Health Policy and Planning Advance Access originally published online on February 13, 2007
Health Policy and Planning 2007 22(2):63-72; doi:10.1093/heapol/czl039
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Negotiating antiretroviral drug prices: the experience of the Andean countries
1Assistant Professor, College of Pharmacy and School of Public Health, and Scholar, Center for Health Outcomes, Policy, and Evaluation Studies (HOPES), School of Public Health, Ohio State University, Columbus, USA.
2Clinical Assistant Professor, School of Public Health, and Associate Researcher, Center for Health Outcomes, Policy, and Evaluation Studies (HOPES), School of Public Health, Ohio State University, Columbus, USA.
* Corresponding author. College of Pharmacy and School of Public Health, Ohio State University, 500 West 12th Avenue, Columbus, Ohio 43210, USA. Tel: +1 614 292 3907. Fax: +1 614 292 1335. E-mail: pharmacoeconomics{at}osu.edu
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Abstract |
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Objectives This study analyses the effect of the Andean countries’ June 2003 negotiation of antiretroviral drug (ARV) prices. The objectives were to assess the problems faced during the negotiation process, to evaluate the impact of the negotiation on ARV prices, and to identify factors that could make it difficult for countries to implement the results of the negotiation.
Methods Price information of ARVs purchased by public programmes during 2004 was collected from the ministries of health. A survey of the ministries of health was conducted using a questionnaire with information related to the countries’ health care and drug regulations and policies. Interviews with a convenient sample of key Andean health authorities and other stakeholders were also conducted.
Results Study results show that the negotiation did achieve lower prices and higher quality and bioequivalence standards for ARVs. However, in general, the public health care programmes of the six countries analysed did not purchase ARVs from the companies that participated in the negotiation, nor did they base purchases on the prices or quality and bioequivalence criteria established in the negotiation. Prices paid by the Andean countries’ public programmes in 2004 were a weighted average of 65% higher than the negotiated prices; and this difference in negotiated prices vs. actual prices represented 39.5% of the programmes’ ARV expenditures in 2004, or US$18 million in ARV expenditures.
Conclusion The successful development and implementation of multinational price negotiations requires that participant countries coordinate pharmaceutical regulations and policies, and pool procurement processes.
Key Words: HIV/AIDS, antiretroviral drugs, drug prices, price negotiation, drug access, Andean countries
KEY MESSAGES
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Background |
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An estimated 1.6 million people in Latin America and 330 000 people in the Caribbean had HIV/AIDS in 2005 (UNAIDS 2006
). The estimated adult (15–49 years old) prevalence in Latin America was 0.5% and prevalence in the Caribbean was 1.6% in 2005. In the same year, the estimated adult prevalence in the Andean countries was 0.1% in Bolivia, 0.3% in Chile, 0.6% in Colombia, 0.3% in Ecuador, 0.6% in Peru and 0.7% in Venezuela (UNAIDS 2006). In 2003, Andean countries dedicated between 4.4 and 7.6% of their gross domestic product (GDP) to health care (Table 1). Pharmaceutical expenditures represented between 14.0 and 25.6% of the health care expenditures in the Andean countries in 2000.
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While increased access to antiretrovirals (ARVs) could have reduced the impact of the disease, increased survival and improved these patients’ quality of life, the World Health Organization (WHO) estimates that only two-thirds of those Latin American patients in need have access to ARV treatment (WHO 2004a
). The high price of ARVs is an important barrier to access, especially in developing countries (Chequer et al. 2002; Kates et al. 2002). Companies’ listed prices for ARVs did decrease after generic entry in the early 2000s, particularly with the participation of Indian companies in the ARV global market. The entry of generic ARVs resulted in a substantial price reduction, especially in those countries whose intellectual property regulations allowed for generic competition (Attaran and Sachs 2001; Attawell and Mundy 2003; Brugha 2003; Anonymous 2004; Zarocostas 2004; Anonymous 2005). Nevertheless, developing countries continue to pay prices that are higher than the companies’ listed prices, depleting scarce financial resources (Vasan et al. 2006). Several price reporting efforts contributed to make more transparent the prices listed by the pharmaceutical companies and the prices paid by health care programmes and international organizations. Since October 2000, the Joint UNICEF–UNAIDS–WHO–MSF Project has published information on the availability and price range of ARVs. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has also set up the Price Reporting Mechanism to collect information about product prices, product quality and supplier performance. The WHO’s AIDS Medicines and Diagnostics Service also publishes reports on the sources and prices of active pharmaceutical ingredients, and established in April 2005 a web-based system to monitor ARV prices. Other organizations including UNICEF, ECHO and IDA also regularly publish price lists.
