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San Francisco Examiner
Selling HIV drugs -- hope or hype?
Lisa M. Krieger, Examiner Medical Writer
July 23, 1997
Firms market medications with ads aimed directly at patients

The handsome man on the bicycle smiles out from billboards around The City, the image of good health.

Is this an ad for toothpaste? Mouthwash? Shampoo?

No, it is a controversial new marketing campaign to sell a potent medicine for the complex treatment of a deadly disease.

As the competitive marketplace for anti-HIV drugs heats up, so does the debate over how companies sell their wares. Ads for AIDS therapeutics, once confined to the sober pages of doctors' journals, now are found on street corners, subway stations, phone kiosks, and the pages of mass-marketed magazines and newspapers.

The approach has promise and peril, doctors and activists say. Although advertisements can be educational, they also can be misleading, sabotaging the complicated task of AIDS treatment.

"Treatment decisions are influenced by more than just which product has the most attractive ad or the biggest billboard. ... Glitzy advertising just pits patients against providers," said Dr. Donald Abrams, a clinical professor at UC-San Francisco and co-director of the AIDS Clinic at San Francisco General Hospital.

Fueling a misconception that AIDS has become an easily manageable disease, the ads promise convenient therapy for people with active lifestyles. Using images of youth, energy and athletic excellence, they appeal directly to patients, particularly racial minorities, who have not yet started treatment.

"I get sick and tired of companies pushing these on people," said Gary Johnson, a 41-year-old San Franciscan who has tried a host of drugs -- AZT, DDI, 3TC, D4T, saquinavir, ritonavir and delavirdine -- only to grow sicker. One drug caused leg pain. Another induced severe vomiting. Others caused ulcers on his lips, tongue and throat.

"These 'miracle drugs' are killing me," said Johnson, who has lost 50 pounds in the past year of treatment. "I can't tolerate them. I've tried. These companies are making lots of money, but I think they're grasping at straws. The virus will still get us, one way or another."

The genesis of the genre

Brand-specific, direct-to-consumer campaigns were rare until 1989, when Upjohn started advertising its Rogaine hair restorer. Since then, with approval from the U.S. Food and Drug Administration, products ranging from contraceptives to cholesterol-lowering medication have been pitched in the mass media.

The taboo against marketing anti-HIV drugs has been broken in the past year by every leading manufacturer. For many years, there were no products to offer patients. Now 11 drugs are on the market -- and more are on the way. An estimated 10,000 new prescriptions are written each month.

The AIDS drugs have extended the lives of many patients, a near-miracle. But if not administered correctly -- say, too early or too late, or in the wrong combinations -- the drugs may hurt, not help.

It is estimated that 10 percent to 20 percent of patients gain no benefit from the drugs. Others suffer intolerable side effects.

The most recent and visible ad campaign -- featuring the smiling bicyclist -- promotes the anti-viral drug D4T, sold under the brand name Zerit by Bristol-Myers Squibb. The campaign targets 26 national gay publications and 20 U.S. daily newspapers, including The Examiner and Chronicle.

Another barrier was broken by Bristol-Myers in July, when Zerit ads appeared in bus shelters, subway platforms, telephone kiosks and bus interiors in four markets: San Francisco, Manhattan, Miami and Jersey City.

The tag line: "Put some freedom into your HIV medication schedule."

An eye-catching ad for the drug indinavir, called Crixivan, in the magazines GQ and Esquire shows a rock climber scaling his way to the top. The message from the manufacturer, Merck & Co.: "In the battle against HIV, there's a change in outlook."

The tag line for the anti-viral agent ritonavir, called Norvir, quotes a patient: "I wanted a protease inhibitor that fits my daily activities."

Most infuriating to critics was a long-running ad, discontinued in July, for the drug saquinavir, called Invirase. A major clinical trial found that the drug is not only ineffective, but undermines future benefit from other drugs. But its ad declared it "A Protease Inhibitor You Can Live With."

