HIV Drug Profiteering and Global Inequality
S Krishnaswamy
THE National Health Service in the UK has recently approved Hemgenix. The gene therapy drug that cures hemophilia B costs around Rs 30 crores (£2.6 million) for a single injection dose. This is now the world's priciest medicine. It is an indicator of our disabled pharma system. Life saving innovations become designer commodities. Much of the development for gene therapy has come from publicly funded research. Though gene therapy drugs involve advanced manufacturing techniques, the price does not arise from that alone. uniQure, which developed Hemgenix, sold it to CSL Behring, its partner, for commercialisation. It received in 2023 a total of about Rs 4109 crores (USD 475 million) for the sale of Hemgenix.
The profit-over-people forces operate with deadly efficacy in HIV treatment also. HIV patients are subjected to astronomical prices for life-saving drugs. This is not because of the costs of production but due to patent monopolies and greed. Such prices are justified by drug companies claiming to spend about Rs 22,100 crores ($2.6 billion) on average on research and development costs per drug. However, more is spent on lobbying and marketing than on actual research and development. They use it to extend monopolies through "evergreening" schemes, where small molecular manipulations are made to extend the patent monopoly. The result is one where medicine becomes a privilege rather than a right, and where the human right to health under the Universal Declaration of Human Rights is trampled by intellectual property regimes and trade agreements.
ACCESS TO MEDICINE
Lenacapavir, which is marketed under the brand name Sunlenca, is a medication used to treat HIV infection. It is a capsid inhibitor, meaning it works by disrupting the HIV capsid, a protein shell that protects the virus's genetic material. This biannual injectable works with near-perfect HIV prevention. It is a potentially groundbreaking medication that has been referred to as "the closest we've ever come to an HIV vaccine." Gilead Sciences charges approximately Rs 36 lakhs ($42,250) per year for two doses required for treatment. Researchers at Liverpool University say this effective medication could be made for just Rs 3500 ($40) per year and still retain a 30 per cent profit margin. The mathematics reveals the sinister logic of drug colonialism: a thousand-fold margin that effectively excludes communities in desperate need of life-saving technology from access to it. The standard corporate strategy employed by Gilead to combat pricing criticism has been to stall taking concrete action while issuing vague promises of "broad, sustainable access globally." When Lenacapavir remains out of reach, the World Health Organisation's emergency July 2025 endorsement of the drug as a revolutionary preventative treatment seems ironic. The PURPOSE1 trials proving Lenacapavir's 100 per cent efficacy in preventing HIV infections enrolled over 5,000 women in South Africa and Uganda – populations now excluded from accessing the very drug that their participation helped validate.
The geographical injustice is further seen in the context of HIV "cures." All instances of HIV remission or cure through stem cell therapy have occurred in non-endemic, developed nations –precisely where HIV burden is lowest. This is not a chance medical happening but systematic exclusion. Stem cell therapies using highly advanced devices and intensive supervision remain concentrated in the research facilities of the global north. It creates a type of medical apartheid where the best interventions bypass the endemic regions completely. While stem cell therapies offer "a glimmer of hope for the creation of an effective HIV cure method," their practical use remains confined to laboratories far from the pandemic's epicenter. Africa harbours 65 per cent of global HIV cases but does not even receive crumbs from the therapy plate, a situation reflecting the colonial origins of global health.
The situation is compounded by classifying most Latin American countries as "middle income" and thus denying them discounted drug programmes despite internal inequalities that lead to their vulnerable populations being ravaged by HIV. Pre-exposure prophylaxis, or PrEP, refers to a medicine that reduces chances of getting HIV through sex or injectable drug use. The PrEP-to-Need ratio (PNR) is the proportion of PrEP users to newly diagnosed HIV patients. It is a way to see whether PrEP use correctly predicts the need for HIV prevention. The low PNR of 1.1 for Brazil shows the unmet need in contrast to the US value of 13.5. This highlights how economic classifications become tools for exclusion. Even in the US the racial imbalance in access is striking. PNR is high for the White population and small for the Black population, indicating greater unmet need amongst Blacks. Patent legislation, which drives up drug costs, constitutes the legal basis for this imbalance in access.
The World Trade Organisation's Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement globalised drug monopolies but contained "flexibilities" in theory to allow governments to evade patents for public health by compulsory licensing or parallel importation. In the early 2000s, Thailand made available the antiretroviral drugs efavirenz and lopinavir/ritonavir using TRIPS flexibilities to authorise compulsory licenses. In retaliation, the United States added Thailand to its Special 301 watchlist, and manufacturers like Abbott and Sanofi threatened and initiated retaliatory measures, including withdrawal of drug registrations, in an effort to intimidate Thailand. This trend is not new in the global south. In 1997, South Africa passed a law allowing lower-priced HIV medicines through generics and parallel importing. Pharmaceutical companies, many of them the world's largest and most powerful companies in the global north, sued the South African government to try to stop it from enacting legislation aimed at reducing the price of medicines for South Africans. However, due to international campaign pressure, they dropped the case in April 2001.
TRIPS "flexibilities" may be written down, but it requires committed political will to act against Western legal and trade reprisals. The Medicines Patent Pool – a UN-initiated initiative to increase generic availability – has no bite without voluntary licensing by patent holders. As a consequence, the majority of Latin American countries get excluded from generic Lenacapavir arrangements. The result is a drug caste system. For example, cabotegravir inhibits the HIV integrase enzyme and prevents HIV replication. These injections are approved for Brazil but are priced at around Rs 18 lakhs ($22,000) annually. Thus the drug is far beyond reach even though it has regulatory approval. In such a profit-oriented world, the models from China and Cuba are beacons of hope.
ALTERNATE MODELS
China's "Four Frees and One Care" policy, enacted initially in 2003, offers free HIV counselling and testing, antiretroviral treatment to the impoverished, medication to prevent HIV transmission to children, education to AIDS orphans, and financial support to affected families. This policy has significantly expanded testing coverage. It has also made voluntary testing and free treatment more widely available. The policies have lowered the cost burden on patients and AIDS deaths. The policy, grounded in equitable access rather than profit-driven structures, continues to be the cornerstone of China's HIV/AIDS response despite some of its shortcomings, like inadequate finances and bureaucratic challenges. Similarly, Cuba's nationwide health system – integrated universal HIV treatment and prevention programme – views health as a right of citizenship rather than a marketable commodity. These actions demonstrate that the promotion of public health over patent protection results in more successful and humane results, acknowledging that the only way to properly treat HIV is to remove cost as a barrier. The battle over the cost of HIV drugs is the front line in the overall struggle for health as a human right.
When a drug that can cost Rs 3500 ($40) is produced and sold for Rs 36 lakhs ($42,000), it is not innovation. It is daylight robbery that is legalised by monopoly. Stem cell "cures" being only available in wealthy nations while Africa remains a research colony is not science. It is medical apartheid. When nations like China and Cuba are able to offer universal HIV treatment while the US files a lawsuit to stop drug price being lowered, it shows the greed behind capitalism. It is necessary that if ‘health for all’ is to succeed, the governments of the global south must oppose patent fundamentalism, corporate greed has to be exposed, and international solidarity is necessary in demanding that life-saving medications be accessible and available to all who need them.
