resistance,increasing treatment failure over time,and the high cost of the drugs. To thesecosts, which are now estimated atUS$10 000–15 000 per annum perpatient, must be added the costs ofdiagnosis, counselling, HIV testing andfollow-up of patients—all of which arepart of recommended treatment. Forexample, the recent guide for antiretroviraltherapy published by the InternationalAIDS Society (USA panel) recommendsearly aggressive therapy based on carefulselection of regimen, and advises thatmonitoring of plasma viral load is a cru-cial element in clinical management forassessing prognosis and the effectivenessof therapy for HIV/AIDS. The difficultiesof antiretroviral therapy have been furtherexplored by a WHO/UNAIDS InformalConsultation held in Geneva in April 1997.

The issue of drug costs is therefore ofutmost importance in the current debateon access to drugs for HIV/AIDS. Inindustrialized countries, this debate ismainly focused on ensuring access totriple antiretroviral therapy. This is under-standable given that many individuals inthese countries already have reasonablygood access to care for opportunistic diseases and other palliative treatments.Although it remains a challenge toensure that all who need these medicinesreceive them, the strong voice of thecommunity of people living with HIVensures that governments do not losesight of the urgency of providing drugsthat cover all the needs of people livingwith HIV.

Efforts to expand access to HIV-relateddrugs must realistically take into accountthe technical, financial and social capaci-ties of individuals and the health-caresystem in individual countries. Experience

confirms that these efforts are mosteffective if the various stakeholders(including governments, producers, sup-pliers, NGOs, UN agencies, and peopleliving with HIV through their representa-tive organizations) agree to work as part-ners. UNAIDS has therefore made thepromotion of such partnerships the cor-nerstone of its efforts in the area ofaccess to drugs (generic and patenteddrugs). These partnerships can be dividedinto the following broad categories:

• partnership with the UN family;• partnership between governments and

the pharmaceutical industry;• partnership with major suppliers and

bilateral donors;• partnership at country level between

communities and health systems;• partnership with NGOs at global and

national level;• partnership with governments;• partnership in the identification of best

practice;• partnership in investigating the role of

traditional medicine where it demon-strates potential for improving the careof people living with HIV.

Issues raised in relation to partnershipstrategy for access to drugsIn general participants were supportiveof UNAIDS’ focus on partnership cre-ation as a way of resolving some of thekey issues related to access to drugs forHIV/AIDS. Concern was voiced on thecomponent of the strategy called part-nership with pharmaceutical companies.These were on issues related to equity,the selection criteria used for countriesinvolvement, the mechanisms for imple-menting, price determination, the howand what is being monitored and howother countries not involved would benefit.In response UNAIDS Secretariat indicatedthat the use of a pilot approach for thiscomponent was to answer some of theseconcerns in a systematic fashion. The

UNAIDS

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pilot projects are taking an actionresearch approach that allows systemat-ic learning during the process of imple-mentation. It was also emphasized thatUNAIDS will continue to explore withcosponsors, NGOs and people living

with HIV for other strategic approachesthat could bring immediate benefit forother countries. The partnership with thepharmaceutical industry is just oneamong many other initiatives in theUNAIDS strategy to access to drugs.

The level of involvement of the UN fam-ily in access to drugs, in general and toHIV/AIDS drugs in particular, varies fromagency to agency (this summary includesdescriptions of activities derived from thedocuments provided by the agenciesthemselves):

WHO through the Drug ActionProgramme (DAP) has been in the fore-front in assisting countries to developnational drug policies that include theuse of an essential drug list. WHO (DAP)has employed a consultant to develop aprioritized drug list for HIV infection andAIDS-related conditions and a model forestimating related drugs using the mor-bidity approach. The Regional Office forAfrica (AFRO) is currently conducting asurvey to assess laboratory capacity formonitoring of patients on antiretroviraltherapy in countries. Preliminary resultsshow that a majority of developingcountries have poor laboratory infras-tructure. In the short term AFRO willfocus on improving access to drugs foropportunistic diseases.

