> The cost, however, is steep — the list, or wholesale, price is $3,960 a month, or more than $47,500 a year. The list price for the one-time initiation dose is $5,490.
Median income in the US is ~$31K apparently. So even in a rich country, this is like 50% more than the income of a typical person.
My understanding is the funding for the trials was partly from NIAID. This seems like yet another case where public funds are used for research, but a company ends up with the ability to dictate pricing.
I'm glad that this works and that there is another, more convenient and effective treatment option. But shouldn't we have some setup where if tax dollars pay for the research, the government should own a share of the IP commensurate with their funding level, and should then be able to have some say in pricing?
Or, if you think that the government itself shouldn't own IP for a product on the market, can we create an independent non-profit which receives ownership, and whose charter aligns with actually treating as many people as possible?
I'm not saying that when real, innovative work happens, pharmaceutical companies shouldn't get some meaningful return on the money they put in. But when the public supports the work, we shouldn't get nothing.
> My understanding is the funding for the trials was partly from NIAID.
I have no particular insight into the pricing of this drug, but in general, NIAID funding doesn't get anywhere close to the level of investment needed to bring a drug to market (NIAID's total budget is something like $5Bn. A single drug can easily require that much money to go to market).
Moreover, it isn't a bright-line distinction between public and private funding: if a novel drug is developed (entirely privately) against a target for which academic researchers once received public funds, does it count as public funding? There's a huge gray area in between. Nearly all drugs can be characterized as "publicly funded", if you look hard enough.
Rules like this sound great, but in practice, they'll lead to perverse incentives (like drug companies completely avoiding targets from the academic world, in the previous example). Nobody rational wants to spend billions of dollars doing late-stage development and clinical trials to be torpedoed by a researcher who took a small amount public funding decades prior.
> I have no particular insight into the pricing of this drug, but in general, NIAID funding doesn't get anywhere close to the level of investment needed to bring a drug to market (NIAID's total budget is something like $5Bn. A single drug can easily require that much money to go to market).
According to [1] "the estimated median capitalized research and development cost per product was $985 million, counting expenditures on failed trials." That billion dollar figure is risk adjusted per product meaning that's the cost of all R&D and clinical trials against the number of products that hit the market. A lucky startup can pull off a successful trial for a few hundred million (i.e. Sofosbuvir), if not tens of millions for an orphan drug.
The most expensive ("oncology and immuno-modulatory drugs" which are similar in complexity to HIV therapeutics) come in at a median of $2.8 billion and a mean of $4.5 billion but only because of an extreme outlier, Dupixent, which cost over $6 billion to develop. Dupixent costs $40k/year and has a much larger target market than this HIV treatment (IIRC on the order of 10 to 100x). This HIV injection is far more likely to be discounted in the developing world so the sticker price likely reflects that too.
A $5 billion a year budget can go very far and the people should get the rewards for taking the risk, especially for a disease like HIV that has significant quality of life impacts on vulnerable populations.
Yeah, $5Bn may be a bit of an exaggeration, but it's not off by an order of magnitude; this review, based on data from Eli Lilly, put the fully capitalized R&D number at $1.8Bn in 2010:
(one can certainly quibble over the "cost of capital" assumptions these days, but the model isn't wildly wrong.)
> That billion dollar figure is risk adjusted per product meaning that's the cost of all R&D and clinical trials against the number of products that hit the market.
Yes, but as you know, you can't simply separate the successful products from the ones that fail. The former pay for the latter.
> A lucky startup can pull off a successful trial for a few hundred million (i.e. Sofosbuvir), if not tens of millions for an orphan drug.
Sure, one can always hit the lottery. But unlike startups (where the N-independent-failures model works OK), drugs don't make it to market without a deep-pocketed company willing to set huge piles of money on fire in the final phases.
Your other comment below does a good job of explaining why trials are insanely expensive...which is why lucky startups almost never run their own. So you're dependent on a system where deep-pocketed mega-corporations need to exist simply to get the drugs on the market, and they are reliant on massive returns to take the risk in the first place.
Globally there are ~50 new drugs per year. Total public and private spending on drug R&D hits ~190B per year. So even including government and charity donations your only up to 4 billion per drug. Private companies nominally cover ~60% of that dropping their investment to ~2.3 billion per successful drug.
However, that’s overly generous as a great deal of tax breaks etc indirectly subsidize that 2.3 Billion. So, it’s true drugs are expensive on average to create, larger numbers tossed around are generally intentionally misleading.
This is not a bad back of the envelope analysis. Forbes did one a while back that looked at 10 year R&D spend and then 10 year approvals (to account for the delay). Numbers vary wildly between companies.
But one thing to keep in mind is using your number, there are plenty of drugs that get approved that only have a few billion in sales over their lifetime. So either break even or not even breaking even. It’s a massive blockbusters like Lipitor ($10B in sales per year) that pays for all the mediocre drugs.
I think the issue people have is the public spends about 1.4 trillion on patented prescription drugs per year globally which is more than 10x what drug companies are spending on R&D. Especially when manufacturing and distribution is such a small fraction of this cost.
While time value of memory explains some of that it’s still a huge discrepancy. Advertising etc make up the difference and while cost effective for the company, their harder to justify as a fraction of drug prices. Especially when over prescription is so harmful due to side effects and adverse drug interactions.
Genuinely curious - why do these drugs cost so much? Can we make it cheaper? I know there’s a lot of hit & miss and that the cost of the drug also covers the misses, but it feels like we should be able to do this for millions, not billions.
It genuinely takes a massive amount of labor using mostly highly paid professionals like doctors, nurses, and research scientists. Even before any trials start, the support materials for a premarketing application for a drug are usually in the thousands of pages and include clinical trial protocols that describe minutiae like how blood samples will be drawn so data is comparable between hospitals. Then you have to find participating hospitals, PIs, and patients which means lots of negotiation and patient screenings and TV/radio/web advertising. Then you have to manufacture the drugs in small to medium quantities. Then you have to actually run the trials which means paying a lot of people and most if not all of their medical care related to the clinical trial.
Phase I trials, for example, are usually carried out under constant medical supervision and push the dosage as high as they can until 50% of the cohort will no longer tolerate it. That alone is usually thousands or tens of thousands per day per patient.
By the time you get to phase III where you have hundreds to thousands of patients, you're shelling out up to $1k per patient for the incentive and $100-1k per checkup for the length of the trial. A 1k person phase III can easily cost tens of millions in labor just to administer the drug and collect samples once a month for a year. Data provenance and normalization is important so a not insignificant chunk of this time is largely unavoidable paperwork.
