Giuliani's Awful Record on HIV/AIDS

Sally Pipes serves as president and CEO of the Pacific Research Institute, a free-market think tank that draws some of its funding from pharmaceutical companies. Given that bit of back story, imagine her distress when the Thai government issued "compulsory patents" to its domestic drug manufacturers at the Government Pharmaceutical Organization (GPO) to copy and reproduce formulas for two antiretroviral drugs.

Spurred to action, Pipes produced an alarmist screed in The Hill last month charging that the Thai government rejected offers for cheaper antiretrovirals and issued the patents primarily to enrich its cronies at the GPO. In the op-ed, she also takes time to wag her finger at Rep. Tom Allen, Sen. Sherrod Brown, and former President Bill Clinton, who have publicly applauded the Thai government's action. Never mind that Thai officials acted completely within the bounds of international law and that their actions will likely make antiretrovirals available to thousands more HIV/AIDS patients.

The point of Pipes' op-ed is to champion the importance of intellectual property rights and minor corporate profits over cheap, effective antiretroviral treatment in the form of generic drugs. She just buries the callousness in hysteria and conjecture.

Of course it's unfortunate but not surprising that Pipes, a free-market doctrinaire, would produce this piece. And were she just running a think tank with pharmaceutical funding, it could be read as a shill piece and dismissed. But there's a bit more to Pipes' biography: She is also a health-care adviser to Rudy Giuliani, the leading Republican candidate for president. (No relation to foreign-policy adviser Daniel Pipes.) Suddenly her op-ed is not so much ridiculous, as frightening.

When she was appointed earlier this summer, Pipes seemed a natural fit for the Giuliani health-care team, which consists primarily of domestically focused, consumer-driven health-care proponents. Pipes had already achieved some notoriety criticizing the state-level health-insurance mandates and regulations backed by Republican presidential candidate Mitt Romney when he was governor of Massachusetts. Thus, her appointment had the benefit of telegraphing a distinction between Giuliani and his main opponent to health-care experts and policy wonks.

And that's about where her significance to this election cycle stopped before her Hill op-ed. Save for taking a few more shots at Romney and popping up occasionally to cheerlead for Giuliani, Pipes had drawn little other attention. With a candidate who is reticent to outline any specific health-care policies, it seemed that she (and the rest of Giuliani's health-care squad) would hang out on the campaign sidelines.

It's unfortunate that she didn't stay there. Her op-ed can be read both as a signal that her role is expanding and as a preview of the HIV/AIDS policy she is encouraging Giuliani to adopt, specifically, one without regard for the immediate need for as many cheap generic antiretrovirals as possible. That in itself is a cause for concern. The real crisis, though, is that Giuliani might actually be receptive to her arguments.

Up to now Giuliani's AIDS policy has been, at best, poorly defined. Though he's expressed an interest in continuing and possibly expanding the President's Emergency Plan for AIDS Relief (PEPFAR), it's apparent Giuliani has thought little about what that actually means. He hasn't outlined a prevention strategy or talked about whether he plans to expand treatment options. When asked this summer about increasing federal support for HIV/AIDS medications, Giuliani's convoluted response touched on terrorism and his mayoralty, but did not include an actual answer to the question. There's nary a mention of an HIV/AIDS policy on his Web site. His lack of investment or concern about the issue leaves him vulnerable to insiders like Pipes whose business-first agendas are prepackaged.

Those assuming Giuliani's reputation for liberal social policies will automatically translate into a progressive HIV/AIDS package should do a rudimentary search through his mayoral record. It is littered with cuts to AIDS programming and relief services, and feuds with activists. Near the end of his second term, a federal judge ruled that Giuliani's administration "chronically and systematically" delayed and terminated benefits to thousands of people with AIDS. As a result, New York's AIDS agency was placed under federal authority for three years. There's no reason to think higher office will induce a heightened commitment to assisting HIV/AIDS patients.

Just the opposite, it now seems. Having invited Pipes to whisper free-market mantras in his ear (and direct large pharmaceutical contributions into his pocket), it's increasingly possible Giuliani will wind up with an AIDS policy that manifests her skewed morality. Observing his effort to woo fiscal conservatives, it's not outlandish to think he might make AIDS relief contingent on buying brand-name antiretrovirals. Or that he would levy trade restrictions and financial penalties on countries, like Thailand, that determine the best way to immediately reach the most HIV/AIDS patients is to produce their own antiretrovirals.

For the hundreds of thousands of people around the world who depend on generic drugs, a Giuliani presidency could be profoundly tragic. Even if it is imbuing too much influence in Pipes to read presidential policy into her op-ed, it's still frustrating to be revisiting the debate over generic antiretrovirals.

By now the international community -- including U.S. presidential candidates -- should be committed to reducing the impact of the HIV/AIDS pandemic in the most efficacious way possible. That means taking advantage of antiretroviral-drug regimens currently in production that will keep HIV/AIDS patients alive for years, even decades longer than they otherwise would be.

But thanks to patent-holding pharmaceutical companies, those years come with an outsized price tag. This is especially true of second-line drugs, like those Thailand is producing, which are critical for patients who have developed a resistance to earlier, first-line treatments. Consequently, the best way to keep the most people alive is to buy and distribute generic antiretrovirals, or as the Thai government has decided, to produce the drugs domestically. They are almost always significantly cheaper than the patented originals, and their price comes without the haggling and without the commitments that the pharmaceutical companies frequently demand in exchange for reduced prices.

AIDS activists and health officials already went a round with President Bush over generic drugs. Though he was initially reluctant to distribute generics under PEPFAR, eventually he relented and expedited the approval process for generic and combination antiretrovirals. Despite the other flaws in his AIDS-relief package, Bush does deserve credit for coming to his senses. If Giuliani is elected, it would be tragic to waste the time and the lives hoping he, too, will eventually come around.

In fact, all of the presidential candidates would be well served to study the AIDS policy Democrat John Edwards has introduced -- the only candidate from either party to put forth a solid, comprehensive plan. He vows to get more aggressive with pharmaceutical companies over drug prices. And, if those prices still prove too high, to maintain the right that countries like Thailand have to issue compulsory patents and produce their own antiretrovirals.

The first move Giuliani should make, though, is to send Pipes back to the sideline and hire some advisers whose values aren't predicated on profit margins.