The meeting held in April 1997 to discussthe implications of antiretroviral treat-ments in resource-constrained settingsrecommended the minimum require-ments for the safe and effective use ofthose drugs. WHO is currently discussingwith WTO and WIPO how the newdevelopments in patent rights for drugscould further facilitate access to drugs indeveloping countries.

UNICEF has traditionally beeninvolved in the procurement and distri-bution of vaccines and drugs and hasexperience in working with the privatesector in the whole area of drug pro-curement and distribution. At global levelthrough its Supply Division, UNICEF hasbeen able to obtain drugs and vaccinesat reasonable prices using an internation-al tender system.

In addition, working together with WHO,UNICEF has had extensive experience in community management schemes(Bamako Initiative) which includes improv-ing access to drugs at community levelusing revolving drug funds.

The UNICEF Essential Drugs price list isbased on the WHO essential drugs listand comprises about 180 stock numbersand 130 formulations. These are primar-ily for use in emergency situations, butalso for regular supply to UNICEF-supported health programmes, govern-mental and non-profit organizations.

The World Bank has been lend-ing to the pharmaceutical sector sincethe early 1980s. Its goal have been toimprove pharmaceutical selection, pro-curement and supply in the public sector,strengthen drug regulation, quality con-trol and promote rational drug use.Loans have been allocated for the pro-curement of drugs, civil works, comput-ers and software (e.g. for drug registra-tion agencies), training, information,

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V.22 Suummmmaaryy——UUNN ppersppecctiivves


education and technical assistance. Inaddition, World Bank activities in thepharmaceutical sector include policy dialogue with governments, training,special grants, research and development.HIV/AIDS pharmaceutical issues havebeen addressed at the operational levelthrough projects with a drug component.

UNESCO is involved in severalactivities that may directly or indirectlyimprove access to drugs (i.e. in selectedcountries, UNESCO has supported thecreation of professorial chairs for rationaluse of drugs in universities, ethical commit-tees, coupons for accessing educationalmaterials for developing countries). In col-laboration with the Fondation Montagnier,UNESCO is promoting basic research forHIV/AIDS in selected countries. UNESCOhosts the International Bioethics Committee,which would be a proper forum to discussissues related to experimental treatmentsincluding HIV/AIDS.

UNDP and UNFPA have nospecific activities related to improvingaccess to drugs. UNDP has in the pastassisted countries in capacity building forlogistical and drug management uponrequest. UNFPA on the other hand hasbeen working on contraceptive logistics,which from a system perspective haveclose resemblance to drug logistics system.

Issues raised concerning the UN presen-tationThe delays associated with procuringdrugs using World Bank loans was raisedas a matter of concern by Zambia andZimbabwe. The World Bank respondedby indicating that it was currentlyreviewing the procurement proceduresto respond to ensure availability of drugswithin reasonable times.

This part of the report will focus on theconclusions and recommendations of thegroup works which will help UNAIDSand its Cosponsors finalize the globalstrategy on access to drugs and identifyconcrete actions that would improveaccess to HIV infection and AIDS drugs.

V.3.1 Chile, Argentina and BrazilThere is consensus in the region thatfocus for improving access to drugsshould be on antiretroviral therapy. Inthis region, the process of introducingantiretroviral therapy has largely beenthe result of community groups takingadvantage of existing political and legalsystems. The issues of concern in mostLatin America is how to ensure the long-term sustainability of the provision ofantiretrovirals. And at the same time to

develop laboratory, social and healthsupport infrastructure in a systematicfashion to avoid the emergence of pooruser and provider compliance in the useof antiretroviral therapies. Currently,treatment for opportunistic diseases inthe countries represented is consideredoptimal and should therefore not be thesubject of focus in the region.

Given the current cost of drugs and lab-oratory reagents, the group felt that theUN organizations could carry out the fol-lowing tasks: • facilitate negotiations with pharma-

ceutical companies;• assist in the development of bulk pur-

chases mechanisms such as the pro-posed Latin American Fund for Drugs;

• facilitate the exchange of experiencesamong countries in the region to avoid

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V.33 Suummmmaaryy——Couuntryy ppersppecctiivves

a process whereby each country re-invents the wheel.