And getting FDA approval is not the finish line. It's just the start of the roll-out. Now employ teams of reps to get the drug covered by every commercial insurance company and all Medicare/Medicaid parties so that patients have access to this life-saving treatment, get policies and authorization forms and billing codes created and implemented. Do outreach to make sure doctors and patients even know that a drug has been approved and how it compares to existing options.
It has to do with the time value of money and long development timelines. Here is a great blog post from a scientist trying to find investors for drug to cure his wife's terminal disease.[1]
>it takes a hundred dollars of drug revenue 17 years from now to motivate someone to invest one dollar today. No wonder drugs are expensive.
That is a 10,000% return on investment required to break even.
"A $5 billion a year budget can go very far and the people should get the rewards for taking the risk, especially for a disease like HIV that has significant quality of life impacts on vulnerable populations."
This requires the starting axiom that profits are more important than human lives with respect to global public health. This is something that we as humans can decide, not some law of nature.
Big pharma's lobbying to enshrine IP rights by embedding them in the WTO has led to untold deaths from lack of access to medications in the developing world.
This Citations Needed podcast on "Vaccine Apartheid" contains much interesting information, even if you don't agree with the headline.
On a purely technical note, it's interesting to think about why it's cheaper to do the R&D to put a rocket into orbit than to develop a new therapy. Why does cutting-edge lab equipment cost $100k - $1M? This supply chain seems ripe for disruption.
>I'm glad that this works and that there is another, more convenient and effective treatment option. But shouldn't we have some setup where if tax dollars pay for the research, the government should own a share of the IP commensurate with their funding level, and should then be able to have some say in pricing?
>Or, if you think that the government itself shouldn't own IP for a product on the market, can we create an independent non-profit which receives ownership, and whose charter aligns with actually treating as many people as possible?
The current model of government funded research is like backing a Kickstarter because you want to see the product made, but get no direct benefit. It is made because we as a people think the world will be better off with the product, than without, and are willing to pay to make that happen.
I think government co-venture is also great option, as long as it is negotiated up front and we can keep political corruption out of it. However, the question then becomes if drug development will dry up once the the government has locked down all the IP and nobody wants to partner with them.
I think another good model would be seed support for independent non-profit pharmaceutical(s) charted to balance reinvested profits with social benefit (without government owning the IP). The question and risk here becomes one of oversight and accountability.
Well, thanks to the US government, the very rare immune mediated neurological disease I have was discovered in the early 2000s, at the Mayo Clinic, via NIH grant funds.
Because of the disease, I had uncontrollable orthostatic hypotension (low blood pressure when sitting/standing up), and I was passing out multiple times a day. I also was diagnosed with multiple types of arrhythmia.
If it were not for the US government, I would not be alive. I am a dual US|EU citizen, and while being American is naturally a huge part of my identity, I would not be afraid to renounce my US citizenship. The only reason why I do not is because the US literally saved my life and others with the disease I have, worldwide.
Independent non-profits trying to fight for individuals in a capitalist-driven society seems to be doomed to fail.
An depressing example; Insulin and how the inventors made sure to make the the process available to anyone;
> The patent would not be used for any other purpose than to prevent the taking out of a patent by other persons. When the details of the method of preparation are published anyone would be free to prepare the extract, but no one could secure a profitable monopoly.
How did that go? 1,000% price increase, accounting for inflation. (US numbers)
Edit: Removed rant-driven generalization and miss-information regarding legal obligations.
Thanks for checking me. I get to upset reading these things.
You are definitely correct and thanks for pointing it out. Generalizations and miss-information doesn't help at all.
I obviously need to go out for a walk before I comment on these type of news. It's super exciting but also extremely depressing since the ones who'd need this the most likely wont afford it.
The FDA approves ~40 drugs a year. If you want 40 new drugs a year, it unfortunately will cost somebody something to coordinate the large number of professionals over many years required by a modern development effort. Few drugs have been developed successfully on good intentions.
I find excitement in the fact that we have found a way to get new treatments and cures. Other systems have been tried that weren’t so successful at pumping out new tech.
I’m not familiar and it’s a complex topic. My knowledge comes from following the reforms in China and picking up bits and pieces of history. The overarching impression I’ve gotten is that a lot of ideas you can think of have been tried before in some capacity.
The USSR had a Ministry of Medical Industry and I think Japan might have gone with a bounty model? You can probably find more info.
Where everything falls over is that it’s just such a long journey from point A to B, where A is “a chemist has found something” and B is “an entire patient population is taking the drug.” There are a lot more steps than you’d think, and any alternative system needs to do well at each step due to the wildly varying incentives between participants.
As a toy thought experiment not based on real-world events, suppose the government has just paid a $500 million bounty for new Drug X that otherwise wouldn’t have been developed. The government now owns Drug X. Okay, great. But doctors aren’t prescribing it. So the government creates a Ministry for Doctor Education that tells clinicians what to prescribe. But the Ministry for Doctor Education develops its own goals and forgets that it’s supposed to help out the pharma bounty program in marketing new drugs. In the meantime, the government is outbid in manufacturing Drug X, and its contracted manufacturers are exporting Drug X overseas, so the government nationalizes the manufacturers. But then the manufacturers forget that they’re supposed to work on novel drugs and decide only to take on low-risk work. Etc. etc.
It just empirically works to have a tech transfer model where a set of entities gets rich by taking a drug on the entire journey into the bodies of thousands/millions of patients.
Does anyone actually end up paying the 47,500 a year for the drug or is this some sort of gimmick on the part of the drug company when they negotiate reimbursement rates with CMS or other payers?
This is a fair point. Negotiated rates are usually lower and the cost should be spread across a pool of insured people, not all of whom have conditions that require ongoing high-cost therapies. Other comments in this thread also point out that there are alternative HIV treatments from Gilead and others that cost less. If the demand is not there for the new monthly injectable, ViiV will suffer for mispricing its own drug.
I don't think either insurers or government health care bodies end up paying the sticker price. They usually have a contracted rate with the pharma companies that is less. Also, pharma companies have patient assistance programs which usually offer major discounts. I really don't know how effective this is and hhow many individuals get stuck with the full bill.
India does not allow patents on pharmaceuticals.[1] As a result, they have an excellent market for generics, but new medicine is 6-8 years behind the rest of the world.
This is a brand new treatment. All things that are the product of cutting edge research and are difficult to get to market will be expensive.
I'm taking an orphan drug that was approved in 2002/3 and costs more than this per month and last I checked the company that developed the drug was still in the red.
This idea that drugs should be cheap and accessible the moment they are approved is incompatible with economic reality. You need a system with a profit motive so that many people and investors are motivated to invest their lives, careers and money in that market so we get progress year after year.
This is a trolley car problem. On one track are all the people you can save in the present by making something immediately accessible to all regardless of the economic reality of those that produced the drug. On the other track all the the people that you can save long term by having an economically viable industry that can continue making advances that save lives in perpetuity.
