Josua Lottering, an 18-year-old from the Western Cape in South Africa, arrived in Dhaka, Bangladesh, recently to obtain a generic version of Trikafta, a cystic fibrosis medication that has revolutionized treatment for patients in wealthier countries but remains prohibitively expensive for many elsewhere. Despite suffering severe coughing fits aggravated by Dhaka’s polluted, humid environment, Josua traveled with his mother to secure a year’s supply of the drug at a fraction of the cost found in their home country.

Trikafta, developed by Boston-based Vertex Pharmaceuticals, has significantly extended and improved quality of life for people with cystic fibrosis since its 2019 launch. However, its high price—around $346,000 annually in the United States—and the company’s exclusive control over its distribution have restricted access in many lower-income countries. Vertex has not registered the drug in numerous markets with fewer resources and has actively resisted the production of lower-cost generic versions to protect its pricing in affluent regions.

In contrast, a Bangladeshi pharmaceutical firm, Beximco Pharmaceuticals, has reverse-engineered the drug, producing a generic named Triko and selling it for approximately $6,350 a year for children, with adult doses costing double that. Bangladesh’s status as a least-developed country exempts it from international patent enforcement, allowing local manufacturers to produce generic drugs without violating intellectual property laws. This environment, combined with legal provisions in many countries permitting patients to import generics for personal use, has enabled individuals like Josua to access life-saving medication otherwise out of reach.

Beximco, which has previously manufactured affordable generics for hepatitis C and COVID-19 treatments, began production of Triko following appeals from cystic fibrosis patients and families worldwide. Rabbi Reza, the company’s chief operating officer, emphasized the ethical commitment behind producing the drug despite patent barriers, framing it as an effort to reduce global inequities in healthcare access.

While Vertex spokeswoman Heather Nichols noted that Trikafta is available in 75 countries through sales or donations and is provided free to patients in 15 countries, many cystic fibrosis patients remain excluded from these programs. Families have pursued alternative routes, including litigation and petitions for compulsory licensing, to obtain the drug. Nichols also stressed that Vertex has invested heavily in extensive clinical trials to ensure the drug’s safety and efficacy, a process not typically undertaken by generic manufacturers.

Patients and families in countries lacking access to affordable treatment face significant challenges. In South Africa, for example, Vertex patented Trikafta but delayed registration, prompting legal battles that resulted in partial insurance coverage for some patients but left many reliant on public healthcare without access. Josua’s mother, Wilna Lottering, was quoted describing the financial impossibility of purchasing the drug locally, even with insurance, equating a six-month supply to selling their home.

In Bangladesh, Aadil Rahman, a six-year-old patient, and his family encountered similar obstacles. Diagnosed late after years of medical visits, they found the original drug out of reach and resorted to exploring clinical trials and direct appeals, none viable due to nationality or cost. The availability of Triko offers hope for families like the Rahmans, though even the generic price remains a significant economic burden.

Beximco has initiated a limited production run sufficient for a few dozen patients and plans to assess demand moving forward. The model of producing generics in low-income countries and facilitating cross-border access is gaining attention among patient groups as a potential mechanism to address disparities in access to life-saving medications worldwide.