Evolution of Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to AIDS Treatment
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{"title"=>"Evolution of antiretroviral drug costs in Brazil in the context of free and universal access to AIDS treatment", "type"=>"journal", "authors"=>[{"first_name"=>"Amy S.", "last_name"=>"Nunn", "scopus_author_id"=>"35961940600"}, {"first_name"=>"Elize M.", "last_name"=>"Fonseca", "scopus_author_id"=>"56253095700"}, {"first_name"=>"Francisco I.", "last_name"=>"Bastos", "scopus_author_id"=>"7004539273"}, {"first_name"=>"Sofia", "last_name"=>"Gruskin", "scopus_author_id"=>"7003874547"}, {"first_name"=>"Joshua A.", "last_name"=>"Salomon", "scopus_author_id"=>"56745638600"}], "year"=>2007, "source"=>"PLoS Medicine", "identifiers"=>{"issn"=>"15491277", "scopus"=>"2-s2.0-36849059227", "pui"=>"350220533", "doi"=>"10.1371/journal.pmed.0040305", "isbn"=>"1549-1676", "sgr"=>"36849059227", "pmid"=>"18001145"}, "id"=>"20b6fdd8-5658-362d-aa0f-a8bf505ee013", "abstract"=>"BACKGROUND: Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazil's AIDS treatment program has been cited widely as the developing world's largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005. METHODS AND FINDINGS: We compared Brazil's ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazil's reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir-ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US$200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US$414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US$7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US$2 billion on drugs for HAART between 2001 and 2005, implying a savings of US$1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazil's locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazil's locally produced generics totaled US$110 million from 2001 to 2005. CONCLUSIONS: Despite Brazil's more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US$1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.", "link"=>"http://www.mendeley.com/research/evolution-antiretroviral-drug-costs-brazil-context-free-universal-access-aids-treatment", "reader_count"=>90, "reader_count_by_academic_status"=>{"Unspecified"=>2, "Professor > Associate Professor"=>2, "Librarian"=>2, "Researcher"=>19, "Student > Doctoral Student"=>4, "Student > Ph. D. Student"=>17, "Student > Postgraduate"=>2, "Student > Master"=>18, "Other"=>3, "Student > Bachelor"=>12, "Lecturer"=>2, "Lecturer > Senior Lecturer"=>2, "Professor"=>5}, "reader_count_by_user_role"=>{"Unspecified"=>2, "Professor > Associate Professor"=>2, "Librarian"=>2, "Researcher"=>19, "Student > Doctoral Student"=>4, "Student > Ph. D. Student"=>17, "Student > Postgraduate"=>2, "Student > Master"=>18, "Other"=>3, "Student > Bachelor"=>12, "Lecturer"=>2, "Lecturer > Senior Lecturer"=>2, "Professor"=>5}, "reader_count_by_subject_area"=>{"Unspecified"=>7, "Environmental Science"=>1, "Nursing and Health Professions"=>2, "Medicine and Dentistry"=>35, "Agricultural and Biological Sciences"=>15, "Pharmacology, Toxicology and Pharmaceutical Science"=>2, "Business, Management and Accounting"=>2, "Chemistry"=>1, "Social Sciences"=>17, "Computer Science"=>1, "Economics, Econometrics and Finance"=>7}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>35}, "Chemistry"=>{"Chemistry"=>1}, "Social Sciences"=>{"Social Sciences"=>17}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>7}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>15}, "Computer Science"=>{"Computer Science"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>2}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>2}, "Unspecified"=>{"Unspecified"=>7}, "Environmental Science"=>{"Environmental Science"=>1}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>2}}, "reader_count_by_country"=>{"United States"=>1, "Brazil"=>6, "Dominican Republic"=>1, "Poland"=>1, "South Africa"=>1, "Kenya"=>1, "Spain"=>1}, "group_count"=>5}

