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Background: Antiretroviral (ARV) prices have fallen substantially in low-income countries, but low prices may not be consistently available in middle-income countries with large HIV epidemics. Several key antiretrovirals are still on patent in middle-income countries.
Methods: Prices and transactions for 8 ARVs used in national treatment programmes (2013-2015) were extracted from the WHO Global Price Reporting Mechanism database for >100 countries, and a Russian government database. Prices were compared between countries, using World Bank data on per-capita gross national income (GNI, US$ PPP).
Results: Prices of generic ARVs in sub-Saharan Africa were not significantly different to prices outside sub-Saharan Africa. However, two originator drugs had significantly higher prices when sold outside sub-Saharan Africa: LPV/r $360 (nonSSA) vs $232 (SSA), DRV $5760 (nonSSA) vs $657 (SSA). There were large differences in darunavir prices between countries with similar GNI (Figure). Prices of generic drugs also differed significantly between countries in Africa with similar GNI. For example TDF/FTC cost $124 in Senegal versus $55 in Kenya; ABC cost $216 in Mauritius versus $113 in Botswana. In Russia, which was reclassified as high-income in 2013, but has a large untreated HIV-positive population, ARV prices were significantly higher than in sub-Saharan Africa: ATV/r was 647% higher, LPV/r 581% higher, DRV/r 592% higher, TDF/FTC 3600% higher (Table).
Conclusions: There are still significant differences in HIV drug prices between countries with similar Gross National Income. Patent restrictions in countries with large epidemics (e.g Russia) lead to very high prices. Mechanisms to ensure fair pricing across middle-income countries need to be improved to ensure the sustainable treatment access.

Price differences for darunavir between countries with similar Gross National Income per capita
[Price differences for darunavir between countries with similar Gross National Income per capita]



DrugOriginator / Sub-Saharan AfricaOriginator / Non Sub-Saharan AfricaGeneric / Sub-Saharan AfricaGeneric / Non Sub-Saharan AfricaRussia (2015)
ATV-r--$228$234$1514
LPV-r$232$360$247$246$1435
DRV$657$5760$792-$4695
TDF+FTC-$91$64$80$2313
TDF+3TC--$54$59$1458
TDF+3TC+EFV--$130$129$2447
ABC-$242$146$136$778
RAL-$2767--$6424
[Antiretroviral average price per patient per year (2013-2015)]

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