The article below, titled "Greed and HIV," was written by Steve Whitson, Ph.D. (editor), and is reprinted from the January/February 1999 issue of
Positively Aware, the monthly newsletter from Test Positive Aware Network in Chicago. You can contact them at 773.404.8726 or visit them at www.tpan.com.
Greed and HIV
A lot of people are getting rich off HIV. The money is so big that it puts a lot of people and companies in a questionable position ethically and morally. And you can be certain that this lure of easy cash dirties more than a few hands. While many activists draw attention to corporate greed by pointing to the high-price of many drugs (most recently Sustiva by ACT UP Philadelphia), the root of the problem goes much deeper. The price of a drug is merely a symptom of a much more vast formal and informal network of perks and payoffs.
Some doctors and some pharmaceutical companies are profiteering from one of the most lucrative illnesses ever to hit humankind. Poised to pounce on this pandemic, the global costs of HIV make it one of the largest pharmaceutical "cash cows" in history. For instance, the treatment costs of HIV would exceed the entire GNP (gross national product) of many African and Asian countries if they were to offer the "cocktail" to everyone positive with the virus.
AdvertisementWith big money comes temptation, and not everyone can resist taking a bite out of this apple. Through various informal schemes, some doctors get free trips to exotic places at fancy resorts. You see, pharmaceutical companies have lists that tell them which doctors are prescribing their drugs. All drug companies monitor doctors and what they write prescriptions for. As a result, doctors who push a lot of a particular med are rewarded with a nice vacation; keep in mind that these trips are usually seminars or workshops, but no one cares if you attend the meetings or not. Much like a "frequent flier" program, these doctors belong to a "frequent prescriber" club.
While the above example may seem relatively harmless, others are not. Some doctors enroll patients in studies without telling them so. Here's how it works: you need to switch meds for some reason and blood work is done to monitor how well you're doing on the new regimen. For a period of time after the switch, a copy of your lab results is sent to the pharmaceutical company where certain reactions, adverse events, problems, benefits are put in a data bank. This is usually done with your name being removed from the lab test, but the results are still monitored. The problem with your doctor sending the findings is that there is no informed consent -- you are neither informed that this is done, nor consent (agree) to it. In other words, you are being studied without your permission.
The pharmaceutical industry is also guilty of blurring ethical lines. While we can be certain that most drug companies engage in questionable activities in order to gain "market share" for their medicine, one recent example demonstrates the moral depths to which they will descend. On 22 September 1998, Investor's Business Daily accurately predicts the protease trend: "A report indicates that Agouron should take away market share from Merck's Crixivan because of Viracept's twice-a-day dosing. Agouron may also benefit from recently announced manufacturing problems at Abbott Laboratories, which makes Norvir." Further, the aggressiveness of Agouron's tactics are well known in the pharmaceutical industry as reported by the San Diego Union-Tribune (9/16/98): "Instead of celebrating the drug's success, Agouron President Peter Johnson has struggled to preserve momentum and to keep Wall Street interested." This prediction did not fall on deaf ears at Agouron. Even though Agouron's profits grew 90% during the first quarter (San Diego Union-Tribune, 10/21/98), and even though "Viracept is now the most widely prescribed protease inhibitor" (PR Newswire, 10/20/98), an ethically dubious move was made to capture even more market share by rewarding doctors if they switched their patients from Norvir to Viracept.
The scheme worked like this: Agouron would give doctors $1,000 if they switched a patient from Norvir to Viracept. Scott McCallister who is a leading HIV specialist in Chicago told Positively Aware that "Agouron was quick to react when the problem with Abbott's Norvir appeared. They came to us and offered a quote-unquote 'trial' using nelfinavir (Viracept). They brought a form with them that first day and offered us a $1,000 a patient to switch them." Dr. McCallister summarizes his reaction to Agouron's approach: "I think any reasonable physician would question Agouron's ethics. It is reprehensible to me that they would take advantage of an unforeseen manufacturing problem by Abbott. And it is reprehensible to me that they would offer us a quote-unquote 'bribe' in order to change drugs."
