South Africa’s public sector will save
US$326 million (around R4.5 billion) over the next three years as a result of
competitive tendering exercise that pushed the price of a fixed combination of
tenofovir, lamivudine and dolutegravir down to $65 (R910) per person per year.
The savings will help South Africa to treat around 2 million extra people,
Herbert Musariri of the Clinton Health Access Initiative told the 10th
International AIDS Society Conference on HIV Science (IAS 2019) held in
Mexico City earlier this week.

South Africa has the largest HIV treatment
programme in the world. Over 4.7 million people are already receiving
antiretroviral treatment, largely through the public sector, making the South
African government the largest procurer of antiretroviral drugs in the world.

The government has steadily driven down the
cost of antiretroviral treatment through tendering exercises. Its most recent
exercise, in 2018, set a maximum price for the first time.

The government was seeking to drive down
the price of the new fixed-dose combination of tenofovir disoproxil fumarate
(TDF), lamivudine and dolutegravir in order to achieve two outcomes:
introduction of dolutegravir-based treatment as the preferred first-line
option, and the affordable expansion of treatment numbers. South Africa will introduce
dolutegravir-containing regimens from September in the public sector (it is now
available in private).

The need to reduce drug costs is especially
acute in South Africa. The country is completing a transition from donor
funding to financing antiretroviral treatment entirely from the national health
budget. In addition, South Africa aims to start an additional two million
people with HIV on treatment by December 2020.

The 2018 tender not only specified maximum
prices but also warned that the government might wish to adjust these prices
downward, either before the tender process was completed, or during the
three-year period covered by the tender. If other countries negotiate lower
prices, the South African government will seek to revisit the prices it pays.

Eight suppliers were selected, including
three in South Africa (Adcock Ingram, Aspen and Cipla), to promote security of
supply and reduce the risk of drug stock-outs.

Musariri said South Africa’s experience
could help other countries to negotiate lower prices too. Widening the pool of
companies invited to tender can drive down costs as well as ensuring security
of supply. Using reference prices set by other countries can also help in
setting maximum prices, as can transparency about prices paid.

Speaking earlier at the congress, Prof Francois
Venter of Ezintsha, a sub-syndicate of the Wits Reproductive Health and
HIV Institute (Wits RHI) at Wits University, presented 48-week results from the
ADVANCE study conducted in South Africa that showed dolutegravir-containing
regimens to perform as well as the current efavirenz-containing one used for
first-line antiretroviral treatment (ART) in South Africa and most of Africa.