Category Archives: 6.13. Global Access to HIV Treatment

6.13. Global Access to HIV Treatment

– Rob Camp –

We all know this data, and we gloss over it every time we go to an international meeting:

•  Some 7,000 people become infected with HIV every day.

•  Approximately 5.25 million people are currently receiving ART, while at least 14.6 million people are still in need.

•  For every 2 people put on treatment, 5 more become infected.

•  With universal access, approximately 6.7 million people would receive life-saving ART, 2.6 million new infections could be averted and 1.3 million lives saved. Based on global goals and targets for 2015, it is estimated that an investment of US$25.1 billion/yr will be required for the global AIDS response in low- and middle-income countries (www.who.org, accessed 19.04.10).

In the developing world, the price of ART has fallen drastically in recent years. Even so their cost remains an obstacle to access for many millions. Moreover, the health infrastructure required to deliver ART and maintain adherence is lacking in many places. Access to drugs depends not only on financial and human resources. It depends also on people being aware of their HIV status, knowledgeable about treatment, and empowered to seek it. Thus public information and education are important elements in widening access, alongside efforts to build or strengthen health services. Stigma has been and remains a major stumbling block in wanting, seeking and taking the treatment regimen correctly. The campaign for universal access to life-saving drugs for HIV and AIDS, started originally by grassroots AIDS activists, is today a major focus of attention of UN agencies and other influential organizations at national and global levels.

The Declaration of Commitment on HIV/AIDS, unanimously endorsed by the UN General Assembly in 2001, embraced equitable access to care and treatment as a fundamental component of a comprehensive and effective global HIV response. Since then many countries, through the support of intergovernmental organizations and donors, have definitively demonstrated the ability to deliver HIV treatment in very resource-limited settings. Access to treatment has helped mobilize communities in response to HIV, preserved the health and viability of households vulnerable to HIV, and strengthened HIV prevention efforts in many parts of the world.

In the goal to reach universal access to HIV prevention, treatment, care and support, leadership at national level is required to establish policies that support treatment scale-up by:

•  increasing the number of people who choose to know their HIV status;

•  reducing HIV stigma;

• building human capacity to sustain treatment through training and better use of current human resources;

• improving supply management and integrating HIV care with other health services.

In 2011, the international community recommitted to the goal of universal access. This time, countries committed to achieving universal access by 2015. The goal of universal access is also part of Millennium Development Goal (MDG) 6 which includes the goal of halting and beginning to reverse the spread of HIV/AIDS by 2015.

The updated 2011-2015 global health strategy was released in June 2011. This strategy outlines four key targets that countries need to achieve if universal access and MDG 6 are to be realised: reduce new infections by 50 percent among young people (15-24 years), reduce TB-related mortality by 50 percent, eliminate new infections in children, and reduce HIV-related mortality.

Major Players

PEPFAR Update

The President’s Emergency Plan for AIDS Relief (PEPFAR) was launched in 2003 to combat global HIV/AIDS, and is the largest commitment by any nation to combat a single disease in history. During PEPFAR’s initial phase covering 2004-2008, the United States invested nearly $19 billion in PEPFAR (defined to include bilateral HIV/AIDS and tuberculosis programs, as well as contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria). For FY 2011, $5.56 billion was enacted for bilateral HIV/AIDS programs, $1.05 billion for the Global Fund; the line item for bilateral TB programs has not been agreed upon yet.

PEPFAR and the fight against HIV/AIDS is now the cornerstone of the US Global Health Initiative, which commits $63 billion over six years to support countries in improving and expanding access to health services. As part of the Global Health Initiative, PEPFAR is moving from its initial emergency focus to a heightened emphasis on sustainability, and serves as a platform for expanded responses to a broad range of global health needs. Through its partnerships with 31 countries, as of September 2010, PEPFAR directly supported ART for over 3.2 million men, women and children. PEPFAR partnerships have directly supported care for nearly 11 million people affected by HIV/AIDS.

