Punk Practice: Bringing a DIY Approach to the Penicillin Pricing Problem

Paul Sax: [00:00:12] Hi everyone. This is Paul Sax. I'm editor in chief of clinical infectious Diseases. And welcome to the Let's Talk ID podcast. Today I'm joined by Dr. Eamonn Vitt. He's an HIV specialist and primary care doctor with a primary care practice in downtown New York City, where he focuses on gay men's health and HIV prevention and treatment. He is also on the faculty at Columbia, where he attended medical school. Welcome, Eamonn.

Eamonn Vitt: [00:00:37] Thanks for having me and thanks for arranging this interview. I'm very honored. I'm a big fan of yours. 

Paul Sax: [00:00:42] All right, well, start us off by telling us a little bit about yourself. I gather you did not have the typical pathway to medical school.

Eamonn Vitt: [00:00:49] Yeah, maybe you heard something from someone, but, yes. I do not come from a medical family. My parents have an interesting background. My mom was a Catholic nun. My dad was a Christian brother and I'll put this all together. But my mom was, her order was the Sisters of Charity. You may have heard of Saint Vincent's Hospital.

Paul Sax: [00:01:08] Yes.

Eamonn Vitt: [00:01:08] And those nuns were walking the walk at that hospital at a certain era in history.

Paul Sax: [00:01:14] Yeah, that was they. They were very, very influential in early HIV treatment.

Eamonn Vitt: [00:01:18] Yeah, very much so. So while I do not have physician parents, I just turned 50. I came up in the 80s. I'm a few years behind you, I imagine. And so it was in the air. It was in the ether, in a certain way. I remember coming up to Greenwich Village when I was a kid to visit my mom's friend who was a priest, right in Greenwich Village, and I was a little kid, but there was some kind of energy, something going on. Around that time, a little bit later, when I was high school age, a friend of mine's uncle was dying from Aids. This was probably 1989, and at that time I was also very into punk rock music, a certain strain of intelligent, underground, arty punk music. You may have heard of a band called Fugazi out of Washington, D.C. maybe. Maybe not. I was obsessed with this. This music and this culture. The band played a show in Washington, D.C. I remember. It was a benefit for, I think, the Wilson Center, which was an HIV Aids provider in Washington, D.C. My friend, whose uncle was dying of Aids at the time, we drove down to the show. The show was unbelievable, moving, aesthetic and spiritual experience for me. And that night I picked up a flyer which had a bright pink triangle on a black background, and I read the contents inside. 

Eamonn Vitt: [00:02:42] And, you know, the fiery words of Act Up were very influential on me. And looking back on this now, now that I'm older, that night definitely, that is kind of what led me to the path of medicine. It's atypical, for sure. And it all relates to why we're talking to. Anyway, I went to undergrad at BU and had the good grades and and all that kind of thing. But I did play in bands when I was younger, played in a band based out of Boston, and we played at the Middle East and T.T. the Bear's and all those clubs you probably know about. I was probably 19. We got signed to a record label, based out of London, in Chicago. And so my undergraduate experience was studying very hard, working a part time job and really just focusing on music. We eventually went on to open for Fugazi, as a young man and play a bunch of shows, some tour dates with them. I had to decide to leave the band to go to medical school. I got into Columbia and I had to choose, and that's how I ended up in medical school in at Columbia.

Paul Sax: [00:03:42] Okay. And then you have a kind of distinctive clinical practice now. What is it like?

Eamonn Vitt: [00:03:47] Yeah. It's interesting. So I went to medical school at Columbia. I did residency at Columbia and family medicine. My first job out of residency was at Betances Clinic in the Lower East Side, where there was a very large HIV population. You know, I started med school in 98. The Aids TB ward existed when I started medical school. By the time I graduated, it was thankfully winding down. That was my introduction to kind of this world that you and I are in. We know a lot of the same people. Hiv medicine, gay men's health in a New York City context, which is a thing. So I became an HIV specialist. I did not do an ID fellowship. I'm a fake ID doctor. I just play one on podcasts, apparently.

Paul Sax: [00:04:31] [laughs]

Eamonn Vitt: [00:04:32] It's just HIV and Aids and gay men's health, there's a lot of ID there. Just day to day as you know, I've seen you speak about 5000 times. Yeah, in New York at all the updates. And so I did a bunch of things. Maybe we can talk about that later because it relates to the price transparency issue and the bicylinder le shortage. Now I'm married and have kids and live in Brooklyn, and I have a direct primary care practice, which is another interesting thing, where it's myself and my admin assistant. I don't have a nurse, I don't have an MA. I draw my own blood. I do my own swabs. I do my own payroll. I'm on call myself 24 hours a day. I have a very low overhead. I have a small office. I have a freezer full of monkeypox vaccines. It's very DIY kind of practice. DIY, meaning do it yourself, taking control of it, just like that band Fugazi back in the day, you would DIY, you'd book your own tours, you put out your own records, you.

Paul Sax: [00:05:32] Yes, yes.

Eamonn Vitt: [00:05:33] Etc. So there is a through line from back then to now.

Paul Sax: [00:05:37] You have the polar opposite of the large corporate health care system.

