Emory International Law Review

TRIPS and Compulsory Licensing: Increasing Participation in the Medicines Patent Pool in the Wake of an HIV/AIDS Treatment Timebomb
Lauren Ulrich Editor-in-Chief, Emory International Law Review; J.D. Candidate, Emory University School of Law (2016); M.S.P.H., Johns Hopkins University (2013); B.S., summa cum laude, Auburn University (2011). The author would like to thank Professor Liza Vertinsky for her thoughtful advice in writing this Comment. The author would also like to thank her parents, Pam and Bruno Ulrich, and David Baker for their continuous love and support.

Abstract

Significant progress has been made in recent decades to increase access to HIV/AIDS antiretroviral treatments in low- and middle-income countries. Despite all that has been done, a treatment timebomb awaits unless immediate action is taken to decrease the price of antiretroviral drugs. The treatment timebomb can be attributed in part to the increasing likelihood that HIV medicines will be patented in developing countries in compliance with the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). The Medicines Patent Pool (MPP) is a collective action mechanism designed to overcome patent barriers resulting from the implementation of TRIPS in developing countries to respond to the treatment timebomb. The MPP works directly with HIV medicines patent holders and generic manufacturers to facilitate access to new and more affordable antiretrovirals in developing countries. This Comment argues that the MPP can serve as a valuable tool to increase access to patented HIV medicines in developing countries if participation in the pool by patent holders can be increased. This Comment proposes that governments in countries hardest hit by the HIV/AIDS epidemic collectively exercise TRIPS flexibilities and issue compulsory licenses for HIV medicines to increase participation in the MPP. Such a concerted effort by low- and middle-income countries to issue compulsory licenses could make the MPP more effective at increasing access to new and more affordable HIV medicines to respond to the growing HIV/AIDS treatment crisis.

Introduction

[W]e are sitting on a treatment timebomb. We can predict many of the changing treatment needs of people living with HIV in the coming decade and they are not compatible with treatments and prices available today. Maintaining HIV treatment to keep people alive will cripple developing economies, or place unbearable strains on richer countries trying to support them. Action is needed now, to avert crisis later.

—United Kingdom All-Party Parliamentary Group on AIDS 1UNAIDS, Global Report: UNAIDS Report on the Global AIDS Epidemic 4 (2013) [hereinafter UNAIDS Global Report]. In 2009, only one-third of adults living with HIV had access to treatment. All-Party Parliamentary Group on AIDS, The Treatment Timebomb 5 (2009) [hereinafter Treatment Timebomb].

In 2012, an estimated 35.3 million people worldwide were living with HIV. 2UNAIDS Global Report, supra note 1. That number is expected to increase five-fold by 2030. 3Drug Firms ‘Must Pool Patents’, BBC News, http://news.bbc.co.uk/2/hi/health/8150457.stm (last updated July 15, 2009). According to one estimate, approximately fifty-five million people will need access to antiretroviral treatments by 2030. Treatment Timebomb, supra note 1. The magnitude of this increase is due in part to growing drug resistance, 4Treatment Timebomb, supra note 1, at 12. rising treatment prices, 5Id. at 10. the increasing likelihood that new antiretroviral drugs will be patented in developing countries, 6See Ellen ‘t Hoen, Jonathan Berger, Alexandra Calmy & Suerie Moon, Driving a Decade of Change: HIV/AIDS, Patents and Access to Medicines For All, 14 J. Int’l AIDS Soc’y 1, 7 (2011) [hereinafter ‘t Hoen et al., Driving a Decade of Change]. and inadequate funding for low- and middle-income countries to purchase medicines. 7See id. at 8. To respond to this so-called “treatment timebomb,” 8The United Kingdom All Party Parliamentary Group on AIDS coined the term “treatment timebomb” in July 2009. Id. at 8. a new collective action mechanism is needed to facilitate access to patented antiretroviral drugs to produce more affordable medicines and develop improved medicines. 9See id. at 1.

The Medicines Patent Pool (MPP) is a new approach to managing intellectual property created to respond to the treatment timebomb and overcome patent barriers imposed by the implementation of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) in 1995. 10Id. at 8. TRIPS requires all World Trade Organization members to provide a minimum level of patent protection in all fields, including pharmaceuticals. Id. at 2–3. The implications of the implementation of TRIPS will be discussed briefly in Part I.A and in greater detail in Part III.B of this Comment. Following the implementation of TRIPS, HIV medicines are more likely to be patented in developing countries and thus less widely available to generic manufacturers. 11Id. at 2–3, 8. The MPP works with patent holders and generic manufacturers to facilitate access to patented HIV medicines in developing countries with the goal of supporting the production of affordable generic medicines, and the development of new treatments. 12Id. at 1. The MPP represents a promising mechanism to respond to the treatment timebomb and overcome the patent barriers described above. 13See id. The MPP, however, faces its own problems in providing adequate incentives for patent holders to voluntarily license their HIV medicines patents to the pool. 14See Rebecca Goulding & Amrita Palriwala, Results for Dev. Inst., Patent Pools: Assessing Their Value-Added for Global Health Innovation and Access 3, 33 (2012).

This Comment argues that the MPP can facilitate access to less expensive and more effective antiretrovirals if participation by relevant patent holders can be increased. This Comment proposes that governments in countries hardest hit by the HIV/AIDS epidemic and the least able to pay for essential antiretroviral treatments collectively issue compulsory licenses to increase participation in the MPP. Compulsory licensing can provide a legal solution under TRIPS to increase participation in the MPP and overcome the patent barriers imposed by TRIPS. A concerted effort by low- and middle-income countries to issue compulsory licenses could make the MPP more effective at increasing access to new and more affordable HIV medicines to respond to the growing HIV/AIDS treatment crisis.

Part I of this Comment introduces patent pools and the HIV/AIDS treatment timebomb, and details the creation of the MPP, including the MPP’s licensing strategy and licensing successes to date. Part II reviews the incentives for patent holders to participate in the pool and examines why the current incentives are not adequate to attract enough patent holders to the pool. Part III introduces compulsory licensing and TRIPS to propose collective public action through compulsory licensing as a tool to increase participation in the MPP. Part IV concludes that the MPP is an invaluable tool for increasing access to new and affordable HIV medicines to respond to the global treatment timebomb and that it can be made more effective by increasing participation in the pool through collective public action in the form of compulsory licensing.

I. The Medicines Patent Pool

This Comment argues that a patent pool for HIV medicines represents a valuable mechanism to increase access to new and more affordable antiretroviral treatments in developing countries. Part A introduces patent pools and the HIV/AIDS treatment timebomb. Part B outlines the road to creating a patent pool for HIV medicines and the MPP’s mission to increase access to antiretroviral drugs. Part C examines the MPP’s licensing strategy and briefly discusses licensing agreements the MPP has concluded to demonstrate that more needs to be done before the MPP can accomplish its mission to facilitate access to patented medicines in developing countries.

A. Patent Pools and the HIV/AIDS Treatment Timebomb

1. What is a Patent Pool?

A patent pool is an agreement between two or more patent holders to license their patent rights to a single entity or pool. 15Michelle Childs, Towards a Patent Pool for HIV Medicines: The Background, 4 Open AIDS J. 33, 34 (2010). Once patents are licensed to the pool, pool administrators can license the right to use the patents to third parties, such as generic manufacturers, typically upon payment of a royalty to the patent holder. 16Id. Patent pools are created for a variety of reasons and can range in size from small, cross-licensing arrangements between two or more competitors to large, industry-wide pools including hundreds of manufacturers. 17IGWG Submission on Collective Management of Intellectual Property, Knowledge Ecology Int’l (Sept. 30, 2007), http://www.who.int/phi/public_hearings/second/contributions_section2/Section2_ManonRess-PatentPool.pdf [hereinafter IGWG Submission]. The benefits of creating a patent pool include reduced transaction costs resulting from only having to negotiate licenses with a single entity, and the management of patents, royalties, and licensing agreements by a single pool administrator. 18Id. Although patent pools have been used in other industries, including agriculture and airspace engineering, since as early as 1856, 19Jorge Bermudez & Ellen ‘t Hoen, The UNITAID Patent Pool Initiative: Bringing Patents Together for the Common Good, 4 Open AIDS J. 37, 38 (2010); see also Bradley J. Levang, Evaluating the Use of Patent Pools for Biotechnology: A Refutation to the USPTO White Paper Concerning Biotechnology Patent Pools, 19 Santa Clara Computer & High Tech. L. J. 229, 236–37 (2002). they are relatively new in the pharmaceutical industry. 20Medicines Patent Pool: Facilitating Access to HIV Treatment, WIPO Mag. (June 2011), http://www.wipo.int/wipo_magazine/en/2011/03/article_0005.html [hereinafter WIPO Magazine]. Historically, the pharmaceutical industry has not been seen as an appropriate forum for a patent pool model for a variety of reasons, including the importance of intellectual property in determining a pharmaceutical company’s worth and the likelihood that pharmaceutical patent holders will disagree over the value of patents in the pool. Comm’n on Intellectual Prop. Rights, Innovation and Public Health, Public Health, Innovation, and Intellectual Property Rights 53 (2006). Perceptions began to change in 2000 when the United States Patent and Trademark Office issued a report concluding that patent pools in biotechnology could be valuable tools to serve the interests of both public and private actors. Id.

2. The HIV/AIDS Treatment Timebomb

Significant progress has been made in recent decades to increase access to HIV/AIDS antiretroviral treatments in low- and middle-income countries. 21See, e.g., ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. Between 2003 and 2009, the number of people with access to HIV/AIDS antiretroviral treatments increased more than twelve-fold due to the increased availability of low-cost generic antiretrovirals, whose prices have dropped by over ninety-nine percent since 2000. See Ellen ‘t Hoen & Suerie Moon, An Innovative Approach to Achieving Access to Medicines For All, Medicus Mundi Switz. (Sept. 2010), http://www.medicusmundi.ch/de/bulletin/mms-bulletin/zugang-zu-medikamenten-fur-alle/debatten-und-ansaetze/an-innovative-approach-to-achieving-access-to-medicines-for-all [hereinafter ‘t Hoen & Moon, An Innovative Approach to Achieving Access]. The World Bank defines low-income countries as those having a Gross National Income (GNI) per capita of $1,045 or less in 2013; middle-income countries are defined as those having a GNI per capita of more than $1,045 but less than $12,746. Country and Lending Groups, World Bank, http://data.worldbank.org/about/country-and-lending-groups (last visited Feb. 7, 2015). The term “developing” is used to denote low- and middle-income countries. Id. The terms “low- and middle-income countries” and “developing countries” will be used interchangeably throughout this Comment. The increase in access has been primarily attributed to widespread generic manufacturing of antiretrovirals, which has driven competition up and prices down. 22Tina Rosenberg, Sharing Patents to Wipe out AIDS, N.Y. Times (July 21, 2011), http://opinionator.blogs.nytimes.com/2011/07/21/sharing-patents-to-wipe-out-aids/?_r=0. Despite these improvements, however, a treatment timebomb awaits, which threatens to set back the progress made unless immediate action is taken to decrease the price of antiretroviral drugs. 23See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. The treatment timebomb can be attributed to a number of interrelated factors that are likely to increase the cost of HIV treatment, decrease access to treatment, and heighten the need to find newer, more affordable treatments. These factors include the high likelihood that persons on antiretroviral drugs will develop resistance; inadequate funding for medicines; the lack of a commercial market for pediatric drugs; and an increase in the patenting of medicines in developing countries in compliance with TRIPS. 24Id. at 1, 7–8; see also Treatment Timebomb, supra note 1, at 12.

The number of people worldwide living with HIV is expected to increase in the coming years, meaning that more people will need access to antiretroviral treatments. 25See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. Currently, the majority of people living with HIV in low- and middle-income countries are first treated with a combination of three antiretroviral drugs—Lamivudine, Stavudine, and Nevirapine—known as combination treatment. 26Treatment Timebomb, supra note 1, at 10. However, merely having access to drugs does not guarantee successful treatment, as most people who have access to antiretrovirals develop resistance to the first set of drugs (first-line drugs) they take. 27Id. at 12 (noting that the “development of resistance is likely to happen to everybody over time”). For these individuals, switching to a newer and more expensive set of drugs (second-line drugs) can be “a matter of life or death.” 28Id.; see also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. It is estimated that only three percent of people receiving antiretroviral treatments in developing countries are being treated with second line drugs. Treatment Timebomb, supra note 1, at 12. An additional complicating factor contributing to the treatment timebomb is that second-line treatments can be up to eleven times more expensive than first-line treatments, putting them out of reach for many HIV patients in low- and middle-income countries. 29See Treatment Timebomb, supra note 1, at 10. The high likelihood that persons receiving treatment will develop resistance to first-line treatments over time in combination with the high cost of second-line treatments means that newer and more affordable treatments will be needed in the near future to avert a global treatment crisis. 30Id. at 12. Combination treatments, however, are difficult to produce because more than one person may own the patented drugs, and manufacturers must obtain permission from all patent holders before the drugs can be combined into a single pill. See id. at 26. The treatment situation is even more dire for children: only ten percent of children who need antiretroviral treatments currently have access, 31Id. at 6. and many of the antiretrovirals that are currently produced are either not approved for pediatric use or are not available in pediatric formulations. 32Id. at 25. The simple solution is to provide more pediatric antiretrovirals for children. 33Id. However, the lack of a commercial market for pediatric drugs means that there are few incentives for pharmaceutical companies to invest in developing pediatric antiretroviral formulations. 34Id.

