Basically we’ve been laying the foundations for an access to HIV treatment campaign, called Treatment Access Movement. We’ve been trying to get drugs into the country, lobbying the government for improved access to treatment, networking with the media and civil society representatives, and mobilising people living with HIV to demand access to treatment.

MSF’s Lagos programme provides anti-retroviral treatment for about 1300 people. While HIV affects Nigerians from all social classes, it’s mostly poor people who come to MSF for treatment. The average monthly income of our patients is about US$35. Many have lost their jobs and been thrown out by their families because of their HIV status and are living hand to mouth. We are one the very few providing treatment free of charge.

While treatment is available it isn’t free; user fees and other costs total around US$50 per person per month, more than the average monthly income of our patients. These fees can push people to interrupt their treatment regime during times of financial hardship, with disastrous consequences. In a recent survey, we found that more than 80% of those who stop treatment do so because of the cost. So we’ve been pushing the government to remove user fees and make treatment free.
There have been other problems in Nigeria too. The government programme is not very well organised and ran out of medicines for a couple of months some time back. This meant people’s treatment was cut off.

Basically, the impact of user fees, government irresponsibility and the fact that the drug market is largely uncontrolled in Nigeria mean a lot of treatment failure among people on first line drugs. In other words, people have started taking first-line treatments (an initial course of HIV medication which a person takes when their immune system drops below a certain level), but because they’ve had to stop treatment the virus has become resistant to these medicines. To stay alive they now need second-line treatments, which are more potent and attack HIV in different ways.

That’s completed misguided. Nigeria is an extreme example, but treatment failure is a problem that all countries face, including in the developed world. Because HIV is crafty it adapts to treatment and finds new ways of reproducing. Even in Switzerland, up to 20% of patients experience first-line treatment failure within two years. On MSF’s South Africa programme, where treatment is heavily controlled, about 16% of patients will need to move on to second line treatments within three years. The bottom line is that whatever country you’re in, progression to second line treatment is normal, and availability of these drugs is becoming more and more important in developing countries.

Generally speaking, no. As with first-line drugs, while people in developing countries account for 95% of patients, they are for the most part excluded from the market. Even those who can get second line drugs generally can’t get the newest or best versions, despite the fact that poverty and poor nutrition are already making things difficult.
50 patients on MSF’s Lagos programme have already switched to second-line treatments, a number likely to reach 200 by the end of the year. Some are taking Kaletra, a drug patented by US Company Abbott Laboratories and recommended by the WHO. While patients in the US are taking a newer version of Kaletra, which is heat stable, has a low pill burden and can be taken on an empty stomach, only the older version which has to be kept in the fridge is available in Africa, making provision a logistical nightmare. Temperatures easily soar to 40 degrees in Nigeria, and most of MSF’s patients don’t have fridges to store their medication. Not to mention the fact that there is no functioning public power supply in the whole of Nigeria. As a result, they have to keep their supply at MSF’s offices, which can mean travelling for up to six hours to access treatment. This not only means incurring travel costs, but also having to take a day off work, so they actually lose income. It’s unacceptable that our patients should endure so much stress when an equivalent drug, which could be stored at home, has already been developed. The only other option is to take a different drug combination, but it is more complicated and less effective. Neither situation is sustainable or acceptable. As soon as MSF can get the new, heat stable version of Kaletra it will switch all second line patients on to it. Access to this drug is not a luxury, it’s a necessity.

New Kaletra hasn’t been registered in Africa yet. Registration was completed in the US in October and is now underway in Europe. Abbott says it won’t start registering the drug in Africa until registration is complete in Europe, where the drug is being produced. This could mean potential delays of years before those who need this drug most can benefit from it.

Our patients cannot wait. So MSF wrote to Abbott a fortnight ago, requesting that they begin registering new Kaletra in African countries immediately, and that they supply enough of the drug to cover the need in 9 of MSF’s treatment programmes, at the same or less cost than the old version of Kaletra (which is more expensive to manufacture).

Abbott responded, reiterating their claim that registration can’t begin until it is complete in Europe. In fact, this is untrue as many countries do not require a certificate from the producer country or region to register a drug. What’s more, if Abbott was really concerned about getting these drugs to Africans that certificate could be obtained from the US where new Kaletra is already on the market.
Abbott also claimed that they couldn’t allow MSF to supply new Kaletra when it hasn’t been registered, as to do so would be breaking the law. This is a lame excuse. MSF has already done this on several instances, and with several different drugs, by obtaining a temporary dispensation from the national drug authorities in the countries where they work. Abbott’s business ends with the supply of the drug to MSF.

It’s personally frustrating to see that in fact, the attitude of these companies has not at all changed in the last five years. We are fighting exactly the same battles as we were in 2000. Price cuts on first line drugs were only achieved because of activism and competition from generics producers. Now we’re facing the same obstacles, stubbornness and ignorance when it comes to getting second line treatments to people, and it reveals the true character of profit orientated companies.
It boils down to the fact that we still have two classes of patients; one in the rich world to whom a whole range of treatments is available, another in the poor world where even first-line treatment is hard to get. If drug resistance develops for the second group, it’s simply hard luck, and this is completely unacceptable. MSF has a medical responsibility to provide our patients with the best drugs available. We will sit down and discuss this with Abbott, or if necessary we’ll fight them on it, and in the end we will get these drugs to our patients, because for them it’s a matter of life or death.

What’s clear is that for all their rhetoric, Abbott obviously doesn’t care about what happens in Africa. But as a profit driven company, they are very sensitive to public opinion in the EU and US because that’s where they make their money. Activism in the UK can inform the public about the problem, can shape public opinion and can therefore provoke Abbott to reconsider their position.
In fact activism is even more important now than in 2000, because the situation is more complex now with generics-producing countries like India under the remit of the WTO TRIPS agreement, making the production of low cost drugs more difficult.

What we’re facing with Abbott is another example of the problems caused by the granting of patent monopolies on essential goods such as medicines. It shows that it is completely wrong to grant an uncontrolled, twenty year monopoly on life saving drugs. If you look at our patients, for them it’s not a luxury to have a drug that doesn’t need to go in the fridge. It’s a necessity; if they don’t have it they will die. There is a huge need to question the current global system of research and development and marketing of pharmaceutical products, because it obviously isn’t meeting the health needs of most of the world’s population, especially those in developing countries.