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/942248"], "description"=>"<p>Patients Receiving HAART in Brazil, 1997–2005</p>", "links"=>[], "tags"=>["haart"], "article_id"=>612657, "categories"=>["Biotechnology", "Science Policy", "Infectious Diseases"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0040305.g001", "stats"=>{"downloads"=>0, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Patients_Receiving_HAART_in_Brazil_1997_8211_2005_/612657", "title"=>"Patients Receiving HAART in Brazil, 1997–2005", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2007-11-13 00:44:17"}
  • {"files"=>["https://ndownloader.figshare.com/files/942316"], "description"=>"<p>Total ARV Costs in Brazil, 2001–2005</p>", "links"=>[], "tags"=>["arv", "costs"], "article_id"=>612722, "categories"=>["Biotechnology", "Science Policy", "Infectious Diseases"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0040305.g002", "stats"=>{"downloads"=>1, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Total_ARV_Costs_in_Brazil_2001_8211_2005_/612722", "title"=>"Total ARV Costs in Brazil, 2001–2005", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2007-11-13 00:45:22"}
  • {"files"=>["https://ndownloader.figshare.com/files/942588"], "description"=>"<p>The overall contribution of a particular drug to total costs in a given year is represented by the area of the rectangle that represents that drug. Changes in quantities for a particular drug appear as changes in the height of the rectangle. Changes in the price per daily dose of each ARV appear as changes in the width of the bars. The values associated with the width of the bars are reflected in the legend. The overall height of the bars in each year reflects the estimated total number of doses purchased in that year.</p>", "links"=>[], "tags"=>["quantities"], "article_id"=>612998, "categories"=>["Biotechnology", "Science Policy", "Infectious Diseases"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0040305.g005", "stats"=>{"downloads"=>2, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Contributions_of_Drug_Price_and_Purchase_Quantities_to_Total_Cost_2001_8211_2005_/612998", "title"=>"Contributions of Drug Price and Purchase Quantities to Total Cost, 2001–2005", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2007-11-13 00:49:58"}
  • {"files"=>["https://ndownloader.figshare.com/files/475338", "https://ndownloader.figshare.com/files/475412"], "description"=>"<div><h3>Background</h3><p>Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazil's AIDS treatment program has been cited widely as the developing world's largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005.</p> <h3>Methods and Findings</h3><p>We compared Brazil's ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazil's reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir–ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US$200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US$414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US$7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US$2 billion on drugs for HAART between 2001 and 2005, implying a savings of US$1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazil's locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazil's locally produced generics totaled US$110 million from 2001 to 2005.</p> <h3>Conclusions</h3><p>Despite Brazil's more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US$1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.</p> </div>", "links"=>[], "tags"=>["antiretroviral", "costs", "brazil", "aids"], "article_id"=>153672, "categories"=>["Cancer", "Science Policy", "Biotechnology"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.0040305.sd001", "https://dx.doi.org/10.1371/journal.pmed.0040305.sd002"], "stats"=>{"downloads"=>14, "page_views"=>16, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/Evolution_of_Antiretroviral_Drug_Costs_in_Brazil_in_the_Context_of_Free_and_Universal_Access_to_AIDS_Treatment_/153672", "title"=>"Evolution of Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to AIDS Treatment", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2007-11-13 01:01:12"}
  • {"files"=>["https://ndownloader.figshare.com/files/942456"], "description"=>"<p>Ratio of Total Annual ARV Costs in US Dollars to Numbers of Patients on Treatment</p>", "links"=>[], "tags"=>["arv", "costs", "dollars", "numbers", "patients"], "article_id"=>612860, "categories"=>["Biotechnology", "Science Policy", "Infectious Diseases"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0040305.g003", "stats"=>{"downloads"=>1, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Ratio_of_Total_Annual_ARV_Costs_in_US_Dollars_to_Numbers_of_Patients_on_Treatment_/612860", "title"=>"Ratio of Total Annual ARV Costs in US Dollars to Numbers of Patients on Treatment", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2007-11-13 00:47:40"}
  • {"files"=>["https://ndownloader.figshare.com/files/942661"], "description"=>"<div><p>(A) Total Cost Estimates in the Absence of Changes in Drug Quantities, 2001–2005.</p>\n <p>(B) Total Cost Estimates in the Absence of Changes in Drug Prices, 2001–2005.</p>\n <p>(C) Total Cost Estimates Using Lowest-Price Generics, 2001–2005.</p></div>", "links"=>[], "tags"=>["scenarios", "arv"], "article_id"=>613068, "categories"=>["Biotechnology", "Science Policy", "Infectious Diseases"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0040305.g006", "stats"=>{"downloads"=>1, "page_views"=>1, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Impact_of_Alternative_Price_and_Quantity_Scenarios_on_Total_ARV_Costs_2001_8211_2005_/613068", "title"=>"Impact of Alternative Price and Quantity Scenarios on Total ARV Costs, 2001–2005", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2007-11-13 00:51:08"}
  • {"files"=>["https://ndownloader.figshare.com/files/942518"], "description"=>"<p>Total Annual Cost by Drug (Left) and Proportion of All Annual Drug Costs (Right)</p>", "links"=>[], "tags"=>["costs"], "article_id"=>612927, "categories"=>["Biotechnology", "Science Policy", "Infectious Diseases"], "users"=>["Amy S Nunn", "Elize M Fonseca", "Francisco I Bastos", "Sofia Gruskin", "Joshua A Salomon"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0040305.g004", "stats"=>{"downloads"=>1, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Total_Annual_Cost_by_Drug_Left_and_Proportion_of_All_Annual_Drug_Costs_Right_/612927", "title"=>"Total Annual Cost by Drug (Left) and Proportion of All Annual Drug Costs (Right)", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2007-11-13 00:48:47"}

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Relative Metric

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