# XOXO, Science **Authors:** Christopher J. Morten **Citation:** XOXO, Science, in *1996* 219 (Matt Keegan and Svetlana Kitto, eds., Inventory Press, LLC/New York Consolidated, 2020) **Source:** https://search.library.nyu.edu/permalink/01NYU_INST/1d6v258/alma990079271640107876 *p. 7* Sometime in 2019, an ad signed XOXO, SCIENCE started appearing around New York City: on bodega walls, on bus stops-just about everywhere, once you started to look for them. The ads are still everywhere as I write this in January 2020, and they seem to be concentrated in three places: low-income neighborhoods; neighborhoods where people of color live; and neighborhoods and public venues where gay men congregate. (I personally have seen the ads pop up in a bathroom in a gay bar [a poster over the toilet] and at the Metropolitan Opera [in Playbill].) Not coincidentally, poor people, people of color, and gay men are three of the groups most at risk of contracting HIV in the United States today. *p. 7* What exactly are these ads? They're not publicservice announcements, though they resemble PSAs, and they're often placed next to actual PSAs from the City of New York. As the small print at the bottom of the ads reveals, these promotions are paid for by Gilead Sciences, Inc., one of the world's largest and most profitable pharmaceutical companies. The ad copy also includes a web address, xoxoscience.com, which leads visitors to the homepage for Biktarvy, a brand-name HIV-treatment pill sold by Gilead. *p. 7* To me, these XOXO, SCIENCE ads represent cooption by Gilead of things that are not and should not be Gilead's. This essay is about why the ads infuriate and inspire me to fight back against Gilead and against corporate co-option, for public science and for an end to HIV. ## Gilead and PrEP4All *p. 7* I'm a lawyer and a teacher. When I was young, I thought I would be a scientist. I got a PhD in chemistry before I turned to law. When Gilead claims the mantle of science for itself, the affront feels personal. *p. 7* One of my legal clients is the PrEP4All Collaboration, 1 a group of HIV/AIDS activists based in New York City. Most PrEP4All members are young queer people, but some are straight, some are older, and some are veterans of ACT UP and the Treatment Action Group (TAG). PrEP4All's core mission is to make PrEP and HIV treatment drugs cheap and accessible for everyone in the US, to do it within the next year or two, and to get new HIV transmissions in the US near zero by 2030. *p. 7* Peter Staley, a member of ACT UP and TAG and a cofounder of PrEP4All, wrote me this capsule summary of how he conceives PrEP4All's mission and its brand of activism: *p. 7* The story of AIDS activism during the plague years is one of triumph, of forcing the country to respond to the crisis and of a relentless push for treatments that now keep millions alive around the world. But after those drugs came out, our activism faded. Deaths went down, but infections didn't. Thankfully, a new generation of activists has stepped up to finish what we started, determined to write the last chapter of the AIDS crisis. They are inspired by the activism of the past, while creating their own playbook for lowering HIV infections, using the courts, Congress and targeted media to force change. ## What barriers stand in the way of ending the AIDS crisis? *p. 7* There are many, but here I'll focus on one: Gilead Sciences, Inc. As of this writing, Gilead holds an absolute monopoly in the US on HIV-prevention therapy ("PrEP")-a ## Chris Morten *p. 7* Opposite: Confide HIV in-home testing ad, Rolling Stone, October 17, 1996. once-a-day pill that reduces the risk of sexually transmitted HIV by about 99 percent. 2 Gilead also holds about three-quarters of the US market for HIV treatment-that is, medicines for people living with HIV. 3 Gilead does not make HIV drugs cheap or universally accessible. Gilead's drugs are expensive, but not because they are particularly costly or difficult to manufacture-generic versions of Gilead's drugs are sold overseas for pennies a pill. 4 Instead, they are expensive (in the US) because Gilead uses patent rights to prevent generic competitors from selling cheaper versions of its drugs. Because it has no generic competitors, Gilead is able to charge over $20,000 per year for PrEP and even more for other pills-for example, about $40,000 per year for Biktarvy, the HIV treatment advertised in those XOXO, SCIENCE ads. 5 (As I explain below, Gilead charges these very high prices despite the fact that much of the research-that is, the science-embodied in these pills was done with public money, not Gilead's.) *p. 8* Many, many people before me have criticized Gilead for its high prices on other patented drugs. These prices strain public health budgets and keep drugs out of reach for the very people who need them. There are vastly more critiques than there is space to quote them here, but to cite just one, a bipartisan Senate committee report from 2015 concluded that Gilead's pricing strategy for Hepatitis C drugs "was focused on maximizing revenue-even as the company's analysis showed a lower price would allow more patients to be treated." 