Fight for cheaper HIV drugs: The extraordinary stories of an Indian and a South African

The paramount barrier in the right to healthcare for all, regardless of their capacity to pay and the gravity of their ailment, is the tension between the pursuit of profits and ensuring healthcare.

Nowhere is this more dramatically manifest than in the powerful global pharmaceutical industry, which, with its close links with governments, especially in high-income countries, charges sky-high – and some would say extortionist – prices for medicines critical to saving lives.

These high prices make medicines unaffordable for the impoverished unless governments subsidise them. People get sicker and die not because treatment does not exist, but because big pharma has pushed these outside their reach.

A third of global health spending is out of the shallow and often torn pockets of patients. Studies reveal that the single item on which people spend the most money is medicines. This makes the high monopoly prices of essential medicines, levied by big pharmaceutical companies, a leading cause of driving people into poverty and destitution, besides of preventable illness and deaths often in millions.

Frequently, the argument in favour of patents in the pharmaceutical sector is that without this there would be no profit incentive for research and development.

To understand the desperate need for affordable medicines to save millions of lives, and pathways to make this possible, I share two extraordinary stories.

Zackie’s heroic civil disobedience

It was the 1990s. The South African people had begun rebuilding their ravaged nation from the ruins of apartheid. A looming early challenge was HIV – the human immunodeficiency virus which causes AIDS – which raged like a malign forest fire across the country, infecting millions and extinguishing tens of thousands of lives.

The first hope stirred in a world overwhelmed by this pandemic was when antiretroviral drugs were invented. By postponing the advent of AIDS, these could keep alive people with HIV infections for many years. This drug began saving lives in countries of the Global North.

But impoverished people in the African continent infected with the HIV virus continued to needlessly die. Pharmaceutical companies refused to forego their super-profits and reduce their astronomical prices to stem this humanitarian catastrophe. The South African government refused to invest the massive public funds required to import the medicines and supply these free in its public hospitals.

As the preventable deaths of literally millions continued in South Africa, public anger exploded and fuelled massive countrywide protests. A popular civilian formation, the Treatment Action Group, emerged. It demanded that multinational pharmaceutical corporations steeply cut prices to save millions of lives. From governments in industrialised countries, it demanded that they do not sanction poorer countries if they purchase inexpensive generic versions of patented AIDS drugs from India, Brazil and Thailand.

At the forefront of the protests was a charismatic activist and film-maker Abdurrazack Achmat, popularly known as Zackie. Born to Muslim Malay parents, as a teenager between 1977 and 1981, he had moonlighted as a gay sex worker. He joined the struggle against apartheid and was frequently jailed for his political activism. He developed a colourful activist resume, including setting fire to his school in 1976 during the student agitations.

In post-apartheid South Africa, he made films about the lives of queer people in his country. But late in the 1990s, he was diagnosed HIV-positive, like millions of his compatriots. He co-founded the Treatment Action Group, which organised “sit-ins and marches … to demand treatment through a public health system that was sending AIDS patients home to die”. Zackie led many struggles, on the streets and in the courts, for free medicines to save the lives of his people.

In a compelling symbolic act of civil disobedience, he travelled to Thailand and returned to his country with his suitcase packed with Biozole. This was a locally manufactured generic copy of Fluconazole, a patented and expensive drug used to treat opportunistic infections in AIDS patients. He bought this at a price 98% cheaper than the price charged in South Africa.

But his civil disobedience did not end there. He stunned the world with his announcement that although he could afford to buy the drugs that would save his life, he would refuse to take them unless and until these were made available free to all his countrymen and women who need the medicine to be able to continue to live. The towering moral power of his civil disobedience, risking his own life in solidarity and resistance, stirred the global public conscience in ways that little else could have done.

Even this was not enough for big pharma to bend. The protests prolonged. Millions continued to die untreated in the AIDS epidemic in Africa. Protesters like Zackie publicly shamed governments and pharmaceutical companies that prioritised private super-profits over human lives. Their challenges began at last to wound.

The first success of the South African civic protests – supported also on the streets of America – was when the US government withdrew its threat of sanctions against South Africa for importing cheaper generic AIDS drugs. Pharmaceutical companies followed with agreements to supply drugs at discounts of up to 95%, and in some cases even to waive their patents and allow poor countries to import generic drugs. Thirty-nine pharmaceutical companies withdrew a lawsuit to block South Africa from importing cheaper generic copies of patented AIDS drugs.

By placing his own life on the anvil in order to secure treatment for millions who could not afford this in his country, Zackie became a hero for the right to health care. Not just in South Africa but around the world.

“People were dying across the country and doctors were saying they could not afford to prescribe the right medicines,” he explained later. “We wanted to set a moral example and put the right to health and life before profit.” Finally, then, the South African government stocked all public hospitals to freely supply these life-saving medicines.

It was a luminous victory of the value of human life over private profit. Its impact resonated far beyond South Africa, inspiring movements for affordable drugs and equitable health care across the globe.

Historic resistance of India’s pharma giant

Zackie’s was not the only story. Resistance to this cynical profiteering by pharmaceutical companies that cost the lives of millions of people in countries of the Global South came from sometimes unlikely sources.

