A small-town HIV doc is invited by a major pharmaceutical company on an all-expenses-paid trip to a four-star hotel in the Bahamas. After listening to company reps extol the advantages of their newest drug and describe its triumph in the latest studies, the doctor enjoys the sun and sand before heading home. Was this an educational business trip or an opportunity for undue influence on a doctor’s practice? If the doctor starts prescribing this drug more frequently to his small-town HIV-positive patients, is it because he picked up some vital news on his excursion—or has he been bought?

Industry experts and community watchdogs have always questioned the ethics of presenting drug data in luxurious surroundings (whatever disease or symptom the medicine is for) and bemoaned the difficulty of measuring the effects of such junkets. “I think a lot of physicians would be embarrassed if the extent of their connections [to pharmaceutical companies] were made public,” says Peter Lurie, MD, deputy director of Public Citizen’s Health Research Group. But there are also arguments in support of strong relationships between doctors and drug companies—perhaps especially in the field of HIV medicine.
Dr. Antonio Urbina, medical director of HIV/AIDS Education and Training at St. Vincent’s Comprehensive HIV Center in New York City, feels that the connections he makes with pharmaceutical representatives benefit his positive patients because they’re collaborative. “I see reps as part of the health care team,” says Dr. Urbina. “I look at them not as salespeople but as people that can supply me with scientific data. I have a higher expectation of them.”

Dr. Urbina says that in addition to meeting with sales reps, he also sits down with company scientists to discuss clinical trials, side effects and drug interactions. “I think years of dealing with physicians and seeing the commitment of the HIV community has shaped the companies,” he says. “We need them, as they need us.”

So what about the money being spent on docs? How much is too much? Does a pewter paperweight have the corrupting influence of a golf weekend? There are voluntary codes in place—the American Medical Association says that gifts must be either clearly educational or not exceed $100 in value—but there are also plenty of loopholes and gray areas. “You get wined and dined and told about this new drug…. And there have been studies that show that this affects prescribing practices,” says Mark Harrington, executive director of Treatment Action Group in New York City. One such study found that physicians who went on free trips to luxury resorts to participate in seminars were responsible for doubling or tripling prescriptions for the sponsor company over the next couple of years.

Lurie argues that the specifics of the HIV industry provide extra motivation on the part of drug companies to try and influence physicians. “There are lots of new drugs coming on the market, and that always creates a more competitive marketplace.” He adds: “In markets where lots of drugs are new—and expensive—there’s going to be very aggressive marketing, and I think that’s the case in HIV.” In a POZ.com poll, 61% said they believe their doctors accept some sort of gifts from pharmaceutical companies.

Eric Campbell, PhD, assistant professor of medicine at Boston’s Massachusetts General Hospital, believes the first step in clearing up questions about the ethics of gifts is requiring all pharmaceutical companies to report this kind of information. Campbell recently coauthored a study that found 94 percent of all physicians get some kind of goodies or extra pay from the drug industry, including free lunches, speaking fees and drug samples. “Drug companies benefit from [influencing docs with luxury],” he says. “If it didn’t work, they wouldn’t do it.”

Indeed, there is a movement afoot to try and deter undue influence by tracking pharma-doc ties. Five U.S. states and the District of Columbia currently require that physician gifts be reported, two of which (Minnesota and Vermont) make the information available to the public, according to Public Citizen’s Health Research Group.  And last year, similar legislation was proposed in 11 other states.

Campbell agrees with Dr. Urbina that physician-pharma friendship can be a good thing. He says that it may even be OK for a doctor to start prescribing more of a drug after attending a conference about it—if the doctor is an ethical one and determines that’s truly what his or her patients need.

What needs to be studied, Campbell says, is whether pharma gifts are doing any damage to people with HIV, with doctors switching patients to new drugs unnecessarily, for instance: “We won’t know what the true effect on patients is until we can link these things to actual patient data—not just prescribing data.”

In the sometimes unique field of HIV care, that may not be necessary. Harrington, for one, has confidence that the HIV community would nip major unethical practices in the bud. “In HIV, there’s a lot more oversight of the industry because the community is a lot more aware,” he says. “I don’t think the industry could get away with some of the more outrageous things [that go on] with other diseases.” 

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