The C.E.O. of H.I.V. – The New York Times


Directors of health care nonprofits are traditionally cautious and courtly, fearful of choking the funding streams that issue from nit-picking grant committees and image-conscious donors. Weinstein, an ex-Trotskyite, is no courtier. He runs his organization as a “social enterprise,” meaning that it generates most of its revenue not from grants and fund-raising but from adjacent businesses. A.H.F.’s main business is a network of pharmacies and clinics that provide primary care to more than 41,000 patients in the United States, most of whom have their insurance claims paid by government insurance programs like Medicaid. The excess income from these patients helps the AIDS Healthcare Foundation provide free care to more than 700,000 H.I.V. patients internationally — the greatest reach of any AIDS organization. This prodigiously successful model has both insulated A.H.F. from typical funding woes and helped it to expand at an astonishing clip. Over the last six years, A.H.F.’s budget has grown from $300 million to more than $1.4 billion, about the size of Planned Parenthood. If their projections hold, it will reach $2 billion by 2020, giving A.H.F. — a private entity effectively under the control of one man — a budget nearly half the size of the World Health Organization’s.

Paradoxically, that projected growth depends in part on whether drug costs remain high. While cutting drug prices is an ideological objective for Weinstein, his pharmacies stand to lose revenue should he succeed in that mission. “Most of the time when people benefit from something, they don’t lobby against it,” he told me recently. “But we’re Robin Hood. If someone was writing an epitaph for this organization some day, it will be: ‘Bit the hand that fed it.’ ”

A.H.F.’s rapid ascent has made Weinstein an object of scorn among his peers, who deplore not only his tactics but also his unorthodox positions on public-health issues. Unlike nearly all other AIDS activists and public-health researchers, Weinstein opposes PrEP, the H.I.V.-prevention pill, which he believes will cause a “public-health catastrophe” by triggering a dangerous increase in risky sex. He has also campaigned to make condoms mandatory in adult films, even going so far as to introduce a statewide referendum in California, Proposition 60. Weinstein’s positions have been assailed by peers as counterproductive fearmongering. “It reminds me very much of the Tea Party people with regard to Obamacare,” Ernest Hopkins, director of legislative affairs for the San Francisco AIDS Foundation, told me in 2013, referring to Weinstein’s opposition to PrEP. “If you’re prepared to say whatever you want and lie and demagogue and misrepresent the facts, then you can get a lot of airtime, and you can also persuade a lot of people.”

To his many critics in AIDS activism, Weinstein is the Koch brothers of public health: a mastermind driven by ideology, accountable to no one, with bottomless funds and an agenda marked by financial opportunism and puritanical extremes. It doesn’t help that A.H.F. has been the subject of near-constant litigation and complaints for questionable business practices, including union-busting, giving kickbacks to patients, overbilling government insurers and bullying funders into denying grants to institutional rivals. (A.H.F. has denied these accusations.)

To his faithful, however, Weinstein is not only a provider of superior health care but also an evangelist of moral urgency at a time when prevention efforts are floundering and drug prices are surging. Weinstein seems to view himself in loftier terms, as a holy warrior sent to save the innocent, not only from the scourge of H.I.V. but also from those he views as the virus’s human collaborators: a satanic trifecta of greedy executives, vainglorious activists and incompetent bureaucrats.

Weinstein’s office, a cold and tidy room overlooking the Hollywood Hills, is an archive of sentimental zealotry. On his desk, an outward-facing plaque greets visitors with a defiant warning attributed to Hannibal — “I shall either find a way or make one,” a reference to herding war elephants over the Alps to destroy Rome. On one wall, a framed resolution from the California State Legislature honoring Weinstein for his community service hangs incongruously beside an orphaned sheet of paper printed with a Harry Truman-ism: “It’s amazing what you can accomplish when you do not care who gets the credit.” Above the Truman quotation, there’s a photo of Weinstein in front of the Taj Mahal, sitting alone in a red shirt; there are no photos of Weinstein’s husband, a Vietnamese immigrant who owns a nail salon. A second piece of Scotch-taped paper bears an aphorism of Weinstein’s own coinage: “Help Defeat Self-Imposed Helplessness.”