Several national and multinational efforts have been organized with the aim of reducing ARV prices. The Accelerated Access Initiative (AAI), created in May 2000 with the participation of international organizations and several originator pharmaceutical companies, achieved price reductions of originator ARVs. The Clinton Foundation HIV/AIDS Initiative, established in 2002, has also negotiated price ceilings for ARVs with generic suppliers. Governments are required to sign a memorandum of understanding with the Foundation in order to obtain the negotiated prices. The GFATM, created in January 2002, has also collaborated to reduce prices through competitive and transparent procurement processes, aiming to achieve quality products at the lowest possible price. Multinational price negotiations were conducted by the Caribbean countries in July 2002 (in Barcelona) and the Central American countries in January 2003 (in Panama) with the companies participating in the AAI. In June 2003, the Andean countries (in Lima) saw the first multinational negotiations with the participation of generic companies. The Andean negotiation was followed by a negotiation by several South American countries in June 2005 (in Buenos Aires).
Participants in the Lima negotiation included the Andean countries along with Argentina, Uruguay, Paraguay and Mexico. The negotiation was coordinated by the Andean Health Agency (ORAS/CONHU). The Pan American Health Organization–World Health Organization (PAHO–WHO) and UNAIDS provided technical support during the negotiation process. Between July 2002 and February 2003, several technical meetings were held to decide the process and the conditions for the negotiation, and to create a comprehensive listing of the companies that would be invited to participate in the negotiation. A total of 11 generic companies and five originator companies participated in the price negotiation. The final statement of intent was signed by seven generic companies and one originator company.
The objectives of the Lima negotiation were to reduce the cost of and expand access to HIV tests and ARVs. Participating companies were required to provide a certificate of good manufacturing practices (GMP) and the WHO certificate of product prequalification; companies were also required to demonstrate bioequivalence for their ARV products according to international standards.
This study analyses the impact of the June 2003 price negotiation on the Andean countries. The study has the following objectives: (1) to assess the problems faced by the Andean countries during the negotiation process; (2) to evaluate the impact of the price negotiation on prices paid by the public sector of the Andean countries; and (3) to identify factors that could make it difficult for countries to purchase ARVs at the negotiated prices and standards.
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Methods |
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The study used the following sources of information: (1) a survey of ARV prices and expenditures directed to the Andean countries’ ministries of health; (2) a survey about drug policy and regulation also directed to the ministries of health; (3) interviews with key Andean health authorities and other stakeholders; and (4) a bibliographic review.
The ARV prices and expenditures survey was directed to the ministries of health. Data were collected for originator and generic ARVs purchased by Andean public health care programmes during 2004 and included the following: drug brand and generic name, formulation, route, dosage, registration date, purchase volume in units, purchase volume and average purchasing price in DDP (delivery duty paid) terms, and company(s) name. Domestic currencies were converted to US dollars using the average annual exchange rates as published by the countries’ central banks. This study did not consider variations in currency exchange rates in the price analysis. The analysis was disaggregated for domestic, originator and foreign generic companies. Domestic companies were those incorporated in the country and manufacturing finished products from imported raw materials and/or semi-manufactured products. Domestic companies excluded wholesalers and distributors of imported finished products and products under license. Companies’ nationality and type (i.e. originator or generic) were first established by the countries’ focal points and then verified by the researchers. ARV purchases were converted to common units (e.g. tablets). The package was the common unit used for suspensions and solutions. The average weighted price was calculated for each programme as the ARV expenditures that had resulted at the average negotiated prices divided by the ARV actual expenditures.
