No Money, No Drugs: Global Barriers to Secondary CVD Prevention

Drugs for the secondary prevention of cardiovascular disease are unaffordable to many patients in low-income countries and may be outright unavailable at their local pharmacies, according to new data from the PURE study published online October 21, 2015, in the Lancet. Such barriers may explain why the medications are rarely used in these regions, researchers said.

“Unless governments in most countries, especially low- and middle-income countries, begin initiatives to make these essential heart medicines available and provided free—as is done for HIV—then their use is always going to be far less than optimal,” investigator Salim Yusuf, MD, DPhil, of Hamilton Health Sciences and McMaster University (Hamilton, Canada), stressed in a press release. “In rich countries, the key question is different—we need health systems in which there are organized approaches to secondary prevention, perhaps run by non-physicians such as trained nurses or other health workers, to improve uptake and adherence.”

About 20% of the estimated 17 million deaths due to cardiovascular disease each year occur in patients with known vascular disease, Dr. Yusuf and colleagues report, noting, “Many of these deaths could be avoided if the use of proven medicines … were increased.”

As part of the PURE study, the investigators prospectively gathered data from 94,919 households living in 596 communities within 18 countries on the availability and costs of 4 cardiovascular disease medicines: aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins. Communities were recruited between 2003 and 2013. Previously, the researchers documented how these drugs were less likely to be used in countries with lower vs higher incomes. With this analysis, they sought to understand the reasons why.

Countries were categorized as being:

• High income (Sweden, United Arab Emirates, and Canada)
• Upper-middle income (Poland, Turkey, Chile, Malaysia, South Africa, Argentina, and Brazil)
• Lower-middle income (Colombia, Iran, China, and the occupied Palestinian territory)
• Low income (Pakistan, Bangladesh, and Zimbabwe)

India was looked at separately to account for “its large, generic pharmaceutical industry,” the paper notes.

Availability, Affordability Both Affected

While the majority of communities in countries with high or upper-middle income had access to all 4 of the medicines at a local pharmacy, they were less commonly available in poorer countries, particularly in rural communities. Indian communities stood out as an exception.

The researchers considered medicines to be affordable if their combined cost was less than 20% of a household’s capacity-to-pay. Using this metric, the 4 medications were unaffordable to 60% of households in low-income countries and 59% of those in India, compared with 25% of households in upper-middle–income countries and 33% of those in lower-middle–income countries. Merely 0.14% of households in high-income countries could not afford the drugs.

Not surprisingly, patients in low- and middle-income countries with a history of cardiovascular disease were far less likely to use the 4 medicines if not all of the drugs were locally available (adjusted OR 0.16; 95% CI 0.04-0.57) or if they were unaffordable to their household (adjusted OR 0.16; 95% CI 0.04-0.55).

“This finding suggests that improvements in the availability and affordability of these medicines are prerequisites to increasing their use,” the researchers said. But even without those hindrances, only 18% of patients who could access and afford to take the drugs in low- and middle-income countries actually did so, they noted. “Thus, … correcting these factors alone might not be sufficient to increase the proportion of patients receiving all medicines to optimum coverage.”

No Clear Path to Universal Access

In an accompanying editorial, health economists Louis W. Niessen, MD, PhD, and Jahangir A.M. Khan, PhD, of the Liverpool School of Tropical Medicine (Liverpool, England) point out that access and affordability are only two factors to consider.

“Households have diverse priorities irrespective of economic development level,” they note, pointing out that “general awareness, health literacy, service quality, and the competence of health workers” also play a role.

Solutions can occur at a national and international level, Drs. Niessen and Khan advise, citing low-cost drugs for patients with HIV/AIDS as the world’s single success story. “Universal access to medicines will be accelerated through increased health financing and greater availability of low-cost medicines targeting major diseases among people with low incomes,” they conclude.

Commenting on the study, Sundeep Mishra, MD, DM, of All India Institute of Medical Sciences (New Delhi, India), told TCTMD in an email, “The limiting factor in India is not affordability or accessibility of drugs; rather, it is health-worker education.”

Physicians and other healthcare professionals, he explained, should be educated to pay more attention to “lifestyle diseases (instead of infectious diseases; for which they already have good training) and their management, so that they can prescribe the correct kind of medications.”

Patients in India are even more likely to have difficulty getting an intervention—whether due to affordability or accessibility—than to lack access to secondary prevention medicines. “However, whoever is able to afford intervention is also able to afford the follow-up treatment because the generic drugs are so cheap (at a small fraction of cost of drugs available in West),” he wrote, adding, “The issue really is proper post-procedure instruction rather than affordability or accessibility of drug in majority of cases.”