Photo

An A.H.F. billboard in Los Angeles.

Credit
Jeff Minton for The New York Times

The first time I visited, in February of last year, Weinstein invited me to sit down without shaking my hand. A lean man with a long forehead, bird-of-prey features and a nerdy, pocket-protector vibe, Weinstein had a formal demeanor but was wearing jeans and a hoodie — a common outfit for a tech leader but unusual for a health care magnate. Weinstein took me on an abbreviated tour, proudly showing off photos he had taken with celebrities and political figures — Magic Johnson, Alicia Keys, former Senator Tom Harkin. Above his desk hung an Expressionist portrait of his best friend, with whom he founded A.H.F., Chris Brownlie. By all accounts, Brownlie was the softhearted yin to Weinstein’s gladiatorial yang, as charming and consensus-seeking as Weinstein was splenetic and introverted. Brownlie died from AIDS-related complications in 1989.

Weinstein has a long history of militancy. Born in Brooklyn’s Bensonhurst neighborhood to a family of left-wing Jews, at age 13 he volunteered for an antiwar congressional candidate and worked as an equipment mule for his filmmaker sister, toting around a 40-pound battery while she shot footage of protesters burning draft cards in Central Park. The next year, he joined a group of activists occupying a new high-rise development to protest what was not yet known as gentrification. Though he realized he was gay early on, he repressed his sexuality for many years, eventually moving in with an older girlfriend. At age 18, he had his first gay encounter with an upstairs neighbor, also officially straight, who knocked on his door one night when both of their girlfriends were out of town.

In 1972, when Weinstein was 19, he traveled to California and joined Los Angeles’s gay activism scene. An outsider among both mainstream gays (for being a Marxist) and Marxists (for being gay), Weinstein decided to start his own group, which he called the Lavender and Red Union. The group eventually merged with a gay-friendly Trotskyite organization in New York called the Spartacist League, which offered Weinstein a leadership position, requiring him to move back to the East Coast. He wasn’t at his new post for long, though, before he fell out with his comrades over an unusual matter: the Roman Polanski sexual-abuse case, in which the director was accused of drugging and raping a 13-year-old girl. “They felt that it was not rape, that the girl knew what she was doing,” Weinstein’s boyfriend at the time, Albert Ruiz, told me. Weinstein believed it was rape and felt strongly enough about the matter, among other disputes, that he resigned.

Disillusioned with activism, Weinstein briefly ran a candy business in Los Angeles before returning to politics to face an unlikely antagonist. In 1986, the right-wing conspiracy theorist Lyndon LaRouche introduced a ballot referendum in California that would have enabled employers to fire people with AIDS and empowered the government to quarantine them. Early polling suggested that LaRouche’s initiative had broad support. Along with Brownlie and other friends, Weinstein started his own group to fight LaRouche’s proposition. In a move that anticipated his later shock-marketing campaigns, Weinstein distributed leaflets with the headline “STOP AIDS CONCENTRATION CAMPS” and organized a torch-lit march on LaRouche’s Silver Lake office. Mainstream gay activists abhorred Weinstein’s strong-arm tactics, fearing he might alienate suburban voters. But after the measure lost in a landslide, with 71 percent opposed, L.A. Weekly named Weinstein “Best Young Activist.” Weinstein determined that there was far greater support for his militant approach than he had realized.

As the AIDS crisis intensified, Weinstein watched more and more of his friends grow ill and die. Los Angeles County hospital had barely developed procedures for handling dying AIDS patients, and many were left to expire alone on gurneys in crowded hallways. Doctors and nurses would often refuse to care for AIDS sufferers, and when the untreated patients died, undertakers often turned them away, too. In some parts of the country, the deceased ended up in garbage bags delivered directly to crematories. Weinstein wanted to ensure that AIDS patients could die in a respectful, peaceful atmosphere. In 1989, he and Brownlie founded the precursor of A.H.F. — the AIDS Hospice Foundation. In 1990, as more AIDS medications became available, Weinstein changed the group’s name to the AIDS Healthcare Foundation and shifted its focus to medical care for the living. In the late ’90s, little by little, A.H.F. expanded from Southern California into Florida and New York. Then, in 2000, A.H.F. made a change that would prove crucial to its business model: It opened its first pharmacy.

