By Matt Douglas-Vail, University of Toronto
For people living with HIV in sub-Saharan Africa, living or dying depends on access to antiretrovirals (ARVs), which is determined largely by pharmaceutical companies. In order to understand the epidemic, it is important to examine how the pharmaceutical companiesí distribution of ARVs has contributed to and exacerbated the climate of HIV/AIDS in sub-Saharan Africa. This paper aims to examine the ways in which pharmaceutical companies, through the unequal distribution of ARVs, have participated in the implementation of contemporary neo-colonialism and thereby worsened the HIV epidemic in sub-Saharan Africa. Briefly, neo-colonialism is the practice of using multi-national corporations to ensure vulnerability, dependency and maintain control over nations. The importance of ARVs will be examined in conjunction with the official policies on access to medications and the role of structural adjustment programs in exacerbating the epidemic.
Antiretrovirals and Neo-Colonialism: Pharmaceutical Companies And The HIV/AIDS Epidemic
In order to understand the harm pharmaceutical companies have done to sub-Saharan Africa, the current climate of the epidemic must be examined. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that in 2012, 35.3 million people worldwide were living with HIV.1 The majority of HIV infections however, occur in sub-Saharan Africa. In 2011, there were 25 million people living with HIV in sub-Saharan Africa. Among the 1.6 million AIDS-related deaths globally, 1.2 million occurred in sub-Saharan Africa.1 Of the 2.3 million new infections that arose globally, 1.6 million occurred in this same region.
The importance of ARVs in combating the HIV/AIDS epidemic cannot be understated. In fact, access to these drugs directly corresponds to HIV/AIDS prevalence rates, especially in sub-Saharan Africa.2 Extensive evidence demonstrates that combined ARVs can substantially extend the life of people living with HIV despite differences in risk factors for transmission of HIV, sex, race or age.3 Initiation of ARVs can also delay the onset of AIDS and reduce the incidence of AIDS-defining diagnoses.4
ARV treatment is also capable of preventing transmission of HIV. The World Health Organization notes that early initiation of ARVs decreases HIV transmission between couples with different HIV statuses (sero-discordant) by 96%.5 As well, ARVs decreased mother-to-child prenatal transmission by 50%.6
To understand fully the effect that pharmaceutical companies have on restricting access to medication and thereby exacerbating the HIV/AIDS epidemic, it is important to examine the official policies outlined by governing bodies like the United Nation and World Health Organization (WHO). These policies represent global expectations concerning access to treatment. In 2001, the UN Commission of Human Rights declared that access to medications is a fundamental process in the goal of achieving the highest attainable standards of health.7 Therefore, in 2002, 12 ARVs were added to the WHO Model List of Essential Medicines.7 Essential Medicines are pharmaceuticals that are classified as absolutely necessary for a “basic health care system.”7 These drugs are intended to be consistently “available in adequate amounts at prices the individual and the community can afford.”8 In 2002, the World Bank founded the Multi-Country AIDS Program (MAP) to increase access to HIV treatment in sub-Saharan African and the Caribbean.7 This program aimed to purchase and distribute ARVs in a safe, equitable, effective and ethical way. UNAIDS aims to ensure access to ARVs for 15 million people by 2015 and eventually universal coverage.1 Unfortunately, 15 million people equates to coverage of less than 75% of the population. As well, the definition of universal coverage itself is problematic. UNAIDS definition of universal coverage only means that 80% of those eligible for treatment receive ARVs.1 This means that even though UNAIDS will have achieved their goal, 1 in 5 people will still be without treatment.
Official policies however, leave no doubt to the public that access to medication is vital to mitigating and reducing the burden of the epidemic in sub-Saharan Africa, which puts enormous power in the hands of the pharmaceutical companies. The legitimization of these products through official policies could allow pharmaceutical companies the ability to argue they are providing an invaluable service. That claim however, must be examined more closely. This legitimization gives control to the pharmaceutical companies and ensures that countries most affected by HV are dependent. This dependence embodies the contemporary neo-colonialism.