One of these was from the founder-chairperson of one of India’s leading pharmaceutical companies, Cipla, the scientist billionaire Yusuf Khwaja Hamied. In 2021, Forbes estimated his wealth to be 3.3 billion US dollars. Without his humanism and extraordinary solidarity with people dying needlessly of AIDS in a distant corner of the globe, the outcomes of the epic South African resistance by Zackie and his comrades would have been incomplete.

Recalled The New York Times in a tribute in September 2011: “Dr. Yusuf K. Hamied, chairman of the Indian drug giant Cipla Ltd., electrified the global health community a decade ago when he said he could produce cocktails of AIDS medicines for $1 per day – a fraction of the price charged by branded pharmaceutical companies. That price has since fallen to 20 cents per day, and more than six million people in the developing world now receive treatment, up from little more than 2,000 in 2001.”

Katherine Eban tells his fascinating story in her book Bottle of Lies. In 1986, when a colleague first told him about azidothymidine or AZT, the only drug available at that time that could postpone the onset of AIDS, Hamied asked “What is AIDS?”

At that time, as the HIV/AIDS pandemic spread, poorer countries were baulked by the prohibitive costs of ARVs that did not cure the virus, but suppressed it and prevented its advance. AZT, the first ARV medication to be developed globally, had demonstrated its power to significantly reduce deaths from AIDS and related diseases and both prolong and improve the quality of patient lives.

Provided, of course, that the infected persons could afford the medicines. In 1991, the only company that manufactured AZT was Burroughs Wellcome in the United States. It sold it at roughly $8,000 per patient a year.

For Hamied, this was intolerable. He launched a version of the drug in 1993 for about $2 a day. This was less than one-tenth of what Burroughs Wellcome charged at that time. But even this was too high for Indians, and the government refused to purchase and distribute the medicine. His stocks were unsold and wasted, and preventable suffering and death from AIDS continued.

Some years later, multinational drug companies developed a cocktail of three drugs called HAART (highly active antiretroviral therapy). This was found to be even more effective in controlling AIDS. The three drugs in question – stavudine, lamivudine and nevirapine – were made by three different multinational drug companies. Their combined price for a single patient was $12,000 a year. Hamied immediately set out to make the drugs in the cocktail at a much cheaper price.

Meanwhile, in 1997, the government of Nelson Mandela in South Africa amended its law to enable the import of low-cost medicine, ignoring pharmaceutical patents. Thirty-nine drug companies sued the South African government, charging South Africa with violating the international trade agreement TRIPS (Trade-related Aspects of Intellectual Property Rights).

In September 2000, Hamied addressed a sceptical audience in the European Commission’s conference in Brussels on HIV/AIDS, malaria, tuberculosis and poverty reduction with these words: “Friends, I represent the needs and aspirations of the third world.” He announced that he would sell the AIDS cocktail for $800 a year ($600 to governments buying in bulk). To make sure that this life-saving drug would reach all who needed it, he would share the technology to make the drugs free to any African government willing to produce its own drugs. And he would supply nevirapine, the drug that limited transmission of the disease from mother to child, for free.

He ended with a moral appeal: “We call upon the participants of this conference to do what their conscience dictates.” Still, no one came forward to accept his proposal.

Unwilling to accept defeat, just months later, he further upped the ante when he announced his plans to an incredulous world that he would sell the cocktail at just one dollar a day. This made it to the front page of the Times, which compared Cipla’s costing of the AIDS cocktail for $350 a year per patient, or roughly $1 a day, to Western prices of between $10,000 -$15,000 a year.

The Times wrote graphically of the ways that Cipla, on this life-saving mission, was being blocked by multinational drug makers that held the patents and how these were backed by the Bush administration. This ignited international outrage and street protests in many cities across continents. Even dishonorable accusations of genocide were assembled.

Charges against Hamied also flew, questioning his motivation. He replied calmly, “I am accused of having an ulterior motive. Of course, I have an ulterior motive. Before I die, I want to do some good.”

The extraordinary cross-continental alliance of Indian drug giant Hamied on one side of the globe and the health rights activists in the United States and South Africa on the other, finally stood tall, victorious. The multinational drug manufacturers on bended knee withdrew their lawsuit against South Africa and waived off their patents.

The outcome of this was that Hamied’s generic AIDS cocktail could be sold cheaply in Africa. Ramani and Mukherjee recall the seismic impact of Cipla’s offer. Multinational corporations (MNCs) dropped the price of their drugs by up to 90%. According to Médecins Sans Frontières (MSF), India played a “major role in scaling up treatment to 17 million people” across the world by reducing the price of ARVs from $10,000 per patient per year in 2001 to less than $300.46. By 2016, the lowest price had fallen to $100.47.

Hamied continued to stand up to powerful giant pharma corporations by manufacturing and selling generic life-saving drugs for AIDS, TB, cancer, diabetes, asthma and other non-communicable diseases at prices that were a tiny fraction of what Western pharmaceutical companies were charging.

Holding firm to his robust moral compass, Hamied declared, “I don’t want to make money off these diseases which cause the whole fabric of society to crumble”. His is an example that very few giant pharmaceutical companies have heeded. If they did, the world would be a different place, a place more kind and just.

I am grateful for the research support of Rishiraj Bhagawat.