In 2010, PEPFAR directly supported prevention of mother-to-child transmission programs that allowed nearly 100,000 infants of HIV-infected mothers to be born without HIV, adding to the nearly 340,000 infants born without HIV due to PEPFAR support during 2004-2009. This of course, is not the limit as it is estimated that less than 25% of pregnant HIV-infected women get the care they need (beyond point-of-care transmission prevention). In FY 2010, PEPFAR also directly supported HIV counseling and testing for nearly 33 million people, providing what may be an important entry point to prevention, treatment, and care.

2004 – 2011 PEPFAR Funding ($ in USD millions)
Program

2004

2005

2006

2007

2008

2009

2010

2011

Total

Bilateral HIV/AIDS Programs1

1,643

2,263

2,654

3,699

5,028

5,503

5,542

5,549

26,332

GFATM

547

347

545

724

840

1,000

1,050

1,050

5,053

Bilateral TB Prog’s

87

94

91

95

163

177

243

ND

950

TOTAL PEPFAR (w/o malaria)

2,277

2,705

3,290

4,518

6,031

6,680

6,835

6,599*

32,335

1 Bilateral HIV/AIDS Programs includes funding for bilateral country/regional programs, UNAIDS, IAVI, Microbicides and NIH HIV/AIDS research.
*Possibly not the final total. For final US spending on PEPFAR 2012, please see Fiscal Year 2012 Budget Tracker at http://www.kff.org/globalhealth/8045.cfm.
Note: All funding amounts have been rounded to the nearest million $ so the numbers shown in the table may not sum to the totals.

GFATM

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing institution that invests the world’s money to save lives. To date, it has committed US$ 22.4 billion in 150 countries to support large-scale prevention, treatment and care programs against the three diseases. Round 11 of the grants cycle is now open until 15 Dec 2011. Right now, however, the Fund is unable to provide any accurate forecast or give assurances regarding the level of resources that will actually be available, since very few pledges have been confirmed.

The actual amount available will be influenced by three key considerations: 1) the level and timing of donor pledges, 2) new pledges to be announced at the time of the mid-term replenishment review in March 2012 and 3) the extent of any savings that the Global Fund will achieve through the stringent application of “value for money” and new performance-based funding principles, which can be seen at http://www.theglobalfund.org/en/application/process/eligibility/.

“More donor assistance is urgently needed to close the financing gap in health in the poorest countries of the world… Assistance from developed nations should increase from the current levels of about US$ 6 billion per year globally to US$ 27 billion by 2007 and US$ 38 billion by 2015”, according to the Commission on Macroeconomics and Health, 2003. As can be seen from the chart above, if PEPFAR represents 50% of the Global total, we are far from the target, about 1/3 of where we need to be.

The Global Fund is meant to constitute a major source of this funding. To operate effectively, the Global Fund requires strong and consistent financial commitments from all of its stakeholders. It is thus essential that substantial new pledges are received to finance additional grants and to continue successful programs.

Pledges and contributions from donors are received on an ad-hoc voluntary basis (www.globalfund.org, accessed 24.05.10). The Global Fund is relatively transparent and has an architecture of application, funding structure, management of performance and future planning that is inclusive and as broad-based as a top-down organism from Geneva that disburses money locally can be (www.globalfund.org/en/grantarchitecture). That much being said, the Fund often has to deal with scandals that stop funding from any one or group of countries temporarily. In 2011, we saw this happen with some European countries in what was a fairly small local abuse of funds report (Germany, Sweden and the Netherlands have all re-committed after temporary halts). For other reasons, like the economic downturn that started in 2008 and that shows little sign of abating in many places, Spain and Italy have not contributed the Global Fund for 2011 as of 8 September, which leaves a funding gap of close to half a billion euros. Other European countries with less commitments (Portugal, Ireland, Switzerland) have also not contributed this year.

