Gilead won’t sell MSF its HIV drug. Its shareholders should ask why

A year ago, the arrival of Gilead’s new HIV drug, lenacapavir, was hailed as a breakthrough with the potential to fundamentally change the course of the epidemic. At a moment when the global response to HIV is faltering, a drug that requires just two injections a year and reduces the risk of transmission to nearly zero should be accessible to the people who need it most.

Somewhere in Gilead’s offices, sales teams are processing orders from hospitals in Paris, clinics in New York, and health systems across the wealthy world. For over a year, Doctors Without Borders/Médecins Sans Frontières (MSF), which provides medical care in more than 70 countries, has been working to introduce lenacapavir into our programs. We expected buying lenacapavir to be straightforward: MSF routinely buys medicines, including from Gilead, and has paid its prices before — even when they were high. 

But to our surprise, Gilead has been steadfast in its refusal to sell lenacapavir to MSF. This is not a dispute about price. Negotiations have stalled on a more basic question: whether we are allowed to buy lenacapavir at all.

Gilead’s position is that access in low- and middle-income countries is confined to its arrangement with The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Rather than sell directly to a willing buyer, as it does in wealthy markets, it directs MSF to a channel that, as we have repeatedly told them, cannot supply us directly, and where any doses we use would come at the expense of other programs.

People are ready for this drug. Organizations like MSF have the resources to buy it and the capacity to deliver it. In Eswatini, which has the highest rate of new HIV infections in the world, MSF is distributing a share of the Ministry of Health’s already stretched supply of lenacapavir. Our stock was depleted in weeks. 

We are asking Gilead to sell us lenacapavir directly. After months of engagement, Gilead is well aware that the Global Fund route is not, in practice, a workable solution for MSF’s supply needs — let alone those of most people in low- and middle-income countries. Over recent months, their answers to our questions about why they cannot sell have grown progressively less convincing. In our most recent exchange, they said that negotiating a contract would be “a lot of work.” 

Gilead's stated vision is "ending the HIV epidemic for everyone, everywhere.” That vision is impossible to reconcile with the reality of its supply strategy. Today, Gilead is the sole supplier of lenacapavir, and no limits seem to exist for wealthy countries. For everyone else, Gilead has left the Global Fund to ration limited supply — enough for just 2 million people over the next three years — to just a few programs. 

Some excluded countries will be able to access generics in 2027. But many countries where HIV infections are rising are locked out of these generic licensing agreements, including Argentina, Brazil, Mexico, and Peru, despite their hosting the clinical trials that helped win Gilead regulatory approval. “Everyone, everywhere” means Gilead's terms, for markets Gilead prioritizes, on Gilead's timeline, at Gilead’s discretion. For most of the world — including buyers like MSF — it means: Not you. 

Fiduciary duty — the legal obligation of executives to act in their shareholders' interests — is not a term that typically appears in global health debates. It should appear in this one. Gilead has a breakthrough product and willing buyers, but declines to sell.

Three explanations are available, and none reflect well on Gilead’s corporate governance. 

The first is neglect. Gilead never built the distribution network to serve the markets where the great majority of people at risk of acquiring HIV live. 

The second is an undisclosed, genuine supply constraint. This would be a material fact that shareholders and the public are entitled to know about. But the company has told investors it has contracted manufacturing capacity with the ability to scale further, and lenacapavir is available without restriction in wealthy markets. 

The third is deliberate strategy. A decade ago, the pharmaceutical industry had a moment of unusual candor at an industry event, when Bayer's CEO was asked about access to its cancer drug. Marijn Dekkers replied, "We did not develop this product for the Indian market … we developed this product for Western patients who can afford this product." The remark went viral and became shorthand for an attitude the industry has spent years trying to distance itself from. 

Gilead has not said anything so explicit. But a company that sells lenacapavir in New York at $28,218 but will not sell it to us at any price is saying the same thing, just more quietly. 

MSF is not asking Gilead to give this drug away. We are asking to buy it at a fair price, so we can get it to the people who need it most. Gilead's refusal to sell lenacapavir is, first, a human failure — one measured in the number of people who will acquire HIV when prevention is within reach. But it is also a governance failure, carrying significant financial, regulatory, and political risk that its shareholders — including the institutional investors who hold Gilead in ethical investment portfolios — have been made to assume without consultation or consent.

MSF wants to know why Gilead refuses to sell its flagship HIV drug. So should its shareholders.