08/06/2013 03:40 pm ET Updated Feb 02, 2016

Truvada Truths: The Money's in the Medicine

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Porn director Michael Lucas' recent "coming out" as an HIV-negative man on pre-exposure prophylaxis (PrEP) has many people talking about the future of HIV prevention.

Although the reality of the drug's side effects still has some taking the treatment with a grain of salt, Lucas makes a clear argument for the use of the drug as a possible vaccine.

The alternative reality is grim too: HIV statistics seem to reflect nothing of the hindsight that 30 years of the epidemic might bring. Infection rates remain steady, when they aren't rising. The rate of condom use remains impossible to enforce or even calculate.

Not a single person in the study of PrEP has tested positive for HIV. Sure, a vaccine taken once a day for the rest of your life sounds a little extreme, but so did the pill that my doctor gave me to take once a day for the rest of my life to keep my HIV from turning my body into a coral reef of infection. And still, if there had been an alternative pill that my doctor could have offered to turn back time and delete that horrible day when I tested positive, I would have taken it without asking about the side effects.

Despite our best efforts, we will never be perfect at preventing HIV. After 30 years there is still no cure and no proper vaccine. Why not democratize what resources we do have to prevent all additional infections? The answer is buried toward the end of Lucas' piece:

"Truvada costs around a thousand dollars per month. But Gilead, the maker of Truvada, is offering assistance (free pills) to qualifying individuals who can't afford it."

Free or impossible: It's a familiar dichotomy to anyone familiar with HIV. Many people living with HIV become masters of cheating the medical establishment. We lie about our income when it's too high to qualify for "assistance" but not enough to afford the doctor's visits, blood tests and daily medication required to live with an incurable virus. We pretend that we're not residents of our home states when they're red states, because in those states the nation's AIDS Drug Assistance Programs (ADAP) are often reduced to political football, an austerity program, a waiting list you might die on.

Doctors love to tell newly infected patients that HIV is no longer a death sentence. It's a great way to make someone stop crying, but that assurance is predicated on the ability to access all the shots, tests and pills necessary to keep someone with HIV alive. Not to mention the psychological effects, the feelings of shame, the stigma for which there is still no pill or assistance program to alleviate the cost.

Truvada has been prescribed for almost a decade at the other end of HIV treatment, as antiretroviral therapy. It is just one of the family of HIV drugs produced by Gilead Sciences, whose antiretroviral combinations have profited from the lion's share of HIV's growing rates of infection. Gilead medicates about three quarters of people treated for HIV, and all of those treatment regimens retail between $1,000 and $2,500 for 30 tablets.

"With new and preventable HIV infections happening every hour," Lucas asks, "is the silence about PrEP among the safe-sex establishment not criminal?"

The answer to Lucas' very earnest question might be found in a Chris Rock stand-up act from 1999:

They ain't never curing AIDS. ... They ain't curing that, 'cause ain't money in the cure; the money's in the medicine. That's how you get paid.... Curing AIDS? Shit, that's like Cadillac making a car that lasts for 50 years. And you know they could do it, but they ain't gonna do nothing that fuckin' dumb.... They can, but they won't. So what they will do with AIDS is the same thing they do with everything else: They will figure out a way for you to 'live with it' ... so they can get more of your money.

Health care investor Nathan Sadeghi-Nejad puts the same idea into a more sober, organizational voice: "HIV generates the vast majority of Gilead's impressive $3.5 billion in annual free cash flow. I don't think that cash flow is at any significant risk, and expect the HIV business will continue to grow modestly through 2021."

Silence is not a crime. Neither are Gilead's "impressive" annual earnings or CEO John Martin's "modest" five-year compensation of $214.92 million. But silence isn't always question of legality. To adapt a phrase still haunting some of us from 30 years of hindsight, sometimes silence is simply a question of life or death.