The comparison of the negotiated prices with prices paid by the Global Fund and the prices collected by the Joint UNICEF–UNAIDS–WHO–MSF Project must take into account the use of different price terms. The Global Fund presents the ARV prices in CIF (Cost, Insurance and Freight) terms and the MSF–WHO listed prices are presented in FOB (Free on Board) terms. Both price terms are slightly lower than the DDP prices collected in this study. CIF terms exclude unloading, import duties and tariffs, and taxes. FOB terms exclude transportation, unloading, duties and taxes. Transportation and unloading costs, import duties and tariffs, and taxes may vary depending on the importer and exporter countries, and also if the trade refers to raw materials or finished products.
The study's survey about drug policy and regulation was e-mailed to the ministries of health and was conducted during January and February 2005 using a questionnaire developed by the authors. The questionnaire asked for information related to the countries’ health care and drug regulations and policies. Each country's ministry of health designated an expert or group of experts (a ‘focal point’) to provide the data sought by the survey. The accuracy of the information provided in the survey was checked using a review of the literature and a review of web pages from governments and international organizations. The information collected was sent back to each ministry of health for comments and corrections.
Seven phone and 14 face-to-face interviews with a convenient sample of key Andean health authorities and other stakeholders were conducted using another questionnaire developed by the authors. The phone interviews were conducted during December 2004 and January 2005. The face-to-face interviews were conducted in Lima, Peru, in January 2005. Participants in the interviews included authorities and technical advisors with the Andean countries’ ministries of health; international organizations’ personnel including UNAIDS, PAHO–WHO, United Nations Development Program (UNDP); representatives of HIV/AIDS patient associations (Red Latino Americana de Personas Viviendo con VIH/SIDA), non-governmental organizations (CARE and Health Action International), professional associations (Colegio Médico del Perú), industry associations (Asociación Nacional de Laboratorios Farmacéuticos de Perú); and representatives of originator, generic international and domestic pharmaceutical companies.
Databases and other resources utilized in the bibliographic review included Medline, LexisNexis, and the web pages of the Andean countries’ ministries of health, commerce and finance; the Andean Community; and various international organizations. Search terms included the following key words: human immunodeficiency virus, acquired immunodeficiency syndrome, ARV, tests, prices, access, Latin America, and the names of the Latin American countries. The search was conducted in both Spanish and English. The bibliographic review included materials published during the years 1990–2004. The review also included the documents produced by PAHO–WHO relating to the negotiation.
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Results |
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The study's findings can be viewed in terms of (1) the problems faced by the Andean countries during the negotiation process, (2) the impact of the price negotiation on prices paid by the public sector of the Andean countries, and (3) the factors that made it difficult for participant countries to purchase ARVs at the negotiated prices and standards.
Problems faced during the negotiation process
All participants in the interviews indicated that the negotiation accomplished the objectives of achieving lower prices and international quality and interchangeability standards for ARVs. Nevertheless, the representatives of HIV/AIDS patient associations indicated that the negotiation did not fulfill their expectations related to universal access to ARV treatment. Other problems faced during the negotiation process and identified by the interviewees are as follows.
Both the process and implementation of the negotiation were limited by the absence of any contractual obligation to parties to the agreement. Pharmaceutical companies could participate in domestic procurement bids regardless of their participation in the negotiation.
In general, the negotiation agreement did not correspond with the regulations and policies of the countries that participated in the agreement. That is, the conditions of the negotiation were not compatible with the countries’ national regulations related to intellectual property and international trade, and drug registration, quality and bioequivalence.
The Andean countries have been members of the World Trade Organization (WTO) since 1995 (1996 in the case of Ecuador). However, in general, the negotiated ARVs were marketed before the implementation of the WTO’s trade-related intellectual property rights in the Andean countries. According to the information provided by the respective ministries of health, when the negotiation took place pharmaceutical patents affected only two ARVs in Bolivia and the drugs indinavir, nelfinavir, efavirenz, and zidovudina + lamivudina in Chile. In Venezuela, didanosine 400 mg capsule had a manufacturing process patent. Colombia had drug exclusivity (also called data protection) at the time of the negotiation that affected atazanavir and the combination lamivudine + zidovudine + stavudine.
