Activists, angling for a dramatic reversal of the trend, drew a line in the sand at Kaletra's price tag, a full 50 percent below the company's target. "There was a feeling that the community had dropped the ball on Reyataz and that now we had to make a stand," recalls ATAC's Nass. It was another case of asking Tibotec, "If not you, then who?"

A letter to Glenn Mattes signed by 400 AIDS organizations, advocates, and patients explained the community's perspective. What was at stake was more than the price of a single drug. With the cost for one year of triple-drug therapy now averaging more than $15,000, a patient with HIV can expect to pay—or hope that public or private insurance will pay—about $2 million for every decade of life. Multiply that by 550,000—a rough estimate of the 1.1 million Americans with HIV who currently need medication—and the costs of HIV drugs in the United States alone will easily exceed a trillion dollars over the next 50 years. And it's far from certain that a healthcare system already in crisis will continue to bankroll life-saving treatment for a preventable disease still widely perceived as the wages of immoral behavior.

There was no uncertainty about the carrot and stick being held out to Tibotec by what was, in effect, the product's entire audience of key opinion leaders and specialists. Charging a "fair" price would set the stage for a primo Prezista launch, while "Most Expensive HIV Drug Ever" headlines and charges of price-gouging could relegate the drug's benefits to the fine print.

As for Mattes, he had his company run its own health-economics modeling—"these exquisite pharmacoeconomic analyses describing beyond any doubt the actual value of our product relative to others." Armed in this way, says Silbert, "we got people to sit down and have an intellectual discussion rather than an emotional one, since pricing is so emotional."

Mattes says only that once his bosses at J&J understood the particular context and history, they gave their full support. Silbert allows that "we had to do considerable internal politics to get it down to 'Let's set a precedent. Let's not be the next one to price up.'"

So when Tibotec announced that the price for Prezista would be $25 per day—$4 less than Aptivus and only a quarter more than Reyataz—the community lined up to kiss the company in the press. Formulary inclusion by public and private payers has been swift, while Tibotec's sales force is boning up on the arcana of resistance, genotype and phenotype, and the non-nuke class's notorious K103N mutation to which etravarine and rilpivirine are immune. "We set a pretty ambitious goal for ourselves in terms of time and percent of patient lives that would be covered for reimbursement," Mattes says. "And so far we've actually exceeded them."

In April, Tibotec signed an agreement with Aspen to distribute Prezista in sub-Saharan Africa at a price of $3 a day. "It's extremely gratifying to be involved in developing Prezista and helping people understand how to use it," Tennenberg says. "I can think of patients who could have benefited from this in my practice had only it been available six, seven years ago. But at least now my contribution is magnified by every doctor and every patient who gets the drug."