Medicating healthy people is not a popular approach, especially when those drugs cost $13,000 annually per patient (most insurance companies, as well as Medicare and Medicaid, cover PrEP). In comparison, the CDC estimates that the annual cost to treat someone who already has HIV is $23,000. If all of the 500,000 high-risk Americans who the CDC recommends use PrEP were to begin the therapy, the gross revenue for Gilead would be $6.5 billion — all for people who aren't even sick.
Despite the potential for astronomical profits, as of September 2013 only 2,319 unique individuals had been prescribed Truvada as PrEP, according to Gilead. Half of those patients are women, suggesting that gay men are not being aggressively targeted for PrEP. When PrEP users who are part of research studies are included, the total number of patients is still estimated to be under 10,000.
One reason for the slow start is a lack of awareness. Outside of big cities, there is less dialogue surrounding HIV and prevention techniques. And even in metropolitan areas, familiarity with Truvada is often limited to the HIV specialist doctors treating patients who already have HIV and wouldn't benefit from PrEP.
"We get a fair number of patients here who are rejected for PrEP from other physicians in the city," said Dr. John Nienow of One Medical Group in the Castro. "I haven't heard about widespread adoption in other offices, but I have heard of other physician groups not wanting to prescribe Truvada for PrEP."
When asked whether the recent CDC announcement endorsing PrEP would change that, Nienow was hopeful.
The CDC announcement "will educate and legitimize PrEP's use on a widespread basis," he said. "I think physicians might be uncomfortable prescribing it, and this will make them more comfortable."
Another reason PrEP has failed to gain traction is that Gilead has spent virtually no money on advertising its own drug. Well, sort of. It is true that Gilead has avoided advertising campaigns — drug companies that push their own drugs tend to stir up controversy — but many of the organizations that have come out publicly in favor of PrEP have received grants from Gilead. According to tax forms, Project Inform and the San Francisco AIDS Foundation, two prominent local nonprofits that support PrEP, have both received large donations from the pharmaceutical company.
One such grant was awarded to Project Inform, for the group to produce videos about PrEP targeted toward young gay men, particularly men of color, according to David Evans, director of research advocacy.
Was this donation a part of Gilead's marketing strategy? It's tough to say for sure; Gilead did not return Bay Guardian calls seeking comment.
Regardless of money, it is clear that a new approach is needed for combating HIV. New infections in the US have stubbornly hovered at around 50,000 incidences per year since the '90s, despite pushes for condom usage and education efforts.
"Yes, PrEP is working. It works when it's adhered to," Nienow said. "It's been extensively studied in populations at risk for HIV, and the conclusion was that it is dramatically successful. So much so that one expert even said that the debate about efficacy is now over."
FROM SELF-PROTECTION TO "SLUT"
It's true that the AIDS Healthcare Foundation is no billion dollar corporation such as Gilead. But with an operating budget this year of $904 million and a presence in 28 countries, AHF is still a force to be reckoned with.