Just a quarter of Pfizer’s COVID-19 treatment orders will go to developing countries

Rich countries have secured almost three times as many courses of a World Health Organisation (WHO)-recommended COVID-19 medicine, Pfizer’s Paxlovid, according to new analysis from Oxfam and the People’s Vaccine Alliance.

Using new data from Airfinity, the organisations found that just a quarter of orders for the treatment will go to low- and middle-income countries, despite the fact they make up 84 per cent of the world’s population and have a much greater need as far fewer people are vaccinated against COVID, unlike rich nations which are largely protected.

On the eve of crunch talks at the World Trade Organization (WTO) over intellectual property rules for COVID-19 treatments and tests, campaigners are warning that we are seeing the same worrying trend of inequity that we saw with COVID vaccines.

Pfizer’s monopoly also means that some middle-income countries could be paying ten times more for Paxlovid than a generic equivalent, with reports of them being quoted as much as $250 per course. This is despite the fact that other lower-income countries will have access to a Clinton Health Initiative (CHAI) deal with Pfizer and undisclosed generic companies, which means they could access the treatment for just $25 a course.

Dr. Catherine Kobutungi, Executive Director of the African Population and Health Research Center said: “When vaccines were our main medical tool to fight COVID-19, big pharmaceutical companies prioritized maximizing their profits by selling doses to the richest countries. Millions died while people in low- and middle-income countries were sent to the back of the vaccine queue. And now, we are witnessing a repetition of the same inequity with COVID-19 treatments and tests.

“Oral antiviral treatments are easy to administer. They reduce hospitalization and cut deaths. And they may reduce the likelihood of long COVID. Yet, right now, they’re nearly exclusively accessible to people in the richest countries. The fact is that if you are a vulnerable person with COVID-19 in a high-income country, you will probably have access to treatments that can help you survive. If you live in a lower-income country, you probably won’t. It’s grotesque inequality and it kills.”

The WHO recommends using Paxlovid to cut COVID-19 hospitalization and death rates, and has called for equitable global access to COVID-19 medicines as part of a strategy to combat long COVID. A recent, non-reviewed study suggests that Paxlovid may lower the risk of patients developing long COVID.

There are hundreds of other potential COVID-19 medicines in the development pipeline, including at least 77 in late-stage clinical trials that could be more effective and have a wider scope of use. However, intellectual property rules are giving a small number of companies a monopoly on supply, allocation, and price, meaning low- and middle-income countries are unlikely to have affordable access to these medicines either.

Because far fewer people in low-income countries are vaccinated than in rich countries, they are more vulnerable to hospitalization and death from COVID-19. These countries have already experienced the highest death toll in the pandemic, a trend that could continue without access to treatments like Paxlovid.

Jennifer Reid, Senior Health and Vaccine Equity Advisor at Oxfam, said: “After the inequity they faced with the vaccine rollout, developing countries are now experiencing access and affordability issues for COVID treatments. It is a disgrace that those who need them the most are receiving the least and that patent laws are handing Pfizer a long monopoly on this lifesaving medicine.

“Addressing both acute and long COVID is essential – and the WHO has been clear that countries need treatments like Paxlovid to cut deaths and hospitalizations. But the patents minefield is a massive barrier preventing many developing countries from getting the medicines and tests they need now and in the future to save lives.”

In June, after a year and a half of negotiations, the WTO rejected proposals to waive intellectual property rules for all COVID-19 medical technologies, adopting a far more limited text that only covers vaccines. Ahead of talks taking place tomorrow in Geneva, civil society organizations are urging WTO member states to immediately agree to an extension to include treatments and tests, which would allow developing countries to produce for their own populations and export for others in need, ensuring essential tools are accessible and affordable.

Mohga Kamal Yanni, Policy Co-Lead for the People’s Vaccine Alliance, said: “Decades ago, governments allowed pharmaceutical companies to control the price, allocation, and supply of lifesaving HIV medicines - and millions of people died without affordable access. Now, the same thing is happening again with COVID-19 vaccines and medicines. Companies have been allowed to decide who lives and who dies. WTO member states must ensure that public health takes precedence over commercial interest.”

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For more information, or to arrange an interview, please contact: Sarah Dransfield in the Oxfam Press Office, sdransfield@oxfam.org.uk + 44 7884 114825 or Joe Karp-Sawey, Senior Media Advisor, People’s Vaccine Alliance Joe.karpsawey@peoplesvaccine.org +44 7428 985985

Notes to editors

A new briefing note from the People’s Vaccine Alliance on the case for the extension of the WTO ministerial decision to therapeutics and diagnostics is available here: https://peoplesvaccine.org/wp-content/uploads/2022/11/A-fact-based-case-for-the-extension-of-the-TRIPS-COVID-19-decision.pdf

Data from Airfinity shows that the richest countries who account for just 16 per cent of the world’s population will receive 74 per cent of all courses ordered of Paxlovid. Low- and middle-income countries who make up 84 per cent of the world’s population will receive just 26 per cent. Despite being first authorized in December 2021, reports suggest that few doses are available to people in low and middle-income countries.