While antiretroviral prices have decreased in the last two decades due to increasing generic competition in low- and middle-income countries, antiretrovirals are still too expensive for most developing countries to purchase and provide to their HIV-infected populations. 35Rosenberg, supra note 22. As a result, many developing countries rely on drug donation programs, funded by organizations such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) program, to assist them in purchasing medicines. 36Id. It is unclear how much longer this lifeline of support will be available to developing countries: the international HIV/AIDS community is facing a financial crisis, which has led to declining contributions in recent years. 37See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. If funding for drug donation programs runs out, developing countries will be left with few options to increase access to antiretrovirals on their own.

Finally, the treatment timebomb can be attributed in part to the increasing likelihood that new antiretroviral drugs will be patented in developing countries in compliance with TRIPS. 38Id. As HIV medicines are more widely patented in developing countries, it will become increasingly difficult for generic manufacturers to produce low-cost versions of the patented medicines and the cost of treatment will rise. 39Id. In addition, it will be more difficult for generic manufacturers to develop new combination or pediatric treatments if the individual HIV medicines needed to produce the treatments are patented in developing countries. 40Id.

The increase in the patenting of medicines in developing countries is occurring in response to the adoption of TRIPS by the World Trade Organization (WTO) in 1994. 41Id. at 2. The World Trade Organization was established in 1995 to govern trade-related transactions between nations. What is the WTO?, World Trade Org., http://www.wto.org/english/thewto_e/whatis_e/whatis_e.htm (last visited Feb. 15, 2015). Under TRIPS, WTO member countries must provide a minimum level of patent protection in all fields of technology, including pharmaceuticals, for twenty years. 42See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 2. In 2011, 153 countries were members of the WTO. Id. Developing countries are often required to provide patent protection exceeding the minimum requirements of TRIPS as part of trade agreements with developed countries, further restricting their ability to produce or import generic versions of patented medicines. 43Id. at 8. The situation is only going to get worse: all WTO member countries must be TRIPS-compliant by 2016, at which time it will be virtually impossible for generic manufacturers to produce or import low-cost versions of patented antiretrovirals. 44Treatment Timebomb, supra note 1, at 20.

A new collective action mechanism designed to facilitate access to patented HIV medicines is needed to confront the intellectual property challenges arising from the implementation of TRIPS. The following section discusses how the MPP anticipated and can overcome these problems by working directly with patent holders and generic manufacturers to produce and develop newer and more affordable antiretroviral treatments. 45See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1, 8.

B. Overcoming Patent Barriers by Creating a Patent Pool for HIV Medicines

Part B provides a short overview of the MPP and its mission to establish a backdrop within which to evaluate the MPP’s ability to overcome patent barriers and facilitate access to patented HIV medicines.

1. The Road to Creating a Patent Pool for HIV Medicines

James Love from Knowledge Ecology International (KEI) 46KEI is a not-for-profit organization that engages in research and advocacy to manage knowledge resources in areas of intellectual property, among others. About KEI, Knowledge Ecology Int’l, http://keionline.org/about (last visited Dec. 13, 2014). first introduced the idea for a patent pool for HIV medicines in 2002 at the International AIDS Conference in Barcelona, Spain. 47See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. Love, who had studied patent pools created by the United States government in 1917 to overcome patent barriers in the aircraft industry, believed that a similar concept could be used to overcome patent barriers in the HIV medicines industry. 48Id.; see also Goulding & Palriwala, supra note 14, at 12. The next step towards creating a patent pool for HIV medicines came in 2006 when UNITAID was created to provide “sustainable, long-term funding” for drugs and diagnostics for HIV/AIDS, tuberculosis, and malaria in developing countries. 49Bermudez & ‘t Hoen, supra note 19, at 38. UNITAID was launched by the governments of Brazil, Chile, France, Norway, and the United Kingdom in 2006. Id. UNITAID is an innovative drug purchasing mechanism that obtains funding through a tax on airline tickets in participating member countries and through contributions from organizations such as the Bill and Melinda Gates Foundation and the Clinton HIV/AIDS Initiative. Id. As of 2010, twenty-nine countries had committed to contribute to UNITAID, the majority of which were low- or middle-income. Id. UNITAID has already experienced “considerable success” in reducing drug prices through bulk purchasing agreements. Treatment Timebomb, supra note 1, at 15. Médicins Sans Frontières (MSF), 50Médicins Sans Frontières, also known as Doctors Without Borders, is a medical humanitarian organization that provides medical care to people affected by armed conflict, natural disasters, and global epidemics, or who otherwise lack access to adequate medical care. About MSF, Médicins Sans Frontières, (last visited Jan. 3, 2015). with support from KEI, submitted a proposal to create a patent pool for HIV medicines to UNITAID and the French Ministry of Foreign Affairs in June 2006. 51Childs, supra note 15, at 34. At that time, UNITAID was perceived as the best entity to implement the patent pool initiative because it takes a “pro-health approach to IP.” 52Bermudez & ‘t Hoen, supra note 19, at 38. UNITAID adopted the proposal in July 2008, 53Id. and the MPP was launched as an independent entity in July 2010 with funding from UNITAID. 54WIPO Magazine, supra note 20; see also Goulding & Palriwala, supra note 14, at 19. UNITAID hoped the MPP would complement other mechanisms that it utilizes to increase access to HIV medicines in developing countries such as financing and drug purchasing programs. 55Bermudez & ‘t Hoen, supra note 19, at 38.

2. The MPP as a Mechanism to Overcome Patent Barriers and Increase Access to Medicines

The MPP was created as a direct response to the changing global intellectual property environment arising from the increased likelihood that HIV medicines would be patented in developing countries in compliance with TRIPS. 56See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. Under TRIPS, patented medicines are not available in generic form until the twenty-year term for patent protection expires, which means that countries hardest hit by the HIV/AIDS epidemic will have to wait a long time before more affordable medicines are made available. 57Rosenberg, supra note 22. The MPP was designed to overcome barriers imposed by patent protection for medicines in developing countries through the collective management of HIV medicines patents in a single pool with a global health goal in mind. 58Childs, supra note 15, at 34; see also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

The MPP’s mission is to “reduce prices and ensure the availability of new and improved AIDS medicines” by producing generic versions of HIV antiretrovirals and developing new combination and pediatric therapies. 59See ‘t Hoen & Moon, An Innovative Approach to Achieving Access, supra note 21; see also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1, 8. Combination treatments are essential for simplifying and improving HIV care in developing countries; however, they are difficult to develop because more than one owner may hold the patents needed to make the combination. 60See Bermudez & ‘t Hoen, supra note 19, at 37. See supra note 30 and accompanying text. As discussed in Part I.A, pediatric treatments are essential due to the unmet treatment need and lack of investment in developing pediatric formulations. 61See Treatment Timebomb, supra note 1, at 6, 25.

The MPP pools patents held by multiple owners in a single entity to make it easier for generic manufactures to access patented medicines that otherwise would only be available to them on a license-by-license basis. 62Asher Mullard, Straight Talk With Ellen ‘t Hoen, 16 Nature Med. 1351, 1351 (2010). See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. By pooling medicines patents together, researchers can “access permission to use the component drugs from a single place, rather than having to negotiate company by company.” Treatment Timebomb, supra note 1, at 28. Such access can lead to lower drug prices and encourage the development of new medicines, including the pediatric and combination treatments that are desperately needed in developing countries, on a shorter timeframe by simulating competition among generic manufacturers. 63See IGWG Submission, supra note 17; ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 6. See also Rosenberg, supra note 22 (noting that patent pools can make patented medicines available to generic manufacturers right away).

In order to facilitate access to patented HIV medicines, the MPP negotiates licensing agreements separately with patent holders and generic manufacturers. 64See Goulding & Palriwala, supra note 14, at 34. Key to the MPP’s success is that it negotiates licensing agreements from a global health rather than from a financial perspective and operates as an intermediary between patent holders and generic manufacturers. 65See id. The MPP’s status as a non-financially-motivated intermediary is essential to its ability to negotiate licensing agreements that will increase access to more affordable patented medicines in developing countries. 66See id.; Mullard, supra note 62, at 1351. In addition, the MPP’s intermediary status is attractive to generic manufacturers, who often have difficulty negotiating favorable bilateral licensing agreements with large, financially superior pharmaceutical companies. 67Goulding & Palriwala, supra note 14, at 3.

The MPP has been well received throughout the international community and seen as a positive step towards decreasing drug prices and increasing access in developing countries. 68See Treatment Timebomb, supra note 1, at 28–29. Since it was created, the MPP has received extensive political support from countries including the United Kingdom, the United States, Thailand, and Brazil, 69See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 6. See also Drug Firms ‘Must Pool Patents’, supra note 3; Mullard, supra note 62, at 1351. which lends credibility and legitimacy to the institution. Organizations such as the World Health Organization, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, as well as the G8 and the European Union have also expressed support for the pool. 70Goulding & Palriwala, supra note 14, at 22.

While the MPP currently focuses exclusively on HIV/AIDS medicines, 71Bermudez & ‘t Hoen, supra note 19, at 39. it will eventually be expanded to address other diseases in developing countries, including tuberculosis and malaria. 72Id. at 38. However, scaling up the MPP to address other diseases can only be justified if the MPP proves to be an effective solution to responding to the current HIV/AIDS treatment crisis. 73See id. The MPP’s ability to serve as a valuable tool to increasing access to patented HIV medicines depends in large part on its licensing strategy and ability to attract key patent holders to the pool, 74See Treatment Timebomb, supra note 1, at 28–29. which will be discussed in the following section.

C. Licensing in the MPP

The MPP is a voluntary pool, meaning that patent holders must voluntarily choose to license their HIV medicines patents to the pool before the patents will be available to generic manufacturers. 75Bermudez & ‘t Hoen, supra note 19, at 38. Once patents are licensed to the pool, generic manufacturers can sublicense the right to produce and sell low-cost generic versions of the medicines in low- and middle-income countries or to combine multiple patents to develop new combination or pediatric treatments. 76Id. at 38–39. Patent holders can receive a royalty from the sale of generic versions of the patented medicines in low- and middle-income countries in exchange for licensing to the MPP. 77Id. at 38. The MPP then relies on market competition among generic manufacturers to bring drug prices down and increase access to treatments. 78See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. However, robust competition will only occur if licenses for HIV medicines are available to multiple generic manufacturers in developing countries where the medicines are patented. 79Id. at 6 (noting that “licenses are critical because they can encourage robust competition among drug manufacturers” and competition drives down prices). See also id. at 8.

The MPP’s licensing strategy is flexible 80Kelly Morris, HIV Drug Patents in the Spotlight, 9 Lancet 660, 661 (2009). See also Ellen ‘t Hoen, Pharmaceutical Companies and the UNITAID Patent Pool, 375 Lancet 30, 30 (2010) (“UNITAID has consulted with a wide range of stakeholders in the ongoing process of designing the Pool”). to attract the maximum number of patent holders to the pool, meaning that licensing terms are variable and subject to negotiation. 81WIPO Magazine, supra note 20. However, the MPP has defined at least four principles that should guide all MPP licenses to maintain a global health-oriented approach. 82Id. First, the terms and conditions of all MPP licenses must be made available to the public and all MPP licenses must be non-exclusive such that patent holders can license to other entities besides the pool. 83Id. Second, licenses must be limited to low- and middle-income countries; developed countries cannot be included within the scope of licensing agreements. 84Id. Third, generic manufacturers must put in place mechanisms to provide quality assurance for the generic products to accommodate the concerns of patent holders whose medicines they will be producing. 85Id. Fourth, the royalties that patent holders receive under licensing agreements must be adjusted based on the recipient country’s HIV disease burden and ability to pay to ensure the broadest possible access to treatment. 86Id.

The next section reviews licensing agreements concluded by the MPP since it was created and shows that the MPP needs to attract more participation by key patent holders to respond to the growing global health crisis. 87Goulding & Palriwala, supra note 14, at 21–22. This Comment argues that the MPP could still become an effective solution to the timebomb if participation can be increased through collective action.

1. Licensing Agreements

The MPP has experienced modest success over the past five years, signing licensing agreements for a total of twelve antiretrovirals and one drug used to treat secondary infections in people living with HIV with six patent holders. 88About the MPP, Meds. Patent Pool, http://www.medicinespatentpool.org/about/ (last visited Sept. 30, 2015); William New, Medicines Patent Pool Signs 7 New Sub-Licenses for Generic HIV Drugs, Intell. Prop. Watch (July 18, 2014), http://www.ip-watch.org/2014/07/18/medicines-patent-pool-signs-7-new-sub-licences-for-generic-hiv-drugs/. After this Comment was written, the MPP released a report highlighting its successes over the past five years. To read more about the MPP’s latest achievements in greater detail, see generally Meds. Patent Pool, Progress and Achievements of the Medicines Patent Pool 2010–2015 (2015), http://www.medicinespatentpool.org/wp-content/uploads/WEB_Progress_Report_2015_EN.pdf [hereinafter progress and achievements of the MPP]. Twelve out of eighteen antiretrovirals included on the MPP’s list of priority medicines have been licensed to the MPP, though one cannot be produced until another patent holder joints the pool. 89Meds. Patent Pool, Antiretroviral Priorities of the Medicines Patent Pool 11 (4th ed. 2015) As of October 2015, the MPP had signed fifty-nine sublicensing agreements with fourteen generic manufacturers. 90See Progress and Achievements of the MPP, supra note 88, at 1. As of December 2014, the MPP had signed sub-licensing agreements with ten generic manufacturers. See Company Engagement, Meds. Patent Pool, http://www.medicinespatentpool.org/company-engagement/ (last visited Sept. 26, 2015). This section will briefly discuss licensing agreements concluded by the MPP to demonstrate that more can be done to attract key patent holders and increase access to HIV medicines.

