Someone was blowing a whistle. A crowd with placards surged into the conference room, chanting “PrEP costs pennies, ViiV’s greed kills”. Not an obvious slogan, but everyone in the room knew what it meant.
The protesters took over the stage, denouncing “pharma’s greed” at the microphone. On the platform, those whose session had been interrupted smiled, even applauded. “Thank you for your advocacy. Please allow the session to continue,” read prepared slides on the overhead screens.
Activists have been part of international Aids conferences since they stormed the stage at the last one held in Montreal, in 1989, insisting to the doctors and scientists that there must be no discussion without them. By the Durban conference in 2000, the protests were huge as the death toll mounted in Africa and Asia.
Effective treatment was then available in rich countries but priced out of possibility in low-income nations. Blood-red paint was thrown over drug company stands in the exhibition area. Marchers filled whole streets.
Activism won that battle, driving down prices. There are 29 million people now on treatment, alive because of the drugs. In Montreal, the activists are still invading, but there is a sense of a conversation going on, not a public drama. It’s still about drugs – but for prevention of HIV infection, not lifesaving treatment, and that’s a harder sell.
Yet it’s great news. Trials have show that injections of ViiV Healthcare’s long-acting cabotegravir every two months stop people getting infected with HIV. The results have been spectacular. It’s a huge breakthrough. The World Health Organization has acted, producing guidelines at Montreal encouraging countries to get and use CAB-LA, as it has been dubbed, as soon as they can.
A decade ago, oral PrEP (pre-exposure prophylaxis) arrived. These are daily pills that do the same job. There was demand in wealthy countries among uninfected men and women whose partners had HIV. At first, the pills were too expensive for low-income countries. Eventually the price came down, thanks to generic manufacturers, permitted to copy the formula. But fewer than 3 million people worldwide have started taking them.
The pills have not solved one of the biggest problems: how to protect women and adolescent girls who, willingly or not, may have sex with those capable of giving them HIV. Their numbers are not going down. At the Montreal conference, UNAids revealed figures showing 1.5 million new infections last year, which is 1 million more than the target.
New infections are highest among girls and young women in sub-Saharan Africa, who have been forced out of school during Covid and subjected to violence from men. Last year, they accounted for 63% of all new HIV infections.
CAB-LA is discreet and highly effective. The obvious comparison is with long-lasting injectable contraception. Young women may be able to get a jab every two months that will protect them from HIV, without anyone in their family or community knowing. PrEP in pill form has been targeted at sex workers and gay men, risking criminalisation in countries with homophobic laws. That inadvertently fed stigma, deterring young women from seeking it out.
But the cost of CAB-LA is high. ViiV has estimated a not-for-profit price of $240-$270 (£195-£220) for a year’s supply for one patient. Chai, the Clinton Health Access Initiative, calculated the actual cost of the ingredients might be $20-$40, a figure that the activists have thrown at ViiV ever since.
“It [CAB-LA] is not a magic bullet but it is extraordinarily effective,” says Asia Russell of HealthGap. “And ViiV is pricing it out of reach of the exact communities who need it. A product that should be an option, as the people’s prevention shot frankly is, instead being treated like a luxury good.”
Russell, who took to the stage in the protest, calls it “pandemic-altering science”, adding: “Our message is: it is evil to put profits before protection from HIV.”
ViiV’s head of government affairs and global public health, Helen McDowell, says the treatment involves a complex technology, and ViiV cannot offer it for the $50 to $60 per patient for a year that the daily pills cost. But, she says, they are collaborating with advocacy groups, funders and everyone else in the field, and if there is demand, they can bring the price down.
In Montreal, the company announced an agreement with the Medicines Patent Pool, which will allow three generics companies to be licensed to produce cheap copies. But this could take up to five years, to give the generics time to invest in nano technology and skilled staff. In the meantime, ViiV is the only source.
McDowell says ViiV is “super-excited about CAB-LA PrEP and the possibilities it has for turning the tide on the HIV epidemic”. “We believe that the strongest opportunity is in adolescent girls and women in sub-Saharan Africa: 6,000 adolescent girls and women are getting infected on a weekly basis still.
“One of the things that stops women taking oral PrEP is that daily box of tablets that is visible. They want something discreet that they don’t have to disclose, and they are empowered and in control of it themselves.”
Mitchell Warren, who runs the advocacy group Avac, is close to HealthGap, and collaborates – without taking funding – with ViiV. He says that Avac is part of a new coalition announced at the conference, with the WHO, Unitaid, UNAids and the Global Fund. The coalition will work out how to fund CAB-LA and get it to those who need it. He thinks they could talk out their differences.
“I’m sad that we don’t find ways to the conversation more strategically. The activists raise really important issues,” he says. “I wish more people would engage with the conversation. I don’t think any of us are that far apart.”
What’s needed now, he says, is to get the message out: “We need to think about how we market prevention. We are in a bubble. If we want people at risk of HIV to even think of any kind of prevention, we have got to raise the temperature.”
The Montreal conference this year had none of the heat of two decades ago, not least because it was partly online. But there was much talk of apathy – not among HIV advocates, but in the world in general. There was a sense that much of the world thinks Aids is a problem of the past.
They are partly a victim of their own success, says Prof Sharon Lewin, president-elect of the scientific International Aids Society, which runs the conference. And while Covid has taught many people about viruses, it has wiped HIV off the front pages. “It’s unrealistic to think we can go back to the visibility of 25 years ago,” she says.
There is, however, a risk gains could be lost. Already, global targets are off track and funding is endangered. CAB-LA is one potential success story. Botswana’s massive achievement in containing its HIV epidemic, so that 95% of people with HIV know their status and 95% of those are on treatment and no longer infectious, is another.
“The virtual elimination of HIV really can be done,” says Lewin. “We want the optimism to be seen everywhere.”
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