With regard to the countries’ drug regulations, the Andean countries require drugs to be registered before they enter the market. Nevertheless, some negotiated products were not registered in each participating country. No system was implemented to allow for accelerated registration by the companies participating in the negotiation. An accelerated registration system could increase competition from generic companies.
The negotiation agreement's GMP, bioequivalence and WHO prequalification prerequisites for registration and participation in domestic bids were more stringent than those required at the national levels. Participating countries’ health programmes did not require the companies from which they purchased ARVs to meet the quality and bioequivalence standards established in the negotiation.
The segmentation of the participant countries’ health care systems resulted in different individual procurement processes for each of the public programmes within these systems. In addition, programme representatives did not actively participate in the negotiation process; instead, the process was conducted by each country's ministry of health.
Parties to the negotiation had limited data available with which to inform their decision making (OASCHU 2003). That is, the countries lacked updated information concerning the number of patients requiring treatment and on treatment; and insurance coverage. This information is critical to estimate a country's procurement needs. The countries did not have information about the ARV market share or national and international ARV price trends, which could facilitate a better understanding of the supply side of the market.
Finally, domestic companies did not participate in the negotiation because, generally speaking, they did not meet the negotiation's standards for drug products (OASCHU 2003). These standards included quality requirements, bioequivalence and pre-qualification of ARV products by WHO. On the other side, the originator companies, with one exception, chose not to participate in the negotiation as the parties were not subject to purchases of a minimum volume and the agreement did not base prices on the countries’ purchasing power, human development index, or similar criteria.
Impact of the negotiation on prices paid by the public sector of the Andean countries
An analysis of ARV prices paid by the Andean countries’ public health care programmes in 2004 was performed to determine the effect of the negotiation on prices. The analysis included 14 ARVs (11 molecules and three combinations). ARV prices were analysed at dosage level for each drug and by country, resulting in 93 items (i.e. drug, formulation and strength) of which 79 (84.9%) were for items whose price had been negotiated, thus making a comparison possible (Table 2).
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Prices paid by the Andean countries in 2004 were generally higher than the negotiated prices. Of the 79 items that were included in the study, only four (5.1%) had prices that were less than the negotiated prices, and one (1.3%) item's price was equivalent to the negotiated price (Table 3). ARV prices paid by the participating countries in 2004 ranged from 84.7% to 4477.8% of the average negotiated prices (prices were up to 44.778 times more than the negotiated prices), with a weighted average of 165.4%. ARV prices paid by the Andean countries in 2004 were also higher than the prices paid by the Global Fund for ARV purchases for Peru, and higher than the ARV prices listed by the Joint UNICEF–UNAIDS–WHO–MSF Project (Table 4).
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Overall expenditures in the Andean countries public programmes for the items included in the study reached $45.5 million in 2004. Ninety per cent of these expenditures were for originator products, 5.4% were for foreign generic products, and 4.6% were for domestic products. The purchase of ARVs at negotiated prices instead of the actual prices paid by the programmes could have saved $18 million, representing 39.5% of the programmes’ ARV expenditures in 2004.
Bolivia's Ministry of Health purchased a small volume of ARVs from a foreign generic company at the negotiated prices in 2003, but did not acquire ARVs in 2004.
In 2004, Chile's Ministry of Health dedicated 96.4% of its ARV expenditures to purchases from originator companies. Prices paid by Chile's Ministry of Health in 2004 ranged from 99.0% to 4477.8% of the negotiated prices, with a weighted average of 205.6%.
With one exception (an originator company), Colombia's Seguro Social (Social Security) programme did not acquire ARVs from the companies that participated in the negotiation. In 2004, most (59.1%) of this programme's ARV expenditures were for originator products, 8.9% were for foreign generic products, and 32.0% were for domestic products. Prices paid by the Colombian social security programme ranged from 65.7% to 1019.8% of the negotiated prices, with a weighted average of 108.9%.