The World Bank

The World Bank supplies more than just money for drugs – large chunks of its investment is intended for infrastructure of health systems (i.e., child health, health system performance, etc). This money, at least that specifically under AIDS, started to fall in 2004. Although the single year with most money was 2007, it did little to change the overall 3-year rolling average of being half now what it was 6 years ago. The 2010 moneys are at about the 1996 investment level. Which does not mean that infrastructure money may not be coming in under other themes – like malaria, nutrition or tuberculosis (http://search.worldbank.org/projects?qterm=HIV, accessed on 20.05.10). They also lend, offer technical support and analytic work. For example, in light of the current economic crisis, the Bank is supporting countries through technical assistance and collaborative efforts for a joint response by assessing the fiscal implications of scaling up national AIDS programs in Botswana, South Africa, Uganda and Swaziland. They lent some $55 million to African HIV programs in 2010, and expect to lend some $90 million in 2011.

UNAIDS

UNAIDS provides technical support to countries to assist them with expertise and planning for their national AIDS programs, to help ‘make the money work’ for the people on the ground, those that need it most. UNAIDS tracks, evaluates and projects the financial resource requirements at global, regional and country levels to generate reliable and timely information on the epidemic and the response. Based on these evaluations, UNAIDS produces guidelines and progress reports. Much of the international data we juggle is set and approved by UNAIDS. At the 2011 IAS meeting in Rome, they set out a plan of how to move forward in middle- to low-income countries in the face of the current economic downturn. The total investment needs should be met by a combination of sources, each of which has the potential to increase: The first is domestic public investment within low and middle-income countries, which can increase as a result of economic growth in those countries, as well as an increase in the historically relatively low level of priorisation to the AIDS response in their domestic budget. This, while a great idea, is not something that can be “turned on” overnight and while the lobbying for this goes on, people need treatment. A second source is to promote the potential for private financing and philanthropic foundations in low and middle-income countries. A third source would be an increase in the level of donor financing, compatible with a movement in the direction of meeting the target of devoting 0.7% of GDP in OECD countries to development assistance. Needed: Low- to middle-income countries’ domestic health budgets have to average at least 15% of government revenue (as in the Abuja Declaration in Africa). Another promising approach would be to expand innovative mechanisms like indirect taxation (airline tickets, mobile phone usage, exchange rate transactions) to support global health initiatives, and ensure that HIV benefits from these in relation to disease burden. The larger community must continue to support and strengthen existing financial mechanisms, including the Global Fund and relevant UN organizations.

The Bill and Melinda Gates Foundation

The largest private philanthropic organization to date is located in Seattle, US, “focusing on improving people’s health and giving them the chance” to emerge from “hunger and extreme poverty.” They have approximately 957 employees with an endowment of USD 36.3 billion. They have committed USD 25.364 billion since inception and in 2010 committed grants to the tune of USD 2.6 billion in over 100 countries. Much of these moneys are for non-AIDS-specific works, including development (reducing poverty and hunger). In health, they fight and prevent enteric and diarrheal diseases, HIV/AIDS, malaria, pneumonia, TB, neglected and infectious diseases, working on integrated heath solutions, improving delivery of existing tools and supporting research and development in new interventions like vaccines, drugs and diagnostics (http://www.gatesfoundation.org). They have supported the Global Fund with some $650 million as of mid-2010.

Drugs available from whom and where

FDA’s qualification of generics

Generic drugs are important options that allow greater access to health care. Generic drugs approved by FDA have the same high quality, strength, purity and stability as brand-name drugs. And, the generic manufacturing, packaging, and testing sites must pass the same quality standards as those of brand name drugs.

For PEPFAR use, all drugs need FDA approval. As of 2 September 2011, FDA had approved some 132 generic drugs for use in the PEPFAR program that are approved in as short a time as two to six weeks. While quality, strength, purity and stability are guaranteed, administration, delivery and correct use is another issue. For example, a drug approved in May 2010 was a fixed-dose combination of d4T and 3TC. And there the rub. Generics companies (in the case of FDA for PEPFAR, to date there are eleven Indian generics companies, 1 South African company, one company from China and one from the US) copy what is easiest and cheap, not necessarily the most innovative or optimal treatments only. We must continue to try to remind the generics companies that what is best for the patient will continue selling for years, while (hopefully) a less-than-optimal combination like 3TC+d4T has a limited life-time, and can do a lot of harm via side effects along the way.