The MPP signed its first licensing agreement with the United States National Institutes of Health (NIH) in September 2010. 91WIPO Magazine, supra note 20. The NIH license is royalty-free and permits research on a drug primarily used to treat drug-resistant HIV infections. 92Krista Cox, The Medicines Patent Pool: Promoting Access and Innovation for Life-Saving Medicines Through Voluntary Licenses, 4 Hastings Sci. & Tech. L. J. 293, 300 (2012); see also WIPO Magazine, supra note 20; Kaitlin Mara, The Medicines Patent Pool: Improving Access to ARVs and Stimulating Innovation for New Medicines, Afr. Health, Jan. 2012, at 20–21. However, the long-term practical usefulness of the license is limited until another patent holder, Tibotec, which owns patents on the drug related to manufacturing, licenses to the MPP. 93Cox, supra note 92, at 301 (noting that Tibotec has so far declined to negotiate with the MPP).

In July 2011, the MPP signed its first licensing agreement with a private pharmaceutical company, Gilead Sciences. 94Id. at 304. The Gilead license covered production of the drugs tenofovir (TDF), elvitegravir (EVG) and cobisistat (COBI), as well as a fixed-dose combination of the four drugs called the Quad; the license contains a covenant not to sue on emtricitabine (FTC). Id.; see also Licenses in the MPP, Meds. Patent Pool, http://www.medicinespatentpool.org/current-licences/ (last visited Sept. 26, 2015). A few terms of the licensing agreement are worth mentioning to better understand the challenges the MPP faces in concluding licensing agreements that will have a significant impact on increasing access to patented medicines in developing countries. 95See infra Part II.A for a detailed discussion of the incentives to participate in the MPP. See infra Part II.B for a discussion of the problems the MPP must overcome before it can attract patent holders and effectively respond to the global health crisis. For example, the license covers generic production of three drugs, including two pipeline drugs, used to treat HIV infections, as well as a four-drug combination product called the Quad; 96Cox, supra note 92, at 304; see also Morris, supra note 80, at 660. the license permits the generic products to be sold in 112 low- and middle-income countries; 97Cox, supra note 92, at 306, 308. and Gilead receives a three to five percent royalty on sales of generic products. 98Id. at 308. Most strikingly and the subject of criticism, the Gilead license excluded a number of middle-income countries, in particular in Asia and Latin America. 99Id. at 306 (noting that “[t]he exclusion of a number of middle-income countries, particularly those in Asia and Latin America, represents one of the main criticisms of the MPP/Gilead license”). In addition, the license restricted the sourcing of active pharmaceutical ingredients and generic manufacturing of the licensed drugs to India. 100Id. at 309. The MPP signed a second licensing agreement with Gilead in 2014, 101Licenses in the MPP, supra note 94. The agreement was amended in June 2015 to cover generic production of EVG in China and South Africa and to include a license to manufacture a combination of TDF/FTC with efavirenz (EFV). Id. which again excluded a number of middle-income countries such as Argentina, Brazil, China, and the Philippines. 102Catherine Saez, New Medicines Patent Pool-Gilead Agreement for New HIV Drug in 112 Countries, Intell. Prop. Watch (July 24, 2014), .

Since concluding the initial licensing agreement with Gilead, the MPP has signed licensing agreements with Bristol-Myers Squibb in 2013, 103Licenses in the MPP, supra note 94. The MPP signed a licensing agreement with Bristol-Myers Squibb in 2013 for a key HIV medicine, which covers 110 low- and middle-income countries. Id. ViiV Healthcare in April 2014, 104Id. The MPP signed two licensing agreements with ViiV Healthcare covering adult and pediatric use of a new drug, dolutegravir (DTG), used to treat HIV in 2014. Id. ViiV Healthcare is a collaboration between GlaxoSmithKline, Pfizer, and Shionogi. Id. The agreement has since been expanded to cover 127 countries for adult use and 121 countries for pediatric use. Progress and Achievements of the MPP, supra note 88, at 4. and with AbbVie in 2014. 105Licenses in the MPP, supra note 94. In November 2014, the MPP signed a licensing agreement with AbbVie for two HIV drugs for children. The Medicines Patent Pool (MPP) Signs Licensing Agreement with AbbVie for HIV Paediatric Formulations of Lopinavir and Ritonavir, Meds. Patent Pool (Dec. 1, 2014), http://www.medicinespatentpool.org/mpp-signs-licensing-agreement-with-AbbVie-for-HIV-paediatric-formulations-of-lopinavir-and-ritonavir/ [hereinafter MPP Signs Licensing Agreement]. The AbbVie licensing agreement covers 102 countries. Id. In addition, the MPP signed a Memorandum of Understanding with ViiV Healthcare in 2013 for pediatric antiretrovirals, 106Licenses in the MPP, supra note 94. The Memorandum of Understanding included a binding agreement to license a drug for pediatric use in 118 countries. In addition, ViiV Healthcare agreed to license a pediatric HIV drug currently in development for use in 118 countries once approved by regulatory authorities. The Memorandum of Understanding was converted into a licensing agreement in April 2014. Id. and a price agreement with Roche in 2013 for a drug used to treat a secondary infection in people living with HIV. 107Id. The price agreement will reduce the price of the drug by ninety percent in 138 developing countries. Id. The MPP signed a licensing agreement with Merck Sharp & Dohme (MSD) for pediatric use of a third-line HIV drug in February 2015. 108Id.

The MPP received support from numerous pharmaceutical companies, including Johnson & Johnson’s subsidiary company Tibotec, Abbott, Boehringer-Ingelheim, Merck, Gilead, ViiV Healthcare, Roche, and Bristol-Myers Squibb, when it was created. 109Mullard, supra note 62. The MPP has signed licensing agreements with many of these pharmaceutical companies. 110 See Goulding & Palriwala, supra note 14, at 2122; Company Engagement, supra note 90. However, several key pharmaceutical companies have declined to participate in the MPP at all 111As of October 2015, the MPP had not signed any licensing agreements or entered into negotiations with Tibotec and Abbott. Medicines Patent Pool Announces Negotiations with Two Additional Pharmaceutical Companies, Meds. Patent Pool (July 18, 2011), http://www.medicinespatentpool.org/medicines-patent-pool-announces-negotiations-with-two-additional-pharmaceutical-companies/. or have failed to conclude licensing agreements with the MPP after several years of negotiations. 112 The MPP has been negotiating with Boehringer Ingelheim since 2011 but as of October 2015 still had not concluded a licensing agreement. Company Engagement, supra note 90. For example, Tibotec and Abbott have declined to negotiate despite the fact that three patented drugs held by Tibotec are included on the MPP’s list of targeted medicines. 113Target Medicines, Meds. Patent Pool, http://www.medicinespatentpool.org/licensing/target-medicines/ (last visited Feb. 13, 2015). In 2015, Johnson & Johnson began working with the MPP to support the Paediatric HIV Treatment Initiative (PHTI), a collaboration between the MPP, UNITAID, the Drugs for Neglected Diseases initiative (DNDi), and the Clinton Health Access Initiative, which was launched in May 2014 to “speed the development of better-adapted HIV medicines for children living in resource-limited countries.” See The Medicines Patent Pool on Janssen’s Extension of its Access Policy for Paediatric Medicine Darunavir (Statement), Meds. Patent Pool, http://www.medicinespatentpool.org/the-medicines-patent-pool-mpp-statement-on-janssens-extension-of-its-access-policy-for-paediatric-medicine-darunavir-to-support-the-work-of-the-paediatric-hiv-treatment-initiative-phti/ (last visited Sept. 18, 2015); Company Engagement, supra note 90. All key patent holders need to participate and the geographic scope of licenses needs to be expanded if the MPP is to achieve its mission to increase access to HIV medicines in low- and middle-income countries.

II. Evaluating Participation in the MPP

This Comment argues that the MPP has not attracted enough participation from key patent holders or concluded licensing agreements that are likely to have a significant impact on increasing access to treatment to effectively respond to the global HIV/AIDS crisis in the post-TRIPS era. Part A reviews the current incentives for patent holders to voluntarily participate in the MPP. Part B discusses why the current incentives are inadequate to elicit sufficient patent holder participation to be an effective patent-oriented solution to the global health crisis. Part II lays the foundation for Part III in which a proposal to increase participation in the MPP through compulsory licensing in compliance with TRIPS will be evaluated.

A. Incentives to Participate in the MPP

Most major pharmaceutical companies have enacted their own programs to increase access to HIV medicines in developing countries, including tiered pricing systems for developed, middle-income, and developing countries, or bilateral voluntary licensing agreements with generic manufacturers for low or no royalties. 114See Treatment Timebomb, supra note 1, at 15; Goulding & Palriwala, supra note 14, at 29. However, these internal mechanisms are insufficient to tackle the multifaceted nature of the treatment timebomb. 115Treatment Timebomb, supra note 1, at 29. For example, bilateral licensing agreements between a patent holder and a generic manufacturer are unlikely to enable the development or production of combination treatments, which often requires bringing together more than one patent holder. 116Id. In addition, the impact of bilateral agreements on reducing prices of existing antiretrovirals is limited where only a few generic manufacturers are allowed to produce generic versions of the patented medicines. 117Id. at 19. A patent-oriented solution that can bring together multiple patent holders and generic manufacturers is needed to facilitate increased access to patented antiretrovirals.

The MPP provides a benefit over patent holders’ existing mechanisms to increase access to antiretrovirals in developing countries because it facilitates access to numerous HIV patents. 118See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1. By pooling together multiple patents in a single pool, generic manufacturers can produce more affordable antiretrovirals and develop new combination and pediatric medicines. 119See id. A key determinant of the MPP’s success will be its ability to provide a range of incentives for patent holders to participate in the pool that outweigh the incentives for patent holders to rely on their own internal mechanisms to increase access to antiretrovirals. 120Bermudez & ‘t Hoen, supra note 19, at 39. The MPP provides a range of incentives for HIV medicines patent holders to participate in the pool, including but not limited to compensation in the form of royalties for licenses granted to generic manufacturers; positive press and a boost in reputation from licensing; the possibility of avoiding the risk of compulsory licensing; and reduced transaction costs. 121Id.

Patent holders will be compensated when they license products to the MPP. 122Mullard, supra note 62. Patent holders licensing to the MPP can receive royalties when generic versions of the patented medicines are sold in low- and middle-income countries included within the scope of the agreement. 123Bermudez & ‘t Hoen, supra note 19, at 39; see also Mara, supra note 92. In addition, patent holders that license to the MPP will receive positive press and a boost in reputation for taking action to improve access to HIV medicines in developing countries. 124Bermudez & ‘t Hoen, supra note 19, at 39; see also Mara, supra note 92. Many patent holders want to contribute to global health; licensing to the MPP provides patent holders with a definite and visible way of doing so 125Mullard, supra note 62. while at the same time giving them access to developing country markets that they otherwise may not supply. 126See Bermudez & ‘t Hoen, supra note 19, at 39.

Further, patent holders may choose to license to the MPP in order to avoid the possibility that their patents will be used in developing countries without their consent. 127Id. This incentive will be addressed in greater detail in Part III.B. Under TRIPS, countries are permitted to issue compulsory licenses for patented medicines under certain conditions, including if there is a national or public health emergency. 128See, e.g., Sara Germano, Compulsory Licensing of Pharmaceuticals in Southeast Asia: Paving the Way for Greater Use of the TRIPS Flexibility in Low- and Middle-Income Countries, 76 UMKC L. Rev. 273, 280-81 (2007). Compulsory licensing and TRIPS will be discussed in greater detail in Parts III.A and B. By voluntarily licensing their HIV medicines patents to the MPP, pharmaceutical companies can avoid the risk that countries will issue compulsory licenses for their patented medicines. 129Bermudez & ‘t Hoen, supra note 19, at 39. This incentive will be addressed in greater detail in Part III.B. Finally, patent holders only have to negotiate a single license with the MPP before their medicines will be made available to generic manufactures. 130See id. As a result, by voluntarily licensing to the MPP, patent holders can reduce the transaction costs and uncertainty associated with negotiating licenses with generic manufacturers on a case-by-case or drug-by-drug basis. 131Id.

Although the MPP provides a range of incentives for patent holders to license to or negotiate with the pool, the MPP faces hurdles in reaching the level of participation needed to become an effective solution to increasing access to HIV medicines in developing countries. These hurdles are outlined in Part B to establish a framework within which to evaluate a proposal to increase participation in the MPP through compulsory licensing.

B. Roadblocks to Increasing Participation in the MPP

The MPP must overcome at least four roadblocks in order to serve as a valuable tool for facilitating access to new and more affordable antiretrovirals to respond to the treatment timebomb: (1) minimal financial incentives for patent holders to participate; (2) imbalance of bargaining power in licensing negotiations; (3) slow pace of licensing negotiations and production of generic medicines; and (4) insufficient consequences for patent holders that choose not to participate in the pool. Part III suggests that collective action through compulsory licensing can be an effective solution to increase participation in the MPP and overcome these hurdles. 132The roadblocks discussed in Part II.B are meant to be an inclusive but not exhaustive list—the MPP may face additional roadblocks in achieving its mission of increasing access to newer and more affordable HIV medicines that are beyond the scope of this Comment.

First, the MPP’s ability to attract key HIV medicines patent holders is limited because there are minimal financial incentives for patent holders to voluntarily participate in the pool. 133See Goulding & Palriwala, supra note 14, at 33. The lack of sufficient financial incentives for patent holders to participate in the MPP comes in many forms, including limited royalties from licensing agreements and the risk of parallel importing. 134See id. at 4, 30.

