The Role of the Private Sector

Motivation for Action

Merck is committed to improving the lives of people living with HIV/AIDS worldwide, with a focus on our traditional area of strength: research and development into new antiretroviral therapies and vaccines that will serve the largest population in the most effective manner. Since 1986, Merck has striven to advance the treatment of HIV/AIDS, spending hundreds of millions of dollars on one of the largest medicines and vaccine research programs in company history.

With 95 percent of the world's 40 million HIV-infected people living in developing countries, better and faster access to care is essential. Although there is no cure for AIDS, medical care in industrialized countries is significantly extending the lives of people living with HIV infection. The challenge now is to improve access to care, including treatments for opportunistic infections and antiretroviral therapy in the hardest hit regions of the world. This is especially challenging in sub-Saharan Africa, where it is estimated that more than two-thirds (28 million) of the world's HIV-infected people live, and yet, resources allocated to health care can be as low as one dollar per person per year.

Merck Response to HIV/AIDS

Merck continues to seek out and support initiatives that address the issue of HIV/AIDS management and drug access in the developing world. Recognizing that a number of approaches are needed to identify the most promising and efficient ways to combat the HIV/AIDS pandemic, Merck is undertaking initiatives and establishing partnerships with multinational organizations to address the impact of HIV/AIDS in the developing world. These include a new major project in Botswana, the Enhancing Care Initiative, and the U.N./Industry Accelerating Access Initiative.

Price Reduction for Medicines

On March 7, 2001, Merck announced a dramatic price decrease in their antiretroviral products to a level where they will not be making any profit. The new prices are $600 per patient per year for Crixivan and $500 per patient per year for Stocrin in developing countries. This is the first time that a member of the class of protease inhibitors has been offered to developing countries at such a low price. These prices apply to developing countries and will be made available to all customers (governments, NGOs, and private-sector employers) who can make the medicines accessible to patients. The only condition is that the medicines must be used in the country where they are sold, and not exported. The offer extends to all low Human Development Index (HDI) countries, according to the United Nations Development Program (UNDP), and all medium HDI countries with an adult HIV prevalence rate of 1 percent or greater.

Botswana Comprehensive HIV/AIDS Partnership (BCHAP)

The Republic of Botswana, in cooperation with the Bill & Melinda Gates Foundation and Merck & Company, Inc., have established the Botswana Comprehensive HIV/AIDS Partnership, a new initiative designed to advance significantly HIV/AIDS prevention, health care access, patient management, and treatment of HIV/AIDS in Botswana, where nearly one in three adults is infected with HIV.

The overall goal of the BCHAP is to bring together the best of the public/private sector to demonstrate the ability to significantly advance HIV management and treatment through a tightly defined initiative in a select resource-scarce setting. While significant resources and expertise will come from various global partners, the project seeks to develop leadership and commitment within the country so that the project can be sustained after the pilot phase. This is critical to the project's success.

Since the public announcement on July 10, 2000, Merck and the other principals of this unique endeavor have been working closely to establish the governance of the project, finalize the internal and external management structure, and initiate multidisciplinary task forces in the Republic of Botswana. Additionally, an evaluation of the level of HIV/AIDS awareness, prevention programs, and the care and treatment of people with HIV/AIDS in Botswana is underway. This evaluation will support the development of a detailed plan that will specify goals, benchmarks for success, and resources needed to complete the project as well as ensure that it can be sustained past the initial five-year commitment.

The Bill & Melinda Gates Foundation will dedicate $50 million over the five years of the project to help Botswana fundamentally strengthen its primary health care system. Merck and the Merck Company Foundation will match the Bill & Melinda Gates Foundation funding for the development and management of the program. Merck and Company, Inc., will also donate antiretroviral medicines, (Crixivan and Stocrin) for appropriate treatment programs decided in conjunction with the Republic of Botswana (and in accordance with nationally approved guidelines) for the duration of the program. Boehringer-Ingelheim has pledged to donate medication for the prevention of mother-to-child transmission of HIV infection, and Unilever PLC will contribute expertise in setting up distribution systems and public communications and awareness programs.