6 Doctors and epidemiologists have shown that Gilead's prices on HIV drugs, specifically, are limiting access and prolonging the HIV epidemic in America. 7 In Australia, for example, PrEP costs less than $400 per year, and HIV transmission and diagnosis rates there are falling as more and more people take it, 8 but in the US, fewer than one in six people at risk of HIV currently take PrEP. 9 And the epidemic rages on: HIV transmission rates are almost exactly as high today as they were in the mid-1990s; 10 about forty thousand Americans still get HIV every year, and more Americans live with HIV today than at any point in history. 11 In 2015, only about half of Americans with HIV (diagnosed and undiagnosed) had achieved viral suppressioni.e., had received effective treatment. 12 On this score, the US-the country that spends more, per capita and in aggregate, on health care than any nation on Earth-does slightly worse than Rwanda. 13 Americans do not bear the burden of the HIV epidemic equally; there are staggering and growing disparities and injustices in diagnosis and death rates. For example, an estimated 14 percent of trans women have HIV, 14 compared to about 0.3 percent of Americans overall, 15 and Black people account for about 12 percent of the US population but more than 40 percent of deaths and new diagnoses. 16 It is no coincidence that as of 2017, only 5.9 percent of Black people who met the indications for PrEP were receiving it, compared to 42.1 percent of white people. 17 Gilead's official mission statement is "to discover, develop and commercialize innovative therapeutics in the areas of unmet medical needs that improve patient care," but commercialization seems to have eclipsed the rest of that mission. 18 In 2017, Gilead recorded profits of about $5 billion on about $26 billion in revenue, 19 and, according to a recent study, it spent a smaller fraction of that revenue on research than any of the ten largest drug companies in the US. 20 Gilead spends billions on marketing every year. 21 In fact, it spends about as much on marketing as it does on research-that is, on science. 22 So back to those XOXO, SCIENCE ads. When I see them, I think of the dollars Gilead spent on them, dollars that could have been spent on actual science but weren't. And I see those ads everywhere, every time I walk to and from work, to the doctor, to see friends. The ads are maddening but also somehow familiar, and sometimes I'm grateful for their provocation. They remind me that the fight against HIV and against corporate power is urgent, and they make something invisible and incomprehensible-the wealth and power of Gilead specifically, and of the pharmaceutical industry more generally-feel concrete and measurable. *p. 8* Three Things That Gilead Has Co-opted I wrote above that the XOXO, SCIENCE ads represent co-option. What exactly has Gilead co-opted? Here are three specific things. *p. 8* The first thing is pop culture, maybe youth culture, or even "gay social media culture," if that is a thing. The tone of the ads is breezy, though the subject is deadly serious, a mash-up of styles that reminds me of Twitter. The ads seem to make other references to social media: large text in white and green on a deep cyan background appears above small black text on a white background, the format evoking an Instagram post. 23 The sign-off, XOXO, is one made famous by the TV show Gossip Girl and (says the Atlantic, finger on the pulse) particularly favored by young women and gay men. 24 I think that by channeling the look and tone of social media, the ads seek to weaken our wariness, to disarm us. The ads mimic messages from a friend. *p. 8* The second thing co-opted by the XOXO, SCIENCE ads is more serious: it's billions of public dollars invested in discovering and developing drugs to treat and prevent HIV. While Gilead's ads suggest that Gilead is doing all the science, much of the science embodied in Biktarvy and its other HIV drugs was done by government labs, or by universities working with government grant money. (This turns out to be very, very common across the pharmaceutical industry-for