> This idea that drugs should be cheap and accessible the moment they are approved is incompatible with economic reality.
I know that orphan drugs are lifesaving and it is life-and-death for the people who do and don’t receive them, but this is generally not true, including for orphan drugs. I know because I have 2 rare immune mediated neurological diseases affecting my peripheral nervous system and I take an orphan drug (blood product) known as subcutaneous immunoglobulin.
Soliris, one of the world’s most expensive drugs, costing ~$600,000/year in countries with “socialized medicine” is estimated to cost less than 1% of that price to produce, as in less than $6,000/year. This is from industry insiders who have technical experience. Not only that, it is estimated that 80-90% of the work was discovered on public, government funds. See at 11:30
https://youtu.be/0uYCw5EDX8U
I have a background in applied science and I agree that this is the general ballpark case for orphan drugs, based on reading patents.
> The cost, however, is steep — the list, or wholesale, price is $3,960 a month, or more than $47,500 a year.
Remember though that this is a replacement for an existing drug therapy, not something totally new. Does anyone know how much the daily pills cost per month?
3k month sounds about right for a chronic condition.
Many many people pay at least this to stay alive. That said , Universal Health Care is needed for stuff like this to work. At 3k a month it makes the most sense to try and emigrate to a better country.
That doesn't scale. If you push the cost of healthcare to other countries when it becomes too expensive instead of fixing the system in the country where you live then every other country with a better system's healthcare will collapse as well.
Vote to improve the system where you live and make sure that your representatives realize that it could be them or their relatives in your situation.
Quite a few countries have restrictions in this anyway, so whether it would even work in individual cases is another matter, for instance, here is Canada's provision:
People buy insulin off Craigslist, in a way that is similar to a drug deal, because they cannot get it elsewhere. They sit in the car while their “insulin dealer” brings them the insulin from Mexico/Canada and they pay them in cash.
From all my research, I've come to the conclusion that while there are things that are broken about the US system, it's not as fundamentally broken as people make it out to be.
Let's say there are two variables you can optimize for, X and Y, and that there are tradeoffs between optimizations such as optimizing for X often reduces Y and optimizing for Y often reduces X.
The problem with the popular discussion today is that no one ever acknowledges what the US system does well. They only talk about what it does poorly. If you don't acknowledge what it does well, it's trivially easy to come up with solutions that address the things it does poorly, but often at the expense of creating a new replacement that now does poorly at the thing that the previous system did well.
In the US, the system is remarkably effective at optimizing for financial incentives. The replacement system many people argue for will likely lay waste to optimizing for financial incentives. This doesn't come without a cost however. Eliminate the financial incentives and you will at minimum get less of two very important things: (1) investment by companies and capital markets in R&D, and (2) investment in a career in the field of drug R&D by individuals deciding what career to pursue. The loss of one or both would be devastating to the development of novel treatments in perpetuity.
As a general heuristic, I've found it valuable to figure out what a system does well before I propose a solution to replace it. If I can't articulate what a system does well, it's typically a sign that I don't yet understand the system well enough and don't understand what that system's designers were optimizing for when it was first implemented. This heuristic is applicable to all pretty much all systems, not just health care.
This comment is in very start contrast with the sibling thread regarding insulin. If a common drug like that is price gouged to the point that people will do street deals on unverified product then things are about as fundamentally broken as they are going to get, fancy discussions about optimizations and trade-offs can be discarded by simply looking at the available evidence.
> At 3k a month it makes the most sense to try and emigrate to a better country.
Countries won't let you in if you're going to cost taxpayers too much. For example, New Zealand won't let you emigrate there if you have serious psoriasis, since treatment can cost thousands of dollars/month.
I used "serious psoriasis" when I should have used "severe psoriasis". If your psoriasis is treatable with steroids and methotrexate, it isn't all that severe.
But psoriasis wasn't the point. Expensive treatment that's expected to be ongoing is.
I believe that the government does own a portion of the IP.
If you read patents filed by defense contractors and pharma/universities they often say something like this "This invention was made with Government support under Contract no. F29601-03-C-0191 awarded by the Air Force Research Laboratory, Kirtland AFB, N. Mex. The Government has certain rights in the invention."
If, as a company, you have the option of charging $X if you accept gov’t funding or 400% * $X, doesn’t that sound like a great way to disincentivized taking govt funding?
And as others have said gov’t funding tends to be a small fraction of total cost of R&D.
And the funding tends to come very early - some professor is researching a new anti-viral and stumbles across a new molecule. It’s still several hundred million and a decade or more away from market.
In contrast, the napkin estimate for the cost of a year's worth of HIV drugs (latest generation integrase inhibitors) was 20K as of around 2 years ago, for western countries. Dolutegravir became generic, but prices likely won't change dramatically (specifically in western countries).
I worked for a drug distributor a long time ago and the joke for AWP (average wholesale price) is that is stood for Ain't What's Paid. Almost all drugs were negotiated down to 70-80% of AWP.
There is a substantial percent of the population whose yearly medical care costs exceed their income.
For example, about 7% of the world’s population collectively has some sort of a rare disease, which is theoretically treated with orphan drugs. There are also people who chronically live with cancer who end up living quite a long time. Diabetes, (type 1 or type 2) with or without complications, is quite expensive in the US.
I personally have 2 rare immune mediated neurological diseases affecting my peripheral nervous system. The only medication that has kept me in pharmaceutical remission is subcutaneous immunoglobulin (intravenous immunoglobulin did not work), and I have tried 10 different treatments plus combinations of them. When I was living in the US, my private commercial insurance paid, under contract (not the amount that was being billed which was much higher!), $100 per gram. In other words, they were paying $23,500/month for my blood product or $282,000/year.
In Europe, where I live now, the price goes for 40 Euro (about $50/gram).
Anyways, you should watch this, “The World’s Most Expensive Drug” (which it no longer is), which is quite revealing: https://youtu.be/0uYCw5EDX8U
Anyways, the prices of these drugs are an insult to the intelligence of a lot of scientists and (formal) engineers.
I also have type 1 diabetes, and because of my training in electrical engineering, I could tell by reading patents on analog insulin patents that a 10 mL bottle of insulin cost somewhere between $1-$10 to produce. Turns out that it costs between $3-$6 to produce. At its worse, in the US, it cost $350 per 10 mL vial for analog insulin.
Anyways, the best way of dealing with this situation is by having even the most disabled people working to offset these prices, along with having universal healthcare with price controls. Unfortunately worker protection against discrimination in the US is very poor and when your health benefits are tied to work then it just does not work. Patent law also needs to be reformed, and if the prices are obscene and unjustifiable, then they should be seized.