There is unfortunately a great disparity between the official policies on access to medications and the number of people who are actually receiving ARVs. The neo-colonial agenda of pharmaceutical companies has contributed to this disparity. While the WHO suggests 28.3 million people require treatment in low and middle-income countries, only 34% of these people are currently receiving ARVs.5 In 2010, only 50% of pregnant women living with HIV in sub-Saharan African received ARVs to prevent mother-to-child transmission. This trend of disparaging coverage is not new. The first medicine designed specifically to treat HIV, known as zidovudine or AZT was released in the United States in 1987.9 By 2002, 800,000 people worldwide were on ARVs. Unfortunately, less than 40% of people on ARVs resided in developing countries even though these countries accounted for 95% of global HIV infections.7 In comparison, ARVs are widely available in the developed world and almost universally available in Canada.10
The United Nations recently reported that a “tipping point” had been reached where the number of people receiving ARVs outpaced the number of new infections.1 This is dangerously misleading. The veritable “tipping point” should actually be defined when access to ARV outpaces total HIV infections and everyone living with HIV receives treatment.
While at first glance, the breadth of statistics available seem impressive, closer examination shows that access to treatment is oftentimes limited and inadequate. Pharmaceutical companies, although responsible for developing these invaluable products, are also responsible for controlling access to treatment. Pharmaceutical companies embodying neo-colonialism by attempting to exploit and assimilate sub-Saharan countries into the capitalist market have severely restricted access to treatment. This limited access and neo-colonial ethic has exacerbated the epidemic by denying treatment to those clearly in need of ARVs.
Pharmaceutical companies in conjunction with international intellectual property laws have ensured that developing countries remain dependent on the production of ARVs. This dependence has exacerbated the HIV/AIDS epidemic in sub-Saharan Africa. In 1995, the World Trade Organization (WTO) passed the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS).11 All countries in the WTO, including 35 of 47 sub-Saharan countries, are bound by the TRIPS agreement.12 Each country is now required to grant patents for inventions “in all fields of technology” including pharmaceuticals, for 20 years without discrimination to availability.13 This allows companies holding drug patents to charge artificially high prices for the drug and ensure monopolies over their production.
Generic drugs provided a possible alternative to brand name pharmaceuticals. Until 1995, India did not grand patents on pharmaceuticals and permitted reverse-engineering of generic drugs. Becoming known as the “pharmacy of the developing world”, India had until 2005 to comply with the TRIPS agreement.14 Drugs patented between 1995 and 2005 can be reverse-engineered in generic form as long as royalties are paid to the patent holders and drugs patented after 2005 cannot be made in generic form. Through these regulations, the TRIPS agreement directly discourages the production of generic medications. In 2001, the WTO signed the Doha Declaration to allow members to grant domestic compulsory licenses to protect the public health of their citizens.14 Unfortunately, countries attempting to procure these licenses faced enormous pressure from foreign governments and pharmaceutical companies. To illustrate, Thailand issued two compulsory licenses and in response, Abbott stopped launching drugs in Thailand and the US government downgraded Thailand’s trade status to poor intellectual property protection. In 2003, the WTO expanded the use of compulsory licenses to allow for the export of generic medicines to countries in crisis.14 Pressure from pharmaceutical companies backed by the US, ensured narrow interpretations of these new regulations to deter countries from applying to import generic drugs. The United States Trade Representative listed South Africa as a priority perpetrator after attempting to import generic drugs.14
Mandating the issuing of product patents has prioritized market dominance over public health and access to medications. The pharmaceutical companies strike again in neo-colonial fashion. These companies advocate for and employ international trade agreements to develop and sustain a global monopoly of ARVs. This allows these companies to limit the access of these essential medicines to the few who can afford them in an attempt to assimilate sub-Saharan countries into global markets. By producing and subsequently limiting access to essential medicines, pharmaceutical companies ensure the vulnerability and dependence of sub-Saharan countries.
Although pharmaceutical companies are not directly responsible for the implementation of structural adjustment programs (SAPs), they have vested interests in reaping the rewards. As the majority of people in the developing world receive medications through government-sponsored programs, the state’s capacity to provide ARVs is crucial. SAPs have significantly impacted this capacity and pharmaceutical companies have profited. A global recession in 1973 left many developing countries in debt.15 Continual economic decline meant that developing nations had to turn to the International Monetary Fund (IMF) and eventually the World Bank to cover foreign debts. To receive this coverage, countries had to agree to the precondition of “stabilizing programs” and undergo drastic economic restructuring.15 These SAPs are violent to developing countries and have only contributed to debt. This has severe downstream effects including worsening poverty.