"It is a drug one could die with -- and many have. People are literally ruined on it," said Martin Delaney of the San Francisco-based treatment advocacy group Project Inform, who pushed for cancellation of what he calls "a horrid, dishonest ad campaign."

Community criticism led to discontinuance of the ad, said Jeff Winton, a spokesman for Roche Inc. of Nutley, N.J., which makes the drug. New ads featuring an improved version of saquinavir will be launched later this year. Roche will let AIDS activists review the next ads before distribution.

"We've learned a lot about what should be in ads, and what shouldn't be," Winton said. "But it is important to remember that in small and rural parts of America, where people don't get as much treatment information as you have in San Francisco, ads are the only way to reach people."

Profits are at stake

Drug companies have invested hundreds of millions of dollars in AIDS drug research -- a gamble that is finally paying off.

The potential market is huge: Analysts estimate that only 200,000 of the world's 23 million HIV-infected people are taking anti-viral drugs. Although companies don't disclose earnings on the product, sales of AZT have surpassed $2.3 billion over the past decade, according to the Economist magazine. Sales of the newer protease inhibitors alone are predicted to exceed $2 billion by 1999.

A three-drug combination of these agents is now recognized as the closest thing to an AIDS cure. The race is on among drug makers to ensure that their product, not others, is part of the combination.

Merck, which sells its indinavir under the name Crixivan, is the leader in the class. But the drug is complicated to use and has been plagued by major side effects.

"It is a very competitive marketplace," said Jeff Trewhitt of the Pharmaceutical Researchers and Manufacturers of America. "Managed care is taking over -- and not every medicine is on the formulary. It is very important, competitively, to make sure the information is out there, so doctors and patients are aware of your product."

"So many products are being approved that it is hard for doctors to keep track," Trewhitt said. "Doctors may not remember everything, so it is important for the patient to be actively involved in his treatment."

Promotion of the drug D4T has been energized by the failure of AZT, an older drug. Bristol-Myers, which makes D4T, wants to establish the drug as the cornerstone of combination therapy, Delaney said.

The D4T ad campaign targets an under-served -- and growing -- market of infected people, said John Kouten, spokesman for Bristol-Myers Squibb Co. Minority patients are hard hit by AIDS but do not take advantage of new treatments, he said.

"Given the changing demographic makeup of the HIV epidemic, we wanted to develop an ad that speaks to the entire HIV-infected population," said Rick Winningham, president of Bristol-Myers Squibb Oncology/Immunology, a division of Bristol-Myers Squibb.

The campaign is welcomed by A. Cornelius Baker of the National Association of People with AIDS: "We are pleased to see an active interest in communicating the importance of seeking appropriate treatment directly to the minority community," he said.

Market analyst Jack Lamberton of the New York investment bank NatWest Securities Corp. observed: "It is the only way. ... If you want to get newly infected people into therapy, you have to do direct-to-consumer advertising because these people would not otherwise have any reason to go to a doctor."

'Raising awareness'

Some doctors are supportive.

"It's about time. I've been in favor of direct promotion to patients for over 20 years," said Dr. Marcus Conant, a San Francisco AIDS expert. "There's nothing wrong with raising awareness, disseminating information and getting patients to ask the appropriate questions. ... The whole paternalistic notion that you go to the doctor and he figures it out -- that is really outdated."

But other doctors say patients are ill-served by the ads.

Dr. John Stansell, medical director of the AIDS Program at S.F. General Hospital, called the ads "absolutely infuriating."

"They focus on very narrow properties of the drugs and fail to take into account toxic interactions, side effects, the stage of disease and the properties of the virus. (Ads) only complicate treatment of a disease that is already very complicated," he said.

To some experts who have watched the evolution of AIDS education, the ad blitz has particular irony.

"I never dreamed that our 'patient empowerment' movement would lead to this," said Delaney of Project Inform. "We want information, but we want it to be balanced, showing the big picture. ... None of these drugs is proven to be a cure.

"This is like selling Coca-Cola or Nike."