Or to approach the same issue from the other direction: Does public funding for research of this type self-sabotage, if it enables pharmaceutical companies to set pricing at a level which meaningfully limits the use of the results of that research?
The cost, however, is steep — the list, or wholesale, price is $3,960 a month, or more than $47,500 a year. The list price for the one-time initiation dose is $5,490.
Supporting a subculture that's heavily into anal sex is extremely expensive.
I have always heard that Truvada (prep) was extremely effective at preventing HIV infection. These new injectables are reported by the article to be 89% and 66% more effective at preventing transmission.
What is this based on? Was I misinformed about Truvada's effectiveness? Is this a decrease in an already very low chance of transmission? Or is this in comparison to people forgetting to take their daily pills vs a shot that a health care provider had record of administering?
It's currently common in the gay community for sexually active, healthy people to take Truvada proactively to protect against HIV because it's understood to be even more effective than condoms. If there is a better option or if the current option is not as effective as widely believed then standard of care should change.
It is a decrease in already low transmission. For ethical reasons, the placebo group is not no treatment, but rather current standard of care.
I had to do some digging to find any source on the effectiveness on preventing transmission (the recent FDA approval is for post infection treatment).
The study I found is [0]. In a double blinded study of 4,600 participants, half were given the cabotegravir injection, and half were given the daily oral treatment. The study notes a "high level of adherence to oral therapy"; however, the actual numbers on adherence are:
> Adherence to oral FTC/TDF was high, based on a random subset sampling that detected tenofovir (> 0.31 ng/ml) in 87% of all samples tested.
I'm not qualified to say if this actually indicates 87% adherence, or if a fully compliant patient may get a negative result on that test.
The result of this study was that 50 particpants got HIV, of which 12 were on the injectable and 38 were on the oral.
By my calculation, this gives a relative effectiveness of (38-13)/38 = 68.4%, although the paper reports 69%.
This is awesome, thank you! The likelihood of pill compliance does seem to be probably higher than normal since everyone had 2 month follow-up appointments for injections, plus presumably they knew they were being blood tested. This looks like a game changer for HIV prevention. 6 shots a year and you can have better protection than any other known method. To me it looks like this is something that should be rapidly adopted.
Cabotegravir is somewhat novel -- not a recompounding of current therapy with different pharmacokinetics.
Americans aren't going to develop an efficient approach that is not highly encumbered because the FDA stacks the deck against approval of efficient solutions in favor of whatever makes the most total profit. So you'll see that sort of thing approved overseas and we'll get it (or not) in a decade or maybe never.
> It is a decrease in already low transmission. For ethical reasons, the placebo group is not no treatment, but rather current standard of care.
I see nothing wrong with sacrificing a few men, who consent and sign up and know the risk, for the far larger majority.
If better drugs can be developed that would serve millions by sacrificing a hundred consenting subjects that know they run this risk, that seems like an overall benefit to me.
It seems rather irrational to not be willing to do this. — It is fine if men die, so long as their blood not be on my hands directly, but only indirectly.
Yikes. There's absolutely no reason to do this. You get equally useful results by comparing to current standard of care, and that's the thing you ultimately need to measure for approval of a treatment for which existing treatments exist anyway (the FDA wouldn't approve a drug that's better than nothing but markedly worse than the current standard of care, so that's the benchmark).
It seems that whenever a perfect placebo be permissible, that is what is being used rather than the current standard of care.
Soldiers can be sent to their death for oil and other resources that benefit the larger majority? but this is “yikes”?, not a phrase I find to occur in conjunction with rational decisions often.
> Then why isn't it done as such in all instances?
It is. Control groups are no-treatment if no approved treatment exists, or current standard of care if there's an approved treatment. That's standard practice.
> It seems that whenever a perfect placebo be permissible, that is what is being used rather than the current standard of care.
If by "perfect placebo," you mean "no treatment," that's not correct, and is considered unethical.
> It is. Control groups are no-treatment if no approved treatment exists, or current standard of care if there's an approved treatment. That's standard practice.
I've read plenty of pharmaceutical trials where the control was a plain placebo, not the current standard of care, when it not involve a life threatening illness.
Clearly this antipsychotics trial does not evaluate the drug 's effectiveness against the current standard of care's, but against a placebo's.
> If by "perfect placebo," you mean "no treatment," that's not correct, and is considered unethical.
I mean giving them a drug that lacks an active ingredient but is otherwise not to the lay eye discriminatable from an effective drug.
And that is very much what is done in the case of the antipsychotics medicine I showed. So it's only unethical when human lives be at stake, apparently.
Logistics-wise, it’s easier to get someone to come into the doctors for blood work every 3 months for testing (as required for prep) than once a month for a shot.
However, from reading the article, I do think there’s a convenience factor at play related to the struggles of taking pills daily.
Note though, the article mentioned a trial of _women_ where truvada and one-shot prevention effectiveness were compared and the one-shot was deemed 89% more effective.
A quick search explains _why_ this might be the case for women. Basically, it takes more truvada to get rid of the disease in vaginal and cervical tissue than it takes for rectal tissue.
Also, doctors have been recommending a different drug, Descovy, for prep instead of Truvada. This isn’t due to effectiveness but side effects I believe. I guess if one experienced side effects though, they would be less likely to continue taking the medicine.
I'm not sure about this one but subcutaneous and intramuscular injectables are pretty easy to self-administer. I self-inject once a week myself.
https://www.poz.com/drug/cabenuva seems to suggest it is intramuscular (administered in the buttocks, which is not hard to do by oneself) but requires a healthcare provider. Not sure why, there might be storage requirements and such.
I think people would rather prefer to take a pill than give themselves an injection. It doesn’t matter if it’s “easy” or not. There’s the “ick” or “ahhh needle” or “breaking skin” factor at play.
Even if you self-inject and find it easy, I’m sure you’re not saying it’s easier and less of a hassle than taking a pill lmao.
In what way is it easier besides you saying that it’s easier? You have a hard time swallowing pills I guess? Or do you remember to take injections more because they stand out more in your mind than pills do?
EDIT: Not sure why this is getting downvoted. Since when on HN is it acceptable for someone to say “I think this way so it must be a fact” without providing an explanation? Even when it comes to subjectivity, there’s an expectation that people share why they believe in their opinion, right?
I swear I dislike this site and the people who use it more and more every week.
I'm pretty sure that "easier" is a subjective determination. But no, I don't have a hard time swallowing pills. It's just that doing something once a week is easier than having to remember to do something everyday. The injections are also more effective for me, as they are here. And finally there's an aesthetic aspect to plunging a needle into one's muscle that I appreciate.
Yes, it’s subjective to some extent, hence why I asked in what way is it easier beside you just saying that it is? I left out “to you” but I thought the HN community was a bit smarter than that. Even if you had said “it’s easier to me. Full stop,” I still would have written the same reply...