Currently, patent holders who contribute to the MPP can receive royalties when generic manufacturers license the right to use their patents to produce and sell low-cost versions of the patented medicines in developing countries. 135Bermudez & ‘t Hoen, supra note 19, at 39. See also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. However, the royalties patent holders receive under licensing agreements with the MPP offer little to no advantage over those patent holders can receive from bilateral licensing agreements with generic manufacturers. 136See Goulding & Palriwala, supra note 14, at 35. For example, Gilead receives royalties between three and five percent under its licensing agreement with the MPP. 137Cox, supra note 92, at 308. In comparison, Tibotec, the Johnson & Johnson subsidiary that has declined to participate in the MPP, receives royalties between two and five percent under a bilateral licensing agreement it negotiated with a generic manufacturer to produce an HIV drug. 138Tibotec Signs Multiple Agreements with Generic Manufacturers to Provide Access to New HIV Treatment, Johnson & Johnson (Jan. 27, 2011), http://www.investor.jnj.com/releasedetail.cfm?ReleaseID=545920. Further, patent holders may be reluctant to license to the MPP due to the risk of parallel importing, whereby generic medicines produced in developing countries leak into developed country markets and erode the patent holders’ profit margin. 139See Goulding & Palriwala, supra note 14, at 30 (noting that patent holders are hesitant to voluntarily license their medicines because of the potential for “unsanctioned reimportation of generic products from lower- or lower-middle-income markets into middle- or high-income markets”). See also Josh Ruxin, AIDS Drugs-For Profit or Not?, Forbes (Nov. 11, 2010), http://www.forbes.com/sites/sciencebiz/2010/11/11/aids-drugs-%E2%80%93-for-profit-or-not/; What’s Behind U.S. Drug Companies’ Response to the AIDS Crisis Abroad?, Wharton (Apr. 11, 2001), http://knowledge.wharton.upenn.edu/article/whats-behind-u-s-drug-companies-response-to-the-aids-crisis-abroad/. To be an effective part of the solution to increasing access to antiretrovirals, the MPP must provide greater financial incentives for patent holders to participate in the pool rather than rely on their own internal mechanisms to increase access to patented antiretrovirals. 140See Nikhil Kumar, Big Pharma and the Business of HIV/AIDS, Independent (Dec. 1, 2010), http://www.independent.co.uk/news/business/analysis-and-features/big-pharma-and-the-business-of-hivaids-2147987.html; Daniel Costello, HIV Treatment Becomes Profitable, L.A. Times (Feb. 21, 2008), http://articles.latimes.com/print/2008/feb/21/business/fi-hiv21.

Second, patent holders have greater bargaining power than generic manufacturers and pool administrators in negotiating licensing agreements. 141See Morris, supra note 80, at 660. Gilead Sciences, for example, the patent owner of tenofovir disoproxil fumarate (TDF), has control over generic manufacturers in negotiating its license agreements. Id. Patent holders have greater bargaining power than generic manufacturers because they can exclude middle-income countries from licensing agreements. 142See id. at 661; Cox, supra note 92, at 306–07. The inclusion of middle-income countries in the scope of MPP licenses was one of the most contentious issues when the MPP was created. Childs, supra note 15, at 35. Patent holders prefer to restrict generic sales in middle-income countries where they can already make a profit from the sale of patented HIV medicines. 143Morris, supra note 80, at 661. In contrast, generic manufacturers prefer to include middle-income countries in licensing agreements so that they can reach economies of scale faster and maximize profits. 144Id. Patent holders also have greater bargaining power than MPP administrators. For example, under the initial licensing agreement with Gilead, Gilead had to give a small portion of the royalties it received to the MPP as a broker’s fee. 145Cox, supra note 92, at 311. One year later, however, Gilead amended the agreements to remove any royalty payments due to the MPP. 146Licenses in the MPP, supra note 94. The MPP and generic manufacturers need additional bargaining tools to negotiate licensing agreements with patent holders that are designed to facilitate broader access to new and more affordable antiretrovirals, with limited or no restrictions. 147Cox, supra note 92, at 309 (noting that negotiations with patent holders involve competing interests and that it may be necessary for the MPP to change certain terms of the licenses or create new incentives in order to achieve more favorable provisions); see also Bermudez & ‘t Hoen, supra note 19, at 38 (noting that licenses need to cover both low and middle-income countries in order to attract multiple generic manufacturers and stimulate the level of competition needed to lower drug prices).

Third, the pace of negotiating licensing agreements and distributing generic medicines is too slow to keep up with the urgency underlying the treatment timebomb. 148See Goulding & Palriwala, supra note 14, at 3, 30 (noting that to be effective, the MPP needs to make it faster and easier for patent holders and generic manufacturers to license patented medicines). As discussed in Part I.A, one of the advantages of creating a patent pool to facilitate access to patented medicines is that patent pools can make the patented medicines available to generic manufacturers right away. 149See supra note 63 and accompanying text. When the MPP was created, pool administrators hoped that there would be a time lag of only one to two years between concluding a licensing agreement and producing and distributing generic drugs. 150Mullard, supra note 62. However, over the past five years, the MPP has only produced and distributed one drug, Tenofovir (TDF), in developing countries. 151See Saez, supra note 102; Progress and Achievements of the MPP, supra note 88, at 1. Tenofovir was licensed to the MPP in 2011 by Gilead Sciences. Licenses in the MPP, supra note 94. The MPP has also distributed TDF combination drugs in 115 countries. Progress and Achievements of the MPP, supra note 88, at 10. While generic production of the drug has decreased prices and increased access, 152Saez, supra note 102 (“The price of TDF has dropped 45%-87% in the past two years and the MPP’s generic partners have distributed three million TDF treatments in the same time period.”). the long-term impact of the MPP will be limited until more generic antiretrovirals are produced and savings are realized. 153See Progress and Achievements of the MPP, supra note 88, at 11 (noting that “for new ARVs, savings are likely to start three-four years after the MPP license is signed”). In addition, MPP administrators hoped that licensing agreements with patent holders would be concluded within one year. 154Mullard, supra note 62. However, most MPP licenses have taken well over one year to be finalized. 155See Company Engagement, supra note 90. Immediate action is needed to decrease the price of antiretroviral drugs and increase access to treatment. 156See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. To accomplish this task, the MPP needs to be able to license and produce generic medicines on a shorter timeframe.

Lastly, there are insufficient consequences for patent holders that choose not to participate in the MPP. 157See Cox, supra note 92, at 319, 323 (noting that there is a need for an additional “stick” to place pressure on and encourage patent holders to participate in the MPP). Since the MPP was created, there have been numerous calls from governments and social activists for pharmaceutical companies to license to the MPP. 158See Hannah Semigran, Altruism and Profit: The Changing Role of Pharmaceutical Companies in Global Health, Harv. C. Global Health Rev. (Feb. 1, 2012), http://www.hcs.harvard.edu/hghr/print/spring-2011/altruism-profit-pharma/. See also Philippe Douste-Blazy & Jorge Bermudez, GSK: Please Extend Patent Pool to AIDS Drugs, 373 Lancet 1339, 1339 (2009); Drug Firms ‘Must Pool Patents’, supra note 3. Despite these calls, several prominent pharmaceutical companies, including Merck and Tibotec—the Johnson & Johnson subsidiary—have been reluctant to negotiate with the MPP, 159Semigran, supra note 158. See also Cox, supra note 92, at 301. Merck only began negotiating with the MPP in the second quarter of 2014. Company Engagement, supra note 90. expressing a preference to rely on their own internal mechanisms to reduce prices and increase access to HIV drugs. 160Elizabeth Sukkar, Patent Pools: An Idea Whose Time Has Come, 338 Brit. Med. J. 974, 975 (2009). As one official from Glaxo-Smith Kline put it:For HIV, we believe that extensive research is already underway, and thus it is not a neglected disease. Millions of dollars are ploughed into research into HIV every year by the pharmaceutical industry. To improve access, we already have an extensive voluntary licensing programme for HIV across Sub Saharan Africa, involving eight licensees. These licensees are free to develop FDCs and paediatric versions and we believe this is a much simpler approach than the creation of a patent pool . . . [a]ll our ARVs are also available at not-for-profit prices in all Least Developed Countries and Sub Saharan Africa. We therefore do not see the need to include our HIV patents in any pool.Treatment Timebomb, supra note 1, at 28–29. Other patent holders have outright declined to negotiate with the MPP. 161Semigran, supra note 158. In 2011, Tibotec issued a formal statement refusing to enter into negotiations with the MPP for darunavir and several of its other HIV drugs. Cox, supra note 92, at 301. The primary consequences facing patent holders that decline to participate in the MPP are criticism from governments and social activists and possible reputational damage. 162See Goulding & Palriwala, supra note 14, at 4–5. The potential to avoid compulsory licensing was listed as an incentive for patent holders to participate in the MPP when it was created in 2010. Bermudez & ‘t Hoen, supra note 19, at 39. However, since the MPP was created, few countries have taken steps to issue compulsory licenses for HIV medicines patents. See Catherine Saez, Ecuador Grants First Compulsory License for HIV/AIDS Drug, Intell. Prop. Watch (Apr. 22, 2014), http://www.ip-watch.org/2010/04/22/ecuador-grants-first-compulsory-licence-for-hivaids-drug/ (noting that Ecuador issued a compulsory license for an antiretroviral drug owned by Abbott in 2010); Peter Maybarduk, US Government Special 301 “Watchlist” and Developing Country Use of Compulsory Licenses for Healthcare, Infojustice (May 2, 2013), http://infojustice.org/archives/29493 (noting that Thailand renewed its compulsory license for two antiretrovirals in 2010). This Comment argues that a more concerted effort by developing countries to issue compulsory licenses for HIV medicines is needed to provide a sufficient incentive for patent holders to voluntarily join the MPP. See infra Part III.C. While criticism and reputational damage are significant consequences, having additional consequences for patent holders that choose not to participate would go a long way towards increasing participation in and the effectiveness of the MPP.

III. A Proposal to Increase Participation in the MPP Through Compulsory Licensing

As a new approach to managing intellectual property created in response to the implementation of TRIPS, 163See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. the MPP has the potential to reduce prices and increase access to new and more affordable antiretrovirals if it can overcome the four roadblocks discussed above. 164See supra Part II.B. However, in order to accomplish its mission, the MPP must find a way to increase participation in the pool by key HIV medicines’ patent holders and conclude licensing agreements that are favorable from a global health perspective with few or no restrictions.

Part A provides background information on compulsory licensing and outlines the provisions of TRIPS and subsequent declarations that permit compulsory licensing under certain conditions. Part A is intended to lay the foundation for Part B, which illustrates how collective action by low- and middle-income countries through compulsory licensing could be utilized to increase participation in the MPP. Part C discusses how developing countries can overcome the hurdles outlined in Part II.B through a concerted effort to issue compulsory licenses for patented HIV medicines; Part C also discusses several obstacles developing countries may face in issuing compulsory licenses in connection with the MPP and how these obstacles can be addressed.

A. An Introduction to Compulsory Licensing and TRIPS

1. What is a Compulsory License?

A compulsory license is an “authorization by the government to itself or to a third party to use the patent without the permission of the patent holder.” 165Germano, supra note 128, at 279–80 (citing Frederick Abbott et al., International Intellectual Property in an Integrated World Economy 55 (2007)). A compulsory license allows a government to override a patent holder’s rights when it is in the state’s interest to do so. 166Goulding & Palriwala, supra note 14, at 15. Compulsory licenses may be issued, for example, when a patent holder fails to offer the patent product on the market, or offers the product at a price that is too high for potential buyers in the market to afford. 167HIV/AIDS, TRIPS, and Second-Line Therapy, AVERT, http://www.avert.org/hiv-drugs-patents-legislation.htm (last visited Feb. 12, 2015). The concept of compulsory licensing has been around for almost as long as patent law itself and the laws of many countries, including the United States, permit some form of compulsory licensing. 168See Germano, supra note 128, at 279; see also Karin Timmermans & Togi Hutadjulu, Indon. Ministry Health, The TRIPS Agreement and Pharmaceuticals 32 (2000).

2. Compulsory Licensing Under Article 31 of TRIPS

Prior to the adoption of TRIPS, patent protection for pharmaceuticals differed among countries. 169Germano, supra note 128, at 277. Many developing countries, including India, provided little to no patent protection for medicines. 170See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 2. India began providing patent protection for pharmaceuticals in 2005. Id. at 4. With the adoption of TRIPS by the WTO in 1994, however, all WTO member countries became required to provide a minimum level of patent protection in all fields of technology, including pharmaceuticals, for twenty years. 171Id. at 2. Within the twenty years of patent protection, generic companies are not permitted to develop or manufacture generic versions of the patented medicines without a license from the patent holder. 172Treatment Timebomb, supra note 1, at 21.

As discussed in Part I.A, the implementation of TRIPS has led to the increased patenting of medicines in developing countries, making it more difficult to develop new antiretrovirals and manufacture generic versions of patented HIV medicines. 173See supra Part I.A. The least developed countries were given a grace period to comply with the provisions of TRIPS. 174Treatment Timebomb, supra note 1, at 19. However, all WTO member countries are required to be in compliance with TRIPS by 2016, after which it will be virtually impossible to produce generic antiretrovirals without permission from the patent holder. 175Id. at 20. Despite increasing patent protection, all hope is not lost. TRIPS includes provisions, known as TRIPS flexibilities, which legally permit countries to overcome the patent barriers imposed by TRIPS by producing or importing generic versions of antiretrovirals under certain conditions. 176Id. at 17.