Lopinavir/r is the first PI approved for generic licensing although there are eight approved PIs on the market in the Global North. Aurobindo got approval for a 25 mg version of ritonavir in early 2009, what could be a very interesting option in boosting in the future. Matrix got an FDA approval of a ritonavir 50 mg version (with lopinavir) on the same day. Matrix and Emcure both have approval for atazanavir (2010).

There are a handful of generics companies with an abacavir approval. As HLA testing for abacavir HSR is not easily available in the Global South, it is very important to train both the medical profession as well as users on diagnosis of HSR and what to do if it occurs, and the importance of never re-starting it once HSR is suspected, things that from an international regulatory agency would be hard to monitor. And although REMS programs from FDA or EMA would accept information on side effects from the Global South (which has up to 5 times the amount of people on drug), they probably contribute little to the overall numbers and thus better definition of safety of these drugs.

In 2011 (until 18 August), FDA has issued one warning letter to one generics company that manufactures HIV products. The letter was unclear about if it was related to an HIV product or not.

In total, in 2011, 400 FDA inspectors will perform more than 2,200 drug-related inspections. FDA takes many different enforcement actions.

WHO-approved generics

Prequalification and quality assurance of antiretroviral products – a fundamental human right

WHO’s Prequalification Programme conducts evaluation and inspection activities and builds national capacity for manufacturing and monitoring high-quality medicines. WHO began reviewing HIV antiretroviral drugs for prequalification in 2001.

In 2005–2006, WHO conducted a quality assurance survey of antiretroviral medicines in Cameroon, the Democratic Republic of the Congo, Kenya, Nigeria, Uganda, United Republic of Tanzania and Zambia. Of the 395 samples tested, none had quality deficiencies that would pose a risk to the people taking them. The results of this and future surveys on drug quality are key to ensuring that the pace of scaling up treatment does not compromise the quality of the medicines available.

Invitations to manufacturers to submit an expression of interest (EOI) for product evaluation are issued not only for HIV/AIDS-related care and treatment products, but also for antimalarial medicines, antituberculosis medicines, influenza-specific antiviral medicines and reproductive health products.

On the WHO List of Prequalified Medicinal Products is an extended list of 290 products (http://apps.who.int/prequal/, accessed 9.09.2011) for HIV/AIDS, made by both originator companies and generics companies. Prequalification may be better described as pre-, on-going, and post-qualification, as they do inspections at all these time points. On this list is atazanavir, which has WHO approval from a BMS manufacturing facility in the US as well as an Indian generics company. Neither Brazil nor Thailand have pre-approved drugs on either list (FDA or WHO) because although they both have and produce generic HIV drugs, they do so only for domestic use.

On the list are many drugs for OIs (acyclovir, ceftriaxone, ciprofloxacin, amongst others). WHO also approves medicines quality control laboratories (QCLs): 21 QCLs are currently prequalified all around the world.

Antiretroviral therapy in low- and middle-income countries by region, December 2009

Region

Estimated number of people receiving ART

Estimated number of people needing ART

ART coverage

Sub-Saharan Africa

3 911 000

10 600 000

37%

Eastern and southern Africa

3 203 000

7 700 000

41%

West and central Africa

709 000

2 900 000

25%

Latin America and the Caribbean

478 000

950 000

50%

Latin America

425 000

840 000

51%

The Caribbean

52 400

110 000

48%

East, South and South-East Asia

739 000

2 400 000

31%

Europe and Central Asia

114 000

610 000

19%

North Africa and the Middle East

12 000

100 000

11%

Total

5 254 000

14 600 000

36%

Source: Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010 (WHO, UNICEF, UNAIDS), p.53.

