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Other important players in this drug war are the pharmaceutical companies who play a vital role in providing ARVs and in research and development. Despite that one interviewed pharmacist described dealing with the pharmaceutical companies as frustrating and found their claim of making little or no profit on ARVs hard to believe, GlaxoSmithKline (one of the ‘Big 5’ pharmaceutical companies) remains committed (according to their company brochures) to “ensure that new and better treatments are developed and that more and more people in the world’s poorest countries get access to our medicines.” Despite this commitment GlaxoSmithKline (GSK) has also drawn some flak from the TAC on the question of drug patents and the issuing of voluntary licences (pharmaceutical companies can issue voluntary licences to subsidiary companies to have their ARVs produced in greater volume and at cheaper prices. The government has the option of forcing pharmaceutical companies to allow their drugs to be mass-produced by issuing compulsory licences). Observing this drawn-out drug war are the persons living with HIV/AIDS who need to pay considerable amounts of money to purchase the drugs which often constitute their only hope of not dying prematurely of AIDS. These people are the real casualties of this drug war.
Since 2000 the prices of virtually all ARVs have been steadily decreasing. The spate of price reductions recently culminated in GSK halving its price for Combivir, its leading AIDS drug in poorer countries, and also significantly reducing the prices for its other ARVs, i.e. Epivir (3TC) and Retrovir. Peter Busse, a person living with HIV/AIDS in South Africa, has been using ARVs for the last few years, and states that the price of one drug that he has been using, Zerit, “fell virtually overnight from R1000-00 to under R100-00. This was because the patent for the drug had expired in 2002.” Because the patent for Zerit had expired, the drug could be mass-produced by different companies and at cheaper rates, and thus it became more readily accessible.
Vicki Ehrich, the Corporate Affairs director of GSK South Africa, attributes the drastic price reductions to continuing improvements in GSK’s drugs manufacturing process, and the resulting economies of scale achieved. “The reductions were not due to competition,” states Ehrich, “since our preferential prices have been reduced since 1997, and now the reductions have been expanded to all our products. The improving exchange rate also played a role, and GSK has re-engineered its manufacturing process. GSK has also been committed to develop its programme of preferential pricing.”
Nathan Geffen, spokesperson for the TAC, believes that ARV prices were reduced primarily because of activists’ pressure. “My concern,” states Geffen, “is that activism cannot always be strong. Sustainability is a problem. Our experience has been that the only way to deal with pharmaceutical companies is through public mobilisation and legal action. GSK's price reductions have come with activism and competition for Global Fund to Fight AIDS, TB and Malaria money GSK’s price reductions have come with competition and action. But what if that action is taken away?” The TAC, states Geffen, “argues for competition between generic and brand-name companies, because under a monopoly we don’t have the lowest possible price. Some countries can, but South Africa cannot access generics (mass-produced ARV’s), and thus there is a growing underground market of generics. What should happen is that voluntary licences should be given to generic manufacturers, and for this a 5% royalty fee should be levied. Thus the big pharmaceutical companies like GSK should allow generic manufacturers to sell in South Africa, and in this way the South African markets can get access to cheaper drugs.”
Things are not quite so easy, believes Vicki Ehrich. “The government”, states Ehrich, “has never been really anxious for issuing compulsory licences to pharmaceutical companies, and compulsory licences would undermine the very important role played by pharmaceutical companies. GSK has indeed issued a voluntary licence to Aspen Pharma Care for the production of three ARV drugs for the public sector, and has reduced the prices for its other drugs without even negotiating with the government. GSK does not believe in donations. The activists are campaigning to peg the price of ARVs so low as to be affordable for people of a very low income, but to what are the supposedly excessive prices of ARVs compared? Other medicines are much more expensive. GSK has committed itself to preferential pricing and research, and the resultant volume increase will adjust the price of ARVs. Somebody still has to make the strategy, and multi-national organisations have put a huge effort into training. In the private sector in South Africa, GSK has followed a general principle of marketing ARVs at lower prices than anywhere else in the world, thus the drugs in South Africa cost on average 20% of (or one fifth of) the level charged in the United States.”