Pharmacy services are, in Weinstein’s words, A.H.F.’s “jet fuel.” That’s because 70 percent of spending on H.I.V. care consists of drug costs. While H.I.V. patients in the United States skew poor, the costly insurance claims they generate by filling prescriptions make them gold mines, not only for pharmaceutical companies but also for certain pharmacies, like Weinstein’s, that take advantage of a federal program called 340B. Passed in 1991, 340B allows pharmacies attached to medical practices serving underprivileged populations to buy drugs directly from manufacturers at, on average, a 35 percent discount but still be reimbursed by insurers for 100 percent of the wholesale price. In effect, 340B allows pharmacies to keep around 35 percent of the pharmaceutical industry’s tab, a roundabout way of subsidizing health care for the poor. As the price of AIDS medications has spiraled upward in recent years, A.H.F.’s coffers have swelled. The cost of the latest first-line H.I.V. treatment — a combination pill from Gilead called Genvoya — is about $34,000 per patient per year. When a patient uses an A.H.F. pharmacy, about $22,000 of that bill goes to Gilead, and $12,000 goes to A.H.F. The foundation’s pharmacies serve 50,000 patients in the United States, generating approximately $1 billion each year in revenue — about $200 million of it surplus. That money subsidizes A.H.F.’s expansion and advocacy as well as the group’s political activities.

The pool of potential patients for an organization like A.H.F. is oceanic. In 2014, 37,600 Americans were newly infected with H.I.V. That number has declined only slightly over the last decade, as America’s epidemic has settled into a baleful equilibrium of slow growth and rising costs. The lack of progress is especially disheartening considering that H.I.V. medications, when properly administered, render patients almost totally noninfectious. These medications aren’t new — they’ve existed for two decades. If every infected American took them, our epidemic would be over. Instead, of the roughly 1.2 million Americans with H.I.V., only 40 percent are on medication, a rate lower than South Africa’s. Weinstein believes that America’s AIDS nonprofits, which he refers to derisively as “AIDS Inc.” — a label meant to evoke sclerotic incumbents who collect renewable grants and stand only for their own perpetuation — have been useless in the face of the epidemic. To win, he thinks, “AIDS Inc.” has to be sidelined so that A.H.F. can lead the way.

Last spring, Weinstein summoned 30 foot soldiers to the Sheraton Hotel in New Orleans for a retreat for A.H.F.’s sales team — a division that doesn’t exist at most nonprofits because most nonprofits have nothing to sell. A.H.F. does: It sells health care to a customer base overwhelmingly composed of patients receiving government assistance, and each new patient it acquires means more cash for its operations. The sales team at A.H.F. is responsible for recruiting new patients, a function they perform by scouring homeless shelters, hosting parties at gay clubs, cozying up to local clinicians and deploying mobile-testing vans to H.I.V. hot spots. It’s a commissions-driven gig. For each new patient who goes to an A.H.F. clinic and fills an antiretroviral prescription at an A.H.F. pharmacy, the rep receives $300. He or she receives an additional $300 when patients fill their prescriptions a second time — the second fill being a more reliable predictor of patient retention.

To recruit new patients, sales reps are expected to hold several events each month, most of them in high-risk zones. Events vary by location. On Los Angeles’s Skid Row, for example, reps hand out McDonald’s gift cards to anyone willing to take a rapid H.I.V. test. In South Central, the reps sometimes set up a game called Cash Box, in which contestants who agree to a rapid test enter a plexiglass booth where they try to grab cash as it is blown around at high speeds. In gay neighborhoods, reps may invite passers-by to play Dildo Toss — a carny-inspired game in which players hurl phalluses of varying colors and sizes into a hole carved out of a plank of wood. “We give them three chances,” explained Edwin Millan, director of sales for the Western United States, “and if it goes in the hole, they get to spin a wheel and they get a prize.” (In 2015, two former employees filed a whistle-blower suit arguing that A.H.F.’s patient incentives amounted to illegal kickbacks; the lawsuit has not yet reached a resolution, and A.H.F. denies the claims.) In addition to seeking out patients directly, sales reps also cultivate referral sources by hosting lunches for area doctors.

