There is always a point in researching any highly specialized subject when the documents you are reading stop being written in English. It doesn’t matter what the field is—biomedical research, law, literary criticism—there is a line in the sand that is inevitably crossed in the nerdy glee of the authors’ scribbling that renders the document utterly useless to 99.9% of the population. I was recently sent a paper from the journal Nature Reviews Immunology, which was intended to help explain the recent strategy devised by The International AIDS Society Scientific Working Group on HIV Cure. It did not do that. What it did do was give me a truly heinous migraine and convince me that HIV researchers secretly devised a scheme to write every third sentence of their published papers in Esperanto. Therefore, I will not be giving an in-depth scientific analysis of the potential benefits and drawbacks of the most recent wave of HIV vaccines, nor will I be demonstrating the mechanisms by which they work. I have no idea what in the holy hell a macrophage or astrocyte is, and I don’t have the time to look it up. Okay, that last bit was a lie. I woke up at 9:30 this morning and the only thing I had to do drive down to DC and pee into a cup for the Federal Government so they could be sure that they weren’t hiring an intern who was on the dope. However, even if I had the energy to look those terms up, I’m fairly confident that most of my readers wouldn’t have the energy to give a shit what they meant. I don’t really care how these vaccines work; I just care that they work. My job is to try and figure out why they haven’t worked yet and why no one seems to be talking about them.
Now, for all of the optimistic talk at AIDS 2012 about having an AIDS Free Generation and getting to zero new infections or AIDS-related deaths, there’s a fairly sizable fly in the ointment. Namely, that with our current strategies of preventing and treating HIV, those goals are patently impossible. That’s not me being pessimistic; it’s just fact. There are 34 million people estimated to be living with HIV globally and that number has to be estimated because it is believed that 20 million of those people have no idea that they’re positive. So, even if, by miracle of all miracles, everyone in the world who is aware of their serostatus were to be put on anti-retroviral therapy, it wouldn’t even cover half of all HIV+ people worldwide. In reality, the United Nations has estimated that for every one person that is put on ART, two more are infected with the virus. Chop off the head and two new ones grow back in its place. At present, all anti-retroviral therapy is doing on a global scale is placing speed bumps in front of the disease. At the individual level, ART is saving millions upon millions of lives and allowing HIV+ people to live full, rich lives, but personal success in this case doesn’t translate into victories in the fight against HIV in the long run. And, on top of that, we have little idea how these potent medications will effect the human body after decades of use and into old age. So far, being positive and being on ART has been shown to dramatically increase the risk for a number of medical issues like heart attack and kidney failure.
It should be clear that anti-retroviral therapy is not an endgame. It is a very imperfect way to suppress HIV, but not to get rid of it or cure it. An ART regimen is extremely difficult to adhere to and any patient who takes it must do so every day for the rest of their life, despite the side effects that come with many medications. If this is the case, then why are we only spending 10% of our government’s 2013 HIV budget on research and an even more paltry 3% on prevention? Staying on the course we have charted thus far will win us a pyrrhic victory at best. Without serious efforts at prevention and vaccine research, the best we can hope to do is treat HIV+ people faster than they can be infected. But, even in that best case scenario, the prevalence rates will still rocket skyward and the number of people who need permanent pharmaceutical and medical assistance will pile up to untreatable levels. Up until this past month when the federal government promised to step in, there were nearly 2,400 HIV+ people in the US who were on ADAP (AIDS Drug Assistance Program) waiting lists—most of them in south. We can’t even give meds to people today when only 28% of all positive Americans are in care and on ART. What does the future look like when we’ve struggled mightily in treating the tip of this ever-expanding iceberg?
For starters, it looks lucrative. Even during these lean times, Big Pharma is doing just fine and HIV medications have contributed mightily to some companies’ profit margins. Gilead Sciences, the makers of the HIV drugs Atripla, Truvada & Complera/Eviplera, saw a 13% increase in total revenues during the 2nd quarter of 2012. Of the $2.41 billion in revenue raked in by Gilead, $1.98 billion of that was generated by HIV medications. Since Gilead had their first anti-retroviral medication—Tenofovir—approved in 2001, their stock has increased more than sixfold from roughly $8 a share to a robust $57 as of this afternoon. That is some serious cash. Well, at least serious enough to not have anyone in the organization bat an eye while CEO John C. Martin pulls in $43 million a year. I mentioned that in my last article on Gilead in June, but goddamn if it is so disgusting that it bears repeating.
From a business standpoint, HIV is the perfect disease to get rich off of. Think about it. You’ve got a massive pandemic that has continued to grow at alarming rates for over 30 years. There is an endless supply of potential customers who have to buy your product or else they die. The best that medical science has come up with is a class of drugs that suppresses the virus, but doesn’t fully get rid of it so that clients have to take the pills for the rest of their life. And, once you get in on the ground floor and create your own anti-retroviral medication, you patent the son of a bitch and have exclusive rights to distribution for anywhere from 10 to 20 years. The kicker is that since the most of your drugs are purchased through Medicare or ADAP programs domestically, the government is the one footing the bill, which bursts a Willy Wonka & The Chocolate Factory glass elevator-sized hole in the ceiling of how much money you can rake in. Because, let’s face it, the Fed ain’t exactly good with managing their finances. When you’re $16 trillion in debt, what’s a few billion here and there?
