“As we showed last year, in relation to the company discounts schemes, lower-middle income and middle income countries are excluded. And that has continued this year. And we’re starting to see the effect, for example, in relation to third line drugs of what that actually means,” she said.

Other options, she said, are “voluntary licenses.”

“Pharmaceutical companies will enter into agreements with generic companies so that they can make medicines and also export them to a number of countries. The problem with voluntary licenses is twofold. Firstly, they are mostly secret. So you do not know the terms and conditions and that can have an important effect on competition. The other important thing that is clear is that there is no voluntary license that covers all developing countries,” she said.

Childs said the trend is to limit voluntary licenses to least developed countries and some areas of sub-Saharan Africa. Some NGOs have moved to block the granting of drug patents in Brazil, another leader in generic drugs.

“The middle income countries are really facing a kind of pincer movement. They are facing rising costs from patenting. They are excluded from discounts. They are excluded from voluntary licensing, which is why there has been now more of a focus on what measures they can take to remove patent barriers,” she said.

There are about 30 antiretroviral drugs now approved for HIV/AIDS. Newer drugs are needed not only because of potential drug resistance, but also toxicity. For example, MSF said some ARVs can actually disfigure a patient’s face by affecting fat deposits.