The retreat’s kickoff dinner was held in the French Quarter, at Deanie’s Seafood. Tucked away in a back room, the gregarious sales reps kibitzed noisily, slurping crawfish étouffée as Weinstein, seated at the head of a long table, examined his battalion. Like other divisions at A.H.F., this group was anchored by black women in floral prints and gay men of all races in checkered shirts; many were new hires Weinstein was meeting for the first time. “Sometimes I have to pinch myself,” Weinstein whispered to me, marveling at how swiftly his organization had expanded.

Photo

An A.H.F. billboard in Los Angeles.

Credit
Jeff Minton for The New York Times

As the sales reps emptied their plates and hailed waiters for second and third rounds of wine, Weinstein tapped his glass with a fork and called the group to attention. “I’d like to officially welcome you to the Big Easy!” he squawked in his blunt Brooklynese. “Do whatever you want as long as you wake up in the morning.” The reps laughed. “You know, this is a really powerful force on behalf of the organization — a powerful force on behalf of the growth. Going out there, pounding the pavement, going after new accounts and clients — you have to be immune to rejection to be successful, and that’s not easy. I’m pretty bad at it myself!” He wasn’t kidding. Weinstein belies the cliché that the best fighters develop a thick skin: He has sustained himself through decades of conflict by salting unhealed wounds, nursing unceasing resentment and preserving grudges in amber.

The morning after the dinner, the sales reps reconvened in a dreary conference room with red tablecloths and damask carpeting. Programming for the first day called for an icebreaker in which employees were asked to scribble unusual facts about themselves on pieces of paper tossed into a hat. One man, a bodybuilder from South Beach with silver hair and pumpkin-colored skin, wrote that he used to train with Madonna; a copper-haired woman from San Francisco disclosed that she swam through garbage during an initiation ritual for Semester at Sea. Weinstein’s own fact, the one he always uses for such exercises, was that he dropped out of high school.

The icebreaker was followed by an exercise intended to explore how to navigate conversations with A.H.F.’s critics. Weinstein gave volunteers the option of representing the San Francisco AIDS Foundation, leaders of which have been vocally critical of A.H.F., or a “PrEP crazy,” someone incensed by Weinstein’s opposition to the H.I.V.-prevention pill. Another volunteer would play A.H.F.

“I’ll be S.F.A.F.!” volunteered the copper-haired woman. Her counterpart was a man whose upper lip was adorned with a sumptuous mustache.

“I’m here to talk to you about the services that we provide,” he began.

“I know all about A.H.F., actually,” replied the copper-haired woman, her eyes narrowing. “Your reputation precedes you.”

Photo

Weinstein, center, with other activists at the 2012 Keep the Promise on H.I.V./AIDS March in Washington.

Credit
Ken Cedeno/Getty Images

“O.K., awesome. Did you know that we started the first AIDS hospice in Los Angeles about 28 years ago?” he asked. “Since then, we’ve grown rapidly, primarily overseas.”

“I know you’ve grown rapidly,” she snapped, summoning a glower. “You’re the Walmart of H.I.V.” She went on: “I’ve been in the H.I.V. field for 30 years! I’ve lived through the epidemic; I’ve seen all my friends die. You guys advertise yourselves as this ‘not-for-profit.’ I know the true thing: You guys are a huge profit source. I can’t even find your financials on your website — you hide those.”

The reps laughed; they’d all heard some version of this tirade a thousand times. Weinstein took the floor and concluded the session by telling a little story about a nun he once met. She ran a hospital, which required her to make tough budgetary decisions in the name of helping people. Whenever people criticized her for being harsh, she had a canned response: “No margin, no mission!” This, according to Weinstein, is what A.H.F.’s critics couldn’t bring themselves to understand. “We should never be in a position of apologizing for our success,” he said. “The fact that we take a business model from the private sector and utilize it on behalf of a nonprofit is a great thing.”