It is a brilliant system and an HIV vaccine completely cocks the whole thing up. Now, I can feel the Oliver Stone-style conspiracy theorists raising their hands already, but that’s not where this is going. There is no international pharmaceutical illuminati keeping HIV vaccines from becoming reality. It’s simply Capitalism at it’s finest. Currently, there is no profit motive for creating a new HIV vaccine, which is why so little money is being pumped into research and development to try and find one. If a truly successful preventative or therapeutic vaccine were mass produced, it would completely eviscerate pharmaceutical companies who depended on HIV drugs for a large chunk of their revenue. Vaccines are easier to administer than pills and the like because you only have to do it but a few times. Suddenly, a never-ending supply of customers becomes dangerously finite. If you’re a drug company and your goal is to turn a profit (forget that altruistic crap…if they could make more money selling car stereos, they’d be doing just that), why would you ever bother investigating a vaccine that would take a hacksaw to your sacred calf?
This might all sound terribly pessimistic and cynical, but if anyone else can give me a better reason why so little attention & funding is being given to curing HIV, I’m all ears. It’s just like the automotive industry and the concept of “renewable energy”. Hell, we could have a whole armada of Hydrogen-powered cars out on the streets if we wanted to. We’ve already made some of them, not to mentioned their electric brethren that are slowly coming of production lines. But, why would an industry that is surrounded by a giant moat of black gold voluntarily cut off their supply line to decades of profit? Renewable isn’t profitable–limited is. The only reason that Ethanol disaster happened in the first place is because we had too much damn corn on our hands and the federal government had to find a way to artificially raise corn prices. Cash is king and until the scientific community can find a way to make an HIV vaccine that raises profit margins along with CD4 counts we’re all going to be popping pills for a long time to come.
Categories: HIV News, Social Justice
Virally Suppressed - Muckraking For The Modern World 
We will not end this epidemic without finding new tools. Yet the massive research budget at NIH for HIV/AIDS uses less than 3 percent for cure research. This is not acceptable! Thanks for writing this well informed article.
I’m an epidemiologist with some experience studying HIV transmission in Africa, and I’m really impressed with this analysis of what holds back HIV prevention in general. My degree is not in internal medicine or any field that would make me useful in vaccine development – instead I study transmission patterns and specialize in evaluating health related research designs to see how valid the conclusions of a given study are. The research on HIV prevention in Africa outside the area of vaccine development includes efforts to design behavior change interventions (not considered very promising in general, but somewhat helpful, moreso when condom uptake is good which is not the case in Africa unfortunately), circumcision (which has the full force of the international health community’s official support behind it, but makes a lot of experts shake their heads in disappointment about the likelihood of giving circumcision recipients false confidence in how protective the procedure is by itself), and control of other STDs that can be cured with antibiotics (again, a marginal protective effect at best, if you can reduce the prevalence of things like herpes that seem to make HIV exposure more likely to result in transmission). Health ministries in Africa probably feel they have to back these half-measures as a good faith effort to help their populations deal with a deadly endemic disease, and they have some international funding to help them do so, but their inability to persuade people in this socially conservative region to use condoms consistently is a huge stumbling block and one they’re tired of dealing with, so they try other options that have less potential to protect people who listen, but are less likely to disappoint people who thought using condoms for what they perceive as especially risky sex and reusing them as needed with a good rinse would be good enough. Poverty levels that make condoms difficult to afford are certainly part of the problem as well. It’s not unusual for the prevention side of public health efforts to get an F for results, but HIV spread in Africa and among the very poor in Western countries is an especially depressing example. I was not aware of how badly the U.S. was doing at enrolling the HIV positive in treatment – can you point out where you found those particular statistics?
Anne,
Thanks for your lengthy reply. Here is another article I wrote recently during the AIDS 2012 conference on the realities of HIV testing in the current medical/geo-political environment: https://virallysuppressed.com/2012/07/24/expecting-consequences-in-hiv-testing/ . The graphic in the article gives the numbers for those (as of 2008, I believe) who are HIV+ in America, who has been diagnosed, who’s in care, who’s on ART and who’s virally suppressed. I got it from the CDC’s website, although if you’re looking for facts and figures on HIV domestically the Kaiser Family Foundation has excellent statistics, as does Avert.org. Hopefully that answers some of your questions.
– Drew Gibson
Thanks so much for the information! The email address for my wordpress account isn’t my name, I didn’t realize it would be displayed as such to other bloggers. My name is Savanna Reid and I’ve mostly looked at unusual transmission routes in developing countries as a researcher in the area of HIV epidemiology, like blood exposures other than transfusions. Injection drug use is an issue in Africa as well, but most of my work has actually been on the risk from unsafe medical injections, which is small relative to the drivers of Africa’s AIDS epidemic but something I see as a social justice issue (those exposures would be easy to avoid if patients weren’t sometimes expected to pay for their own sterile supplies, despite how little it would cost to simply donate a new needle and syringe when the patient couldn’t pay for their own). I will bookmark those sources you mentioned including your own recent paper for future reference.