The UN is asked to respond rapidly withthe provision of technical guidelines, giventhe speed at which new technology isappearing.

V.3.2 Côte d’Ivoire, Senegal, Togo andMoroccoThe responses by governments on accessto HIV/AIDS drugs in the region varyfrom country to country. Owing to thepoor economic performance of countriesrepresented, there are still problems inrelation to availability of drugs for treat-ing opportunistic infections. In view ofthis, the participants stressed that accessto antiretroviral therapy as well as drugsfor opportunistic diseases is still verymuch on the agenda. One area of dis-cussion was whether governments couldconsider purchase of antiretroviral drugsgiven the limited budgetary allocation tohealth. To respond to this problem thegovernment of Togo has come up with apolicy approach for provision of anti-retroviral therapy in the private sectorwhile the government focuses on qualityassurance and provision of the regulatoryframework.

The African region has serious problemsrelated to the issue of how to affordantiretroviral therapy in both the shortand long term. The Paris Summit wasrecognized as the first forum to addressthe issue of access to drugs, and it wasunfortunate that no concrete action wastaken after the meeting. The politicalinstability in countries was mentioned as anegative element in the development ofa sustainable strategy on access to drugsin general and HIV/AIDS in particular.

The following were mentioned as strongpoints that could facilitate access todrugs: the governments are willing to

consider HIV/AIDS treatment and arecommitted to considering any action thatwould help in reducing the price of drugssuch as tax reduction, subsidies, improve-ment of the distribution system andtechnology.

• In order to have people living with HIVadd their voice to the need for accessto drugs, mechanisms such as volun-tary counselling and testing should beencouraged. This would facilitate thecreation of networks of people livingwith HIV/AIDS who add their voice tomaking access to drugs a high priority.

• The concept of caring and compassionis part and parcel of the African cultureand this is going to be an importantelement in the management of HIV/AIDS given that the new treatmentregimens are complex.

• The creation of South-South andNorth-South collaboration amongNGOs in the region needs to be facili-tated. The current collaborative effortsshould be studied and strengthenedfor the care of people living withHIV/AIDS.

• Regarding the role of the UN, thegroup noticed that at present there isno clear advocacy on the content ofHIV/AIDS management. Responses tocountry requests for antiretroviraltreatment are rarely satisfied. The issueof treatment and care of HIV infectionand AIDS is not perceived as a prioritywithin the UN system.

• The UN should assist governments sys-tematically examine the variousoptions for providing care for peopleliving with HIV.

• The UN should assist governments innegotiating with pharmaceutical com-panies for better pricing of drugs.

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V.3.3 Zimbabwe and ZambiaCurrently both countries are experienc-ing privatization and decentralizationand both are engaged in health sectorreforms. Zambia is taking a more radicalapproach in the reform of its health sec-tor while as Zimbabwe takes the moregradual approach to re-organizing thehealth system. The discussions on accessto drugs should then be seen in the con-text of health sector reforms. This groupdid not see the introduction of antiretro-viral therapy as mutually exclusive fromimproving treatment for opportunisticinfections. They saw advocating forantiretroviral therapy as an opportunityto increase the resource base for care forHIV/AIDS in particular and the healthsystem in general. In their view countriesshould not wait for the availability ofantiretroviral drugs to start preparing fortheir introduction. To increase resourcesfor drug purchases both Zimbabwe andZambia are currently beneficiaries ofWorld Bank credit facilities. And bothhave experienced difficulties with theBank's tendering and procurement pro-cedures, which have resulted in delays inreceiving the drugs. Both countries areimplementing mechanisms such as cost-sharing schemes and exempting drugsfor HIV and TB from taxes, as a way ofincreasing access to drugs for people liv-ing with HIV. Some private pharmaceuticalcompanies are producing generics fortreating opportunistic diseases.