This saintly narrative is complicated by the fact that Weinstein has drawn from his plentiful war chest to underwrite a dizzying number of controversial projects, some of which seem only tenuously connected to his core mission. In addition to the drug-pricing initiative and the condoms-in-porn bill, he filed a lawsuit against Gilead Sciences, the leading manufacturer of AIDS drugs, for patent manipulation (Gilead prevailed in court; A.H.F. has filed an appeal). He led a petition drive in Mississippi to remove Confederate symbols from the state flag, and he funded an anti-density campaign in Los Angeles that sought to halt construction on most new residential towers for two years, including a 28-story project across the street from Weinstein’s global headquarters.

And then there are the billboards. In major American cities — and increasingly, around the world — Weinstein’s most visible impact is his trolling approach to sexual-health messaging. In 2013, he put up signs in several cities with the image of a magma-spewing volcano captioned, “SYPHILIS EXPLOSION.” The following year, in South Central, he posted billboards with two black men spooning in bed alongside the leading question “Trust Him?” Some ads have been humorous and topical — a sendup of the Netflix logo replaced with the mantra “Get Tested and Chill,” a Bernie Sanders parody with the modified slogan “Feel the Burn?” Others have hectored the public with reproachful questions: “Friends With Benefits?” “Sexually Reckless?” “Worried?” One A.H.F. billboard managed to cause a national scandal in Uganda. Unusually for a nonprofit, A.H.F. employs a 15-person in-house creative agency to create its messaging. The expense is justified because the billboards are a marketing channel: They seek to stir dread in the libertine masses, not only to stem what Weinstein sees as a rising tide of promiscuity but also to drive traffic to his clinics.

In the press, Weinstein has attracted the most attention for his hostility to PrEP, a once-a-day antiretroviral that reduces the likelihood of contracting H.I.V. by 99 percent. In 2015, the C.D.C. began recommending PrEP for anyone at “high risk” for H.I.V. infection, including any gay man not in a monogamous relationship who has had sex in the last six months without a condom (1.2 million people, according to the C.D.C.’s estimates). Many hailed it as an era-defining advance. Weinstein, virtually alone among major AIDS figures, has assailed PrEP, calling it a “party drug” that could lead to a collapse in condom use. In a citizen petition to the Food and Drug Administration following PrEP’s approval in 2012, A.H.F.’s lawyer denounced the treatment as “unsafe and ineffective.” Weinstein called on Margaret Hamburg, the agency’s commissioner, to resign over the issue, suggesting she was part of a pharma-led plot to put millions of Americans on a new medication.

Weinstein’s critique of PrEP is a fringe view. According to Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, support for PrEP among researchers and regulators is all but universal. “It’s having an extraordinarily positive impact,” he says. Robert Grant, a professor of medicine at U.C.S.F. and a leading PrEP researcher, credits the treatment with “a plummeting decline” in H.I.V. transmission rates among white gay men in San Francisco.

Nevertheless, Weinstein is quoted regularly in articles about the treatment, and his noisy skepticism has reverberated across the internet. Some argue that Weinstein’s grandstanding during public hearings delayed PrEP’s approval by the C.D.C., and that his sowing of doubt about the medication is continuing to suppress its use, especially in black and Latino communities. “What I find in my practice,” Grant says, “is that A.H.F.’s propaganda does not impress or influence privileged groups of gay men. They can see right through it. But when I talk to some people of color who are clients in my clinics, I find they’ve heard the A.H.F. message, and it gives them pause, it makes them concerned, it appeals to their sense that this isn’t for them.” Despite the C.D.C.’s efforts, very few people, even now, are on PrEP; according to recent estimates, only about 100,000 people take it.

Weinstein’s concerns about PrEP are in line with his other heterodox positions, which often cut against the sexual-liberationist doctrine embraced by other activists. Many issues that have been controversial in the gay community, he claims, like laws that make it illegal to intentionally infect a sexual partner with H.I.V., are no-brainers for ordinary voters. “Some people are so extreme,” he told me. “There’s a group here in California that wants to reduce intentionally infecting somebody from a felony to a misdemeanor. There’s articles being written basically saying we should be proud to bareback” — slang for condomless sex. “In the hothouse environment of the gay community, that point of view is very popular, but it isn’t in the community at large, and it isn’t in the medical community either.”