Agouron's side of the story is a little different. They angrily responded that such speculations were untrue and that Agouron has worked hard to help the HIV community. In fact, the money given to the doctors was to be used for research and was not a pay-off. The doctors we contacted, however, don't see it that way. Dr. Robert Brandt of Dayton, Ohio reported to Positively Aware that: "I have never seen a research protocol constructed this way, it was simply a ploy to gain market share." Scott McCallister further explains that this was the "first time he was approached by a drug company presuming that their drug would improve the problems associated with another drug. This was an unusual practice, we do a lot of studies in our office, this is something we have not seen before."
Besides the obvious ethical questions, matters of health are also compromised. Another doctor, David Butcher of the Kansas city Free clinic, says he was asked to switch patients, but won't because of the potential for a viral rebound with Viracept. His research indicates a significant number of patients experience an increase in viral load after switching protease inhibitors. In his words "the holding power of Viracept is inferior to Norvir. It would be sinful to switch."
From these few examples we see how money corrupts some individuals in the treatment and study of HIV. While Agouron's behavior probably represents more a lapse in ethical judgment than a pattern of practices, such conduct should be brought to light and made public so as to maintain our system of checks and balances with drug companies.
-- by Steve Whitson, Ph.D.
Women Alive Editor's Note
"lapse in ethical judgement" rather "than a pattern of practices," but maybe not. This article was written in the beginning of 1999. Since then, it could seem to an observer that truly, this pharmaceutical company behavior has become routine practice or is rapidly becoming commonplace rather than rare.
As treatment advocates, we observe that medical regimens are often based on where people get their care, rather than how many T-cells they may have. Many of us have noticed that all of our clients that go to a particular clinic (let's just say "The North Clinic") are all on the same medications. All of the clients that go to the other clinic across town ("The South West Clinic") are all on the same medications as each other, yet a different regimen than the North Clinic.
Are you following this? Let's just say hypothetically that everyone who goes to the North clinic, regardless of their T-cell count or their viral load, or their gender are taking Combivir and Sustiva. Everyone getting treatment for HIV at the South West Clinic is being prescribed Norvir, ddI, and Zerit. This situation raises suspicion among many of us. For example, why would someone who is known to be intolerant to Norvir -- I mean, like totally intolerant, like the smell makes you puke, there's no way you can keep it down even if you manage to gag it down, you throw up -- why would a provider continue to prescribe this same individual this same medication over and over and over again for almost four years? Why?
Fastest Finger Question
Starting with the most to the least, put these companies in order according to who offers the biggest bribes to AIDS doctors in exchange for prescribing their product.
Agouron, Ortho, GlaxoSmithKline, DuPont? (. . . hmmmm?)
Anyway, we at Women Alive have some things to say to any and all providers who take bribes from pharmaceutical companies that in turn compromise the care of any PWA or any other patient: Our community is only as strong as our weakest link. So, go on your junkets, we don't really care (except all that money may be better spent in the laboratory, researching a CURE). Get all the perks you can, but don't do it off the backs of sick people with AIDS. Ask yourselves: are you compromising an HIV-positive person's health by prescribing according to your "incentive/bribe" program, or are you prescribing based on what is the optimal treatment and care for the individual?
- Who in your town needs to turn their stethoscope over to the ethics committee?
- Whose cheese has slipped off their cracker?
- Whose belt doesn't go through all the loops?
- Whose mental power is experiencing rolling blackouts?
- Who's one brain short of a brain?
- Who among us cannot tell the difference between LIFE and a box of chocolates?
- Purge the parasites; parole the pathetic!
- One of you (or maybe more of you), quite rightly are about to leave with NOTHING!
"You are the weakest link! . . . Goodbye!"