V.3.4 Philippines and ThailandThailand has had extensive experience inthe use of antiretroviral therapy and hasgone through a process of policy devel-opment that is becoming more systemat-ic than earlier days. However, the effectsof the recent economic setback arebeginning to be felt in terms of resourcesavailable for drug purchases. Thailandhas used these economic problems as anopportunity to broaden the resource

base in two ways. The first has been toprovide antiretroviral therapy to patientswho show the potential for good compli-ance. Although concerns about equitywere raised, Thailand is using actionresearch as an approach to define suchpolicy measures. Secondly, the NationalAIDS Programme has integrated HIV/AIDScare financial requirements in all the otherdivisions of the Ministry concerned withgeneral care. This has had the effect ofincreasing the overall allocations for HIV-related drugs and hence ensuring long-term sustainability of the approach.

On another level the stigma associatedwith HIV/AIDS adversely affects people’saccess to drugs in Thailand (and thePhilippines). The stigma prevents peoplefrom seeking treatment when they needit. It also causes people to forego theirright to reimbursement of expenditureson drugs that have been bought for HIV-related conditions so as to avoid identifi-cation of their HIV-status.

In the Philippines there is no access toantiretroviral therapy in the public sectorand access to drugs for opportunistic dis-eases outside the capital is very limited.The only access to such therapy so farhas been through a six weeks drug trialwith no assurance of continuation oftherapy. This has contributed to the gen-eral feeling among people living withHIV in the Philippines that they are beingused as guineapigs.

To improve access to drugs in Zambia,Zimbabwe, Philippines and Thailand, theUN system could assist in the following:• facilitate partnership between public

and private sector;• monitor and evaluate rational drug use;• disseminate information on ARVs;• facilitate beneficial competition between

private providers and public sector;• establish anthropological training to

improve care at community level.

UNAIDS

17

V.3.5 Community/NGO perspectiveFive representatives of people living withHIV were present at the consultativemeeting. These people living with HIVare active in their own countries and alsoin international collaboration to improveaccess to care and drugs, particularly indeveloping countries. They were verysupportive of the UNAIDS efforts toimprove access to drugs through part-nership and other measures, stressingthat many people in developing coun-tries did not have access to drugs foropportunistic infections or antiretroviralto treat the HIV infection. They pointedout that although not all people wouldgain access through the UNAIDS-ledpartnerships, it was important to havethe courage to start somewhere andexpand from there if possible. In addition

to the financial obstacles that preventHIV-infected people from having accessto the necessary drugs, the people livingwith HIV also drew attention to thestrong stigma that is the reality in manydeveloping countries. This stigma causessome people living with HIV to lose theirjobs and hence effectively their income.In other cases they are too afraid of thestigma to claim reimbursement for med-ical expenditures related to HIV treatment,thus experiencing additional barriers todrug access. People living with HIV areincreasingly being represented in rele-vant government bodies dealing withHIV/AIDS policies. Improving the partic-ipation of people living with HIV in all relevant policy-making bodies was stressedas being essential to an adequateresponse to the epidemic.

Representatives of UNDP, UNESCO,UNFPA, WHO and UNAIDS met to dis-cuss the key follow-up steps. It wasagreed that preparatory work on accessto drugs for HIV/AIDS be delegated tothe UNAIDS Secretariat and WHO. Thiswas in recognition of WHO’s long-termexperience in improving access to drugsin general and UNAIDS’ strategic posi-

tion that would ensure that inputs fromother actors are taken into account. Itwas further agreed that to finalize theglobal strategy on access to drugs, theUNAIDS Secretariat and WHO shouldjointly open and maintain communica-tions with key partners both at globaland country level to identify concreteactions to implement the strategy.

