End of life photography: A photographer captures his patients before they are killed to allow their relatives to say goodbye, as was seen in India (Picture: AFP/Getty Images) Drug companies say they are doing everything possible to improve access to medicines in developing countries but are being thwarted by corrupt government officials, who siphon off bribes intended for the state’s healthcare programme. In India, the issue was highlighted by the government’s failure to pay the full price for the antiretroviral drugs it needs for 1.2 million people living with HIV – most of them migrant workers from poorer neighbouring countries, who cannot afford the drugs. The government paid only 1.3bn rupees (£12.8m) for 30,000 treatment courses of a single drug for HIV, rather than the 3.6bn rupees that had been negotiated. The drug industry says it will not work with the government if they continue to pay the negotiated price but only the cheapest price available in the market. ‘The first thing that should happen is that we should all sit down and talk about this,’ says Michael Tuff, the former president of the International AIDS Society. ‘We’ve got to put a human face on this problem, to focus on the human cost of corruption and to try to find ways of reducing that.’ The situation is complicated by India’s vast HIV epidemic, with 2.2 million Indians living with HIV. More than half of those infected are unaware of their status. In 2003, when the Indian government was rolling out its prevention and treatment programme for HIV, a pilot project was launched in a remote part of southern India where nearly 60 per cent of the population live below the poverty line. The antiretroviral drugs covered by the programme were donated by Merck Sharp & Dohme – then a subsidiary of Merck KGaA, now known as EMD Serono – which supplies a similar drug to the British market under the name Viramune. Patients are treated by Dr Vasantha Rao at Leprosy Missionary Hospital in Bangalore, India (Picture: AP Photo/Mohammed Yusuf) The Indian Health Ministry said it had to ensure drug prices were low enough to make the programme sustainable. The drugs were manufactured by Cipla Ltd, a subsidiary of the pharmaceutical company Cipla, a public company based in Mumbai. ‘The government is supposed to be an honest broker between suppliers and recipients,’ Tuff said. ‘And if it is, you should not be talking about [selling] low-cost generics [compared to patented versions of the same drug].’ More than 1.5 billion people do not have access to HIV treatment, according to UNAIDS, the main global body for HIV prevention, care and support. In these countries, a single course of medication costs about £22 or roughly the same as a month’s supply of food for a patient in India, said Dr John Kaldor, chief executive of UNAIDS. The manufacturers say they are determined to improve access to these drugs in developing countries, especially for those who cannot afford patented drugs. ‘That’s why you see us partnering with the GAVI initiative,’ said Dr Tiffany Schreiber, head of corporate social responsibility at Merck. It is not known what percentage of patients in India who need the anti-HIV drug are able to access it. ‘We are still unsure of the final figures,’ said Lila Mehta, the head of communications for the Indian Drugs Controller General of India (DCGI). The World Health Organisation said 1.7m HIV-positive people were on antiretroviral therapy in India as of December 2013. But only 15 per cent were receiving antiretroviral therapy that had been donated by pharmaceutical companies, the WHO said. ‘If more money was available to India, would this happen?’ Tuff asked. ‘Without the full support of donors to ensure more resources are made available, we are not going to be successful.’ In 2005, the manufacturers launched a ‘buy-in’ programme to support the programme for HIV-positive people who needed antiretroviral drugs but could not afford them. ‘If people can’t get the full price, they won’t give the drug,’ Tuff said. ‘As an industry, we are prepared to deliver this. But we want support from the government.’ More than 1.5 billion people do not have access to HIV treatment, according to UNAIDS, the main global body for HIV prevention, care and support. In these countries, a single course of medication costs about £22 or roughly the same as a month’s supply of food for a patient in India, said Dr John Kaldor, chief executive of UNAIDS. A spokesperson for the DCGI said the programme would ‘only be sustainable in the long run with adequate funding’. ‘The budgetary allocation for public health in India is around 1.8 per cent of the total national expenditure, a tiny fraction of India’s overall healthcare expenditure. Hence, any initiatives to expand the availability of medicines in the country will have to necessarily seek a funding source. The national drug policy of India envisions this,’ he said. ‘The drug manufacturers have always been willing to take the responsibility of supporting the poor through the government’s public health scheme,’ he said. ‘We are committed to increasing availability of quality drugs to the poor people at affordable rates. It’s just a matter of the government funding the programme.’ The Indian government said in its statement that it ‘fully supports generic substitution’. Merck said they were ‘committed to reducing treatment costs in the developing world as a necessary first step towards expanding access to antiretroviral therapy’. ‘We are exploring all opportunities to provide access for people in need in India, such as through the Indian Government’s Patient Assistance Programme,’ it said. An executive from one of the companies said they do not expect any action from the Indian government. ‘They can work with us but they cannot buy our drug at the market price because they have no pricing power in the market,’ she said. An Indian doctor checks a patient’s health at an AIDS clinic in Mumbai (Picture: AFP/Getty Images) ‘We are working with governments and UN bodies to negotiate better prices. India and many other developing countries can and should achieve prices much lower than these prices.’ ‘No one will give [Indian government] their patented drugs at these prices. Every other country has come to us for help. The government should be the best customer for us,’ she added. India is not the only country where HIV drugs are underpriced. A study from Vietnam found that HIV treatment, which should cost less than $90 a year, is sold to patients for about $400. ‘The price is not what really matters here,’ said Dr Tricia Collingham, director of UNAIDS global support team. ‘The way they are priced means you can’t start treatment for some. You’ve got the problem of where the money comes from to do that. And to give people access to treatment, you have to make sure they’re accessible in the community, which often means they’re subsidised by the state. So what really matters is the price of the antiretroviral drugs.’ An Indian doctor checks a patient’s health at an AIDS clinic in Mumbai (Picture: AFP/Getty Images) In the meantime, patients in India are dying. The government has said that it will begin negotiations with Cipla and Merck as soon as the ‘buy-in’ programme is over. ‘To get the best possible price for patients, we need to work with them for the present, but then with an eye to the future,’ Tuff said.