With the new threshold of starting treatment at 350 CD4s, even with more people starting treatment, the percentage of those treated who should be on treatment has actually fallen.

A chasm

Improved treatment in line with scientific evidence and recognized international standards of care

Médecins Sans Frontières (MSF, Doctors without Borders) serves approximately 210,000 of the ~5 million people today on treatment, and because they are on the front lines in clinics and health centers in more than 70 countries, their advocacy is not of the ivory tower type. Due to the implementation of ART, they have seen first hand the reduction in mortality for both adults and children, the lowering of incidence of TB as well as the importance of supporting HIV prevention by lowering incidence. They believe that not continuing to invest today in improved treatment and protocols will cost lives down the road, increase a double standard in HIV care and lead to increased costs later. They believe that there is a clear risk that donors may not continue to support or try to delay the implementation of proven and recommended medical strategies for the sake of short-term savings. They recommend:

• Supporting initiation of ART at a CD4 T cell threshold of 350/μl to reduce the incidence of TB and other OIs and improve survival rates, reducing the need for costly and complex acute care.

• Implementing a tenofovir-based first-line regimen will allow patients to stay on their first regimen as long as possible with fewer side effects and delay the need for more costly second-line regimens.

• Providing access to viral load testing to support adherence and detect treatment failure earlier, thereby preventing resistance and needless switching to expensive sub-optimal second-line treatment.

• Supporting innovation that can lead to further improvement and simplification of HIV treatment in resource-poor settings.

According to MSF, most people with HIV/AIDS in need of treatment in the world will die within three years if they do not gain access to treatment now.

How to ensure that prices of drugs and diagnostics remain reasonable?

The international community needs to support policies that will enable funds to stretch as far as possible to meet needs and contain costs in the short- and long-term by ensuring a competitive supply for drugs.

In accordance with the Doha Declaration on TRIPS and Public Health, governments can authorize governmental use or compulsory licenses to ensure generic production of patented products (as in Brazil and Thailand).

Companies and governments can support the Medicines Patent Pool for antiretroviral medicines that originated at UNITAID (www.unitaid.eu), now a freestanding organization at http://www.medicinespatentpool.org. This mechanism brings together patents held by different owners and makes them available to others for generic production and further development. MSF has started a ‘Make It Happen Campaign”. Gilead was the first company to sign on, in July 2011. They are currently negotiating with F. Hoffmann-La Roche, Sequoia Pharmaceuticals, the US National Institutes of Health and ViiV Healthcare. BI and BMS have just started to negotiate. This Pool could save lower income countries more than $1 billion a year in drug costs.

Prices of first-line regimens in low-income countries

The median price paid for tenofovir+3TC+efavirenz (prequalified by WHO) in low-income countries in June 2011 ranged from US$ 143 per person per year for the two pill dose to US$ 173 for the fixed-dose combination. The weighted average median price of the four combinations most widely used in first-line treatment (representing 86% of the prescribed first-line treatments in low-income countries) was US$ 170 per person per year in 2007. The decline in drug prices between 2004 and 2007 can be attributed to the scaling up of treatment programs, increased competition between a growing number of products prequalified by WHO, new pricing policies by pharmaceutical companies and successful negotiations between the William J. Clinton Foundation (CHAI) and major generic manufacturers. While combinations with d4T are cheaper, and studies continue to be carried out with even-lower doses, etc, the long-term side effects do not outweigh the harm, and programs should move to tenofovir-containing regimens as soon as they can.

Second-line regimens

Second-line regimens are still significantly more expensive than first-line regimens in low- and middle-income countries. In 2011, the median cost of a regimen of AZT/3TC+atazanavir/r, a newly indicated second-line regimen, was US$ 442 in low-income countries and up to six times that in middle-income countries. The actual prices paid for second-line regimens vary significantly between countries. For example, South Africa pays an average price of US$ 1,600 per person per year for ddI+abacavir+lopinavir/r, whereas El Salvador paid US$ 3,448 per person per year for the same regimen in 2007.