example, a recent paper showed that every single one of the 210 new prescription drugs approved Opposite: Gilead Sciences XOXO, SCIENCE ad, New York, 2020. Photo: Chris Morten. *p. 9* between 2010 and 2016 received funding from the leading federal biomedical research agency, the National Institutes of Health [NIH].) Here are three examples of Gilead co-opting public research on HIV: 25 Biktarvy, the lucrative drug that is the product being pushed in the XOXO, SCIENCE ads, is one pill that contains three active pharmaceutical ingredients-three chemical compounds that fight HIV. One of those compounds, emtricitabine, was invented not by Gilead but by chemists at Emory University, who did their research with grant money provided by the NIH. 26 After taking millions of dollars of grant money from the NIH-that is, from the American public-Emory sold its patent rights in emtricitabine to Gilead in an exclusive deal worth more than half a billion dollars, 27 thereby privatizing the profits from this publicly funded compound. While Gilead and Emory have reaped huge benefits from emtricitabine, the NIH has recouped nothing. *p. 9* The story of PrEP is one of co-option: it was not Gilead but scientists at US government labs-the NIH again, along with the Centers for Disease Control and Prevention-who first discovered and then proved that a once-a-day pill can prevent transmission of HIV. Dr. Robert Grant, a professor at UC San Francisco who was the lead investigator on the first clinical trial to prove that PrEP works, 28 testified before the House of Representatives that "the US government is by far the majority funder of PrEP research" and that "Gilead Sciences did not provide leadership, innovation, or funding for" scientific research on PrEP. 29 Yet Gilead has been able to use our nation's patent and regulatory systems to capture the entire market for PrEP in the United States, and it now earns more than $2 billion every year from sales of PrEP (at, again, a cost of more than $20,000 per patient per year). 30 In January 2020, Gilead announced that it had acquired from Rockefeller University in New York "exclusive global licenses to develop and commercialize" therapeutic "broadly neutralizing" anti-HIV antibodies, which "have potential for use in HIV long-acting therapies for treatment and prevention, as well as cure strategies." 31 Rockefeller's scientists invented the antibodies with grant money from, among others, the NIH. 32 Rockefeller and Gilead have not, to my knowledge, disclosed the terms of their licensing deal. *p. 9* The third thing co-opted by the XOXO, SCIENCE ads is related but distinct, I think. It is subtler but possibly more serious-more depressing even than co-option of public science. It is co-option of our collective will to care for people with HIV, to find a cure for HIV, to find cures for myriad other diseases, and, very broadly, to discover and distribute new technologies of every sort, medical and nonmedical. It is, perhaps, co-option of the idea of science itself. Gilead's ads purport to speak both for "we" and for "science," and as such, they quietly insist that science is fundamentally an enterprise for and by pharma companies. (Gilead not only owns the domain name xoxoscience .com, it has trademarked the phrase and claims an exclusive right to use it in the field of "promoting public awareness about HIV/AIDS and treatments for HIV/AIDS." 33 ) As such, these ads quietly insist on a neoliberal model of HIV drug development, and of health care and health science more broadly-a model under which we generally rely on for-profit corporations to sell us health care and generally permit those corporations to set prices and R&D agendas as they please. (I say neoliberal rather than liberal because there is no genuinely free market for medicines or health care in the United States; we instead have markets that are dominated by a relative handful of entrenched, spectacularly wealthy corporations and sheltered both from new competition and from democratic "interference." 34 ) The pharma industry spends a lot of money on lobbying-every year it spends much more than big tech, fossil fuels, insurance, finance, or any other industry-to keep it that way. 35 We Can Take Back the Things That Gilead Has Taken from Us *p. 9* We don't have to accept Gilead's ads, its co-option, or this entire state of affairs as natural, inevitable, or permanent. The first co-opted thing I identified was Gilead's co-option of youth culture, pop culture, gay culture. That kind of corporate co-option has been a fixture of American life for decades, and it was reviled at least as far back as my Adbusted and No Logo-ed early-millennial childhood, circa 1996. I leave the problem of reclaiming culture to artists and activists, though one small helpful legal step might be finding a way to ban direct-to-consumer pharmaceutical advertising, including these XOXO, SCIENCE ads. Direct-to-consumer pharma ads were nearly nonexistent in the US until the 1980s, and they are illegal in most countries. 