The HIV prevention drug that could save millions of people – if they can afford it

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Someone was blowing a whistle. A crowd with posters stormed the conference room, chanting “PrEP costs pennies, ViiV greed kills”. It wasn’t an obvious slogan, but everyone in the room knew what it meant.

Protesters took to the stage, denouncing “the greed of the pharmaceutical industry on the microphone. On the platform, those whose session had been interrupted smiled, even applauded. “Thank you for your defense. Please allow the session to continue,” read the slides prepared on the drop-down screens.

Activists have been attending international AIDS conferences since they stormed the stage at the last one in Montreal in 1989, urging doctors and scientists that there should be no discussion without them. At the Durban conference in 2000, the protests were huge as the death toll rose in Africa and Asia.

Effective treatment was then available in rich countries, but out of reach in low-income countries. Blood-red paint was sprayed onto pharmaceutical company booths in the exhibition area. Protesters filled entire streets.

Activism won that battle, driving prices down. There are 29 million people now in treatment, alive because of drugs. In Montreal, activists are still invading, but there’s a sense of conversation going on, not public drama. It’s still about drugs – but for HIV prevention, not life-saving treatment, and that’s harder to sell.

However, it’s great news. Tests have shown that ViiV Healthcare’s long-acting cabotegravir injections every two months prevent people from becoming infected with HIV. The results have been spectacular. It’s a big step forward. The World Health Organization took action, producing guidelines in Montreal encouraging countries to obtain and use the CAB-LA, as it was dubbed, as soon as possible.

A decade ago, oral PrEP (pre-exposure prophylaxis) arrived. These are daily pills that do the same job. There was demand in rich countries among uninfected men and women whose partners had HIV. At first, the pills were too expensive for low-income countries. Eventually, the price dropped, thanks to generic makers being allowed to copy the formula. But less than 3 million people worldwide have started taking them.

An empty condom dispenser inside a brothel on March 16, 2022 in Bukakata, Uganda. Photography: Luke Dray/Getty Images

The pills have not solved one of the biggest problems: how to protect women and adolescents who, voluntarily or not, can have sex with people capable of transmitting HIV to them. Your numbers aren’t dropping. At the Montreal conference, UNAids revealed figures showing 1.5 million new infections last year, 1 million more than the target.

New infections are highest among girls and young women in sub-Saharan Africa, who were forced out of school during Covid and subjected to violence from men. Last year, they accounted for 63% of all new HIV infections.

This is the science that changes the pandemic. Our message is: It’s wrong to put profits before HIV protection

Asia Russell, HealthGap

CAB-LA is discreet and highly effective. The obvious comparison is with long-acting injectable contraception. Young women can get a vaccine every two months that will protect them from HIV, without anyone in their family or community knowing. PrEP in pill form was targeted at sex workers and gay men, risking criminalization in countries with homophobic laws. This inadvertently fueled stigma, preventing young women from seeking it out.

But the cost of CAB-LA is high. ViiV has estimated a non-profit price of $240 to $270 (£195 to £220) for a year’s supply for one patient. Chai, the Clinton Health Access Initiative, has calculated that the actual cost of the ingredients could be $20 to $40, a figure that activists have pitched to ViiV since then.

“This [CAB-LA] it’s not a magic bullet, but it is remarkably effective,” says Asia Russell of HealthGap. “And ViiV is pricing it out of reach of the exact communities that need it. A product that should be an option, as it is frankly people’s prevention shot, instead of being treated as a luxury good.”

Russell, who took the stage at the protest, calls it “science that alters the pandemic,” adding, “Our message is: it’s bad to put profits before HIV protection.”

Potential PrEP trial volunteers receive information at a community outreach session, Bukakata, Uganda.

Potential PrEP trial volunteers receive information at a community outreach session, Bukakata, Uganda. Photography: Luke Dray/Getty Images

ViiV’s head of government affairs and global public health, Helen McDowell, says the treatment involves complex technology, and ViiV cannot offer it for the $50 to $60 per patient for a year that daily pills cost. . But, she says, they’re collaborating with advocacy groups, funders and everyone else in the field, and if there’s demand, they can lower the price.

In Montreal, the company announced an agreement with the Medicines Patent Pool, which will allow three generic companies to be licensed to produce cheap copies. But that can take up to five years, to give generics time to invest in nanotechnology and skilled personnel. Meanwhile, ViiV is the only source.

Related: Leading figures urge pharmaceutical company to lower price of HIV prevention drug ‘game changer’

McDowell says ViiV is “super excited about CAB-LA PrEP and the possibilities it has to change the course of the HIV epidemic.” “We believe that the strongest opportunity lies with adolescent girls and women in Sub-Saharan Africa: 6,000 adolescent girls and women are still being infected weekly.

“One of the things that stop women from taking oral PrEP is that daily pill box that is visible. They want something discreet that they don’t have to publicize, and they themselves have power and control over it.”

Mitchell Warren, who directs advocacy group Avac, is close to HealthGap and collaborates – without receiving funding – with ViiV. He says Avac is part of a new coalition announced at the conference, with WHO, Unitaid, UNAids and the Global Fund. The coalition will figure out how to fund the CAB-LA and get it to those who need it. He thinks they could talk about their differences.

“I’m sad that we can’t find ways to talk more strategically. Activists raise really important questions,” he says. “I wish more people would engage with the conversation. I don’t think any of us are that far apart.”

What is needed now, he says, is to get the message out: “We need to think about how we market prevention. We’re in a bubble. If we want people at risk of HIV to think about any kind of prevention, we have to turn the heat up.”

Professor Sharon Lewin speaks during a roundtable on monkeypox at the AIDS 2022 conference in Montreal.

Professor Sharon Lewin speaks during a roundtable on monkeypox at the AIDS 2022 conference in Montreal. Photography: Canadian Press/REX/Shutterstock

This year’s Montreal conference lacked the heat of two decades ago, not least because it was partially online. But there was a lot of talk of apathy – not among HIV advocates, but in the world at large. There was a sense that much of the world thinks that AIDS is a problem of the past.

They are, in part, victims of their own success, says Professor Sharon Lewin, president-elect of the International AIDS Society, which runs the conference. And while Covid has taught many people about viruses, it has taken HIV off the front pages. “It’s unrealistic to think that we can go back to the visibility of 25 years ago,” she says.

There is, however, a risk that gains may be lost. Global targets are already out of the way and funding is in jeopardy. CAB-LA is a potential success story. Botswana’s great achievement in containing the HIV epidemic, so that 95% of people with HIV know their status and 95% of them are on treatment and are no longer infectious, is another.

“Virtual elimination of HIV really can be done,” says Lewin. “We want optimism to be seen everywhere.”

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