What motivates Weinstein to adopt such lonely views? Weinstein’s fiercest critics have often searched for a financial motive, some even going so far as to suggest that he aims to profit from the spread of H.I.V. Those who know him personally dismiss this explanation. Phill Wilson, president of the Black AIDS Institute, first met Weinstein in 1980 when Wilson was dating Chris Brownlie. In fact, the first iteration of A.H.F. was founded in Wilson’s living room. “This is the mistake that people make when they think about Michael,” Wilson told me. “Whether what he does is good or bad, he does what he believes is in the best interests of people living with H.I.V. or at risk of infection.” Weinstein was “primarily driven by mission,” Wilson said. Even Peter Staley concedes that point. “I don’t think it’s about the money for him,” he told me, unsurprised to learn that in Weinstein’s most recent annual report, he disclosed a comparatively humble salary of $400,000, low for directors of similarly sized nonprofits. “The core of the business at A.H.F. is not something that has been scandalous,” Staley says. “It is an empire worth building. A.H.F.’s problem is that once it created the largest AIDS empire on the planet, it started using that power for nefarious purposes: Michael Weinstein’s twisted political views.”

On paper, 2016 was Weinstein’s best year ever. He opened six new pharmacies and one clinic in the United States and started new programs in Indonesia, Bolivia and Zimbabwe. But on the advocacy side, he suffered significant setbacks. In November, his drug-pricing initiative failed. So did his condoms-in-porn initiative, despite the fact that he had managed to pass a similar law in Los Angeles County in 2012. Most recently, on March 7, voters in the city of Los Angeles resoundingly rejected, by a 2-to-1 margin, his quixotic anti-density measure. The public, it seems, is not on board with Weinstein’s agenda.

Even so, when I visited Weinstein at his office in February, he showed no sign of disappointment. Discussing recent losses, he wasn’t merely philosophical; he was downright giddy. “I had never been involved with a campaign,” he said, referring to the drug-pricing initiative, “where people were so enthusiastic about something that didn’t win.” (He would later use the same line with reporters when his anti-density ordinance went down in flames.) As we chatted, he sipped from a radioactive-looking bottle of apple-melon Isopure; he said he liked his chances for this November, when he would try again with a new drug-pricing initiative, this time in Ohio. The problem in California, he said, was that the drug companies had flooded the airwaves — “total aerial bombardment, 3,500 gross rating points a week” — but he doubted that kind of “razzmatazz” would work in flyover country. “Midwesterners are kind of square-shouldered, common-sense people. I’d think there’d be a backlash if they dumped $80 million into Ohio.”

If that referendum were to pass, Weinstein figured, then Big Pharma’s citadel — the American market — would start to crack. Ohio would be copied by other states, and the V.A.’s price for drugs would become the universal price, as even private insurers would demand to pay the new public rate. Billions would be shaved off pharma’s bottom line, meaning the industry would no longer have the muscle to bully Congress into propping up its international patent regime. Drug prices would plummet across the world, AIDS medications would flow freely and the industry’s lobbying operation would shrink so much that it could be drowned in a bathtub. This sequence of events seemed far-fetched, but Weinstein was nevertheless optimistic about the coming year, win or lose. His equanimity in the face of failure reminded me of something he once said to me about Prop. 60, the condoms-in-porn bill. It lost at the ballot box by an eight-point margin, but Weinstein found a reason to declare victory. “We’ve had more than 10,000 stories on condoms in porn,” he boasted. “Forget about porn: That’s a lot of free advertising for condoms.”

Weinstein often consoles himself in moments of defeat by reaffirming his commitment to the long game. This is part of what makes him so frustrating to his critics: It is difficult, and sometimes impossible, to distinguish his cynical ploys from his ideological commitments. In his person, the will to power and the will to change the world seem to fuse. It wasn’t simply that he cared more about fighting than about winning. Eventually, he believes, people will come around to his view. And if they don’t, that’s fine, too: A.H.F. will continue to thrive, even in a fallen world.

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