36 It is not at all clear that we benefit from permitting pharma companies to talk directly to us. 37 (Unfortunately, banning direct-to-consumer pharma ads may require reinterpreting the First Amendment of the US Constitution first, as freedom of speech, too, has arguably been co-opted by corporate powers. 38 ) I know we can take back the second co-opted thingthose public science dollars spent discovering and developing drugs to treat and prevent HIV-or at least we can start to, through our elected leaders. We, the people, already hold all of the medical and legal tools we need to eliminate new HIV transmissions in the US. 39 Under existing US law, the federal government can recoup its investment in drugs that have been privatized by pharma, and it can break pharma's patent monopolies when high prices are preventing people from getting access to medicines they need. These legal rights work for patents somewhat like the eminent domain rights that permit governments to use privately owned land for public purposes, like building a public park. In 2018, PrEP4All published a national action plan for universal access to PrEP that explains how the federal government can use these rights to break Gilead's monopolies on HIV drugs, drive down their cost, and provide medicines to everyone in the US with and at risk of HIV. 40 We just need the political will to use these tools. Political leaders have lacked that will for decades, but as I write this in January 2020, two leading presidential contenders, Senators Bernie Sanders and Elizabeth Warren, have vowed to use them aggressively to fight big pharma's power and bring drug prices down. And perhaps some will is starting to gather even under President Trump: a recent patent-infringement lawsuit brought against Gilead by the Department of Health and Human Services (HHS), demanding compensation for the public's investment in HIV PrEP, 41 provides some basis for cautious optimism. The United States v. Gilead lawsuit is one that PrEP4All, academic colleagues, and I advocated for for months. 42 That the Trump administration actually filed suit against Gilead is remarkable, as the federal government has historically gone to court very rarely to enforce its patents, even when major corporations use and sell publicly generated technology without compensation to the public. As I've (co-)written elsewhere, "HHS's lawsuit suggests that we are in a new political era: the long-running status quo in which Americans pay twice for prescription drugs-first as their tax dollars fund research into new medicines and again as they pay for those medicines-may no longer be stable." 43 As the case goes forward, the key is to pressure HHS to commit to using any revenues collected from the lawsuit's judgment or settlement to fight the epidemic and expand access to HIV prevention and treatment in the communities hardest hit. It's on us to demand that our leaders use the laws we have to promote public health, over the objections of Gilead and the rest of the pharma lobby. *p. 10* And I know we can take back the third thing-"science" itself. Gilead may own the trademark on XOXO, SCIENCE, but it does not own science or the fight against HIV. We should take pride in the enormous achievements of public science-economist Mariana Mazzucato has documented that it is public investment in science and technology that has driven the success not just of pharma and biotech but of most innovative industries in the US. 44 We could, collectively, commit not just to celebrating public science in the US but to a longer-term project of expanding it. We could, for example, imagine reducing our reliance on private drug companies and shifting toward government-and nonprofitfunded development, manufacturing, and distribution of medicines. Nonprofits like the Drugs for Neglected Diseases Initiative (DNDi) 45 and TB Alliance, 46 among others, have shown that not-for-profit drug development works, as have nonprofit activist and patient groups. For example, activists from ACT UP and TAG deserve much credit for fostering the development of the first protease inhibitors (saquinavir, ritonavir, and indinavir), which helped convert HIV from a death sentence to a chronic disease when they reached the market in 1995 and 1996-at least for those with access to the drugs. 