Ecuador's Ministry of Health dedicated 97.4% of its ARV expenditures to purchases from originator companies in 2004, while 2.6% of purchases were from domestic companies. This programme's prices ranged from 100% to 3510.6% of the negotiated prices.
Peru's Ministry of Health acquired one ARV from a domestic company in 2004, and the price paid for this drug was 138.8% of the negotiated price. Peru's social security programme allocated 99.8% and 0.2% of its ARV expenditures to purchases from originator and domestic companies, respectively. Average prices paid by this programme ranged from 394.6% to 656.9% of the negotiated prices, with a weighted average of 461.8%. Finally, the Peruvian Policía Nacional (National Police) programme allocated 5.2% of its ARV expenditures to purchases from domestic companies, 88.3% to purchases from originator companies, and 6.5% to purchases from international generic companies. Average ARV prices for this programme ranged from 384.1% to 869.3% of the negotiated prices.
Venezuela's Ministry of Health did not purchase ARVs from the companies that participated in the negotiation. Prices paid by the Ministry of Health in 2004 ranged from 71.5% to 1595.7% of the negotiated prices, with a weighted average of 134.7%.
Difficulties of trying to purchase ARVs at negotiated prices and standards
The interviewees identified several factors that made it difficult for participating countries to acquire ARVs at the negotiated prices and standards.
The negotiation established reference prices for ARVs and did not include any contractual clause requiring participants to abide by the results of the negotiation. The voluntary nature of the agreement allowed participating companies to present higher prices in domestic bids and also allowed public programmes to purchase ARVs from companies that did not participate in the negotiation.
According to the Andean countries’ focal points, with the exception of Bolivia in 2003, these countries did not apply the negotiation agreement to subsequent ARV purchases. Participating countries did not adapt their procurement systems to the requirements set forth in the agreement, as follows.
First, participating countries’ procurement regulations did not allow direct purchasing from the companies that took part in the negotiation; thus, new domestic procurement bids were made, yet none of the countries applied the relevant negotiation outcomes to the technical specifications set forth in these bids. In addition, companies that participated in the negotiation did not have any preference in the adjudication of domestic bid contracts. However, domestic companies in Bolivia, Colombia, Peru, and Venezuela had preference in the adjudication of bids regardless of their participation in the negotiation. The Andean countries did not participate at the moment of the negotiation in the WTO Agreement on Government Procurement that prohibits domestic companies’ preference in public procurement contracts.
Secondly, the Andean countries’ regulations required that companies participating in domestic bids be registered and maintain a subsidiary in the country where the purchase would be made. Because not all participating companies had subsidiaries in these countries, their participation in the domestic bid processes was limited.
Finally, there was a lack of coordination of domestic bid processes, purchases, and quality and bioequivalence standards among the public health care programmes within individual countries. Moreover, these programmes did not always allocate the necessary resources for ARV purchases.
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Discussion |
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Multinational price negotiations could allow developing countries to share their expertise and technical resources, pool their ARV purchases and increase their leverage in negotiations with the pharmaceutical industry. For these reasons, multinational negotiations could possibly reduce ARV prices and increase the likelihood that these drugs conform to specified quality and bioequivalence standards. However, the Lima price negotiation demonstrates the limitations of an agreement of voluntary observance and the advantages of negotiating prices on the basis of assured payments. A multinational negotiation that included a contractual obligation to participants could specify purchase volumes and could require participating countries to both coordinate ARV purchases and make advance commitments of specific financial resources using a common currency for these purchases. Such negotiations could reduce the need for domestic bids and encourage more pharmaceutical companies to participate, thus increasing competition and reducing ARV prices even further.
The successful development and implementation of multinational price negotiations also require that participant countries coordinate drug regulations and policies. The registration, GMP, and drug quality and bioequivalence standards set forth in the Lima negotiation were recommended by the WHO and were higher than those in effect in participating countries. Nevertheless, national regulations were not adapted to the agreement's standards, and companies with lower ARV quality and bioequivalence specifications were allowed to participate in domestic bids.