Enhancing Care Initiative

Merck is supporting the Enhancing Care Initiative (ECI), a multidisciplinary, multinational partnership designed to improve the care of people with HIV/AIDS in the developing world, including several countries in Africa. Coordinated by the Harvard AIDS Institute and the Francois Bagnoud Center for Health and Human Rights at Harvard's School of Public Health, this five-year initiative includes local experts on HIV/AIDS, community groups, and governmental and non-governmental organizations. The multidisciplinary approach works through local teams of experts, including patients, physicians, nurses, economists, and government officials. The teams assist in designing the infrastructure essential to implement feasible and cost-effective improvements in HIV/AIDS clinical case management and health care delivery. To date, the Enhancing Care Initiative involves in-country multidisciplinary teams in Senegal and KwaZulu Natal Province in South Africa, and outside Africa, in Brazil and Thailand.

The program advances basic knowledge about HIV/AIDS care-related policies and programs, supports development of proposed intervention strategies in developing countries, and provides assistance in building the necessary infrastructure to achieve these improvements. As an example, in Senegal the initiative completed an overall assessment of HIV/AIDS care; finalized direct and indirect cost analysis of HIV/AIDS testing, counseling, and a national program of antiretroviral therapy; performed an economic analysis; and prepared recommendations for appropriate interventions.

UN/Industry Accelerating Access Initiative

The UN/Industry Accelerating Access Initiative is a cooperative endeavor of UNAIDS, the World Health Organization (WHO), the U.N. Children's Fund (UNICEF), the U.N. Population Fund (UNFPA), the World Bank, and five research-based pharmaceutical companies (Merck, Boehringer-Ingelheim, Bristol-Myers Squibb, F. Hoffmann-LaRoche, and GlaxoWellcome).

The Accelerating Access Initiative is designed to accelerate sustained access to, and increase the use of, appropriate good quality interventions for the prevention, treatment, and care of HIV/AIDS-related illnesses (and the prevention of perinatal transmission of HIV) in developing countries.

Accelerating Access employs a country-led process. Improving access to HIV care and treatment is more than just drugs. Offers of significant discounts are available to countries that decide they want to invest in antiretrovirals now, and those discussions are proceeding through the Accelerating Access Initiative. Merck is working with UNAIDS and the other U.N. agencies to respond to the individual needs of different countries in a way that makes sense to country officials who carry the primary responsibility for the health of their populations.

To date, 58 countries from Africa, Central Europe, and Latin America have sought information or expressed an interest in participating in the endeavor. In October 2000, Senegal was the first country to reach an agreement with the companies, followed by Uganda in December. To date, 12 countries have completed agreements, and products are being shipped at the reduced prices.

Common Principles

Participants in the UN/Industry Accelerating Access Initiative have set out a common vision of how to tackle the HIV/AIDS epidemic most effectively in developing countries. A "Joint Statement of Intent" issued in May 2000 articulated the following principles:

• Unequivocal and ongoing political commitment by national governments;
  
  
• Strengthened national capacity;
  
  
• Engagement of all sectors of national society and the global community;
  
  
• Efficient, reliable, and secure distribution systems;
  
  
• Significant additional funding from new national and international sources;
  
  
• Continued investment in research and development by the pharmaceutical industry.

Results and Lessons

Given the dimensions of the HIV/AIDS access crisis, and the urgency to find answers, Merck stands ready to play our part in the search for sustainable solutions. Today, many stakeholders are beginning to make important contributions, often through creative new partnerships. As U.N. Secretary-General Kofi Annan has said, "No company and no government can take on the challenge of AIDS alone. What is needed is a new approach to public health --combining all available resources, public and private, and using all opportunities, local and global." ¹

By working in this spirit -- finding new approaches that work -- Merck believes that we can find innovative solutions to help the millions of people living with HIV/AIDS who do not have adequate access to care and treatment today. Merck, and the research-based pharmaceutical industry, will continue to be a constructive partner in these efforts, and we look forward to continuing to work with other stakeholders to defeat a common enemy -- HIV.

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