47 The NIH could expand beyond its current focusconducting and funding groundbreaking basic research-to partner with patient and nonprofit research organizations to conduct clinical trials and shepherd drugs through the FDA approval process. 48 Drug discovery and development could be focused on those areas where medical need is greatest, rather than on prospective profits. Government factories could manufacture medicines (Senator Warren has proposed a federal Office of Drug Manufacturing along these lines 49 ), and Medicare for All could ensure that every American gets the drugs and other care they need, regardless of their income and wealth, free at the point of care. *p. 10* To remake health care and corporate power in America is beyond the scope of this essay, but it's not beyond our collective reach. Currently, we as a nation spend tens of billions of dollars every year on HIV/AIDS-even as the epidemic shows little sign of slowing down. Most of these dollars go to industry-to drug companies, insurance companies, for-profit hospitals, and so on. I'm individually part of this conundrum: I'm gay, and I currently take Gilead's Truvada for PrEP to reduce my risk of getting HIV from sex (and to reduce my anxiety around sex). When I fill my prescription for Truvada every month, my insurance pays Gilead something like $1,800 for thirty pills. 50 (I've already said it, but I have to reiterate: holy shit! Sixty dollars apiece, for a pill that costs literally pennies to manufacture!) I'm grateful-and privileged-to have health insurance, but my insurance just spreads this outrageous cost over more people. It bothers me that to take PrEP, I must enrich Gilead at the expense of my coworkers and other fellow insured individuals. *p. 10* Imagine if we spent our national billions on HIV differently. HIV drugs can and should be cheap, and if they were, we could buy them for everyone who needs and wants them and still have billions left over to spend on all the other health care people need and deserve: a primary-care doctor, mental-health care, food and housing for those who don't currently have them, and so on. We could fund community sexual-health clinics in places like the rural Deep South that desperately need them. 51 We could concentrate more resources on the search for an HIV vaccine or cure. *p. 10* PrEP4All and the Technology Law and Policy Clinic at NYU Law (where I work and teach) are doing what we can to loosen Gilead's stranglehold on HIV drugs to spur competition and make the drugs cheaper and more accessible. In December 2019, we filed a petition with the US Patent and Trademark Office challenging Gilead's patent monopoly on Descovy-a pill approved as PrEP in late 2019, for which Gilead charges over $20,000 per year 52 -and a number of other important but high-priced HIV drugs that Gilead sells. 53 But I think most of the work of remaking pharma, health care, and science can't be done by individual activists or individual lawyers; it has to be done collectively, through broader organizing, through deep restructuring of political and economic power in the United States. 54 Perhaps it has always been true that it is lots of us working togetherqueers and trans people and sex workers and intravenous drug users and everyone who lives with HIV and its specter and shadow-that lead the fight against HIV, not the corporations who profit from it. In the next stage of that fight, it may be a grand coalition of people currently being exploited and underserved by drug companies and our health care system as a whole, not just people with HIV but those with hepatitis, diabetes, cancer, the afflictions of old age, and on and on, who come together to reimagine it. We can do more than repair and reinforce a broken system; we can demand and build a better one. Perhaps some of what I've sketched above-not just recouping but embracing and expanding public investment in medicine and in science more generally-will be part of the collective action we take. I don't have all the answers, but I know that now is the time to act, and I would like to be a part of that action. *p. 10* To return, one last time, to those XOXO, SCIENCE ads: if you see one, maybe you'll think about the ads as I do, aware that every dollar Gilead spent on them is a dollar not spent on science. Maybe you'll feel wary of this drug company's claim to speak on science's behalf. Science belongs to all of us, not to Gilead. Maybe the ads will irritate and inspire you, as they do me, and remind you not to give up. ## Footnotes > Opposite: Gilead Sciences XOXO, SCIENCE ad, New York, 2020. Photo: Chris Morten.