While there is little data available on how many doses of Pfizer’s antiviral treatment have actually been delivered to low and middle-income countries, they have been waiting for months to receive doses through Paxlovid supply agreements from global initiatives like UNICEF and the Global Fund. Pfizer has allegedly insisted that the prices in these agreements remain secret, and the initiatives have not revealed the prices Pfizer charges for courses through their agreements.

Allocation to high-income vs low- and middle-income countries

Proportion of agreed allocation to high-income vs low- and middle-income countries of Pfizer: Ritonavir-Boosted Nirmatrelvir (Paxlovid):

• High-income countries: 31,828,000 (74%)
• Low- and middle-income countries: 11,221,666 (26%)

Source: Airfinity, a life sciences analytics company

Data note: These figures reflect deals agreed with Pfizer. There are a number of generic manufacturers expected to produce Paxlovid that have signed agreements through the Medicines Patent Pool. However, these agreements are not expected to be producing/exporting finished drug products at scale until early 2023.

• According to the World Intellectual Property Organization (WIPO), there are at least 1,465 patents on treatments and 417 on vaccines for COVID-19, making it a “minefield” for developing countries to navigate.
• Two years ago, South Africa and India proposed a waiver of the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement for medical technologies relevant to COVID-19, including vaccines, tests, and treatments. The waiver was supported by more than 100 low- and middle-income countries but was blocked by a small number of rich countries including the EU, UK, and Switzerland.
• After 18 months, the WTO finally decided in June 2022 to streamline existing rights to use compulsory licenses to produce generic COVID-19 vaccines for domestic use and for export without the patent holder’s permission. The June decision required member states to reach a decision on tests and treatments by December 2022. Negotiations to reach a decision on tests and treatments are ongoing. The WTO TRIPS council next meets on Tuesday 22 November.
• A selection of letters that have gone to WTO member states, urging them to support extending the June decision to cover treatments and tests, is available here: https://app.box.com/s/bhbiggkwj44miwi6fhppg6eebk32ofh6n
• Fulfillment of UNICEF’s Paxlovid order has reportedly been delayed for months: https://www.nature.com/articles/d41586-022-02939-7
• A Global Fund deal for Paxlovid was only finalized in late September: https://www.theglobalfund.org/en/news/2022/2022-09-22-the-global-fund-signs-agreement-with-pfizer-to-expand-access-to-paxlovid-antiviral/
• Pfizer allegedly pressured UNICEF to keep Paxlovid pricing secret: https://genevahealthfiles.substack.com/p/pfizer-allegedly-pressured-unicef
• According to BIO's COVID-19 Therapeutic Development Tracker, there are 77 antivirals and treatments in "late stage clinical" phase as of Nov 14: https://www.bio.org/policy/human-health/vaccines-biodefense/coronavirus/pipeline-tracker
• Reports indicate that many countries classified at WTO as ‘developing’ and ‘least developed’ remain unable to access affordable therapeutics in necessary volumes. A report from the ACT-Accelerator Facilitation Council Working Group finds that “equitable roll-out of COVID-19 diagnostics and therapeutics continues to be inadequate and threatens to undo public health gains achieved throughout the pandemic.” Nature similarly says, “limited supplies and high costs have restricted the flow of COVID-19 antivirals to low- and middle-income regions.”
• Pharmaceutical companies claim that licensing agreements and donations announced in recent months will ensure doses reach lower-income countries, but these agreements exclude many developing countries, particularly in Latin America. This is despite Latin America accounting for a significant portion of the world’s estimated preventable COVID-19 deaths. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02796-3/fulltext
• Four times as many people have died due to COVID-19 in lower-income countries than in rich countries. Deaths per capita in low- and lower-middle-income countries are almost a third higher than high income countries: https://www.oxfam.org.uk/media/press-releases/covid-death-toll-four-times-higher-in-poorer-countries-than-rich-countries/
• According to the World Intellectual Property Organization (WIPO), there are at least 1,465 patents on treatments and 417 on vaccines for COVID-19: https://www.wipo.int/edocs/pubdocs/en/wipo-pub-1075-en-covid-19-related-vaccines-and-therapeutics.pdf