In the UK, a recent study showed that first-line treatments can last 8 years or longer, but by then, of those who start, more than 25% of people will have failed (UK Chic 2010). If ARV access started in earnest in 2002, we are at the 8-year mark. What to do with the approximately 1 million people who must need to move to a new regimen? And of the regimens that fail, NNRTIs fail at a rate almost three times higher than the rate of PIs. Most people in resource-limited settings are on an NNRTI containing regimen. MSF estimates that regimen failure is “largely under-diagnosed” due to limited lab facilities for viral load testing, which can only lead to resistance and harder-to-construct post-first-line regimens.

How to expand treatment to more people plus switch those currently failing to an effective regimen, all within a framework of cutting back on donor spending?

As the absolute numbers of people who need access to second-line regimens continue to grow, addressing the high cost of second-line regimens will become increasingly important to ensure the most cost-effective use of available resources. A third-line treatment is currently US$ 2766 in low-income, US$ 5870 in middle-income countries.

Future Funding

As funding stalls, major funders – US, UK, Netherlands, France, Germany, Norway and Sweden – may be becoming fatigued. In 2001 at the UNGCP meeting, recipient countries were asked to dedicate 15% of their national budgets to health, agreed to n theory by the Abuja Declaration. Only 8 countries have done so. More than half of African countries spend less than the UN minimum of 34 US$ per capita.

New strategies have to be developed – small taxes on currency transactions, etc. Small airline ticket tax from many countries (see above). Product (Red) is a fund-raiser of the Global Fund that coordinates profits from sales from partner businesses and has recently reached the USD 170 million mark.

As mainstays of program centers are at best maintaining previous amounts (flat-funding, like PEPFAR) or unclear about their budgets for this year (GFATM), it is important that we all contribute, both economically and using advocacy, about how to continue to arrive to the amount needed (USD 25.1 billion/yr).

Europe gets involved

The European Union can impact access to medicines for developing countries through its policies, legislation and bilateral and regional trade agreements. The EU can adopt appropriate measures to improve access to existing medical tools (medicines, diagnostics, vaccines) as well as stimulate the research and development of better tools for people in resource-starved countries. The Working Group on Innovation, Access to Medicines and Poverty-Related Diseases will create a meaningful dialogue between Members of the European Parliament, the European Commission, and civil society.

More problems than solutions

It is quite possibly easier to flag the difficulties than offer or implement solutions, but one survey was recently carried out, this time by Oxfam. In a recent analysis of meeting the Millenium Development Goals, they criticized Europe overall as not valuing poor people “enough to … guarantee … by making aid commitments legally binding. … This year alone, the EU is 19 billion euros short of its targets … enough to have saved 3 million lives in poor countries.” They have started a Robin Hood tax (a tiny tax on bankers that could generate billions of US$). In their change.org blog, they say that donors are not transparent with how their money is spent and where. For example, they highlight Kenya, where PEPFAR purportedly spent over one 500 million dollars on AIDS programs in 2008. A representative of the Kenyan Ministry of Health says that they cannot get “a list of partners, where they are working, how much they are spending, on what” from the US (http://globalpoverty.change.org/blog/view/how_transparent_is_us_foreign_aid). Which makes an integrated strategy on AIDS hard to accomplish. Without being too blithe, imagine that happening in the North: we knew how much we are spending, but not on what!

The unconscionable health gap: a global plan for justice

In the Lancet, Lawrence Gostin outlined a plan for health access for all (Gostin 2010). Despite robust international norms, health disparities render a person’s likelihood of survival drastically different depending on where she or he is born. WHO urges “closing the health gap in a generation” through action on the social determinants of health.

International health assistance has quadrupled over two decades rising to US$21.8 billion in 2007 (Ravishankar 2009). This level of funding might seem impressive but sits modestly beside the annual $1.5 trillion spent globally on military expenditures (2.43% of global gross domestic product), and $300 billion in agricultural subsidies.