TRIPS flexibilities are found in Article 31, which permits “other use without authorization of the right holder,” including the use of a patent by the government or third parties authorized by the government without the patent holder’s consent. 177Agreement on Trade-Related Aspects of Intellectual Property Rights art. 31, Apr. 15, 1994, Marrakesh Agreement Establishing the World Trade Organization, Annex 1C, 1867 U.N.T.S. 31875 [hereinafter TRIPS]. See also Treatment Timebomb, supra note 1, at 17. Article 31 has been interpreted to authorize WTO member countries to issue compulsory licenses for patented medicines provided that certain conditions are met. 178See Germano, supra note 128, at 281–82. Several points about Article 31 are worth mentioning.

TRIPS flexibilities are only available to those countries wherein domestic law permits some form of compulsory licensing. 179TRIPS, supra note 177. Thus, a country wishing to issue a compulsory license under Article 31 must already have in place or must put in place laws authorizing compulsory licensing. 180Germano, supra note 128, at 284–85. Under Article 31, governments wishing to use patents without the patent holder’s permission must have made prior unsuccessful attempts to gain the patent holder’s authorization “on reasonable commercial terms and conditions.” 181TRIPS, supra note 177. Countries are permitted to bypass the authorization provision and issue a compulsory license without first attempting to obtain the patent holder’s consent if there is a national emergency, “other circumstances of extreme urgency,” or in the case of a “public non-commercial use.” 182Id. In the case of a national emergency or “other circumstances of extreme urgency,” countries wishing to issue compulsory licenses are required to notify the patent holder of its intentions to issue a compulsory license as soon as possible. 183Id. Authorization to issue the compulsory license is terminated when there is no longer a national emergency or situation of extreme urgency. 184Id.

Under Article 31, the scope and duration of compulsory licenses are limited to the specific authorized use; 185Id. the license must be non-exclusive; 186Id. and the license can only be used to supply the domestic market of the country issuing the license. 187Id. Finally, the patent holder must be remunerated for the use of its patent without its permission. 188Id. Such remuneration must be “adequate” and take into account the economic value of the patent that is subject to the compulsory license. 189Id.

3. The Doha Declaration: Expanding Compulsory Licensing Flexibilities under TRIPS

In 2001, the WTO issued the Declaration on the TRIPS Agreement and Public Health, known as the Doha Declaration, which expanded the instances in which WTO member countries could utilize TRIPS flexibilities. 190World Trade Organization, Ministerial Declaration of 14 November 2001, WTO Doc. WT/MIN(01)/DEC/2, 41 I.L.M. 746 (2002) [hereinafter Doha Declaration]. The Doha Declaration acknowledged that protection for intellectual property is important to facilitate the development of new medicines but emphasized that TRIPS “does not and should not prevent [WTO] members from taking measures to protect public health.” 191Id. ¶¶ 3–4. In particular, the Doha Declaration reaffirmed the right of WTO member countries to use TRIPS flexibilities “to protect public health and, in particular, to promote access to medicines for all.” 192Id. ¶ 4. The Declaration permits WTO member countries to determine under what circumstances compulsory licenses can be issued under Article 31 of TRIPS. 193Id. ¶ 5(b). Most importantly, the Declaration recognized that public health crises, including the global HIV/AIDS crisis, constitute a national emergency for which countries could grant compulsory licenses. 194Id. ¶ 5(c).

Part B builds on the introductory discussion of compulsory licensing and TRIPS to argue that developing countries hardest hit by the HIV/AIDS epidemic can collectively utilize TRIPS flexibilities to increase participation in the MPP and facilitate access to patented antiretrovirals.

B. Exercising Compulsory Licensing Flexibilities in Connection with the MPP

The MPP was created to respond to the changing intellectual property environment under TRIPS through the collective management of HIV medicines patents. 195See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. At the time the MPP was created, compulsory licensing was not seen as a favorable solution to overcoming patent barriers imposed by TRIPS because it requires a country-by-country approach. 196See Bermudez & ‘t Hoen, supra note 19, at 39 (noting that compulsory licensing is not a systematic solution to solving the global HIV/AIDS crisis). However, this Comment argues that the MPP has been unable to achieve the level of patent holder participation needed to decrease drug prices and increase access on its own. This Comment suggests that collective action through compulsory licensing by governments in low- and middle-income countries is needed to boost participation in the MPP to make the MPP more effective at increasing access to medicines. 197Although MSF preferred a voluntary licensing approach in its initial proposal for an HIV medicines patent pool, it did not rule out the possibility that a mandatory system should be adopted, if the voluntary approach failed. Childs, supra note 15, at 34. At least one scholar has suggested that countries could support the MPP by issuing compulsory licenses. Cox, supra note 92, at 323. This Comment explores more seriously compulsory licensing as an option to increase participation in the MPP, in arguing that compulsory licensing is an effective tool to increase participation in the MPP and respond to the treatment timebomb.

Compulsory licensing provides a legal solution to overcoming patent barriers that fits within the existing international intellectual property framework of TRIPS. 198See, e.g., ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 3. Article 31 of TRIPS permits WTO member countries to authorize the use of a patent by the government or a third party authorized by the government without the permission of the patent holder. 199TRIPS, supra note 177. This means that developing countries could issue compulsory licenses authorizing the MPP, a third party, to use HIV medicine patents, even if the patent holder has not given the government or the MPP permission to do so. The MPP could then negotiate licensing agreements with generic manufacturers that would produce generic versions of the patented medicines for sale in developing countries or to develop new combination or pediatric treatments. The compulsory licenses could be directed to patent holders that have not licensed to the MPP or that have licensed to the MPP but excluded middle-income countries from the scope of the license. 200See Cox, supra note 92, at 321–22. For example, compulsory licenses could be issued to Tibotec, which holds the patents needed to manufacture the drug licensed by the NIH, because Tibotec has declined to participate in the MPP. 201See id. at 301. In addition, middle-income countries excluded under the Gilead license could issue a compulsory license requiring Gilead to include them within the geographic scope of the license. 202See id. at 319–20 (noting the role that compulsory licenses could play in increasing the geographic coverage of the MPP/Gilead license).

Developing country governments issuing compulsory licenses would not be required to authorize the MPP to use the patents but could instead choose to use the patents themselves. 203See TRIPS, supra note 177. However, including the MPP as an authorized third party is essential to ensuring that the patented medicines are available to enough generic manufacturers to stimulate competition and have a significant impact on driving drug prices down. 204See Treatment Timebomb, supra note 1, at 19 (noting that “where few generic manufacturers are allowed to produce a medicine, the impact [on reducing drug prices] will be limited because competition is limited”); see also Rosenberg, supra note 22. In addition, pooling the patented medicines subject to the compulsory license in a single entity such as the MPP is essential to ensuring that generic manufacturers have access to all the patents needed to develop and produce new combination and pediatric treatments. 205Rosenberg, supra note 22.

Compulsory licenses for HIV medicines patents issued by WTO member countries would be compliant with TRIPS and the Doha Declaration provided that certain conditions are met. The Doha Declaration recognized that the HIV/AIDS epidemic constituted a public health emergency 206Doha Declaration, supra note 190, ¶ 5(c). such that the requirement that governments attempt to obtain authorization from patent holders before issuing the license is waived. 207TRIPS, supra note 177. However, in order to comply with TRIPS, countries wishing to issue compulsory licenses for HIV medicines must notify HIV medicine patent holders of their intention to do so. 208Id. In addition, the compulsory license must terminate when there is no longer a national emergency, 209Id. although this is unlikely to occur anytime in the foreseeable future with the global HIV/AIDS epidemic. Countries issuing compulsory licenses must also remunerate patent holders for the use of their patent without authorization, taking into account the economic value or importance of the patented drug. 210Id. A detailed discussion of remuneration guidelines is beyond the scope of this Comment. For a more detailed discussion on remuneration guidelines, see James Love, Measures to Enhance Access to Medical Technologies, and New Methods of Stimulating Medical R&D, 40 U.C. Davis L. Rev. 679, 688-694 (2007). Remuneration guidelines used by developing countries should be transparent and predictable to ensure fairness among patent holders. 211James Love, World Health Org., Remuneration Guidelines for Non-Voluntary Use of a Patent on Medical Technologies 58 (2005). Further, compulsory licenses would be TRIPS-compliant provided that the use of HIV medicines patents is non-exclusive, 212TRIPS, supra note 177. meaning that patent holders could voluntarily license the patents to generic manufacturers or the MPP on their own. However, because TRIPS requires that patents subject to compulsory licenses can only be used to supply the domestic market of the country issuing the license, 213Id. a concerted effort by multiple developing countries is needed to increase participation in the MPP and have a measurable impact on decreasing drug prices. 214See Bermudez & ‘t Hoen, supra note 19, at 38.

Issuing compulsory licenses for HIV medicines could also function as a tool to increase participation in the MPP by facilitating voluntary licensing. 215See Treatment Timebomb, supra note 1, at 19 (noting that voluntary licensing is “an effective way to avoid expense and damaging legal battles over compulsory licensing”). Because compulsory licenses allow a government to override a patent holder’s rights without their consent, patent holders have little control over the terms or conditions of the compulsory licenses. 216See Goulding & Palriwala, supra note 14, at 15. In addition, the terms of compulsory licenses are unlikely to be uniform or predictable across countries, creating greater uncertainty for patent holders. 217See Bermudez & ‘t Hoen, supra note 19, at 39. In contrast, patent holders have leverage and bargaining power when negotiating the term of voluntary licensing agreements with the MPP. 218See supra notes 141–47 and accompanying text. By voluntarily licensing to the MPP, patent holders could negotiate more favorable licensing terms, in particular royalty rates, than if a compulsory license is issued. 219See Germano, supra note 128, at 291 (noting that HIV medicines patent holders subject to a compulsory license issued by the Indonesian government only received a 0.5% royalty). As a result, the threat of compulsory licensing can serve as a bargaining tool for the MPP and developing countries in negotiating licensing agreements with patent holders that are favorable from a global health standpoint; the threat of compulsory licensing may also provide a financial incentive for patent holders to voluntarily participate in the MPP. 220See id. at 294. This threat in itself may provide a sufficient reason for patent holders to voluntarily participate in the MPP and avoid the uncertainty associated with compulsory licensing. 221Goulding & Palriwala, supra note 14, at 35; see also Germano, supra note 128, at 279–80.

Several countries have already taken advantage of TRIPS compulsory licensing flexibilities with impressive results. In 2004, Malaysia became the first WTO member country to issue a compulsory license for HIV antiretrovirals. 222Germano, supra note 128, at 286. After the compulsory license was issued, Malaysia began manufacturing and distributing generic antiretrovirals domestically, ultimately reducing the cost of treatment. 223Id. at 288. The compulsory license was successful in reducing the cost of three antiretroviral drugs by eighty-one percent. In addition, the compulsory license led pharmaceutical companies to make additional price reductions on other first and second-line treatments. Id. The governments of Indonesia, Thailand, and Brazil have also issued compulsory licenses for HIV medicines with similar results. 224Id. at 289–93; see also Goulding & Palriwala, supra note 14, at 13. These instances demonstrate that issuing compulsory licenses for HIV medicines can have a measurable impact on decreasing prices and increasing access to HIV medicines. 225Goulding & Palriwala, supra note 14, at 16. The potential for compulsory licensing to have similar effects when utilized in connection with the MPP will be evaluated in the next section.

C. Impact of Compulsory Licensing on Participation in the MPP and the Treatment Timebomb

Part II.B outlined four obstacles the MPP must overcome to increase participation in the pool: 1) minimal financial incentives for patent holders to participate; 2) imbalance of bargaining power in licensing negotiations; 3) slow pace of licensing negotiations and production of generic medicines; and 4) insufficient consequences for patent holders that choose not to participate in the pool. 226See supra Part II.B. Part C demonstrates how collective action by governments in low- and middle-income countries through compulsory licensing could be used to overcome these and other roadblocks to increase participation in the MPP and facilitate access to patented antiretrovirals.

Compulsory licensing can provide an additional financial incentive for patent holders to voluntarily license to the MPP. 227See supra notes 216–19 and accompanying text. To be compliant with TRIPS, low- and middle-income countries issuing compulsory licenses must remunerate patent holders for the unauthorized use of their patents. 228TRIPS, supra note 177. Remuneration under compulsory licenses issued for public health reasons in low-income countries typically ranges between zero and six percent of the price of the generic product. 229Marla L. Mellino, The TRIPS Agreement: Helping or Hurting Least Developed Countries’ Access to Essential Pharmaceuticals?, 20 Fordham Intell. Prop. Media & Ent. L. J. 1349, 1364 (2010). In contrast, patent holders have been able to negotiate royalties between three and five percent in voluntary licenses with the MPP. 230See Cox, supra note 92, at 310. Since patent holders have little control over the terms of compulsory licenses, 231See Goulding & Palriwala, supra note 14, at 12. patent holders are likely to voluntarily license to the MPP if remuneration from the compulsory license would be less than the royalties the patent holder would receive from the MPP. 232See supra note 219 and accompanying text. In this way, the mere threat of compulsory licensing and uncertainty over the terms of compulsory licenses places pressure on patent holders to voluntarily license to the MPP. 233Cox, supra note 92, at 320; see also Goulding & Palriwala, supra note 14, at 13. This threat of compulsory licensing can serve as an additional bargaining tool in licensing negotiations, lessening the imbalance of bargaining power in licensing negotiations between patent holders, pool administrators, and generic manufacturers. 234Cox, supra note 92, at 320; see also Goulding & Palriwala, supra note 14, at 13.

