Background Following the international aid crisis, developing country governments have assumed greater financial responsibility in the fight against HIV/AIDS. First-line antiretroviral drugs (ARVs) have become more affordable, yet, assuring lifetime treatment requires the provision of expensive second and third-line therapy. Considering the longterm perspective, this analysis examines ARV mean cost evolution in Brazil and highlights main factors influencing its behaviour.

Methods Transactional data for ARV procurement made by the Brazilian Ministry of Health (BMoH) between 1998 and 2011 were used to calculate mean annual ARV cost, adjusted to 2011 US$. Literature review on ARV price determinants and interviews with BMoH representatives have complemented the analysis.

Results From 1999 to 2003, thanks to local generic production and repeated compulsory licencing threats, total ARV expenditure fell by 56%, despite patient increase of 72%, which led to a 74% decrease in the cost per patient per year. Following the inclusion of third-line ARVs, in 2005, total expenditure peaked at about US$ 460 million (2011 US$) for the treatment of nearly 160,000 patients. Although the compulsory licencing of Efavirenz, in 2007, together with assertive price negotiations on patented drugs led to a significant drop in costs, most recently, as the number of patients continues to increase, local production remains highly uncompetitive, and, new-generation patented drugs are further being incorporated, mean annual cost has recovered speed, reaching values 35% higher than 2003.

Conclusion The downward trend in mean ARV costs reached an inflexion point in 2003, after when limited savings from generic production and originator firm discounts were no longer able to compensate for the incorporation of highly expensive second and third-line ARVs. This finding reinforces patent protection being a major barrier to quality and longterm treatment in developing countries. In the case of Brazil, it further calls for higher efficiency on local production capacity.