Well, PrEP is a miracle drug that has gone criminally underutilized in the fight to eradicate HIV. It would be nice to see governments really push it hard for a change.
In many countries it's easy and relatively cheap the get. It's horrible it's only available with insurance and high costs in the US.
For those curious; in Australia, it's prescribed and costs about $50-60 p/month. In the UK, it varies; England and Wales are doing trails, and Scotland it's prescribed. Under the NHS, it's £9. In Canada, the generics cost upward of $300 per month.
The drug has several non-minor side effects, is prohibitively expensive, and is the same as the treatment for someone who already has the virus. I for one think it's improper to prescribe a drug with these nephrological side effects to a large number of otherwise healthy individuals, not even accounting for the cost.
If it weren't for Gilead's legal efforts to extend the patent on Truvada, it'd be a dirt cheap generic by now; it already is in many countries.
You might think it's improper, but the evidence says otherwise - PrEP is safe, well-tolerated, marginally cost-effective at proprietary prices and clearly cost-effective at generic prices.
One of the fundamental principles of modern medicine is informed consent. Patients have the right to make their own decisions about their treatment based on their own assessment of the risks and benefits. PrEP is an incredibly compelling proposition for a lot of patients.
I think PrEP is great and I don't think we do a great job of getting it to people for whom it makes sense. That being said, the CDC has an excellent position on who should be getting it and that's not a lot of people.
PrEP is well tolerated given it's known side effects but conservative medicine dictates that we don't prescribe medications unless we have a measurable benefit and that's not a large group of people. A homosexual male who has lots of unprotected sex with strangers should probably be on it. A hetereosexual mostly monogamous person probably shouldn't be.
A big factor here is that the prevalence of HIV in the US is low, at .34%. Globally it's a bit higher at .48%. It is also often not that contagious. That being said, under the right circumstances it could be so it's real important to be aware of the risk factors.
They were speaking of medicine rather than policy, and getting it wrong. PReP is not the same course as treatment, and prophylaxis is always a thing given to healthy people rather than sick ones. The side effects are considered manageable: you watch for signs of liver problems and you don't give the drug to people prone to them.
I'm not a doctor but I can read the prescribing information[1], which they don't seem to have done.
Arguing the facts is totally good. And you may very well be right (I don't know anything about the subject). But attacking the commenter's position because he/she is not a doctor (like you are not a doctor), struck me as poor form.
Of course. In many circumstances, the experts don't even agree. It's incumbent on me to inform myself, and I can lean on those very experts, but I'm not at all comfortable ceding how to weigh those tradeoffs to the people who identified them scientifically.
I'm not necessarily saying you ought to cede to the experts, I'm saying you ought to do the research they have already done if you expect them to take you seriously about changing the way they do their jobs.
Obviously it's not breaking any laws to post an uninformed opinion on the internet, but what is going to be accomplished by it?
My husband and me both take prep, his first Doctor refused since it promoted "promiscuity" and would only prescribe it if you are in a relationship with someone positive.
Which is bull.
Find a new doctor that is actually sex positive and won't refuse it for stupid reasons.
(Admittedly I am lucky where I am though to have a doctors office that focuses on LGBT issues, which happens to include HIV prevention/care)
Yes, that is the case. Tenofovir and emtricitabine are generally well-tolorated. They can affect bone density and kidney function and this should be monitored; the majority of people experience no side-effects.
Go to a doctor or clinic that focuses on the LGBT community. It's very easy to get, and they'll take care of setting you up on the Gilead copay assistance program, so the medication should be completely free. Their program will cover up to $7,200/year in copays.
You can get it prescribed online. I think you just video chat with a doctor, then they prescribe. Plushcare and Nurx are 2 sites I found just by searching.