The deficiencies of the epidemiology and information systems available in these countries limited the ability to evaluate the actual need for ARV treatments, and prioritize such treatments; and became an important obstacle to the negotiation.
With regard to the purchases examined in this study, the finding that most ARV expenditures in 2004 were dedicated to purchases from originator companies is not related to ARV intellectual property status. That is, most of these products were not protected by patents or data exclusivity. However, the market share achieved by originator companies could be related to the monopolistic and oligopolistic nature of the pharmaceutical market. Nevertheless, future negotiations will require a better understanding of the implications of products’ intellectual property status.
Finally, HIV/AIDS treatment costs constitute an important barrier to ARV access, especially in developing countries where insurance is limited and a significant portion of drug expenditures are paid out-of-pocket (Attawell and Mundy 2003). However, health care systems face additional problems that limit access to ARVs, such as inadequate health care infrastructures, limited numbers of health care professionals with adequate training, deficient epidemiology systems, deficiencies in drug procurement and distribution systems, inadequate resource coordination and poor management, and a lack of integrated care (Berkman 2001; Galvao 2002; Opuni et al. 2002; Attawell and Mundy 2003; Kober and Van Damme 2004; Loewenson and McCoy 2004; Homedes and Ugalde 2006). Moreover, the process by which health care programmes are evaluated or prioritized is inadequate (Creese et al. 2002; McGough et al. 2005).
Limitations of the study
This study is based on interviews and surveys; thus, it is possible that some of the responses received are inaccurate. The selection of the experts for the interviews was based on a convenient sample intended to identify the main issues involved in the negotiation, but does not necessarily represent the opinions of each party. The study is also limited in that it did not consider variations in currency exchange rates in the price analysis. At the time of the data analysis the dollar devaluated in comparison with the currencies of Chile, Colombia and Peru; appreciated in Bolivia and Venezuela; and remained unchanged in Ecuador. Finally, the study cannot be generalized to all public purchases within the Andean countries, nor can it be generalized to private purchases in the region.
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Conclusion |
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Companies’ listed prices for ARVs decreased dramatically after generic entry in the early 2000s. Several national and international initiatives including the Accelerated Access Initiative, GFATM, UNAIDS, WHO HIV/AIDS, MSF, and the Clinton Foundation HIV/AIDS Initiative have also contributed to the reduction in listed ARV prices. Multinational price negotiations could also contribute to set higher quality standards and reduce drug prices. The analysis of the Andean countries price negotiation found that public health care programmes of the countries analysed purchased ARVs at higher prices and different standards to those established in the negotiation.
Changes at the national and multinational levels are required to achieve an effective reduction in ARV prices and increase access to ARVs. Specific policy recommendations designed to extract the maximum benefit of drug price negotiations include: (1) coordination of drug and procurement regulations and policies of participant countries; (2) definition of common technical standards; (3) negotiation of final acquisition prices, resulting in contractual obligations to the participants; (4) improvement of participating countries’ epidemiology and information systems; (5) coordination of financial resources and procurement processes among both participating countries and health care programmes within the same country; and (6) implementation of international GMP and bioequivalence standards for the ARVs produced by the domestic industry.
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Acknowledgements |
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The study was funded by the Pan American Health Organization–World Health Organization. The authors thank the Andean countries’ ministries of health, international organizations, representatives of patients living with HIV/AIDS, and representatives of national and multinational pharmaceutical companies who participated in this study. The authors are also grateful to the Pan American Health Organization–World Health Organization and the Organismo Andino de Salud – Convenio Hipólito Unanue for coordinating communication with the countries. The authors also thank the two anonymous referees for their helpful comments and suggestions.
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References |
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TopAbstractBackgroundMethodsResultsDiscussionConclusionReferences |
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Attaran A and Sachs J. 2001. Defining and refining international donor support for combating the AIDS pandemic. The Lancet 357:57–61.
Attawell K and Mundy J. 2003. Provision of antiretroviral therapy in resource-limited settings: a review of experience up to August 2003. London DFID Health Systems Resource Centre Online at: [http://www.who.int/3by5/publications/documents/en/ARTpaper_DFID_WHO.pdf]..