Compulsory licensing could also be used to expand the geographic scope of existing MPP licensing and sublicensing agreements. In addition, compulsory licenses could make patents available where the holders had previously been unwilling to negotiate with the MPP or the MPP had been unable to conclude a licensing agreement despite years of negotiations. 235See Cox, supra note 92, at 320. Most importantly for responding to the treatment timebomb, the exercise of TRIP flexibilities would allow developing countries to bypass the twenty years of patent protection guaranteed to medicines under TRIPS. 236See Germano, supra note 128, at 279. As a result, generic manufacturers could begin developing and distributing new and more affordable medicines right away, without first having to obtain the patent holders permission or conclude a voluntary licensing agreement. 237Id. at 292 (noting that Thailand began importing generic medicines only five weeks after it issued a compulsory license). Finally, by incorporating compulsory licensing into the MPP, criticism and reputational damage would no longer be the only significant consequences facing patent holders that decline or refuse to license to the MPP. Rather, patent holders that do not license to the MPP would face the very real possibility that their HIV medicines patents could be used without their consent and on potentially unfavorable terms by multiple developing countries collectively exercising their TRIPS flexibilities.

By issuing compulsory licenses, developing countries have the potential to increase participation in the MPP and make the MPP better equipped to facilitate access to new and more affordable HIV medicines. Developing countries should include the MPP in compulsory licenses to ensure that the patented medicines are available to multiple generic manufacturers to simulate competition and that generic manufacturers have access to all the patents needed to develop combination or pediatric treatments. 238Rosenberg, supra note 22. However, developing countries must overcome at least two obstacles before compulsory licensing can be used to make the MPP more effective at responding to the treatment timebomb. To successfully increase participation in the MPP and increase access to medicines, countries wishing to issue compulsory licenses under TRIPS must have the capacity and legal know-how to exercise TRIPS flexibilities. 239See Germano, supra note 128, at 284–85. In addition, developing countries must be prepared to face and overcome backlash from patent holders and developed countries. 240Treatment Timebomb, supra note 1, at 17; see also HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167.

TRIPS flexibilities are only available to a country if that country’s domestic law permits some form of compulsory licensing. 241TRIPS, supra note 177. Thus, countries must enact legislation and have administrative procedures in place before they can take advantage of TRIPS flexibilities and issue compulsory licenses. 242See Germano, supra note 128, at 284–85. However, the procedures for issuing compulsory licenses are complex and cumbersome, 243Id. (quoting a WHO representative who cited a “widespread lack of clarity about the options available” and a “lack of local legal and technical expertise to incorporate and implement TRIPS flexibilities in national law and policy” as major obstacles to issuing compulsory licenses). See also Treatment Timebomb, supra note 1, at 17 (noting that there is “impenetrable paperwork” required to exercise and implement TRIPS flexibilities). and countries often lack the legal capacity and know-how needed to exercise TRIPS flexibilities. 244Treatment Timebomb, supra note 1, at 17. To overcome this hurdle, organizations such as the World Intellectual Property Organization or the WTO could create technical guidelines to assist countries in establishing TRIPS legislation and administrative procedures. 245See id. at 18.

In addition, countries that issue compulsory licenses under TRIPS are likely to face backlash from patent holders and developed countries. 246Id. at 17 (citing “heavy political pressure from companies and foreign governments . . . not to use the flexibilities” as reasons why countries may be hesitant to issue compulsory licenses). See also HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167 (noting that compulsory licensing has not been used much by low- and middle-income countries because of the repercussions these countries may face from large pharmaceutical companies if they issue compulsory licenses). For instance, in 1997, forty-one pharmaceutical companies and the South African Pharmaceutical Manufacturers Association filed a lawsuit against the South African government after it passed legislation to issue compulsory licenses for patented HIV medicines. 247Mellino, supra note 229, at 1368; see also Germano, supra note 128, at 280–81. Similar incidents have occurred in Brazil 248A similar incident occurred in 2001 after the Brazilian government threatened to issue compulsory licenses for patented antiretrovirals if pharmaceutical companies did not authorize generic production of the patented medicines in Brazil. Germano, supra note 128, at 281. and Thailand. 249In 2007, Thailand issued several compulsory licenses for antiretroviral drugs owned by Merck and Abbott. HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167. Shortly thereafter, Abbott announced that it would not sell seven of its newest pharmaceutical products in Thailand. Id. In addition, both South Africa and Thailand were placed on the United States’ “watch list” after they issued compulsory licenses, subjecting them to potential trade sanctions for failing to provide adequate protection for intellectual property. 250See Mellino, supra note 229, at 1376–77; HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167. The backlash is not confined to countries issuing compulsory licenses; patent holders that oppose compulsory licensing are also likely to face criticism from the international global health community, which can have a significant impact on patent holder behavior. 251Mellino, supra note 229, at 1369. The lawsuit against South Africa was eventually dropped after the pharmaceutical companies faced backlash from the international community, including MSF. Id. Developing countries can act in concert with one another and with the international community to place pressure on patent holders or developed countries seeking to limit the exercise of TRIPS flexibilities to deter such action in the future. 252See Germano, supra note 128, at 294 (noting that by acting together, countries will have greater strength when going up against pharmaceutical companies and developed countries); Mellino, supra note 229, at 1369.

While compulsory licensing is not without controversy, encouraging developing countries to issue compulsory licenses can serve as a favorable, legal solution to overcome patent barriers imposed by TRIPS and respond to the treatment timebomb. In some cases, the mere willingness of developing countries to engage in compulsory licensing can serve as a sufficient incentive for patent holders to voluntarily participate in the MPP. 253Goulding & Palriwala, supra note 14, at 13; see also Germano, supra note 128, at 283. However, because compulsory licenses must be issued on a country-by-country basis, collective action by developing countries is needed to increase access to medicines on the urgent timeframe required by the treatment timebomb. 254See Bermudez & ‘t Hoen, supra note 19, at 39 (noting that compulsory licensing is less likely to reach economies of scale rapidly because they must be issued on a country-by-country basis). Only a concerted effort by low- and middle-income countries to issue compulsory licenses for patented HIV medicines can represent a viable solution to increasing participation in the MPP and facilitating access to new and more affordable antiretrovirals.

Conclusion

Significant progress has been made in recent decades to reduce drug prices and increase access to antiretrovirals to respond to the global HIV/AIDS crisis. 255See supra note 21 and accompanying text. However, the global health community is facing an impending treatment timebomb, due in part to the increased patenting of HIV medicines in developing countries in compliance with TRIPS. 256See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1, 7–8. A new collective action mechanism is needed to facilitate access to patented HIV medicines to overcome patent barriers underlying the treatment timebomb that have resulted from the implementation of TRIPS. 257Id. at 1, 7.

The MPP is a new approach to managing intellectual property designed to increase access to new and more affordable antiretroviral treatments that was created to respond to the treatment timebomb and overcome patent barriers imposed by TRIPS. 258Id. at 8. By pooling HIV medicine patents in a single entity, the MPP makes it easier for generic manufacturers to gain access to all the patents needed to develop and produce new combination and pediatric treatments. 259See Rosenberg, supra note 22. The MPP faces problems in attracting key patent holders to the pool and concluding broad licensing agreements, limiting its ability to effectively respond to the treatment timebomb.

This Comment has argued that the MPP is a valuable tool to increase access to new and more affordable HIV medicines if the incentives to participate can be increased. Compulsory licensing provides a legal solution under TRIPS to increase participation in the MPP and overcome patent barriers imposed by TRIPS. However, compulsory licenses must be issued on a country-by-country basis. 260Bermudez & ‘t Hoen, supra note 19, at 39. As a result, a concerted effort by developing countries hardest hit by the HIV/AIDS epidemic and least able to provide affordable treatment is needed to make the MPP more effective at increasing access to new and more affordable HIV medicines.

While compulsory licensing represents a viable solution to increasing participation in the MPP to facilitate access to HIV medicines in developing countries, a patent pool is only one of a broader set of policy changes needed to increase access to treatment in response to the global HIV/AIDS crisis. 261See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1. More funding for drug donation programs and research for new treatments, as well as support for global health initiatives from developed countries and pharmaceutical companies, is needed to ensure that access to medicines is protected “as a fundamental component of the human right to health.” 262Id. In the meantime, however, developing countries can collectively exercise their compulsory licensing flexibilities to push for more participation in the MPP and ensure that patent barriers imposed by TRIPS are not jeopardizing the ability to respond to the impending HIV/AIDS treatment timebomb.

Footnotes

1UNAIDS, Global Report: UNAIDS Report on the Global AIDS Epidemic 4 (2013) [hereinafter UNAIDS Global Report]. In 2009, only one-third of adults living with HIV had access to treatment. All-Party Parliamentary Group on AIDS, The Treatment Timebomb 5 (2009) [hereinafter Treatment Timebomb].

2UNAIDS Global Report, supra note 1.

3Drug Firms ‘Must Pool Patents’, BBC News, http://news.bbc.co.uk/2/hi/health/8150457.stm (last updated July 15, 2009). According to one estimate, approximately fifty-five million people will need access to antiretroviral treatments by 2030. Treatment Timebomb, supra note 1.

4Treatment Timebomb, supra note 1, at 12.

5Id. at 10.

6See Ellen ‘t Hoen, Jonathan Berger, Alexandra Calmy & Suerie Moon, Driving a Decade of Change: HIV/AIDS, Patents and Access to Medicines For All, 14 J. Int’l AIDS Soc’y 1, 7 (2011) [hereinafter ‘t Hoen et al., Driving a Decade of Change].

7See id. at 8.

8The United Kingdom All Party Parliamentary Group on AIDS coined the term “treatment timebomb” in July 2009. Id. at 8.

9See id. at 1.

10Id. at 8. TRIPS requires all World Trade Organization members to provide a minimum level of patent protection in all fields, including pharmaceuticals. Id. at 2–3. The implications of the implementation of TRIPS will be discussed briefly in Part I.A and in greater detail in Part III.B of this Comment.

11Id. at 2–3, 8.

12Id. at 1.

13See id.

14See Rebecca Goulding & Amrita Palriwala, Results for Dev. Inst., Patent Pools: Assessing Their Value-Added for Global Health Innovation and Access 3, 33 (2012).

15Michelle Childs, Towards a Patent Pool for HIV Medicines: The Background, 4 Open AIDS J. 33, 34 (2010).

16Id.

17IGWG Submission on Collective Management of Intellectual Property, Knowledge Ecology Int’l (Sept. 30, 2007), http://www.who.int/phi/public_hearings/second/contributions_section2/Section2_ManonRess-PatentPool.pdf [hereinafter IGWG Submission].

18Id.

19Jorge Bermudez & Ellen ‘t Hoen, The UNITAID Patent Pool Initiative: Bringing Patents Together for the Common Good, 4 Open AIDS J. 37, 38 (2010); see also Bradley J. Levang, Evaluating the Use of Patent Pools for Biotechnology: A Refutation to the USPTO White Paper Concerning Biotechnology Patent Pools, 19 Santa Clara Computer & High Tech. L. J. 229, 236–37 (2002).

20Medicines Patent Pool: Facilitating Access to HIV Treatment, WIPO Mag. (June 2011), http://www.wipo.int/wipo_magazine/en/2011/03/article_0005.html [hereinafter WIPO Magazine]. Historically, the pharmaceutical industry has not been seen as an appropriate forum for a patent pool model for a variety of reasons, including the importance of intellectual property in determining a pharmaceutical company’s worth and the likelihood that pharmaceutical patent holders will disagree over the value of patents in the pool. Comm’n on Intellectual Prop. Rights, Innovation and Public Health, Public Health, Innovation, and Intellectual Property Rights 53 (2006). Perceptions began to change in 2000 when the United States Patent and Trademark Office issued a report concluding that patent pools in biotechnology could be valuable tools to serve the interests of both public and private actors. Id.

21See, e.g., ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. Between 2003 and 2009, the number of people with access to HIV/AIDS antiretroviral treatments increased more than twelve-fold due to the increased availability of low-cost generic antiretrovirals, whose prices have dropped by over ninety-nine percent since 2000. See Ellen ‘t Hoen & Suerie Moon, An Innovative Approach to Achieving Access to Medicines For All, Medicus Mundi Switz. (Sept. 2010), http://www.medicusmundi.ch/de/bulletin/mms-bulletin/zugang-zu-medikamenten-fur-alle/debatten-und-ansaetze/an-innovative-approach-to-achieving-access-to-medicines-for-all [hereinafter ‘t Hoen & Moon, An Innovative Approach to Achieving Access]. The World Bank defines low-income countries as those having a Gross National Income (GNI) per capita of $1,045 or less in 2013; middle-income countries are defined as those having a GNI per capita of more than $1,045 but less than $12,746. Country and Lending Groups, World Bank, http://data.worldbank.org/about/country-and-lending-groups (last visited Feb. 7, 2015). The term “developing” is used to denote low- and middle-income countries. Id. The terms “low- and middle-income countries” and “developing countries” will be used interchangeably throughout this Comment.

22Tina Rosenberg, Sharing Patents to Wipe out AIDS, N.Y. Times (July 21, 2011), http://opinionator.blogs.nytimes.com/2011/07/21/sharing-patents-to-wipe-out-aids/?_r=0.

23See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8.

24Id. at 1, 7–8; see also Treatment Timebomb, supra note 1, at 12.

25See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8.

26Treatment Timebomb, supra note 1, at 10.

27Id. at 12 (noting that the “development of resistance is likely to happen to everybody over time”).

28Id.; see also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8. It is estimated that only three percent of people receiving antiretroviral treatments in developing countries are being treated with second line drugs. Treatment Timebomb, supra note 1, at 12.

29See Treatment Timebomb, supra note 1, at 10.