Perhaps more countries should follow Thailand's approach:
On January 25, 2007, Thailand’s interim government issued compulsory licenses–which require
manufacturers to license generic versions of their patented drugs–for two Western medicines:
Kaletra, an advanced anti-AIDS medicine manufactured by Abbott; and Plavix, a blood-thinning
treatment to help prevent heart disease, produced by the France-based Sanofi-Aventis and U.S.
firm Bristol-Myers Squibb. These attacks were preceded in November 2006 by a violation of
Merck’s patent on the anti-AIDS drug Stocrin.[5] The government threatened to break
patents on eleven more drugs.[6] Explaining the rationale behind Thailand’s decision, health
minister Mongkol Na Songkhla said that “the move is permissible under international trade
rules in the event of national public health emergencies. . . . We have to do this because we
don’t have enough money to buy safe and necessary drugs for the people under the government’s
universal health scheme.”[7]
> On January 25, 2007, Thailand’s interim government issued compulsory licenses–which require manufacturers to license generic versions of their patented drugs–for two Western medicines: Kaletra, an advanced anti-AIDS medicine manufactured by Abbott; and Plavix, a blood-thinning treatment to help prevent heart disease, produced by the France-based Sanofi-Aventis and U.S. firm Bristol-Myers Squibb. These attacks were preceded in November 2006 by a violation of Merck’s patent on the anti-AIDS drug Stocrin.[5] The government threatened to break patents on eleven more drugs.[6] Explaining the rationale behind Thailand’s decision, health minister Mongkol Na Songkhla said that “the move is permissible under international trade rules in the event of national public health emergencies. . . . We have to do this because we don’t have enough money to buy safe and necessary drugs for the people under the government’s universal health scheme.”
Are you using an app such as Materialistic or Hews, or just using your browser? For what it's worth I don't recall any problems reading quote blocks on Materialistic.
I've checked and it's € 50 a month in the Netherlands for the pills. There is something else going on with that pricing. There are doctor fees on top of that, but a few checks a year will never consitute the $15k difference.
I can confirm in the US it is truly that expensive (which is fucking crazy). I have pretty good insurance (or at least the best I can get self-buying) but I still have to pay 30% of meds costs. That is something like $400 /month. Luckily Gilled will reimburse up to 7500 /year.
Fucked up private insurance in US, they charge that much and then do the reimbursement so they can bill the huge monthly cost to plans / government that will cover it.
We should be giving this out for free.
My MD said Truvada might go generic next year, so perhaps there's hope.
In the US, we’re paying obscene prices because no other country pays their fair share to recoup the cost of development plus bringing the drug to market plus a reasonable margin for the effort.
The US should establish an agreement whereby US patients pay a LOT less but that the foreign patients need to pay the same.
The amount the industry earns should be low enough to make it reasonably financially accessible to patients but high enough to prompt our best and our brightest to pursue new drug development as a career.
> During the quarter [2019 Q2], Gilead generated $2.2 billion in operating cash flow, repaid $500 million of debt, made dividend payout of $800 million and spent $588 million on share buybacks.
> Adjusted product gross margin was 87.3% compared with 84.2% in the year-ago period. Research & development (R&D) expenses were relatively flat at $916 million. Selling, general and administrative (SG&A) expenses increased 20.8% to $1.01 billion.
You're basing your argument on cherrypicking one single pharmaceutical company that is doing exceptionally well recently because it had the second best selling drug of 2018, Harvoni, a drug to treat Hep C.
What about when you take all the pharma companies and average how well they do over several years? The average net profit margin for the industry is 14.05% according to a January 2018 study by New York University’s Stern School of Business.
14.05%, not great, not terrible.
In addition, the overwhelming majority of those dividends and share buybacks from one company are subsequently plowed back into the industry in different companies depending on which of those companies are working on the most profitable drugs.
source: I have several friends that control a lot of AUM that specialize in pharma investments.
> You're basing your argument on cherrypicking one single pharmaceutical company that is doing exceptionally well recently because it had the second best selling drug of 2018
Well, the discussion was about the atrocious cost of HIV medication, and Gilead is the company that holds the patent on Truvada. You didn't provide a link, but http://pages.stern.nyu.edu/~adamodar/New_Home_Page/datafile/... suggests it's actually lower in 2019 at 10.94%.
From the linked Excel sheet there, there are 28 industries with higher net margins, and 65 with lower net margins. They're still doing just fine :).
28 with higher net margins and 65 with lower net margins.
As I said, not great, not terrible. They're doing just fine, but they are also far from abusing their position. An industry abusing its position would be one with higher net margins than almost all other industries. The fact that 30% of industries have better net margins suggests that this industry is far from being abusive in its pursuit of profit while improving people's quality of life.
