From HIV to obesity: Lessons in global health equity and the promise of new treatments

Obesity is a major risk factor for a range of diseases, including heart disease, stroke, diabetes, and various types of cancer. Worldwide, its prevalence has been growing, becoming a leading cause of morbidity and mortality in countries of all income levels, as illustrated in Figures 1 and 2.
 

Figure 1

Figure 2

A new generation of diabetes drugs known as GLP-1 receptor agonists (GLP-1s), including semaglutides such as Ozempic and Wegovy, have been clinically proven to help with weight loss and have been approved by the U.S. Food and Drug Administration. These drugs have been described as game changers. Despite supply constraints and their high prices (ranging from $215-1300/month in the US, depending on rebates and insurance coverage), their use is quickly, although unevenly, becoming a standard part of treatment in high-income countries. 

However, at such prices, these new treatments - which patients might need to take for life - are unaffordable for a large majority of people and health systems in low- and middle-income countries (LMICs). The World Health Organization (WHO) has not included these drugs among its list of essential medicines and has declared that “These drugs are definitely an important tool, but they should not be seen as a solution to the problem.” The NCD Risk factor collaboration emphasizes the urgent need for obesity prevention and concludes that: “New pharmacological treatment of obesity, although promising, is likely to have a low impact globally in the short-term, due to high cost and the absence of generalizable clinical guidelines.”

This implicit debate between treatment and prevention reminds me of the discussions around antiretroviral treatments (ART) for HIV/AIDS patients in the early 2000s. The new AIDS drugs – also life-long treatments - were saving lives in rich countries, but their prices were so high that they were not perceived as affordable in LMICs, especially in Africa where prevalence was the highest.

However, over the years, the prices of antiretroviral therapies declined sharply in LMICs, in part thanks to the efforts of activists as well as initiatives such the Clinton Foundation, which negotiated substantial price cuts with the pharmaceutical companies. At the same time, donors, like the Global Fund and the US-funded PEPFAR committed large resources to pay for antiretroviral treatments for HIV/AIDS patients across the globe. Currently, ART is available practically everywhere and is estimated to have saved 18.6 million lives between 2000 and 2021 (WHO 2022). The widespread availability of ART has also contributed to HIV prevention since people living with HIV/AIDS who are on treatment have a much lower viral load and are therefore less likely to infect their sexual partners.

For obesity as well, the debate between treatment and prevention might present a false dichotomy. The new drugs do not work as a “magic pill” that people take to lose weight despite having eaten too much. Instead, they facilitate behavior change by reducing the patients’ craving for food.

As noted by WHO, it is too early to assume that the new drugs will be the solution to the global obesity epidemic. The long-term impact of the new medicines, including their side-effects, needs to be further investigated, together with their effectiveness among other patient populations and the need for long-term patient adherence. But the analogy with the expansion of HIV/AIDS treatment across the world suggests that if the promise of the new obesity drugs is confirmed, it will be worth to look beyond their current high sticker prices and seriously considering how to expand their global availability. Much of the high prices are driven by a mark-up made possible by patent protection, and there clearly is room for price reductions. Whether the price reductions will come from voluntary or negotiated agreements with the pharmaceutical companies producing them or from the competition from generic versions of the drugs remains to be seen, but the global heath community should prepare itself to seize the opportunity offered by these new obesity drugs.

In conclusion, while this blog isn't tied to specific existing research, it builds on ideas I shared in my presentation during the February Policy Research Talk, with a goal to spark a conversation and potentially kickstart a new research agenda.