Progress! (

After decades of steep increases in the number of people worldwide living with AIDS, at the end of 2011, something positive happened: The devastating plague started to level off in one of the greatest public health victories of the modern age. Now, however, pharmaceutical industry pressure on the biggest source of the drugs that stemmed the epidemic -- India --could put a hitch in that progress.

There are lots of reasons AIDS is more under control these days, from improved sexual education to needle exchange programs. Most important, though, is the widespread availability of anti-retroviral drugs, which allow HIV and AIDS patients to live with lower viral loads, making it less likely that they'll pass the disease on. That never would have worked if off-brand manufacturers hadn't been able to produce the pills at a much lower cost than the drug companies who'd brought them to market initially. And a huge percentage of those manufacturers are in India, which produces 86 percent of the AIDS drugs being taken around the world.

The American pharmaceutical industry has never been happy about competition from the Indian generics, which drive down prices. And lately, they've stepped up their complaints -- the Chamber of Commerce has labeled India an "international outlier on intellectual property," as part of a broader campaign to push back against the subcontinent's economic protectionism. There's been intense pressure on the U.S. trade representative and on Wednesday the White House, which earlier this year put India on a special trade blacklist over its patent laws, sent Vice President Biden to Mumbai to chide officials for putting up barriers to trade.

South Africa's Treatment Action Campaign, which has played a key role in bringing the disease to heel despite a sometimes-challenging political environment, is worried about the screws tightening on India's generic drug industry. Earlier this week, they sent off a long letter to U.S. Trade Representative Michael Froman, warning of serious consequences if India is forced to back down on the generic drugs, as South Africa itself was forced to do in the late 1990s. "We urge the US government to stand strong against pressure from the pharmaceutical lobby and actively support and applaud enabling policies that ensure that India, the ‘pharmacy of the developing world’, can continue to produce affordable generic medicines that so many of us rely on to stay alive," wrote chairperson Anele Yawa.

The pharmaceutical industry says it's confused by TAC's alarm. "Nothing that anybody is talking about is AIDS drugs," says PhRMA spokesman Mark Grayson. "There's nothing that will stop India from providing those low cost medicines." That's true, at least for the time being: The industry is mostly fighting over cancer drugs, not existing AIDS cocktails like AZT. Rather, the industry says, these efforts are aimed at prodding India to come up with its own drug recipes, instead of ripping off those of multinational companies. "That's really not about providing medicines to low income people," Grayson says. "It's about aiding their own companies."

The problem is, though, that the currently available generic AIDS drugs aren't going to work forever. The oldest ones are cheap but also come with terrible side effects, and the AIDS virus is rapidly becoming resistant to some of the earlier drugs. There are no generic versions of "third-line" drugs, which can be very effective when earlier versions fail and which now cost at least $2,000 per patient per year in even the poorest countries. In its latest report on the availability of AIDS medication, Doctors Without Borders worried that U.S. pressure and an India-European Union trade deal that's been under negotiation for several years might tighten patent rules such that those medicines and even newer ones in the pipeline never become available for generic use.

And AIDS activists, already disappointed with declining funding for the biggest AIDS-fighting program the United States has, are throwing the issue in the Obama administration's face.

"The actions of the U.S. government right now gives a lie to Obama's promise for an AIDS-free generation," says HealthGAP activist Paul Davis.

The cost differential in drugs on the first, second, and third line of defense. (Doctors WIthout Borders)
The cost differential in drugs on the first, second and third line of defense. (Doctors WIthout Borders)