Britain's Outperforms and is Cheaper than US on HIV Drugs-- Why Is That?

Britain’s National Health Service far outperforms America’s health care system — for far less money — at keeping H.I.V. patients healthy.

By Tina Rosenberg

Ms. Rosenberg is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.  

Justin Sullivan/Getty Images  Last week, the High Court of England and Wales announced a momentous decision: It invalidated the pharmaceutical company Gilead’s patent on Truvada, opening the way to generic competition.

Truvada, a combination of two drugs, is one of the world’s most-used H.I.V. medicines. For treating H.I.V., it’s used along with a third drug. But many H.I.V.-negative people also take Truvada daily as a preventive. That’s called pre-exposure prophylaxis, or PrEP.

In the United States, Truvada is available only as a brand-name drug. It costs $20,000 a year.

Here’s how it will work in Britain’s National Health Service, according to Dr. Andrew Hill, a senior research fellow at Liverpool University who studies the cost of medicines. “The N.H.S. will say to a group of generic companies: ‘We need PrEP for 20,000 people. Give us your best price.’” The cost of making PrEP is $55 per year, Dr. Hill said. He believes that the generic will sell for between $100 and $200.

All over the world, more and more people are taking H.I.V. drugs. These medicines are very good at their job — keeping people healthy and noncontagious — so most patients will take them until they die of something that isn’t H.I.V. Patients are also starting earlier on antiretroviral therapy; the new recommendation is to start immediately upon diagnosis. And now with PrEP, a potentially enormous new group of patients has arisen: H.I.V.-negative people who are at risk for catching the virus. 

ion for the same amount or less money each year. England’s region of the health service spends about half a billion dollars per year on H.I.V. drugs. There are no increases for inflation, and lots of pressures for further cuts.

It’s lucky, then, that Truvada will have generic competition. It should allow the health service to greatly lower costs and offer PrEP to anyone who needs it.

The health service does an admirable job with H.I.V. Around the world, countries measure the percentage of people living with H.I.V. who have no virus detectable in their blood. In the United States, only 49 percent have achieved this. In Britain, the number is 78 percent.

While the National Health Service has a lot of problems, it has some huge advantages over the American system that allow it to provide high-quality H.I.V. care in a cost-efficient manner.

So it’s worth looking at what the British health service does right, because some of those strategies could work in America, even though the two systems are structured very differently.  

About the American health care system’s indifference to cost. There’s virtually no one in the system with the incentive, responsibility or power to lower the astronomical cost of H.I.V. drugs. Panels that establish guidelines recommend, and doctors tend to use, the newest drugs, even if they offer little benefit over existing ones. Patients are content because manufacturers help them with co-pays for expensive drugs. Generics are almost never used.

This year, the generic company Mylan introduced some lower-cost medicines. They are still not cheap; Mylan’s equivalent of Truvada costs $12,000 a year. Still, the creation of these new drugs has inspired a few experimental attempts to substitute them for equivalents that are even more expensive.

Even when brand-name drugs have no generic equivalents, the medicines in the British system cost a small fraction of what they cost in America. Most brand-name triple therapies cost about $6,500, said Dr. Laura Waters, an H.I.V. physician who is a member of the health service’s H.I.V. Clinical Reference Group, which sets policy. She said that a combination pill that includes some generics would cost between $2,600 and $4,000. Full generics usually cost 70 to 80 percent less than comparable brand names. One completely generic H.I.V. regimen costs $400 per year.

The National Health Service has long relied on generics to treat most diseases. But that wasn’t the case with H.I.V. Once effective drugs were developed, the field moved so fast that by the time a drug went off patent, it was no longer commonly prescribed.

But that’s not true anymore.

The first H.I.V. therapies, in 1995, were lifesaving — and toxic, with horrible side effects. Some of them required patients to take 20 pills a day.

Now patients around the world take one or two pills a day. All the regimens do well at controlling the virus. They all have some side effects for some people, but patients can switch to find a regimen they can tolerate well. What used to be a big leap forward with each new drug is now a tiny step — or an advance for only a subset of patients. So older drugs are still in use. Truvada is one example.

Three years ago, the National Health Service’s push for generics started to cover H.I.V. drugs. Dr. Waters estimated that at the time, fewer than 5 percent of H.I.V. patients were taking a generic. Now, she said, the number is more like 30 percent.