All you said was “it’s easier” in your original point. You obviously felt the need to clarify yourself in your most recent comment. So clearly your first comment was lacking information. There was no reason to downvote me just because you felt my original comment made you look stupid.
FWIW, even though “easy” is subjective, there’s still a consensus to be considered. For example, finding piercing your skin with a needle to be an asthetically-pleasing act does not fit that consensus...
Something that _does_ fit the consensus is that taking a pill every day is a hassle.
It’s disgusting that I’m being downvoted when the main point in my great-great-grandfather post was explaining about the effectiveness of the trial mentioned in the article.
Not whether some random Internet weirdo prefers to inject themself...
He edited his comment to say “(for me)” after I had replied.
Also, if you click damnyou@‘s comment history, you’ll clearly see that he loves using the phrase “in fact” without supporting his assumptions. I didn’t deserve to be downvoted.
You didn’t edit your comment minutes afterwards. It was at least 1 hour afterwards.
And sorry if you actually do prefer those gender terms. But honestly, it sounds like you’re just making shit up. I’m assuming you’re just a young white kid. I’ve met many of you in the tech industry who act like that. “Oh, I said something stupid and fucked up, let me pretend to be ‘woke’”. People like you exhaust me.
Ok... and 10.6 million use birth control pills according to the CDC.
Also, just because something appears convenient doesn’t mean that it actually is.
Have you looked up how many women use one of those invasive contraceptive implants?
Technically, a woman only has to get a new implant once every 4 years+. But have you not read the horror stories about the implants becoming dislodged and causing internal bleeding and severe damage?
You seem to be implying that IUDs are much less popular than the pill. That is not the case. They are just behind the pill in popularity.
Also, people on PrEP already need to do regular bloodwork, so needles and appointments are already involved every few months. Doing an appointment every 2 months instead of every 3 and not needing to take a daily pill as well is a huge win in level of effort.
I'm not quite sure what your point is. Mine was that millions of people choose from a variety of treatment options and that there's no clear evidence that a pill is vastly preferred to an injection or even some more invasive delivery method. I think my link about birth control usage just shows that the more options, the better. Presumably we'll cover the at-risk population better if there are more good options.
I think this is a wonderful thing and that we should spread the word when these new treatments are available so that more people know they have options if they like the sound of occasional injections but don't like daily pills or vice versa.
Compliance is a big issue, as is price. In the US, Truvada's retail price is about $2,000 for a 30 day supply. Truvada costs about $40 in other countries.
Compliance is a huge issue because health insurance will do a lot to make you jump through huge hoops to get it. I have had prescriptions “disappear” into the CVS “specialty pharmacy” and you have to wait on the phone for hours for them to “find” it.
I helped my mom deal with 2 specialty pharmacies for some Parkinson's drugs she was taking. The drugs weren't available from other pharmacies (that CVS runs one of the largest specialty pharmacies can make this confusing, but normal CVS probably don't stock it if the prescription goes to their specialty pharmacy).
They present themselves as helping the patient navigate a complex drug, but in practice this just meant they had a bunch of questions to tick off each time you talked to them. Their outreach and phone tree were both pretty bad, clearly designed for high operator utilization and not customer service.
The side effects are of the type where a small group of users will experience changes in kidney function, and you have to check for it, but the vast majority won't. The side effect profile for most people is very low.
Truvada is commonly taken proactively by sexually active people in high risk categories. It is true that it has side effects, so the risk of those needs to be balanced against the risk of HIV exposure.
I don't have stats, but Biktarvy has been advertised for PReP lately. Descovy is approved by the FDA for such use. The shot is around the same price (at list anyway) as some of the other treatments, so if it's even equally effective the convenience might win.
Biktarvy doesn't make any sense for PrEP, Descovy is emtricitabine and tenofovir alafenamide, Biktarvy is emtricitabine and tenofovir alafenamide plus an integrase inhibitor which just adds possible additional side effects and isn't necessary.
As someone who is in this high-risk community: good news.
(Well, except for that price tag.)
People, to a first approximation, are just terrible at pill compliance. Doesn’t matter the demographics, people just aren’t perfect at taking a pill, every day, at the same time, forever and ever. Having that injection where you can set it and forget it? Nice advance. Not game-changing, but still a nice move forward.
And I think it’ll be a bigger move forward for people who are at high risk of HIV, but also have not great access to medical care where they live. If you…oh boy, here I go, potentially getting into trouble. Non-white and/or non-affluent communities tend to come down much harder on homosexuality. It is much more discreet to get a periodic shot than heading to Walgreen’s and bringing home a bottle full of blue pills. It’s safer. It’s a bit more private.
I'm not one to lead the cancel brigade but you could have just said "some communities". There are plenty of white communities that frown on homosexuality so I don't know what is gained by citing demographics. Since there's no purpose in calling out race, but you did anyway, I can see how some might see this as an unprovoked attack.
It’s frustrating that it’s so expensive for the most at-risk communities in the US.
Because you can totally work the systems to get it affordably. Besides insurance, there are clinics, there are coupons, there are programs…but you have to have the information literacy and the time to figure out how to jump through all those hoops.
Me, I work remotely, I have insurance, I live on the north side of Chicago, I can get my Truvada easily. You live on the west side of Chicago with no Howard Brown nearby, and you work a service sector job where your hours are algorithmically doled out to you? Far, far harder.
This implies that becoming HIV+ is increasingly a disease of the working poor (in countries like America without public health care). Or do public health care clinics have sufficient vouchers? In which case why wouldn’t people just resell their Truvada?
I think, same as with vaccinations, this clearly highlights how all of society really benefits from universal health care. In fact, why isn't preventable infectious disease talked more about in that debate? Pretty obvious, no?
It is expensive, but it is accessible. Truvada for PrEP has a program both for insured patients that covers co-pays up to $7,200 per year (I pay zero dollars a year because of this), and a medication assistance program for uninsured patients where after signing up and meeting eligibility requirements (which are basically 'are you at risk of getting HIV' and 'are you not wealthy to the point where you should definitely be able to afford insurance') you receive the medication at zero cost.
This is true of many medications, but Truvada is especially famous for it. As a gay man I have a lot of friends on it, and because of the aforementioned program, only two of the thirty+ pay any co-pay at all, and it's something like 20 bucks for them.
I don’t know anyone paying full price for Truvada. It’s either free, or whatever your insurance copay for drugs happens to be. (It’s annoying I have to go to a specific pharmacy with my drug plan, but whatever.)
That's better than I had imagined it was, though I wonder about those on really lousy insurance, or no insurance. Or perhaps those on their parent's insurance that aren't "out" yet, etc.
