The world didn't come to an end on December 21st, as predicted by some. The old Mayan calendar is launching a new round of 5,125 years. Meanwhile we're clicking into a new twelve-month round on the white man's calendar, not to mention the fourth decade of the AIDS epidemic. I'm looking at the year ahead - which surely will be a time of growing economic stress on humanity no matter whose calendar is on the wall. And I'm already losing hope that we'll see anything new in the AIDS world.
Indeed, what I see is dogged drum-beating for more testing, more treatment. In short, more of a problematical thirty-year-old AIDS tech that is working less and less well, because of buildup of drug-resistant strains.
I've been writing this column for fourteen years, and now and then I have to scratch my head at things that don't make sense. Sense often vanishes with AIDS because of the colossal push-me, pull-you impact it has on politics. There is the colossal political chasm it has opened, between those who see AIDS as a humanitarian cause and those who see it as the devil's work. There is the colossal money involved - the colossal amounts needed for domestic and global treatment and - let's face it - colossal profits for the pharmaceutical industry.
How It All Started
When AIDS first exploded in the early 1980s, the treatment choice was something new called antiretroviral drugs (ARVs). LGBT people marched and clamored for access to new drugs because gay and bi men were hit so hard. They got their wish. Today, three decades later, there are half a hundred patented drugs, a few of them still experimental, that group into half a dozen categories, and are used in different combinations.
The drugs do buy time, so the industry has rushed to re-label AIDS as "chronic" rather than "fatal." In the case of my friend theater director Michael Ward, they bought him almost twenty years. But those years were hardly "chronic"--along the way Michael battled Kaposi's and other serious additional issues. It was sheer will to live that kept him going. In the case of another friend, TV commercial producer Philip Labhart, he got just a few years of grace, before galloping lymphoma swept him away.
Defenders of antiretroviral treatment (ART) argue that U.S. death rates have plummeted, people live way longer, hospitalization is down, etc. But truth must be told -- ARVs are still problematical. There is the individual body's intolerance of some drugs. There is growing resistance of HIV strains, and the well-documented side effects of many drugs, some of which are severe and possibly fatal. Sooner or later, time usually runs out on "chronic."
Most of all, there is the staggering lifetime cost of treatment for Americans. An updated figure comes from a 2008 study reported in Medical Care. It puts the total at over $600,000 for twenty-four years, said to be an average extended survival time. But that figure doesn't always include managing and treating side effects, treating opportunistic infections, etc. In Michael Ward's case, according to his surviving partner, the total ran into millions. One AIDS doctor I've interviewed tells me, "One of the big costs comes in the last weeks of life, keeping a person alive in intensive care."
I'm baffled that, all this time, the LGBT community has stuck so politically with the drugs. Sure, we got what we asked for. Sure, our well-to-do can afford their own treatment. Plus some of us landed invitations to the White House, and six-figure jobs with nonprofits and government agencies. But at the end of the day, some of us still die of AIDS. And there are still community members who are poor or unemployed or homeless...who can't qualify for programs or get into ADAP.
So I'm scratching my head at why LGBT people aren't marching and clamoring for something better... and cheaper.
The Life-and-Death Cost Gap
In a time of economic meltdown, a safe, effective, inexpensive vaccine is the logical answer to ending the AIDS epidemic. Instead of costing those millions of dollars to keep a single person alive with drugs, a vaccination might cost as little as--say, 23 cents. Bill Gates likes to talk about the 23-cent vaccine. But given the profit motive running the U.S., an AIDS vaccination might be marked up to, say, $500. That's roughly what the HPV series costs. The HPV vaccine is one of the most expensive--$390, according to the CDC, plus extra for office visits. Say, $500 as a round total.
But hey... $500 for a lifetime of full protection from HIV infection sure beats $600,000 (maybe even millions) for twenty-four years of after-the-fact AIDS treatment.
In the case of HIV-negative gay and bi men who want to have unlimited sex--if they were vaccinated, they could go out and have it, and not worry one minute about getting infected. The faithful HIV-negative gay partner wouldn't have to worry about being unknowingly infected by an errant spouse, if both were vaccinated.
Yet I've noticed that the LGBT community is not marching and clamoring for a vaccine the way they did for the ARVs. Instead, many in the community still buy into this thirty-year-old treatment model that is not only expensive and problematical--but causes them a lot of anxiety.
With developing countries, a similar gap looms between treatment and vaccination costs. It's true that drugs must be heavily discounted out there, because cash-strapped governments must buy them for free distribution to their poorest citizens. So lifetime cost is not as awesome, compared to cost of existing vaccines used in developing countries. But there is still a significant spread. In 2012, according to PEPFAR, annual cost of one person's treatment with generic ARVs was $335. If that HIV-positive person lives for 10 years, the lifetime total is $33,500.
For rough comparison to an existing vaccine, we can go to WHO's anti-polio effort. The oral polio vaccine (OPV) distributed by UNICEF costs between 11 and 14 U.S. cents for one dose. But that one dose confers lifetime immunity. If an AIDS vaccine could be marketed at a comparable price, doesn't it make sense to get a person's whole lifetime for 11-14 cents, instead of just ten years for $33,500?
Questions About Why
Why is the United States stuck in this nonsensical policy?
We are the country that came from behind in the space race, to put men on the Moon in seven years. President Kennedy said, "We choose to go to the Moon in this decade...because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win." Yet when it comes to AIDS, the United States is apparently "willing to postpone" this new challenge.
To make a comparison -- if this were polio, we would still be toiling to keep already-paralyzed people alive in iron lungs instead of preventing polio with a vaccine that we fought to create. Indeed, it took having a President with polio--Franklin D. Roosevelt, running World War II from a wheelchair--to show Americans that a vaccine was vital. It was FDR who personally launched polio-vaccine research with a project at the National Foundation for Infantile Paralysis. The project hired Jonas Salk, who discovered the vaccine in 1955. In short, the polio vaccine was achieved in just 10 years.
Why are we not putting the same kind of race-to-the-Moon polio-vaccine energy into marketing an AIDS vaccine?
Is it because (as some conspiracy writers assert) certain powers-that-be want to see a global-population reduction of several billion people, so they aim to let lots of people die of disease? Is it because religious conservatives don't want a vaccine that lets people feel they can safely engage in "immoral sex" outside of marriage? Is it because most of the biotech industry is now mired so deep in conflict of interest and corporate profit from the drugs that it can't find its way out of a wet paper bag? Is it because organized nonviolent protest has finally been effectively crushed in the U.S., making it impossible to repeat the fierce AIDS demonstrations of the 1980s?
Is it maybe all of the above?
To date, Bill and Melinda Gates have forked out $2.5 billion in grants for HIV/AIDS research. But apparently they still haven't committed to a likely vaccine candidate and its clinical trials. Last summer, Gates stated to the press, "There is a very good chance it will be a decade plus before we'll have the thing."
So here I am -- hearing the 2013 drum rolls for more of the same MO that leaves humanity without a truly effective and affordable way of stopping AIDS. More testing, more people treated, and of course more drug sales for corporations. A minimum $600,000 spent per person instead of, say, $500. It doesn't make sense at all.
(A version of this commentary appeared originally in the January 2012 issue of A & U Magazine.)