Huge variations in price paid for same antiretroviral drug between low-income countries

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An analysis of prices paid for antiretroviral drugs by 113 countries between 2002 and 2008 shows that prices for some generic antiretroviral drugs varied as much as tenfold between low-income countries, and some middle-income countries paid up to 16 times more than other countries with similar levels of development.

The analysis by Brenda Waning and colleagues at Boston University School of Medicine is published this month in the Journal of Generic Medicines.

Based on data gathered from purchases of antiretroviral drugs with Global Fund grants in 113 low and middle-income countries, as well as data on drug purchases gathered separately by the World Health Organization, the analysis looks at prices paid in around 15,000 ARV procurements worth more than $1 billion that took place between 2002 and 2008.



In relation to medicines, a drug manufactured and sold without a brand name, in situations where the original manufacturer’s patent has expired or is not enforced. Generic drugs contain the same active ingredients as branded drugs, and have comparable strength, safety, efficacy and quality.

middle income countries

The World Bank classifies countries according to their income: low, lower-middle, upper-middle and high. There are around 50 lower-middle income countries (mostly in Africa and Asia) and around 60 upper-middle income countries (in Africa, Eastern Europe, Asia, Latin America and the Caribbean).

low income countries

The World Bank classifies countries according to their income: low, lower-middle, upper-middle and high. While the majority of the approximately 30 countries that are ranked as low income are in sub-Saharan Africa, many African countries including Kenya, Nigeria, South Africa and Zambia are in the middle-income brackets. 

reverse transcriptase

A retroviral enzyme which converts genetic material from RNA into DNA, an essential step in the lifecycle of HIV. Several classes of anti-HIV drugs interfere with this stage of HIV’s life cycle: nucleoside reverse transcriptase inhibitors and nucleotide reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). 


A precursor to a building block of DNA or RNA. Nucleosides must be chemically changed into nucleotides before they can be used to make DNA or RNA. 

Overall, two-thirds of the drugs procured were generic formulations. Although prices of generic and branded drugs fell over the six-year study period, analysis of year-by-year changes revealed some complex patterns.

In particular, price reductions tended to be smaller for protease inhibitors, and smaller for all branded products than for generic versions.

There were also big variations between countries in the prices paid for both generic and branded products, even within the same income bands. In middle-income countries for example the price of almost one in five branded antiretroviral products varied at least threefold between purchases, and in low-income countries the price of five generic products varied at least threefold in 2007-2008 alone.

Although the authors do not offer explanations for the extent of variation between purchases, they say that greater transparency about the prices being paid for antiretroviral drugs could assist countries in getting better value for money.

They also note that their analysis confirms the oft-repeated observation that countries pay less for most generic versions of antiretroviral drugs, although they note that generic versions of protease inhibitors remained more expensive, on average, than branded versions up to the end of 2008.

They suggest that low global demand for protease inhibitors, coupled with the wide range of possible products, may explain the higher prices paid for this class of drug. If procurement were to be consolidated around a much number of products in this class, prices might be driven down further, the authors speculate.

However, greater generic competition will also be needed to drive down prices, and the same is true for abacavir and tenofovir, which also remained expensive relative to other drugs of the nucleoside reverse transcriptase inhibitor class at the end of 2008.

Mechanisms such as the patent pool for ARVs being developed the international drug purchase fund UNITAID will also help to promote competition and drive down prices, the authors suggest.


Waning B et al. Temporal trends in generic and brand prices of antiretroviral medicines procured with donor funds in developing countries. Journal of Generic Medicines 7 (2): 159-175, 2010. (Full text article freely available here).

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