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VI. FFollllow--uupp of aacctiions


Dr Laura AstarloaNational AIDS Control Programme1, Av. 9 de Julio, Piso 8Buenos Aires – Argentina

Dr Annabella ArredindoNational AIDS Control ProgrammeMinisterio de SaludMAC-Iver 541 Of. 68Santiago – Chile

Dr Anibal HenriquezNational AIDS Control ProgrammeMinisterio de SaludMc Iver 541 Of. 68Santiago – Chile

Dr Issa CoulibalyExecutive DirectorMinistry of Public Health, B.P.V. 104Abidjan – Côte d'Ivoire

Dr Hakima HimmichAssociation marocaine de Lutte contre le SIDA17, Bd. Massira Al KhadraMaarifCasablanca – Morocco

Mr Joventino DominguezKabalikat ng Pamilyang Pilipino Olongapo City AIDS FoundationCity Health DepartmentRoom 201, 1/F WestwoodCondominium Olongapo CityPhilippines

Professor Salif BadianeHead, Division of Infectious DiseasesClinique des Maladies infectieusesIbrahim Diop MarDakar – Senegal

Dr Ibra N’DoyeCoordinator, National AIDS ProgrammeP.O. Box 3435Dakar – Senegal

Dr Chaiyos KinanusontChief, Medical Services and CareDevelopment SectionAIDS DivisionMinistry of Public Health88/21 Tiwanond RoadNonthaburi 11000 – Thailand

Dr Kpanté BassabiDirector, National AIDS ProgrammeMinistry of HealthB.P. 365Lomé – Togo

Ms Peggy FulilwaNational AIDS Control ProgrammeP.O. Box 32346Lusaka – Zambia

Ms Katherine Nyirendac/o Dr Moses SichoneNational AIDS Control Programme, P.O. Box 32346Lusaka – Zambia

Dr Moses SichoneProgramme ManagerNational AIDS Control ProgrammeMinistry of HealthP.O. Box 32588Lusaka – Zambia

Mr Charles Kasekec/o Dr E. MarowaNational AIDS Control ProgrammeP.O. Box CY1122Causeway, Harare – Zimbabwe

AAnnex 11: Liist of ppaartiicciippaants

UNAIDS

19

Dr Owen MugurungiNational AIDS Coordination ProgrammeP.O. Box CY1122Causeway, Harare – Zimbabwe

Ms Susan LucasCoordinator, U.K. NGO AIDS Consortium5, Kelross RoadLondon N5 2QS – United Kingdom

Mr David ChipantaPresident, Network of African Peoplewith HIV/AIDS(NAP+)/NZP+, P.O. Box 32717Lusaka – Zambia

Dr Arnaud Marty-LavauzellePrésident AIDES Fédération Nationale10, rue Nonnains75010 Paris – France

Ms Laure NakiDeputy Secretary-GeneralLumière ActionRue Fleming, Zone 4C B.P. 778 Abidjan – Côte d'Ivoire

Mr Richard MarlinkExecutive Director, Harvard AIDS Institute651 Huntington AvenueBoston, MA 02115 – USA

Mr Sjaak BavelaarUnited Nations Population Fund,European Liaison OfficePalais des NationsCH-1211 Geneva 10 – Switzerland

Mrs Marie-Paule RoudilUnited Nations Educational, Scientificand Cultural OrganizationScience Sector, Bâtiment Bonvin1, rue de MiollisParis 75015 – France

Mrs Mina Mauerstein-BailSenior Programme CoordinatorHIV and Development ProgrammeUnited Nations DevelopmentProgrammeOne, United Nations PlazaNew York, NY 10017 – USA

Dr Debrework ZewdieSenior PHN Specialist and HIV/AIDSCoordinatorHealth and Human DevelopmentDepartment – The World BankWashington, DC 20433 – USA

Dr Vincent HabiyambereAction Programme on Essential Drugs20, avenue Appia1211 Geneva 27 – Switzerland

Dr Susan FernyakOffice of HIV/AIDS and SexuallyTransmitted Diseases, 20, avenue Appia1211 Geneva 27 – Switzerland

UNAIDS Secretariat• Dr Peter Piot• Dr Awa Coll-Seck• Dr Roland Msiska• Dr Jos Perriens• Dr Joseph Saba• Dr Sam Kalibala• Ms Noerine Kaleeba• Dr Anne Reeler• Ms Marthe Mpendubundi• Ms Bai Bagasao• Dr Paulo Texeira (short-term profes-sional from the State of São Paulo, Brazil,provided insights on the Brazilian experi-ence on introducing access to drugs forHIV/AIDS).

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