It could wipe out H.I.V. in America, but its high price keeps it out of reach for too many.
On July 3, 1981, this newspaper wrote about a “rare cancer” killing gay men in New York and California. Though few knew it, what followed would be a generation-defining battle: for attention, for legitimacy, for our very lives. Today, after 37 years, we finally have a proven pathway to ending the AIDS epidemic in this country.
The only catch? Poor policy and pharmaceutical price-gouging have blocked the way, making critical drugs a luxury rather than an imperative.
The solution comes in a pill: Taken daily, Truvada, the brand name for a type of pre-exposure prophylaxis, or PrEP, is up to 99 percent effective at preventing H.I.V. infection. Used as directed, it’s one of the most effective methods of preventing a viral infection ever discovered, as good as the polio vaccine, the miracle of modern medicine. When you combine PrEP’s effectiveness with the discovery that people living with H.I.V. cannot transmit the virus to others once they become undetectable, we could be on the verge of a swift end to the epidemic.
Truvada was approved by the Food and Drug Administration in 2012. But over six years later, the United States is failing miserably in expanding its use. Less than 10 percent of the 1.2 million Americans who might benefit from PrEP are actually getting it. The major reason is quite clear: pricing. With a list price over $20,000 a year, Truvada, the only PrEP drug available in the United States, is simply too expensive to become the public health tool it should be.
Gilead Sciences, the company that makes Truvada, maintains a monopoly on the drug domestically. In other countries, a one-month supply of generic Truvada costs less than $6, but Gilead charges Americans, on average, more than $1,600, a markup from the generic of 25,000 percent.
Infuriatingly, American taxpayers and private charities — not Gilead — paid for almost all of the clinical research used to develop Truvada as PrEP. Yet the price stays out of reach for millions, and will for at least several more years.
The disparities in PrEP access are astounding: Its use in black and Hispanic populations is a small fraction of that among whites. In the South, where a majority of H.I.V. infections occur, use is half what it is in the Northeast. Women use PrEP at drastically lower rates than men, and while there’s no national data on PrEP and transgender Americans, it’s almost certainly underused. The issue of PrEP access has become an issue of privilege.
The ability of PrEP to greatly reduce new H.I.V. infections is no longer in question. In New South Wales, Australia, a program providing free access to PrEP led to a drop in H.I.V. diagnoses in the most vulnerable communities by a third in just six months, one of the fastest declines recorded since the global AIDS crisis began.
So how can we import such progress into the United States? Faced with more than half a decade of inaction by the federal government, activists have developed their own national strategy to begin the end of the H.I.V. epidemic. At the International AIDS Conference later this month, our organization, the PrEP4All Collaboration, will release its plan for a national PrEP program to ensure all Americans who need PrEP can get it.
A critical component of this plan is insisting that federal agencies use their statutory authority to break Gilead’s undeserved monopoly. With low-price, generic Truvada, the cost to cover every American who needs PrEP — including both drug costs and clinical care — would be less than a tenth the amount that the federal government already spends on H.I.V. care. The billions saved could pay for vital services to ensure those who need PrEP the most can get it and those living with H.I.V. can keep the virus suppressed. If the patent on Truvada remains, the plan will cost over $20 billion.
In addition to preventing more than 10,000 new H.I.V. infections a year, a national PrEP program would connect some of the most vulnerable in our communities to care. Frequent screening — a required component of PrEP care — could decrease rates of other sexually transmitted infectionsthrough prompt treatment, even if rates of condom use decrease.
In under 40 years, we’ve lost more Americans to H.I.V. than to combat in all of our wars combined. Science has delivered answers, but Gilead’s greed and the government’s inaction are keeping it from those who need it most. There’s a pill that stops H.I.V. We can make it possible for everyone who needs that pill to get it.
By James Krellenstein, Aaron Lord and Peter Staley
Mr. Krellenstein and Mr. Staley are co-founders of the PrEP4All Collaboration. Dr. Lord is a physician at New York University School of Medicine.