After long, long pressure from activists, PrEP is now covered by insurance in Europe (at least Germany). Same as the accompanying monthly(?) bloodwork for potential side effects (liver damage?), of course.
I’ve been HIV+ since I was 18 (mid-20’s now). I’ve taken the Gilead combo pills since a few months after I was diagnosed, first Stribild and now Genvoya, the difference being a new form of tenofovir.
I miss probably one dose a month, maybe two. I don’t take my pill at the same time everyday, probably in a 4 or 5 hour window vs. the 2 hour window my doctor recommends. I’ve never had any side effects and I’ve been undetectable since I began treatment.
I’m not sure I’m interested in this injectable regimen. My HIV treatment will last for the majority of my life; I don’t feel like I can risk any amount of reduced long term efficacy with a new drug. I also don’t love needles. I’m excited to talk to my doctor about it, though.
Like birth control, the more options there are, the better. HIV treatment is truly a marvel of modern medicine.
Great news. There are definitely a number of people out there who, in part due to social circumstances have difficulty taking meds daily and this will likely help a good proportion of them.
As someone who grew up in the 80s with the fullblown AIDS crisis, this really is a testament to human ingenuity. When we were kids, this sounded like the end of the world: a virus that attacks the immune system itself. It was so terrifying to hear about such a horrible disease that had no cure, and was so insidious that we couldn't even create a vaccine to stop it.
In a few decades we as a species have found a way not only to completely eradicate it to undetectable levels (it still hides in cells to protect itself) but now we are at a monthly injection.
The way we have created a vaccine for SARS-CoV-2 is also absolutely incredible. It's great to be alive these days, now if only we can get a firm solution over cancer and other diseases like dementia, etc!
> When we were kids, this sounded like the end of the world: a virus that attacks the immune system itself. It was so terrifying to hear about such a horrible disease that had no cure, and was so insidious that we couldn't even create a vaccine to stop it.
I was born in '86. Even into the 90's this line of thinking hadn't changed all that much. The attitude around most diseases and the like that had a 'social' component was best described as "shock and shame" - e.g, you're screwed long-term and society blamed you.
> In a few decades we as a species have found a way not only to completely eradicate it to undetectable levels (it still hides in cells to protect itself) but now we are at a monthly injection.
I was going to ask how this works until you answered the question for me (if it's undetectable, why isn't this considered cured?) Last I heard research is still trying to figure this out. At the same time, I can remember hepatitis C having a similar wrap in the 90's - 'you have it, and probably always will' - Mavyret/Epclusa changed that. It still blows my mind that the problem is pretty much solved at this point.
I think the reason it's not considered cured is because if you go off of your meds it'll (might?) return and potentially gain resistance to the medication. So it's more like keeping it in check through active medication, not curing it away: https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treat....
> In 2018, for instance, there were approximately 36,400 newly infected patients living with HIV in the U.S.
It's 2021, why are we only seeing 3 year old HIV infection numbers? How come I can see coronavirus infection numbers updated pretty much hourly but reporting on HIV infection rates in this country is lagging 3 years?
> In their monthly Vital Signs report out Tuesday, the Centers for Disease Control and Prevention reported that the median time between infection and diagnosis with HIV was three years in 2014, about seven months shorter than in 2011.
If you got HIV in 2020, chances are you don't know about it yet.
I understand that, but I don't see what is so complicated about reporting # of HIV tests conducted in a certain timeframe (daily, monthly, whatever) and what portion of those tests came back positive, just like we currently do with coronavirus. It doesn't matter what the lag time is in between being exposed and receiving a positive test. What we are interested in is # of positive tests, why is there a 3 year lag here?
Couldn't find on the linked article, but what's the lag for people who actually get tested?
I mean, seems that this 3 years lag is because people only get tested if they have any apparent health issue and the doctor thinks it might be HIV.
With Covid, it might take a few days for a test show positive, after exposure - say, Christmas dinner. If someone thinks they might have been exposed to HIV, how long until a test can safely tell it's a true negative/positive?
The death toll in the US for COVID over the last year is up to 60% of the total for AIDS deaths over the last 50+ years. That leads to an urgency for COVID data that doesn't quite exist for HIV/AIDS which presumably hasn't been changing as rapidly.
1. I would be curious how these stats compare when measured in lost person-years. COVID primarily kills the elderly, AIDS (when untreated) kills everyone.
2. We have a 40 year head start on HIV vs. COVID. Surely it can't be that hard, in the digital age, to set up a central database with the following columns, updated in real time: [Datetime of Test, Zip code, Result (pos/neg)]
It isn't that it is hard to set this up. The question is what value is there to setting this up? Especially the way that HIV/AIDS was originally and to a certain extent still is stigmatized. Many people have had friends or family die of AIDS and still refuse to acknowledge that was the reason for their death.
The end result is that not only is this type of project more valuable for a new and rapidly spreading disease like COVID, the bar that the value needs to clear to justify this system is also higher because an HIV/AIDS status is considered more private from a societal standpoint (not necessarily a legal one).
It would be anonymized data, obviously, and it would be helpful to know whether or not we are getting a handle on this pandemic. Apparently we have no idea whether infections are increasing or decreasing over the last couple of years. If I were a public health official, I would really want to know that information.
As someone who is bipolar I will say I know many people including myself who need injections to be able to manage life. The injections may be abused by a percent of the population but there is a much smaller percent(disabled mainly) that need them.
Pharmacy (i.e. the cost of drugs) is a big contributor to rising healthcare costs and injectables are an increasingly more popular and very expensive way to deliver drugs. This is a good example of how R&D and drug development works in the US. Invest time and energy in a much more profitable form of treatment for a disease that is already managed.
All the low hanging fruit for medical treatments have been done already, so right now it's incredibly hard to improve on the situation.
I'm really hopeful though about the genetic revolution that's happening though, I just wish it was happening faster (my girlfriend just got diagnosed with cancer again today :( )
Ok, so I work in healthcare in the US and I read a lot of papers and think "well yeah, but that's not very actionable information".
The best analysis I've found so far is from McKinsey.[1] They took a very clever approach to benchmark US healthcare spending to other OECD countries. They adjusted for US GDP (richer countries spend more on healthcare), then broke down costs by category and figured out how much more/less the US spent compared to OECD countries. Very eye opening if you check out the graph at the bottom of page 4.
Findings: 1) out-patient care is driving ~70% of the extra cost, 2) in-patient costs are ~10% higher than OECD, 3) the US spend 50% more on drugs, but it's a small part of overall spending, 4) administration is 200% higher, but again, it doesn't add up to that much, 5) the US spends less on long-term and home care and 6) the US invests 50% more in healthcare, but it's not a large absolute amount.