30Id. at 12. Combination treatments, however, are difficult to produce because more than one person may own the patented drugs, and manufacturers must obtain permission from all patent holders before the drugs can be combined into a single pill. See id. at 26.

31Id. at 6.

32Id. at 25.

33Id.

34Id.

35Rosenberg, supra note 22.

36Id.

37See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

38Id.

39Id.

40Id.

41Id. at 2. The World Trade Organization was established in 1995 to govern trade-related transactions between nations. What is the WTO?, World Trade Org., http://www.wto.org/english/thewto_e/whatis_e/whatis_e.htm (last visited Feb. 15, 2015).

42See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 2. In 2011, 153 countries were members of the WTO. Id.

43Id. at 8.

44Treatment Timebomb, supra note 1, at 20.

45See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1, 8.

46KEI is a not-for-profit organization that engages in research and advocacy to manage knowledge resources in areas of intellectual property, among others. About KEI, Knowledge Ecology Int’l, http://keionline.org/about (last visited Dec. 13, 2014).

47See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

48Id.; see also Goulding & Palriwala, supra note 14, at 12.

49Bermudez & ‘t Hoen, supra note 19, at 38. UNITAID was launched by the governments of Brazil, Chile, France, Norway, and the United Kingdom in 2006. Id. UNITAID is an innovative drug purchasing mechanism that obtains funding through a tax on airline tickets in participating member countries and through contributions from organizations such as the Bill and Melinda Gates Foundation and the Clinton HIV/AIDS Initiative. Id. As of 2010, twenty-nine countries had committed to contribute to UNITAID, the majority of which were low- or middle-income. Id. UNITAID has already experienced “considerable success” in reducing drug prices through bulk purchasing agreements. Treatment Timebomb, supra note 1, at 15.

50Médicins Sans Frontières, also known as Doctors Without Borders, is a medical humanitarian organization that provides medical care to people affected by armed conflict, natural disasters, and global epidemics, or who otherwise lack access to adequate medical care. About MSF, Médicins Sans Frontières, (last visited Jan. 3, 2015).

51Childs, supra note 15, at 34.

52Bermudez & ‘t Hoen, supra note 19, at 38.

53Id.

54WIPO Magazine, supra note 20; see also Goulding & Palriwala, supra note 14, at 19.

55Bermudez & ‘t Hoen, supra note 19, at 38.

56See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

57Rosenberg, supra note 22.

58Childs, supra note 15, at 34; see also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

59See ‘t Hoen & Moon, An Innovative Approach to Achieving Access, supra note 21; see also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1, 8.

60See Bermudez & ‘t Hoen, supra note 19, at 37. See supra note 30 and accompanying text.

61See Treatment Timebomb, supra note 1, at 6, 25.

62Asher Mullard, Straight Talk With Ellen ‘t Hoen, 16 Nature Med. 1351, 1351 (2010). See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8. By pooling medicines patents together, researchers can “access permission to use the component drugs from a single place, rather than having to negotiate company by company.” Treatment Timebomb, supra note 1, at 28.

63See IGWG Submission, supra note 17; ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 6. See also Rosenberg, supra note 22 (noting that patent pools can make patented medicines available to generic manufacturers right away).

64See Goulding & Palriwala, supra note 14, at 34.

65See id.

66See id.; Mullard, supra note 62, at 1351.

67Goulding & Palriwala, supra note 14, at 3.

68See Treatment Timebomb, supra note 1, at 28–29.

69See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 6. See also Drug Firms ‘Must Pool Patents’, supra note 3; Mullard, supra note 62, at 1351.

70Goulding & Palriwala, supra note 14, at 22.

71Bermudez & ‘t Hoen, supra note 19, at 39.

72Id. at 38.

73See id.

74See Treatment Timebomb, supra note 1, at 28–29.

75Bermudez & ‘t Hoen, supra note 19, at 38.

76Id. at 38–39.

77Id. at 38.

78See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

79Id. at 6 (noting that “licenses are critical because they can encourage robust competition among drug manufacturers” and competition drives down prices). See also id. at 8.

80Kelly Morris, HIV Drug Patents in the Spotlight, 9 Lancet 660, 661 (2009). See also Ellen ‘t Hoen, Pharmaceutical Companies and the UNITAID Patent Pool, 375 Lancet 30, 30 (2010) (“UNITAID has consulted with a wide range of stakeholders in the ongoing process of designing the Pool”).

81WIPO Magazine, supra note 20.

82Id.

83Id.

84Id.

85Id.

86Id.

87Goulding & Palriwala, supra note 14, at 21–22.

88About the MPP, Meds. Patent Pool, http://www.medicinespatentpool.org/about/ (last visited Sept. 30, 2015); William New, Medicines Patent Pool Signs 7 New Sub-Licenses for Generic HIV Drugs, Intell. Prop. Watch (July 18, 2014), http://www.ip-watch.org/2014/07/18/medicines-patent-pool-signs-7-new-sub-licences-for-generic-hiv-drugs/. After this Comment was written, the MPP released a report highlighting its successes over the past five years. To read more about the MPP’s latest achievements in greater detail, see generally Meds. Patent Pool, Progress and Achievements of the Medicines Patent Pool 2010–2015 (2015), http://www.medicinespatentpool.org/wp-content/uploads/WEB_Progress_Report_2015_EN.pdf [hereinafter progress and achievements of the MPP].

89Meds. Patent Pool, Antiretroviral Priorities of the Medicines Patent Pool 11 (4th ed. 2015)

90See Progress and Achievements of the MPP, supra note 88, at 1. As of December 2014, the MPP had signed sub-licensing agreements with ten generic manufacturers. See Company Engagement, Meds. Patent Pool, http://www.medicinespatentpool.org/company-engagement/ (last visited Sept. 26, 2015).

91WIPO Magazine, supra note 20.

92Krista Cox, The Medicines Patent Pool: Promoting Access and Innovation for Life-Saving Medicines Through Voluntary Licenses, 4 Hastings Sci. & Tech. L. J. 293, 300 (2012); see also WIPO Magazine, supra note 20; Kaitlin Mara, The Medicines Patent Pool: Improving Access to ARVs and Stimulating Innovation for New Medicines, Afr. Health, Jan. 2012, at 20–21.

93Cox, supra note 92, at 301 (noting that Tibotec has so far declined to negotiate with the MPP).

94Id. at 304. The Gilead license covered production of the drugs tenofovir (TDF), elvitegravir (EVG) and cobisistat (COBI), as well as a fixed-dose combination of the four drugs called the Quad; the license contains a covenant not to sue on emtricitabine (FTC). Id.; see also Licenses in the MPP, Meds. Patent Pool, http://www.medicinespatentpool.org/current-licences/ (last visited Sept. 26, 2015).

95See infra Part II.A for a detailed discussion of the incentives to participate in the MPP. See infra Part II.B for a discussion of the problems the MPP must overcome before it can attract patent holders and effectively respond to the global health crisis.

96Cox, supra note 92, at 304; see also Morris, supra note 80, at 660.

97Cox, supra note 92, at 306, 308.

98Id. at 308.

99Id. at 306 (noting that “[t]he exclusion of a number of middle-income countries, particularly those in Asia and Latin America, represents one of the main criticisms of the MPP/Gilead license”).

100Id. at 309.

101Licenses in the MPP, supra note 94. The agreement was amended in June 2015 to cover generic production of EVG in China and South Africa and to include a license to manufacture a combination of TDF/FTC with efavirenz (EFV). Id.

102Catherine Saez, New Medicines Patent Pool-Gilead Agreement for New HIV Drug in 112 Countries, Intell. Prop. Watch (July 24, 2014), .

103Licenses in the MPP, supra note 94. The MPP signed a licensing agreement with Bristol-Myers Squibb in 2013 for a key HIV medicine, which covers 110 low- and middle-income countries. Id.

104Id. The MPP signed two licensing agreements with ViiV Healthcare covering adult and pediatric use of a new drug, dolutegravir (DTG), used to treat HIV in 2014. Id. ViiV Healthcare is a collaboration between GlaxoSmithKline, Pfizer, and Shionogi. Id. The agreement has since been expanded to cover 127 countries for adult use and 121 countries for pediatric use. Progress and Achievements of the MPP, supra note 88, at 4.

105Licenses in the MPP, supra note 94. In November 2014, the MPP signed a licensing agreement with AbbVie for two HIV drugs for children. The Medicines Patent Pool (MPP) Signs Licensing Agreement with AbbVie for HIV Paediatric Formulations of Lopinavir and Ritonavir, Meds. Patent Pool (Dec. 1, 2014), http://www.medicinespatentpool.org/mpp-signs-licensing-agreement-with-AbbVie-for-HIV-paediatric-formulations-of-lopinavir-and-ritonavir/ [hereinafter MPP Signs Licensing Agreement]. The AbbVie licensing agreement covers 102 countries. Id.

106Licenses in the MPP, supra note 94. The Memorandum of Understanding included a binding agreement to license a drug for pediatric use in 118 countries. In addition, ViiV Healthcare agreed to license a pediatric HIV drug currently in development for use in 118 countries once approved by regulatory authorities. The Memorandum of Understanding was converted into a licensing agreement in April 2014. Id.

107Id. The price agreement will reduce the price of the drug by ninety percent in 138 developing countries. Id.

108Id.

109Mullard, supra note 62.

110 See Goulding & Palriwala, supra note 14, at 2122; Company Engagement, supra note 90.

111As of October 2015, the MPP had not signed any licensing agreements or entered into negotiations with Tibotec and Abbott. Medicines Patent Pool Announces Negotiations with Two Additional Pharmaceutical Companies, Meds. Patent Pool (July 18, 2011), http://www.medicinespatentpool.org/medicines-patent-pool-announces-negotiations-with-two-additional-pharmaceutical-companies/.

112 The MPP has been negotiating with Boehringer Ingelheim since 2011 but as of October 2015 still had not concluded a licensing agreement. Company Engagement, supra note 90.

113Target Medicines, Meds. Patent Pool, http://www.medicinespatentpool.org/licensing/target-medicines/ (last visited Feb. 13, 2015). In 2015, Johnson & Johnson began working with the MPP to support the Paediatric HIV Treatment Initiative (PHTI), a collaboration between the MPP, UNITAID, the Drugs for Neglected Diseases initiative (DNDi), and the Clinton Health Access Initiative, which was launched in May 2014 to “speed the development of better-adapted HIV medicines for children living in resource-limited countries.” See The Medicines Patent Pool on Janssen’s Extension of its Access Policy for Paediatric Medicine Darunavir (Statement), Meds. Patent Pool, http://www.medicinespatentpool.org/the-medicines-patent-pool-mpp-statement-on-janssens-extension-of-its-access-policy-for-paediatric-medicine-darunavir-to-support-the-work-of-the-paediatric-hiv-treatment-initiative-phti/ (last visited Sept. 18, 2015); Company Engagement, supra note 90.

114See Treatment Timebomb, supra note 1, at 15; Goulding & Palriwala, supra note 14, at 29.

115Treatment Timebomb, supra note 1, at 29.

116Id.

117Id. at 19.

118See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1.

119See id.

120Bermudez & ‘t Hoen, supra note 19, at 39.

121Id.

122Mullard, supra note 62.

123Bermudez & ‘t Hoen, supra note 19, at 39; see also Mara, supra note 92.

124Bermudez & ‘t Hoen, supra note 19, at 39; see also Mara, supra note 92.

125Mullard, supra note 62.

126See Bermudez & ‘t Hoen, supra note 19, at 39.

127Id. This incentive will be addressed in greater detail in Part III.B.

128See, e.g., Sara Germano, Compulsory Licensing of Pharmaceuticals in Southeast Asia: Paving the Way for Greater Use of the TRIPS Flexibility in Low- and Middle-Income Countries, 76 UMKC L. Rev. 273, 280-81 (2007). Compulsory licensing and TRIPS will be discussed in greater detail in Parts III.A and B.

129Bermudez & ‘t Hoen, supra note 19, at 39. This incentive will be addressed in greater detail in Part III.B.

130See id.

131Id.

132The roadblocks discussed in Part II.B are meant to be an inclusive but not exhaustive list—the MPP may face additional roadblocks in achieving its mission of increasing access to newer and more affordable HIV medicines that are beyond the scope of this Comment.

133See Goulding & Palriwala, supra note 14, at 33.

134See id. at 4, 30.

135Bermudez & ‘t Hoen, supra note 19, at 39. See also ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

136See Goulding & Palriwala, supra note 14, at 35.

137Cox, supra note 92, at 308.

138Tibotec Signs Multiple Agreements with Generic Manufacturers to Provide Access to New HIV Treatment, Johnson & Johnson (Jan. 27, 2011), http://www.investor.jnj.com/releasedetail.cfm?ReleaseID=545920.

139See Goulding & Palriwala, supra note 14, at 30 (noting that patent holders are hesitant to voluntarily license their medicines because of the potential for “unsanctioned reimportation of generic products from lower- or lower-middle-income markets into middle- or high-income markets”). See also Josh Ruxin, AIDS Drugs-For Profit or Not?, Forbes (Nov. 11, 2010), http://www.forbes.com/sites/sciencebiz/2010/11/11/aids-drugs-%E2%80%93-for-profit-or-not/; What’s Behind U.S. Drug Companies’ Response to the AIDS Crisis Abroad?, Wharton (Apr. 11, 2001), http://knowledge.wharton.upenn.edu/article/whats-behind-u-s-drug-companies-response-to-the-aids-crisis-abroad/.