14.05% Is FUCKING GREAT considering they make their money over the misery of people. It's actually a disgrace that the profit margin is anything over 2%.
14.05% is perfectly reasonable considering they are giving people hope for a better quality of life.
Profiting off someone's misery would be when you cause the problem and provide the solution. If you merely recognize an existing problem and provide a solution where there previously was none or where the previous solution was inadequate/inferior.
Attitudes like yours makes me not want to continue using my talent to create on solutions to problems that qualitatively and quantitatively improve people's lives. If people are going to look at it as profiting off misery and deny me the opportunity to increase my wealth, I and others will just take our talents elsewhere. There is no lack of other industries and problems where those capable of contributing solutions can make money and not be subject to your shitty attitude towards how they make a living.
Lastly, I say all this as someone who takes an orphan drug myself that would not exist at all if the US didn't have a legal framework that gives pharmaceutical companies the incentive to bring drugs to market. The drug I take is available in only one other country and only because a US pharmaceutical company brought it to market.
I don't agree at all. No profit should be had for developing medicine. You deserve a nice salary for your work but no profit should be made by the company.
a person who is sick is just a person who is sick. They don't become a consumer until they consume something and for that you need someone to produce something to consume. A consumer is defined by consumption. Consumption is only possible if there is something to consume. They is only something to consume if that something is produced/created. That means that someone cannot be a consumer without the people who create whatever it is they consume.
This is pretty simple semantics. Not sure what you're struggling to understand here.
I once presented to the monthly board meeting of one of the biggest global pharma companies. The audience was the top execs plus the top-10 country heads.
All they talked about during the dinner was price fixing, tricky deals to block generics, and schemes to maximise the amount they could get each country to pay. Nothing about the science, medicine behind the drugs, or benefits to patients.
Not just pharma. Most industries care about increasing profits and blocking competitors. Hardly surprising since Top execs are measured on such metrics.
Pricing is always and inevitably what the market can bear, not anything about “fairness”. If prices are too high or communities are too poor (communities not countries), those communities go without. Right now, the US is so expensive that in cases like this it makes sense for patients to fly to another country to get the medicine. That’s unsustainable.
It fundamentally is about fairness albeit in a peripheral sense - the market doesn't exist in a vaccuum - those high prices depend upon granted monopoly rights and regimes which are a bargin wrongly conflated with property and treated like an entitlement instead of the contracts they are. Nothing is owned - only the ability to stop others from doing things. An unfair contract is increasingly likely to be ripped up because there is nothing more to be lost by doing so.
That people are flying abroad is the start of ripping up their local monopoly along with uncertifified online pharmacy importation and grey market sales - taking risks to avoid costs is a sign that the market /isn't/ bearing it.
The reason markets don't really work well for healthcare is that 2 things efficient markets require are competition and symmetrical information. Drug companies have exclusive patents. Doctors require extensive licensing that limits the labor supply. Prices are not transparent from providers. And maybe most importantly, in many cases people don't really have a choice whether they want to participate in the market or not; it's sometimes a choice of "pay whatever they say for treatment" and "die".
Since when the market knows the word fair? You charge as much as you can, in this case Americans are the suckers, but if it makes you feel any better for yourself and natural pride keep calling it as you pay for the whole worlds market.
Oh look you created an incredibly inefficient, expensive and corrupted system to research drugs and now you claim you spend more on drug research than anybody. Have a pat on the back.
Can you substantiate your rant with facts? The U.S. for decades has been the leading country in drugs r&d and other countries do use the results of it on subsidized terms.
I find this SO hard to believe. It just does not pass the bullshit test, you know?
How come the US spends zillions on drug research and then sells that research for pennies to everybody except themselves?
I mean the logical conclusion to me, is that the real value of this drug research is in fact much lower than the pharma industry pretends it to be, hence they can't sell it for such insane prices abroad as they can in the US where they control regulation.
ABPI - Association of the British pharmaceutical industry. That's not a source, that's propaganda, so we're back to the default: What has been brought up without proof can be dismissed without proof.
One reason pharma R&D is higher in the US is that the general costs to bring a product to the US market are far higher than in other countries (e.g. the requirements of the FDA are costlier, see: https://www.sciencedirect.com/science/article/pii/S2452302X1... )
Monosopy doesn't depend upon anything the US does. They have local control of IP even if they tied it to others.