Berkman A. 2001. Confronting global AIDS: prevention and treatment. American Journal of Public Health 91:1348–9.
Brugha R. 2003. Antiretroviral treatment in developing countries: the peril of neglecting private providers. British Medical Journal 326:1382–4.
Chequer P, Cuchi P, Mazin R, Garcia Calleja JM. 2002. Access to antiretroviral treatment in Latin American countries and the Caribbean. AIDS 16:Suppl. 3, S50–7.
Creese A, Floyd K, Alban A, Guinness L. 2002. Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. The Lancet 359:1635–43.
Galvao J. 2002. Access to antiretroviral drugs in Brazil. The Lancet 360:1862–5.
Homedes N and Ugalde A. 2006. Improving access to pharmaceuticals in Brazil and Argentina. Health Policy and Planning 21:123–31.
Kates J, Sorian R, Crowley JS, et al. 2002. Critical policy challenges in the third decade of the HIV/AIDS epidemic. American Journal of Public Health 92:1060–3.
Kober K and Van Damme W. 2004. Scaling up access to antiretroviral treatment in southern Africa: who will do the job? The Lancet 364:103–7.
Loewenson R and McCoy D. 2004. Access to antiretroviral treatment in Africa. British Medical Journal 328:241–2.
McGough LJ, Reynolds SJ, Quinn TC, et al. 2005. Which patients first? Setting priorities for antiretroviral therapy where resources are limited. American Journal of Public Health 95:1173–80.
MSF. 2005. Untangling the web of price reductions: a pricing guide for the purchase of ARV for developing countries. Geneva Médecins Sans Frontières Online at: [http://www.accessmed-msf.org/documents/untanglingtheweb%208.pdf]..
OASCHU. 2003. Diez países latinoamericanos y un propósito común por las personas que viven con VIH/SIDALima Organismo Andino de Salud Convenio Hipolito Unanue.
Opuni M, Bertozzi S, Bollinger L, et al. 2002. Resource requirements to fight HIV/AIDS in Latin America and the Caribbean. AIDS 16:Suppl. 3, S58–65.
UNAIDS. 2004. 2004 Report on the global AIDS epidemic: 4th global report. Geneva Joint United Nations Programme on HIV/AIDS (UNAIDS) Online at: [http://www.unaids.org/bangkok2004/GAR2004_pdf/UNAIDSGlobalReport2004_en.pdf]..
UNAIDS. 2006. Overview of the Global AIDS Epidemic: Report on the global AIDS epidemic. Online at: [http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp]..
UNICEF–UNAIDS–WHO–MSF. 2005. Sources and prices of selected medicines and diagnostics for people living with HIV/AIDS. Geneva Joint UNICEF–UNAIDS–WHO–MSF Project Online at: [http://www.accessmed-msf.org/documents/sources.pdf]..
Vasan A, Hoos D, Mukherjee JS, et al. 2006. The pricing and procurement of antiretroviral drugs: an observational study of data from the Global Fund. Bulletin of the World Health Organization 84:393–8.[CrossRef][ISI][Medline]
WHO. 2004a. "3 by 5" Progress Report. Geneva World Health Organization Online at: [http://www.who.int/entity/3by5/pr_en.pdf]..
WHO. 2004b. The World Medicines Situation, 2004. Geneva World Health Organization Online at: [http://whqlibdoc.who.int/hq/2004/WHO_EDM_PAR_2004.5.pdf]..
WHO. 2006. The World Health Report 2006: Working together for health. Geneva World Health Organization Online at: [http://www.who.int/whr/2006/annex/en]..
WHO HIV/AIDS. 2004. Plan January 2004 – December 2005. Investing in a Comprehensive Health Sector Response to HIV/AIDS. Scaling up Treatment and Accelerating Prevention. Geneva World Health Organization Online at: [http://www.who.int/3by5/en/HIV_AIDSplan.pdf]..
Zarocostas J. 2004. WHO puts HIV/AIDS pandemic at top of its agenda. The Lancet 363:1615.
Accepted for publication 11 October 2006.
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