Where exactly does this struggle between lobbying groups (or activists), the government, and pharmaceutical companies leave those people actually set to survive or die because of ARVs or a lack of them? “Its problematic,” states Peter Busse (AIDS counsellor, trainer and person living with AIDS). “There is a lot of division in the AIDS world. Everybody living with AIDS is supporting access to treatment, but they are split on how this should be achieved. Who speaks for whom? Is the TAC speaking for itself or is it representative of all people living with AIDS? These things are blurred and confused. Also, the TAC has taken such an oppositional stance towards the government and this produced the unfortunate side effect that people don’t want to back down.” As for the pharmaceutical companies, states Busse, “Their stance has changed. They hold much power but they have been forced to change their stance, mainly through pressure from the TAC. Initially they held quite an arrogant attitude, but now they are much more responsible regarding the need for treatment. Where pharmaceutical companies were initially fuelled solely by profit, their stance has now softened.”
In regard to the success of ARVs Busse’s conviction is clear: “I have had a CD4 count of 6, but currently (and mainly due to the use of ARVs) my CD4 count is well above 200” (the CD4 cell count is a useful marker of the state of the immunity in a person with HIV/AIDS. The normal CD4 cell count ranges from 600 to 2000 cells/mm3. Generally a person is said to have AIDS when the CD4 count drops below 200). In the face of his successful ARV treatment, Busse finds the government’s persistent unwillingness to formulate a national ARV treatment plan disappointing: “While we read in the newspaper billboards that the Treasury believes that ARVs are affordable we still find that the government is not doing anything. Namibia and Botswana are two countries that have instituted national anti-retroviral programmes, and South Africa has greater resources than both these countries but the government is simply not doing enough.”
Busse’s thoughts on the role (or lack thereof) of the government are shared by Nathan Geffen. “We have had disappointing results from the government,” states Geffen. “This has been the bulk of the TAC focus, and the justification for our civil disobedience campaign. One of our biggest complaints is that the Minister of Trade and Industry and the Minister of Health have both not used legislation approvingly, especially when it comes to issuing compulsory licences for generic drugs to be produced. The two ministers have the power to issue compulsory licences, but they have made no effort to do so at all. In fact they have been quite obstructive.”
Vicki Ehrich also testifies to the hesitant and indecisive dealings of the government. “In 1997,” states Ehrich, “we offered the Minister of Health preferential pricing. Nothing came of this until May of 2000, when five companies along with UNAIDS issued the Accelerating Access Initiative in order to promote comprehensive treatment at preferential pricing. In June of 2001 we offered the government an expanded offer. Throughout this period, however, the government has been reluctant to treat people living with HIV/AIDS and has never taken up our offer. It has not even come to a final decision yet, but the national strategy must be led by the government. They might have limited resources, but the government must lead the national strategy on AIDS.”
So with the government indecisive and the AIDS world in South Africa divided, what does the future hold for South Africa’s drug war? Peter Busse believes that people living with HIV/AIDS will pay less for their ARVs in the future: “The trend of prices coming down will continue. The cost of triple therapy has also shown a downward trend, and more patents are going to expire, which will lead to the availability of more generic drugs. Generic drugs could be cheaper and more readily available, since they could be manufactured locally.” So there might be light at the end of the tunnel in South Africa’s ongoing drug war. With South Africa scheduled to produce its own affordable generic ARVs (with the first pills available by 2004), and with the South African government seemingly set to depart from its meandering in dealing with the HIV/AIDS epidemic in South Africa, there might be hope of an end to this war shortly. Yet if South Africa’s people living with HIV/AIDS are to experience the end of this drug war, they had to have procured ARVs when the war was at its zenith and its outcome in doubt.
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