There would be costs involved but they can always tell them to get stuffed and manufacture their own if they won't be reasonable. Notably there is a lack of pharmaceutical companies who decide to abandon world markets entirely because positive N is always greater than 0.
I am not sure this explains the discrepancy between the healthcare cost between US and Switzerland.
More in depth analysis:
"There were two causes of this massive increase: government policy and lifestyle changes.
First, the United States relies on company-sponsored private health insurance. The government created programs like Medicare and Medicaid to help those without insurance. These programs spurred demand for health care services. That gave providers the ability to raise prices. A Princeton University study found that Americans use the same amount of health care as residents of other nations. They just pay more for them. For example, U.S. hospital prices are 60 percent higher than those in Europe. Government efforts to reform health care and cut costs raised them instead.
Second, chronic illnesses, such as diabetes and heart disease, have increased. They are responsible for 85 percent of health care costs. Almost half of all Americans have at least one of them. They are expensive and difficult to treat. As a result, the sickest 5 percent of the population consume 50 percent of total health care costs. The healthiest 50 percent only consume 3 percent of the nation's health care costs. Most of these patients are Medicare patients. The U.S. medical profession does a heroic job of saving lives. But it comes at a cost. Medicare spending for patients in the last year of life is six times greater than the average. Care for these patients costs one-fourth of the Medicare budget. In their last six months of life, these patients go to the doctor's office 29 times on average. In their last month of life, half go to the emergency room. One-third wind up in the intensive care unit. One fifth undergo surgery. "
You can read the rest it is very informative. I still don't think that healthcare cost in the US is caused by the rest of the world not paying their fair share in drug discovery.
> For example, U.S. hospital prices are 60 percent higher than those in Europe.
That's a rather weird statement.. I suppose it's true in some sense, but what I'm reading online from real people in the US is that they get bills that are easily 10-100x as much money for going to the hospital than I get.
There's a few others I wonder about:
> These programs spurred demand for health care services. That gave providers the ability to raise prices.
At least requires some numbers, because I'm constantly hearing about Americans not going to the doctor because for the real fear it might bankrupt them.
> The healthiest 50 percent only consume 3 percent of the nation's health care costs.
This is also questionable. Again maybe technically true, but not suitable for conclusions.
The ailments, pain and other bad stuff that Americans will walk around with instead of going to the doctor is incredible (again for the real fear it might bankrupt them). In the US I spoke to a real person who was trying DIY dentistry. There was an AskReddit thread about what general advice doctors say people shouldn't do, and the top advice was: don't perform operations on yourself.
I'm pretty sure it's the price driving down demand.
> The U.S. medical profession does a heroic job of saving lives.
Wait, why does it suddenly stop comparing to the EU?
> But it comes at a cost. Medicare spending for patients in the last year of life is six times greater than the average. Care for these patients costs one-fourth of the Medicare budget. In their last six months of life, these patients go to the doctor's office 29 times on average. In their last month of life, half go to the emergency room. One-third wind up in the intensive care unit. One fifth undergo surgery.
And this is different in the EU because ... ?
I don't like these statistics. I think they're using them to lie with.
dillondoyle>> Fucked up private insurance in US, they charge that much and then do the reimbursement so they can bill the huge monthly cost to plans / government that will cover it.
I was reflecting to this. If drug cost is part of healthcare cost than by definition it cannot be apples to oranges comparison.
But that's the payment after co-payment by insurance or third party (in case of GGD the municipality). For a fair comparison I looked up the over the counter price of the generic medicine (or to be fair, public news about that price, I didn't look in the price register). My conclusion is that in the US case it's somewhat unfair to blame the insurer if the base price of a medicine is amplified about 20 times.
My friend who’s on a high-deductible plan says they reimburse you for the portion that’s before your deductible. It’s actually kind of a sweet deal because you hit your deductible without being out any money. Then you don’t have to worry about paying for medical care for the rest of the year.
Who is “they”? There’s a copay card you can use from Gilead that helps pay your co-pay but not aware if that helps you hit out of pocket expenses before you hit your deductible or if that counts as your copay.