Foreign aid simply is not predictable and scalable to needs and often reflects donors’ geostrategic interests rather than the key determinants of health. Developed countries recognize the health gap, but are resistant to taking bold remedial action.

If the health gap is unfair and unacceptable, how can the international community be galvanized to make a genuine difference? A global plan for justice would be a voluntary compact between states and their partners. It would simply encourage WHO to exercise its constitutional powers and leadership.

A global plan for justice would set achievable funding targets for a global health fund to be distributed according to need (Ooms 2008). Although WHO would negotiate the funding levels, developed countries could donate, for example, 0.25% of gross national income (GNI) per annum, in addition to current foreign assistance.

A global plan for justice would guarantee a universal package of essential services, comprising three core components: essential vaccines and medicines, basic survival needs, and adaption to climate change.

The international community must do more than lament ongoing, unconscionable health inequalities. It must act boldly and with a shared voice, such as through a global plan for justice. If the world does not act, the avoidable suffering and early death among the world’s least healthy people will continue unabated—a breach of social justice that is no longer ethically acceptable (Gostin 2010).

The amount of people who need access to ART in the next few years – in the short term – will grow substantially. Because of this, we need to keep up the pressure on all actors – donor organisations as well as individual nations, manufacturers, health care workers and affected communities of all sizes – to do their part in order to provide the most current and useful treatment strategies possible, to whole populations. In order to achieve this, we can not sit idly by and hope for the best – we must continue to push that boulder up the hill for as long as it takes so everyone who needs it has access to treatment and care as early and for as long as necessary.

 

Because global access is such a moving target, all references are web-based and in the text.

References

Collaborative Group on HIV Drug Resistance and UK CHIC Study Group. Long-term probability of detecting drug-resistant HIV in treatment-naïve patients initiating combination antiretroviral therapy. Clin Infect Dis 2010, 50: 1275-85.

Gostin L. The unconscionable health gap: a global plan for justice. Lancet 2010, 375:1504-5.

Harrigan RP. HIV drug resistance over the long haul. Clin Infect Dis 2010, 50: 1286-87.

Ooms G, Hammonds R. Correcting globalization in health: transnational entitlements versus the ethical imperative of reducing aid-dependency. Public Health Ethics 2008; 1: 154-170.

Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 2009; 373: 2113-2124.

Greener R. Financing the response to HIV in low- and middle-income countries: how it is affected by the economic crisis? UNAIDS presentation at IAS Rome, 20 July 2011.

Utw.msfaccess.org, Untangling the web of antiretroviral price reductions, 14th edition, Medecins Sans Frontieres, July 2011.

Links

Europe is Missing in Action, http://www.oxfam.org/en/pressroom/pressrelease/2010-06-17/europe-missing-action-when-should-be-leading-poverty-charge, 17 June 2010

FDA enforcement actions in the year 2008, http://www.fda.gov/downloads/ICECI/EnforcementActions/EnforcementStory/UCM129812.pdf.

http://www.globalfund.org/en/applicantsimplementers/resources/?lang=en

PEPFAR, http://www.pepfar.gov/press/80064.htm

 “Punishing Success? Early Signs of a Retreat from Commitment to HIV/AIDS Care and Treatment”, November 2009, http://www.msf.org/msfinternational/ accessed online 29.04.10.

http://www.msfaccess.org/main/access-patents/european-parliament-working-group/about-working-group/

World Health Assembly. Reducing health inequities through action on the social determinants of health, http://apps.who.int/gb/ebwha/pdf_files/EB124/B124_R6-en.pdf, accessed Jan 4, 2010

UNAIDS, http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2011/june/20110610psdeclaration/

http://www.un.org/en/ga/aidsmeeting2011/

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Filed under 6.13. Global Access to HIV Treatment, 6.9. Salvage Therapy, Part 2 - Antiretroviral Therapy