In 2000, when MSF first began using ARVs in its HIV/AIDS programmes, most ARVs were neither available nor affordable in developing countries. In industrialized countries, a triplecombination of ARVs generally costs US$10,000 to US$15,000 per patient per year (ppy), and the medicines were only available as patented products from originator companies. In addition, there were no alternative generic sources of ARVs whose quality had been assessed, nor were ARV supply channels set up in developing countries. As a result, only a small number of patients in the developing world had access to ARVs, usually through the private sector, donations or participation in clinical trials.
Since 2000, the international prices of some first-line ARVs have tumbled, due to a combination of sustained public pressure, discount offers from originator companies, competition from generic companies, vocal criticism of the TRIPS regime, and in general, the growing political attention paid to the AIDS epidemic. Several major events have played a key role, beginning with the local manufacture of ZDV (AZT) by the Brazilian government in the early 1990s. In 1996, a presidential decree led to universal free access to HIV medicines including ARVs, which made it possible to guarantee HIV-positive Brazilians access to treatment. Brazil's triple-combination at less than US$3000 ppy demonstrated that lower prices were possible, and that developing countries could have an alternative to originator products. Public pressure on the pharmaceutical companies built up over the next few years, and in May 2000, five originator firms announced a new partnership, Accelerating Access to HIV/AIDS Care, Treatment and Support (also known as the Accelerating Access Initiative (AAI)). This is a private/public partnership with the United Nations to offer discounted ARVs to developing countries. It was the first time that these firms had initiated differential pricing policies for ARVs.
In February 2001, the Indian generics firm Cipla shattered the price barrier when it publicly announced that it would sell a triple combination for US$350 ppy, demonstrating how low prices could fall. In MSF's experience, the ability to use generics has been critical for a number of reasons: even with differential pricing, originator medicines were often much more expensive than generics; generic production was necessary to introduce competition to the market; and the right of developing countries to use generic pharmaceuticals was at the core of a wider debate about the tension between intellectual property rights and public health (see box on p. 13).