The way it was explained to me is: you use the Gilead card to pay you copay, and that counts toward your deductible. So, my last post was wrong to use the word “reimburse”.
That's insane. In Kenya, PrEP is offered free of charge in all public hospitals while in private hospitals, brand name drugs will set you back about $35, while generic equivalents cost about $4.
WHAT!? Here in Germany, my PrEP costs me €40 per month, and I only have to pay that because it’s one of the rare things that insurance doesn’t cover here.
yeah, shocking. if you have diabetes or a thyroid issue or hiv or really any chronic disease that requires medication you are out 12k a year easy, 6 for your insurance premiums and 6 for the deductible and copays. if you are broke there are some provisions, but if you are above the poverty line you gotta pay.
Is this true for health insurances paid by the employers too? I am just curious since people say if you have a tech job you have nothing to worry about healthcare in the US.
In many cases the premium is paid for by your employer entirely, and the max out of pocket is lower, like $4k a year. But it depends on the employer and what plans afte offered.
Also about 20% of Americans are on medicaid, and generally do not pay any premiums, deductibles, or copays
I have 20 years in c++ dev experience at an f500, in silicon valley I probably would get double the pay and full health benefits, but I probably would be too old to work there. so it depends on what you mean by tech.
That's insane. In the UK the NHS doesn't supply it yet, and GPs won't officially recommend it. But you'll find the NHS clinics quite often recommending prep purchase through international websites and referring you to HIV charities.
It costs about £30 pm in that case which is about $40
Often they'll be running studies at the same time to assess the feasibility of Prep on the NHS.
Unless PrEP succeeds in eradicating HIV (which might be possible if enough people are on it to limit the spread of the virus), it seems tailor-made to breed resistance. We don't generally give antibiotics prophylactically. Using anti-retrovirals this way seems like a bad idea from a drug resistance perspective.
I wonder if that's true though. I don't have a medicine background but I'm loosely following this development. I think the term drug resistance became popular with all these tuberculosis cases. What happened was that people got TB, they went to the doctor and got medicine. Then things got better and people felt healthy again so they stopped taking their medicine. BUT in reality they were supposed to take it for a longer period of time and then TB broke out again. And thus becoming drug resistant.
Right. For resistance to evolve, some part of the treated population must survive. (You can't evolve resistance to atomic weapons dropped on your head.) Is PReP really effective enough to ensure that there are no survivors? Sure, maybe it is, used correctly at therapeutic doses.
What if it becomes common enough to get into the water at much lower doses? What if people split pills to reduce costs? ISTM that there are many potential avenues for evolving resistance.
It doesn’t really work like that because of the lifecycle of HIV.
If someone is using PrEP and is exposed to HIV, then either the drug works and they avoid infection (in which case there is obviously no impact on drug resistance) or they become HIV+. But in that case, they were either exposed to an already-resistant variant, or they were astonishingly unlucky and the drug failed to prevent infection - in which case, resistance is a moot point.
A person needs to develop an active HIV infection in order to communicate the disease to another. PrEP prevents this from happening in the first place.
Or the person was not taking PrEP as prescribed, either missing doses or taking it inconsistently. Once they're infected, if they keep taking just Truvada, then that strain will begin developing resistance, which they can pass on, potentially to others taking PrEP correctly. There have been I believe 6 cases of people being infected with resistant strains while in PrEP.
That's why it's important for people taking PrEP to be screened regularly, and put on a proper cocktail if they test positive.
It is not about who the drug is being intended for -- it is about who the drug is being marketed to.
For example there's a massive campaign targeting both men and women engaging in any sort of sexual activity that includes fluid exchange promoting usage of PrEP. One can see it in a subway and on local commercials on TV.
Yes. NYC, specifically. It dropped off a bit during the summer, but it was all over the subway/local TV channels in the spring.
There's some new campaign now which unfortunately i don't quite recall but it is highly bizarre. It something along the lines of "equality. make hiv undetectable. Truvada for PrEP." or something like that.
Accidental sharing is very much a thing; it's not just needles and syringes that pose a risk, but other injecting equipment like spoons and filters. Nobody is infallible, especially intoxicated people, but that's no reason to deny them the benefits offered by PrEP.