140See Nikhil Kumar, Big Pharma and the Business of HIV/AIDS, Independent (Dec. 1, 2010), http://www.independent.co.uk/news/business/analysis-and-features/big-pharma-and-the-business-of-hivaids-2147987.html; Daniel Costello, HIV Treatment Becomes Profitable, L.A. Times (Feb. 21, 2008), http://articles.latimes.com/print/2008/feb/21/business/fi-hiv21.

141See Morris, supra note 80, at 660. Gilead Sciences, for example, the patent owner of tenofovir disoproxil fumarate (TDF), has control over generic manufacturers in negotiating its license agreements. Id.

142See id. at 661; Cox, supra note 92, at 306–07. The inclusion of middle-income countries in the scope of MPP licenses was one of the most contentious issues when the MPP was created. Childs, supra note 15, at 35.

143Morris, supra note 80, at 661.

144Id.

145Cox, supra note 92, at 311.

146Licenses in the MPP, supra note 94.

147Cox, supra note 92, at 309 (noting that negotiations with patent holders involve competing interests and that it may be necessary for the MPP to change certain terms of the licenses or create new incentives in order to achieve more favorable provisions); see also Bermudez & ‘t Hoen, supra note 19, at 38 (noting that licenses need to cover both low and middle-income countries in order to attract multiple generic manufacturers and stimulate the level of competition needed to lower drug prices).

148See Goulding & Palriwala, supra note 14, at 3, 30 (noting that to be effective, the MPP needs to make it faster and easier for patent holders and generic manufacturers to license patented medicines).

149See supra note 63 and accompanying text.

150Mullard, supra note 62.

151See Saez, supra note 102; Progress and Achievements of the MPP, supra note 88, at 1. Tenofovir was licensed to the MPP in 2011 by Gilead Sciences. Licenses in the MPP, supra note 94. The MPP has also distributed TDF combination drugs in 115 countries. Progress and Achievements of the MPP, supra note 88, at 10.

152Saez, supra note 102 (“The price of TDF has dropped 45%-87% in the past two years and the MPP’s generic partners have distributed three million TDF treatments in the same time period.”).

153See Progress and Achievements of the MPP, supra note 88, at 11 (noting that “for new ARVs, savings are likely to start three-four years after the MPP license is signed”).

154Mullard, supra note 62.

155See Company Engagement, supra note 90.

156See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 7–8.

157See Cox, supra note 92, at 319, 323 (noting that there is a need for an additional “stick” to place pressure on and encourage patent holders to participate in the MPP).

158See Hannah Semigran, Altruism and Profit: The Changing Role of Pharmaceutical Companies in Global Health, Harv. C. Global Health Rev. (Feb. 1, 2012), http://www.hcs.harvard.edu/hghr/print/spring-2011/altruism-profit-pharma/. See also Philippe Douste-Blazy & Jorge Bermudez, GSK: Please Extend Patent Pool to AIDS Drugs, 373 Lancet 1339, 1339 (2009); Drug Firms ‘Must Pool Patents’, supra note 3.

159Semigran, supra note 158. See also Cox, supra note 92, at 301. Merck only began negotiating with the MPP in the second quarter of 2014. Company Engagement, supra note 90.

160Elizabeth Sukkar, Patent Pools: An Idea Whose Time Has Come, 338 Brit. Med. J. 974, 975 (2009). As one official from Glaxo-Smith Kline put it:For HIV, we believe that extensive research is already underway, and thus it is not a neglected disease. Millions of dollars are ploughed into research into HIV every year by the pharmaceutical industry. To improve access, we already have an extensive voluntary licensing programme for HIV across Sub Saharan Africa, involving eight licensees. These licensees are free to develop FDCs and paediatric versions and we believe this is a much simpler approach than the creation of a patent pool . . . [a]ll our ARVs are also available at not-for-profit prices in all Least Developed Countries and Sub Saharan Africa. We therefore do not see the need to include our HIV patents in any pool.Treatment Timebomb, supra note 1, at 28–29.

161Semigran, supra note 158. In 2011, Tibotec issued a formal statement refusing to enter into negotiations with the MPP for darunavir and several of its other HIV drugs. Cox, supra note 92, at 301.

162See Goulding & Palriwala, supra note 14, at 4–5. The potential to avoid compulsory licensing was listed as an incentive for patent holders to participate in the MPP when it was created in 2010. Bermudez & ‘t Hoen, supra note 19, at 39. However, since the MPP was created, few countries have taken steps to issue compulsory licenses for HIV medicines patents. See Catherine Saez, Ecuador Grants First Compulsory License for HIV/AIDS Drug, Intell. Prop. Watch (Apr. 22, 2014), http://www.ip-watch.org/2010/04/22/ecuador-grants-first-compulsory-licence-for-hivaids-drug/ (noting that Ecuador issued a compulsory license for an antiretroviral drug owned by Abbott in 2010); Peter Maybarduk, US Government Special 301 “Watchlist” and Developing Country Use of Compulsory Licenses for Healthcare, Infojustice (May 2, 2013), http://infojustice.org/archives/29493 (noting that Thailand renewed its compulsory license for two antiretrovirals in 2010). This Comment argues that a more concerted effort by developing countries to issue compulsory licenses for HIV medicines is needed to provide a sufficient incentive for patent holders to voluntarily join the MPP. See infra Part III.C.

163See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

164See supra Part II.B.

165Germano, supra note 128, at 279–80 (citing Frederick Abbott et al., International Intellectual Property in an Integrated World Economy 55 (2007)).

166Goulding & Palriwala, supra note 14, at 15.

167HIV/AIDS, TRIPS, and Second-Line Therapy, AVERT, http://www.avert.org/hiv-drugs-patents-legislation.htm (last visited Feb. 12, 2015).

168See Germano, supra note 128, at 279; see also Karin Timmermans & Togi Hutadjulu, Indon. Ministry Health, The TRIPS Agreement and Pharmaceuticals 32 (2000).

169Germano, supra note 128, at 277.

170See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 2. India began providing patent protection for pharmaceuticals in 2005. Id. at 4.

171Id. at 2.

172Treatment Timebomb, supra note 1, at 21.

173See supra Part I.A.

174Treatment Timebomb, supra note 1, at 19.

175Id. at 20.

176Id. at 17.

177Agreement on Trade-Related Aspects of Intellectual Property Rights art. 31, Apr. 15, 1994, Marrakesh Agreement Establishing the World Trade Organization, Annex 1C, 1867 U.N.T.S. 31875 [hereinafter TRIPS]. See also Treatment Timebomb, supra note 1, at 17.

178See Germano, supra note 128, at 281–82.

179TRIPS, supra note 177.

180Germano, supra note 128, at 284–85.

181TRIPS, supra note 177.

182Id.

183Id.

184Id.

185Id.

186Id.

187Id.

188Id.

189Id.

190World Trade Organization, Ministerial Declaration of 14 November 2001, WTO Doc. WT/MIN(01)/DEC/2, 41 I.L.M. 746 (2002) [hereinafter Doha Declaration].

191Id. ¶¶ 3–4.

192Id. ¶ 4.

193Id. ¶ 5(b).

194Id. ¶ 5(c).

195See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 8.

196See Bermudez & ‘t Hoen, supra note 19, at 39 (noting that compulsory licensing is not a systematic solution to solving the global HIV/AIDS crisis).

197Although MSF preferred a voluntary licensing approach in its initial proposal for an HIV medicines patent pool, it did not rule out the possibility that a mandatory system should be adopted, if the voluntary approach failed. Childs, supra note 15, at 34. At least one scholar has suggested that countries could support the MPP by issuing compulsory licenses. Cox, supra note 92, at 323. This Comment explores more seriously compulsory licensing as an option to increase participation in the MPP, in arguing that compulsory licensing is an effective tool to increase participation in the MPP and respond to the treatment timebomb.

198See, e.g., ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 3.

199TRIPS, supra note 177.

200See Cox, supra note 92, at 321–22.

201See id. at 301.

202See id. at 319–20 (noting the role that compulsory licenses could play in increasing the geographic coverage of the MPP/Gilead license).

203See TRIPS, supra note 177.

204See Treatment Timebomb, supra note 1, at 19 (noting that “where few generic manufacturers are allowed to produce a medicine, the impact [on reducing drug prices] will be limited because competition is limited”); see also Rosenberg, supra note 22.

205Rosenberg, supra note 22.

206Doha Declaration, supra note 190, ¶ 5(c).

207TRIPS, supra note 177.

208Id.

209Id.

210Id. A detailed discussion of remuneration guidelines is beyond the scope of this Comment. For a more detailed discussion on remuneration guidelines, see James Love, Measures to Enhance Access to Medical Technologies, and New Methods of Stimulating Medical R&D, 40 U.C. Davis L. Rev. 679, 688-694 (2007).

211James Love, World Health Org., Remuneration Guidelines for Non-Voluntary Use of a Patent on Medical Technologies 58 (2005).

212TRIPS, supra note 177.

213Id.

214See Bermudez & ‘t Hoen, supra note 19, at 38.

215See Treatment Timebomb, supra note 1, at 19 (noting that voluntary licensing is “an effective way to avoid expense and damaging legal battles over compulsory licensing”).

216See Goulding & Palriwala, supra note 14, at 15.

217See Bermudez & ‘t Hoen, supra note 19, at 39.

218See supra notes 141–47 and accompanying text.

219See Germano, supra note 128, at 291 (noting that HIV medicines patent holders subject to a compulsory license issued by the Indonesian government only received a 0.5% royalty).

220See id. at 294.

221Goulding & Palriwala, supra note 14, at 35; see also Germano, supra note 128, at 279–80.

222Germano, supra note 128, at 286.

223Id. at 288. The compulsory license was successful in reducing the cost of three antiretroviral drugs by eighty-one percent. In addition, the compulsory license led pharmaceutical companies to make additional price reductions on other first and second-line treatments. Id.

224Id. at 289–93; see also Goulding & Palriwala, supra note 14, at 13.

225Goulding & Palriwala, supra note 14, at 16.

226See supra Part II.B.

227See supra notes 216–19 and accompanying text.

228TRIPS, supra note 177.

229Marla L. Mellino, The TRIPS Agreement: Helping or Hurting Least Developed Countries’ Access to Essential Pharmaceuticals?, 20 Fordham Intell. Prop. Media & Ent. L. J. 1349, 1364 (2010).

230See Cox, supra note 92, at 310.

231See Goulding & Palriwala, supra note 14, at 12.

232See supra note 219 and accompanying text.

233Cox, supra note 92, at 320; see also Goulding & Palriwala, supra note 14, at 13.

234Cox, supra note 92, at 320; see also Goulding & Palriwala, supra note 14, at 13.

235See Cox, supra note 92, at 320.

236See Germano, supra note 128, at 279.

237Id. at 292 (noting that Thailand began importing generic medicines only five weeks after it issued a compulsory license).

238Rosenberg, supra note 22.

239See Germano, supra note 128, at 284–85.

240Treatment Timebomb, supra note 1, at 17; see also HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167.

241TRIPS, supra note 177.

242See Germano, supra note 128, at 284–85.

243Id. (quoting a WHO representative who cited a “widespread lack of clarity about the options available” and a “lack of local legal and technical expertise to incorporate and implement TRIPS flexibilities in national law and policy” as major obstacles to issuing compulsory licenses). See also Treatment Timebomb, supra note 1, at 17 (noting that there is “impenetrable paperwork” required to exercise and implement TRIPS flexibilities).

244Treatment Timebomb, supra note 1, at 17.

245See id. at 18.

246Id. at 17 (citing “heavy political pressure from companies and foreign governments . . . not to use the flexibilities” as reasons why countries may be hesitant to issue compulsory licenses). See also HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167 (noting that compulsory licensing has not been used much by low- and middle-income countries because of the repercussions these countries may face from large pharmaceutical companies if they issue compulsory licenses).

247Mellino, supra note 229, at 1368; see also Germano, supra note 128, at 280–81.

248A similar incident occurred in 2001 after the Brazilian government threatened to issue compulsory licenses for patented antiretrovirals if pharmaceutical companies did not authorize generic production of the patented medicines in Brazil. Germano, supra note 128, at 281.

249In 2007, Thailand issued several compulsory licenses for antiretroviral drugs owned by Merck and Abbott. HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167. Shortly thereafter, Abbott announced that it would not sell seven of its newest pharmaceutical products in Thailand. Id.

250See Mellino, supra note 229, at 1376–77; HIV/AIDS, TRIPS, and Second-Line Therapy, supra note 167.

251Mellino, supra note 229, at 1369. The lawsuit against South Africa was eventually dropped after the pharmaceutical companies faced backlash from the international community, including MSF. Id.

252See Germano, supra note 128, at 294 (noting that by acting together, countries will have greater strength when going up against pharmaceutical companies and developed countries); Mellino, supra note 229, at 1369.

253Goulding & Palriwala, supra note 14, at 13; see also Germano, supra note 128, at 283.

254See Bermudez & ‘t Hoen, supra note 19, at 39 (noting that compulsory licensing is less likely to reach economies of scale rapidly because they must be issued on a country-by-country basis).

255See supra note 21 and accompanying text.

256See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1, 7–8.

257Id. at 1, 7.

258Id. at 8.

259See Rosenberg, supra note 22.

260Bermudez & ‘t Hoen, supra note 19, at 39.

261See ‘t Hoen et al., Driving a Decade of Change, supra note 6, at 1.

262Id.

Editor-in-Chief, Emory International Law Review; J.D. Candidate, Emory University School of Law (2016); M.S.P.H., Johns Hopkins University (2013); B.S., summa cum laude, Auburn University (2011). The author would like to thank Professor Liza Vertinsky for her thoughtful advice in writing this Comment. The author would also like to thank her parents, Pam and Bruno Ulrich, and David Baker for their continuous love and support.