Breaking the Silence:
Activist efforts to improve global access to AIDS medications

Mark Milano, Alan Berkman, MD, David Hoos, MD
Delivered at the XIII International AIDS Conference, Durban, South Africa July 6, 2000

Due to the high price of antiretroviral drugs (a 3-drug combination sells for over $12,000 per year in the U.S.), over 90% of people with HIV worldwide have no access. But generic manufacturers have estimated that triple therapy could be produced at a cost as low as $265 per year, if patent restrictions were eased.

The 1995 agreement that formed the World Trade Organization (WTO) contained the TRIPS (Trade-Related Intellectual Property) agreement, which allows developing nations to use two methods to provide essential medications to their citizens:

1. Compulsory Licensing: Issuing a license for generic production of medicine without the consent of the patent holder, providing a royalty is paid

2. Parallel Importing: Importing drugs at the lowest price

South Africa's Actions

In 1997, South Africa passed an amendment to its Medicines and Related Substances Act authorizing the use of these two methods to provide medications to S. Africans in need. The Act was never implemented, however, due to aggressive actions by both the U.S. government and the pharmaceutical industry.

The United States Trade Representative (USTR), Charlene Barshefsky, placed S. Africa on the 301 Watch List, a preliminary step leading to a further review of possible trade sanctions. U.S. Vice President Al Gore met with South Africa's then Deputy President Thabo Mbeki to urge that the amendment be dropped. The pharmaceutical industry immediately filed a lawsuit blocking the Act. HealthGAP Coalition

After the 1998 International AIDS conference in Geneva, a core group of AIDS activists circulated a conception paper that argued that the time was right for a grassroots, activist campaign in the US that targeted the role of the US government and the pharmaceutical industry in blocking expanded global treatment access. A positive response from a range of organizations and individuals led to the formation of HealthGAP in January 1999.

HealthGAP was created as a broad coalition, including ACT UP chapters from New York, Philadelphia and Paris, South Africa's Treatment Action Campaign (TAC) Ralph Nader's Consumer Project on Technology (CPT), and the International Gay and Lesbian Human Rights Commission (IGLHRC). A working alliance was built with MÈdecins Sans FrontiËres (MSF), and relationships established with AIDS activists in Thailand and Central America.

Direct Action

An ad hoc group of activists calling themselves AIDS Drugs for Africa worked in concert with HealthGAP to bring public attention to the issue. US Vice President Al Gore was chosen as a target, since he had pressured S. Africa to drop its plans to produce generic medicines, had aides with ties to drug companies, and was beginning his campaign for U.S. President. Since he hoped for support from such constituencies as the AIDS community, lesbians and gays, and African-Americans, it was felt he would be concerned about negative publicity on the issue.

A dozen activists traveled to Carthage, Tennessee and disrupted Gore's Presidential campaign announcement with chants and banners reading GORE'S GREED KILLS: AIDS DRUGS FOR AFRICA. The next day in Manchester New Hampshire, protesters stood and held a banner directly behind Gore, and activists also disrupted his appearance the same day on Wall Street in New York City. Numerous actions followed, including

June 16: Carthage, Tennessee
June 17: Manchester, New Hampshire
June 17: Wall Street, New York City
June 28: A 700 person march at a Gore fundraiser in Philadelphia
June 29: Tipper Gore fundraiser, NYC
July 16: Tipper Gore fundraiser, Washington, DC
August 8: Gore fundraisers, New Hampshire
August 23: Blocking the entrance to Gore's offices in D.C.
October 6: A 1,000 person march to the USTR offices in D.C.
November 17: Occupying the offices of the USTR and unfurling a banner on its balcony
November 30: A 900 person march to the White House on the eve of World AIDS Day

Members of HealthGAP also spoke at Congressional hearings on the issue and attended meetings with officials, including Lois Boland of the US Patent Office, Sandy Thurman, the US "AIDS Czar," Donna Brazille of Gore's staff, Joe Papovich of the USTR, Tom Novotny of the Department of Health and Human Services, and other government representatives.

Media Response

Media attention was an important component of the actions. Previous to the Gore actions, the media had been largely silent on the issue, save for a well-written piece in the Chicago Tribune. After the Gore disruptions, the issue became a top story for both print and broadcast media. Articles appeared in the Washington Post, the Wall Street Journal, the Los Angeles Times and others, and eventually the New York Times ran an editorial supporting the HealthGAP position.


On September 17, 1999, USTR Charlene Barshefsky announced an agreement with South Africa that would lead to its removal from the 301 Watch List. Other than general statements that it would honor the TRIPS agreement, the S. African government did not change its policies - a major victory for S. Africa as well as health advocates in general.

On December 1, 1999, President Clinton announced, at the WTO meeting in Seattle, that the U.S. government would change U.S. trade policy to support greater access to lifesaving medications:

"...the United States will henceforward implement its health care and trade
policies in a manner that ensures that people in the poorest countries won't
have to go without medicine they so desperately need."

Secretary Donna Shalala also announced a new cooperative arrangement whereby the USTR would work with HHS to assess the health ramifications of the U.S. intellectual property rights policy when applied to trade disputes.

HealthGAP held a series of meetings with USTR staff in early 2000 to press for an explicit description of this process, and broadened the request to include not just sub-Saharan Africa, but all developing countries. Representatives from the offices of the President and Vice President were pressed to seek a Federal Executive Order codifying this policy change.

In March 2000, the new USTR Trade Watch List was announced; most countries placed on this list in prior years due to pharmaceutical related conflicts had been removed.

On May 10, 2000 President Clinton signed an Executive Order codifying the Administration's new policy. The Order stated:

"The United States shall not seek, through negotiation or otherwise, the revocation or revision of any intellectual property law or policy" of sub-Saharan African countries provided that they promote "access to HIV/AIDS pharmaceuticals or medical technologies for affected populations in that country."

The Executive Order also stated that the U.S. would not invoke its trade laws concerning patents, but instead hold sub-Saharan countries to the less stringent standards of the TRIPS agreement.

Next Steps

The HealthGAP Coalition understands that these policy statements will exist in word only unless the U.S. government is pressured to implement them.

For those reasons, the HealthGAP Coalition continues to mobilize support from other HIV/AIDS organizations, organizations concerned with international development, and domestic fair pharmaceutical pricing groups.

In addition, HealthGAP has worked to raise awareness that efforts by pharmaceutical companies to provide affordable essential medications have been woefully inadequate. HealthGAP has been active in the international campaign to press Pfizer Pharmaceuticals to make Diflucan (fluconazole) available at an affordable price in developing countries.

HealthGAP, again in concert with groups outside the U.S., has been highly critical of the recent announcements by 5 drug companies of plans for major price reductions of HV medications in developing countries. HealthGAP considers these price reductions to be insufficient, and in fact the announced plan has not been followed by any actual price reductions as of July 2000.

The optimal answer to drug access for developing countries is to produce or import generic versions of needed drugs, rather than relying on corporate drug "donation" and "price reduction" programs.




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