Accessibility to LDL-C Lowering Treatments
Access to medication in LMICs is limited (67). If LDL-C lowering treatments are not included in the basic medication plans, the population requiring treatment will not have access due to financial barriers. The availability of medication for chronic diseases (including ASCVD) was reported to be less than 30% in public facilities across six LMICs, with a wide variation in affordability of one month of IHD treatment, ranging from 1.5 to 18.4 days of a minimum wage (68). Affordability of combination therapy for secondary prevention of ASCVD (aspirin, beta-blockers, ACE inhibitors, and statin) using a threshold of 20% of per household capacity to pay was evaluated. In low income countries, the use of the four drugs was not affordable for 60% of participants, and 33% of those in lower-middle income countries (68).
Access to pharmacological treatment for LDL-C is uneven within the countries in the region. Costs of these treatments may be more relevant in some instances. For example, in Brazil, the median cost of the recommended statin for ASCVD was only affordable for 3% of Brazilian households (67, 69). High-intensity statins are available in various public health systems across the region. However, in some countries these medications are not covered, making them unaffordable for the majority of the population (70). In other scenarios, high intensity statins, although approved, are not available at local pharmacies. The alternative to access medication through judicialization is a reality in several LATAM countries; this strategy demonstrates the need to implement effective measures for the correct access to medication (71).
Decreasing drug prices achieved with the introduction of generics have a strong impact on the incremental cost-effectiveness ratio for statin therapy and may prove to be appropriate treatment even for very low-risk patients. From a cost perspective, treatment decisions should not be made strictly based on financial criteria, but through an evaluation of each patient’s risk level as well as the current drug availability. It should be noted that treating patients based purely on an evaluation of cost-effectiveness would mean statin therapy should be expanded beyond current treatment guidelines to include lower risk patients (72). The programs that follow the clinical practice guidelines based on statin reduction of LDL-C are cost-effective across the spectrum of cardiovascular risk. The addition of ezetimibe and PCSK9i for high risk patients and patients with high-risk FH is also cost effective. These economic analyses are needed to allow health systems to recognize the population that will benefit from such therapies (73).
Several access barriers to management of ASCVD have been identified across the region. Medical inertia to implement preventive medicine has been reported in LATAM countries (74) because physicians treat the disease and not the cardiovascular risk.
Some of the programs implemented in LATAM are aimed at reducing NCDs and focus on reducing ASCVD, however, LDL-C profiles are not measured and treatment awareness in both the primary and secondary settings is lacking (74). Throughout the years, LATAM has strengthened the generic medication policy by encouraging uptake in treatment by patients, aiming to reduce the number of deaths and hospitalizations due to NCDs (75-77). ASCVD is the leading cause of death in LATAM and despite a consistent decrease in mortality trends it continues to account for over 5 years of life lost in most countries (78).