It feels like there has been a significant leap in treating common diseases, infections, and ailments during the last few years. Is there any data that can show it or is this just a happy feeling?
> In 2018, for instance, there were approximately 36,400 newly infected patients living with HIV in the U.S.
This number seems insane to me in the USA. Why is a well known deadly disease, with well understood transmission vectors, still spreading so prominently here?
Why is it spreading? Because ACCESS TO CARE is extremely unevenly distributed. It can be extremely difficult for people with limited resources to get proper care.
I was about to reply: because no one ever recovers from HIV infection. Then I realised it isn't true. People being treated for HIV are not contagious, so they "recover" in the epidemiological sense the moment they start treatment. The only way that can happen is if a lot of people have HIV but don't know it.
No, that's not the reason, given that PrEP exists. The actual reason is that Truvada, like other healthcare, can be hard to get in the American system.
The incidence rate of HIV infection is the same in the US as it is in France, Span, or Italy though higher than the Scandinavian countries. I couldn't easily find data for the current rate of new infections, but its not immediately obvious to me that access to health care is the major driving factor.
I don't know enough to comment on European countries, but I wouldn't be surprised if access was a big problem there as well. The American healthcare system is pretty bad, but it's not the only bad system in existence. There may be other linked factors like stigma at play as well.
Telling people to not ever have sex is different from telling people to not meet in large groups during an acute and temporary pandemic. Especially when you only forbid sex for a subset of the population while the remainder of the population is allowed to have sex. The group ban on the other hand is mostly unrestricted and thus more fair.
No, that's the strategy for lower-caste straight people. Telling them that leads to socioeconomically capturing a large percentage of them by burdening them with children before they can hit early potential.
Yeah, I'm persuaded by the Julia Marcus school of thought that simply ordering people to stay home is important but not nearly enough. You have to provide ways for people to reduce their risk in case they decide not to listen to your orders.
I personally stay home as much as I can, but I have certain privileges many others don't.
Ronald Reagan had a hand to play in this, and the AIDS epidemic in america can be seen as the real birth of the neoconservative movement in united states' politics.
Regan refused to even acknowledge the disease until he couldn't get away. This put the US on a deficit addressing AIDS that continues to this day.
Because people don't have healthcare. We've decided as a society that it's better for undesirable people (gay men, IV drug users) to die instead of paying a cent more than we absolutely must in taxes.
I'm hopeful that this is a step towards getting an injectable on a longer time scale even though it's likely the treatment technology would be different. If we could get to something on a 2-year or 5-year time horizon we may just start giving it to everyone preventatively, the way we do tetanus shots. The larger volume might mean enough total profits at a price scale that makes it affordable for the pharma company to do that at a price point that makes sense for the buyer. If we get to a universal treatment that we can apply globally, we may see AIDS become a thing of the past in a few generations. Given unequal access to care that may be substantially challenging in regions with poor health care and we may need an outright vaccine that lasts permanently to successfully treat it globally. But this seems to be a step along that pathway even if new technologies are needed to complete it.
"Eschew flamebait. Don't introduce flamewar topics unless you have something genuinely new to say. Avoid unrelated controversies and generic tangents." https://news.ycombinator.com/newsguidelines.html
There are plenty of researchers who would find a cure if it was possible. HIV integrates into the DNA of the cells it infects, and is virtually impossible to detect and remove completely.
I don't really understand the downvotes and reactions of the other commenters to the gp's post. There's a whole bunch of studies showing there's less incentive to find cures opposed to ongoing treatments under for profit health systems.
On a website where products as a service are discussed regularly i'm confused as to how the parallels between that and profit driven 'healthcare as a service' are ignored or looked at with hostility.
Thanks for pointing that out. Sorry for adding to an offtopic, flamewar inspiring subthread. I hoped providing some sources for the GP's comment might spur on some more productive discussion and i genuinely thought the other commenter was asking in good faith about sources for discussion. I was also genuinely curious as to the harsh reaction
I do see now the flamewar aspect to it and didn't really stop to consider the initial topic of the article when I responded. I was just trying to focus on the actual topic of the commenter's statement and kinda got lost in searching up articles. I was hoping to maybe bring some data and information into the discussion that might steer it in a more productive direction.
It is an issue that could productively be discussed. It seems it didn't end up being the case though and probably wasn't the most appropriate comment thread to do so on.
Thanks—I appreciate that! We all underestimate how provocative our posts will end up being. I struggle with this daily.
I think it's because in our mind, the comment is blended together with the intention behind the comment, which is usually benign. We take our intent for granted and assume it will come across, but of course the people who read it have no direct access to that intent, and often it doesn't come across.
> Is the flamewar tangent part of this the comment on capitalism or "Capitalized medicine"? Doesn't really seem flamie to me but obviously others disagree.
The problem is the generic ideological tangent. You can perhaps (maybe!) imagine a substantive article and thread on the economics of cures vs. treatments. But that would require different initial conditions—primarily an interesting, informative article that brought lots of relevant information. Relevant information is flame retardant.
The situation is different when the topic is "FDA approves first monthly injectable to treat HIV infection" and the comment is swerving generically into "capitalized medicine". Generic tangents, especially when the impetus is snarky or unsubstantive, make threads reliable less interesting, and generic ideological tangents almost always turn into flamewars. The reason is that there's very little specific information to discuss—that's the meaning of "generic".
Off-topic tangents can be great when they're unpredictable and curious, but generic tangents are the opposite of that. They're more like getting sucked into the gravitational field of a much larger body, if not a black hole, that pulls all nearby topics toward itself and renders them all the same. Avoiding repetition is the biggest problem that a forum like HN—dedicated to curiosity—actually has, so it's a big deal: https://hn.algolia.com/?dateRange=all&page=0&prefix=false&so....
I hope this helps explain things a bit. There are lots of past explanations at https://hn.algolia.com/?dateRange=all&page=0&prefix=true&sor... also, but you'll unfortunately—and ironically—have to wade through some generic repetition to find the interesting bits.
If you mean in this case, that may be, but it's certainly not true in the general case.
Moderation comments have multiple functions. If it were just about this specific case it wouldn't be worth spending so much time on it, but they're also opportunities to explain the principles of this site to readers who might not have encountered those principles yet.
For those who do already know this stuff, it's true that such comments are tedious. I'm sorry about that. If it helps at all, they're even more tedious to write than they are to read.
A comment that spawns a lengthy subthread of meta trying to parse out what the commenter actually meant, why precisely they are being downvoted, etc, is bad. As is the subthread of meta.
I am sure there is some evidence on both sides, but at the end of the day, people get into medicine and medical research to heal people, not keep them sick. The USA does not have the only medical system in the world and many countries run their systems with the goal of controlling costs, not increasing them. I don't think this kind of pessimistic conspiracy thinking adds to the conversation.