SAPs have left countries unable to fund HIV prevention programs. In 1993, the WHO estimated that a comprehensive HIV prevention program would cost $2.6 billion, saving $90 billion by 2020.15 The economic constraints of SAPs left countries unable to fund prevention programs and much of the direct cost of HIV now goes to treating HIV infections and consequently pharmaceutical companies. SAPs have mandates, which require countries to curb health services.15 This has forced developing countries to charge for previously free services, including accessing essential medicines. The pharmaceutical companies again, reap the rewards. This situation causes treatment stratification where only those who can afford treatment receive it.
The preoccupation with international financial institutions’ desire to achieve economic balance has jeopardized the right to health of many in sub-Saharan Africa. SAPs and the compliance of pharmaceutical companies with these programs maintain the exploitation of the global South by the North. By utilizing the social and economic conditions created by SAPS, the pharmaceutical companies have limited access and ensured uneven distribution of ARVs. Sub-Saharan countries are left vulnerable and dependent. This exploitation and the attempted assimilation of sub-Saharan countries into western lifestyles of consumption again expose the neo-colonial project by pharmaceutical companies that has exacerbated the HIV/AIDS epidemic.
- UNAIDS report on the global AIDS epidemic 2013. 2013. Joint United Nations Programme on HIV/AIDS. Print.
- Heimer, C. 2007. Old Inequalities, New Disease: HIV/AIDS in sub-Saharan Africa. Annual Review of Sociology Vol. 33: 551-577.
- Gilks, Charles , Siobhan Crowley, Rene Ekpini, Sandy Gove, Jos Perriens, Yves Souteyrand, Don Sutherland, Marco Vitoria, Teguest Guerma, and Kevin De Cock. 2006. The WHO Public-health Approach to Antiretroviral Treatment Against HIV in Resource-limited Settings. The Lancet, 368(9534), 505-510. doi:10.1016/S0140-6736(06)69158-7.
- Palella, F , K Delaney, A Moorman, M Loveless, J Fuhrer, G Satten, D Aschman, and S Holmberg. 1998. Declining Morbidity and Mortality Among Patients with Advanced Human Immunodeficiency Virus Infection. HIV Outpatient Study Investigators. The New England Journal of Medicine. 338(13), 853-860. doi:10.1056/NEJM199803263381301.
- The strategic use of antiretrovirals to help end the HIV epidemic. Geneva, Switzerland: World Health Organization, 2012. Print.
- Paintsil E., Andiman WA. 2009. Update on Successes and Challenges Regarding Mother-to-child Transmission of HIV. Current Opinion in Pediatrics. 21(1), 94. doi:10.1097/MOP.0b013e32831ec353.
- International HIV Treatment Coalition. 2002. World Health Organization. Print.
- Equitable access to essential medicines: a framework for collective action. 2004. World Health Organization. Print.
- Avert.org. 2013. HIV Treatment in the U.S. | AVERT. [online] Available at: http://www.avert.org/hiv-treatment-us.htm
- Hivclinic.ca. 2012. Toronto General Hospital Immunodeficiency Clinic Drug Reimbursement. [online]
- Elliot, R., Bonin, M., & Devine, C. 2003. In Elliot R., Bonin M. and Devine C.(Eds.), Patents, international trade law, and access to essential medicines (3rd ed.). Canada: Canadian HIV/AIDS Legal Network / Doctors Without Borders.
- Musungu S. 2007. Access to ART and other essential medicines in sub-Saharan Africa: Intellectual property and relevant legislation. United Nations Development Program. Print. 1-33.
- Avafia T., Narasimhan SM. 2006. TRIPS agreement and access to ARVs. United Nations Development Program HIV/AIDS Group . Print. 1-30.
- Babovic S. and Wasan KM. 2011. Impact of the Trade-related Aspects of Intellectual Property Rights (TRIPS) Agreement on India as a Supplier of Generic Antiretrovirals. Journal of Pharmaceutical Sciences. 100(3), 816-821. doi:10.1002/jps.22326.
- Lurie, P., Hintzen P., and Lowe RA. 1995. Socioeconomic Obstacles to HIV Prevention and Treatment in Developing Countries: The Roles of the International Monetary Fund and the World Bank. AIDS (London, England) 9.6 : 539-46. Print.