If there's more money to be made from keeping people sick than outright curing them, that logically is a disincentive from curing them.
It's not conspiracy thinking to look at the incentive structures within systems to predict possible negative outcomes.
Of course, there's a moral incentive to not keep people sick, but history shows that we can not rely on people acting morally. The pessimism is justified.
If we expect companies to provide cures over treatments, we at least must allow them to profit as much or more from a cure as they would from a treatment.
> we at least must allow them to profit as much or more from a cure as they would from a treatment
I think that’s where you go wrong. There are huge profit incentives for a cure. If a biotech company comes up with a cure they will instantly have the business of every afflicted person on the planet. The market for that and price they can charge will be way larger than a slightly different treatment.
Beyond that, there are labs all over the world funded by public dollars to research avenues to a cure, it’s just way more complicated than effective treatment.
There are indeed huge profit incentives for a cure. There are even larger profits to be had from a monthly treatment that the patient has to take for the rest of their lives.
Are you saying people that aren’t taking a monthly biologic injection for example will start coming out of the woodwork for a cure when normally they wouldn’t seek treatment for their malady?
You speak as if there is just one entity making these things. There isn’t, there are hundreds of labs all over the world working on this. If one of them comes out with a treatment alternative like this it may gain some traction but if they came out with a cure they would dominate the global market
> It's not conspiracy thinking to look at the incentive structures within systems to predict possible negative outcomes
It is when one mischaracterizes the system.
Medical research is not an oligopoly. It is oligopolistic within some domains, but as we've seen with the Covid vaccine, there are at least four nation-state domains (e.g. Russia, China, India and "the West") operating competitively, and within those domains, there are varying degrees of competitiveness (e.g. Pfizer vs. Moderna vs. AstraZeneca).
If you have a cure to something everyone else can only treat, you'll make a money selling the cure and taking your competitors' market share. Because if you don't, they will. It's a classic cartel / prisoner's dilemma problem with the added explosive of a multi-decade patent-protected monopoly for the first mover.
I'm not sure every claim is worthy of debate. Setting aside all the private investment and philanthropy dollars going towards a cure, governments spend billions annually on HIV research.
Yes, they spend billions on developing the exact types of treatments that this article is about. Their business model depends on maximizing revenue so any treatment cannot cure the patient and it cannot kill the patient. Sad, but true.
> I'm curious what evidence there is on either side of this claim
Looking at the list of the most deadly non-tropical infectious diseases [1], most can be vaccinated against and/or cured. The standouts remain lower respiratory infections, e.g. influenza, and HIV/AIDS.
When confronted with a novel coronavirus, it took a few months for the world's medical systems to devise various treatments and a vaccine. Neither of those are recurring revenue streams.
Most damning to this conspiracy theory is the recent Hep C cure. That's a real disease. It was profitable to treat. But it's more profitable to cure. Those incentives remain elsewhere. A cure for HIV is worth billions.
Dealing with mortality and sickness is difficult. It's more comforting to some to imagine an evil cabal holding back medicine, and I don't need to take that from them. But if you're entertaining these thoughts as anything more than a coping mechanism, the last half century--or even decade--of progress in curing, not treating, curing a variety of medical issues has been under-reported (lots of niche illnesses) and breathtaking.
The Hep C cure wasn't all that profitable, from what I understand. On paper it was a clear win-win - the cure would save the various healthcare services lots of money compared with treatment, whilst still raking in boatloads of money. The trouble is that healthcare services everywhere balked at buying it regardless of their structure and despite the fact that not doing so would cost them money in the long term, and even at those rejected prices it wouldn't have been nearly as profitable as a long-term ongoing treatment because it eliminates its own customer base.
I came here to post about the Hep C cure. You did a great job.
Only thing I would embellish on is that, much like software - when something is wrong its easier to treat the symptoms than to fix the problem a lot of the times. So it's really no wonder alot of treatments are amelioration rather than cures.
I recently did a major refactor at work to fix database and caching problems in our backend. It took months but only yielded 50% scaling improvements. Past teams just kept stacking shit and adding hardware and we can all understand why.
You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...
Well not sure if it is "evidence", but in terms of marginal preventing people in the US from getting HIV, lowering the cost of Truvada from $2,000 out of pocket and publicizing it would likely have a much larger impact than this once a month shot.
The claim logically holds together. There is even evidence on its side.
But one reason for the downvotes may be that it might be too narrow-minded. For one thing, it completely neglects to consider the relative difficulty of treating symptoms versus being fully curative. Secondly, it half undermines itself by lumping vaccines into the same bucket as symptomatic treatment. Clearly the economic incentives for vaccine, versus symptom management, versus cure depends on the disease being treated.
Finally, while it carefully uses the word "incentive" instead of talking in black and whites, it doesn't explain why "big pharma" makes cures at all. A lot of the the supporting material for "pharma makes more money on symptom treatment" references Gilead's experience with Hep C. But the economics of how that drug would have worked was clear as day before Gilead spent resources of it. So why would Gilead have gone to market with a cure at all?
The claim doesn't logically hold together: it assumes a monopoly in medicine. It might not be profitable for the company with a treatment regimen to develop a cure. But for the company without the treatment regiment to develop a cure and take away all of a competitor's business and capture a significant part of it as their own? That's extremely profitable. You can charge far more for a cure than for a regular preventative treatment (per dose) so margins are far higher even if volume over time is lower. Suffice it to say cures are sufficiently profitable to enough of the actors in the system that they are worth exploring. And there is evidence of cures being researched successfully as referenced in the comment above. Also, I don't think all pharma companies are perfectly 'rational' actors in this sense. They are composed of people who got into medicine with the interest to help people, and those people know both cures and vaccines help more than just symptom mitigation. The motivation of the actors in the system to do good leads to even more research of cures and vaccines than the non-zero amount that is sufficiently incentivized (even if cures are less profitable than symptom mitigations).
Median income in the US is ~$31K apparently. So even in a rich country, this is like 50% more than the income of a typical person.
My understanding is the funding for the trials was partly from NIAID. This seems like yet another case where public funds are used for research, but a company ends up with the ability to dictate pricing.
I'm glad that this works and that there is another, more convenient and effective treatment option. But shouldn't we have some setup where if tax dollars pay for the research, the government should own a share of the IP commensurate with their funding level, and should then be able to have some say in pricing?
Or, if you think that the government itself shouldn't own IP for a product on the market, can we create an independent non-profit which receives ownership, and whose charter aligns with actually treating as many people as possible?
I'm not saying that when real, innovative work happens, pharmaceutical companies shouldn't get some meaningful return on the money they put in. But when the public supports the work, we shouldn't get nothing.