Eamonn Vitt: [00:05:42] Correct, this is by design and choice. Because of my, you know, became an HIV specialist. There's a certification many moons ago after working in Africa with Doctors Without Borders, I worked for the Indian Health Service in the Arctic for a couple of years, had many adventures. Now I'm married with two young kids and I'm at that stage, and I opened this practice in 2013, a year after PREP was approved. So around 2013, the demand for for people at risk for HIV who were HIV negative, there were not a lot of providers. But if you're HIV positive in New York City, there have been amazing clinicians forever. But if you're negative around that time, the regular primary care people, internal medicine people were often scared of HIV testing, even terrified of the stakes, unfamiliar with the drugs, which you and I know are quite straightforward, but I think mostly they just didn't know how to talk to people about sexual health and the usual doctoring 101 stuff. So my practice became very, very busy around that time, 2013, 2014. It's been pretty full ever since. And of course, we've seen the changes in the medications. We don't have to bring up the purpose to data from yesterday, but that's incredibly interesting vis a vis the the BICILLIN® LA pricing issue as well. Right. 

Paul Sax: [00:07:08] Yes. Well, you know, that allows us to transition to the I mean, in addition to the fact that you've got a fascinating background, I thought, to invite you to discuss how you solved a problem, which you've alluded to briefly. So what is the problem you were trying to address? Let's  talk about benzathine, penicillin, long acting, benzathine penicillin.

Eamonn Vitt: [00:07:28] Let's talk about that. I prefer not to kvetch with you for the next few hours because we doctors do that. And there's a lot of frustration, but I'm really, really happy you invited me, because I want to bring a lot of optimism, positive mental attitude, and great DIY energy. And this little story is completely exemplary that that approach can actually fix things. This is not a "billionaires are going to solve all our problems" narrative. I didn't ask Daddy Warbucks for, you know, money to buy my kids' Christmas presents, right? It's far more interesting than that. So anyway, syphilis. You may have heard of it. It's funny to me, I've been diagnosing and treating syphilis all day, every day since I was in medical school, since I was a baby. That's not a universal experience out there. You and I get that. That's my New York City world and the field I'm in and the patients I take care of. Syphilis is tricky to diagnose. It's known as the great imitator. Osler had his sexist comment, "He who knows syphilis knows medicine." Those were different times. So anyway, syphilis is common in my practice in men who have sex with men and transgender women. It's very, very common. I talk about syphilis every day. I talked about it a few times today before we're doing our podcast. It's a interesting biopsychosocial kind of disease. It afflicts disadvantaged people. Again, in my practice, men who have sex with men nationally, I've worked in the Indian Health Service.

Eamonn Vitt: [00:08:55] You'll see it there. African American populations. Anyway, the main treatment is a drug you may have heard of called penicillin, discovered in 1928 by Fleming, fortuitously said to have helped the allies beat the Nazis in World War II. The first wonder drug. You know, it went generic a long, long time ago. And in my world, different than your world. In academic medicine, you don't have the bandwidth to deal with the nooks and crannies that I have to deal with. You have much more delegation and division of labor. I'm very jealous about that on some days. When my patient comes in. Most of my patients are privately insured or have no insurance, uninsured. New York City, a lot of artists, a lot of musicians. People are hustling. It's better post ACA, of course, but it's still a thing. I have a tiny little practice, as I've mentioned, and if I have a patient who comes in, I've diagnosed them with syphilis and it's primary or secondary or early latent. My operations are I send a prescription to a pharmacy down the block where New York City, there are more pharmacies than traffic lights. I send the patient's insurance info and the pharmacy will run it through the insurance and tell me how much it will cost. Most of the time for the past ten years, it's the price has been 4 to $500 if they've not met their deductible. Okay. A very high price most of the time. And if they're uninsured, it will be about the same.

Eamonn Vitt: [00:10:22] I have amazing patients, super smart people, very well developed BS detectors and they all are unhappy with this. Right. I have an economically diverse practice. I have patients who work in fast food, and I have doctors and lawyers and attorneys. No one wants to pay $500. I understand that if they're pre deductible. So I've been tuned into this price thing for a very long time for years. And again, because I'm the only person in my office, I have all the data points all the time, and I advocate as much as I can, but that's how it goes. So that's been going on for years, and we could talk about why that is. When I describe this to my 11-year-old, the company that makes it has a monopoly. We learn when we're 11, that monopolies are bad for the consumer, and it's probably one of the few bipartisan things in the country that both the red team and the blue team agree on, that monopolies are bad. There's been a monopoly when there was a monopoly suboptimal for the consumer. The price can be gouged. That's been going on for a long time. I've tried to talk to you about it with people. The thing is, doctors like you and I are extremely busy all day, every day. And when you start talking about these things, it's, you know, more cyanogenic than a fistful of Ambien to most normal people. They tune out asking someone the square root of 99 or ask them to do long division.

Eamonn Vitt: [00:11:46] It's very hard to get people to pay attention to these pricing issues and health care. This, however, is beautiful because it's the original antibiotic, and it went generic a long time ago since, you know, the Flintstones era, things got a little crazier when in April 2023, a shortage was declared, which again, I'm, you know, I'm a bit long in the tooth and I've been through multiple shortages, as have you. And we know the second line drug is doxycycline. It's around there's not a shortage of that now although there have been quasi shortages and price gouging episodes where a 100 milligram tablet orthodoxy was $8 a pill. You and I remember that. Anyway, so there's this shortage, and it was a real shortage in the sense that my patients with syphilis, HIV positive or negative who were broke, who I would send to the DOH, where they would choose to wait in line for two hours to get the free drugs. It was not even available there in New York, in LA, in Chicago, Miami, Boston. We have amazing public health workers and providers, the infrastructure in New York. I love the DOH here. I'm an outlier, I realize that kind of nationally. Anyway. But they were out straight up out for people with an RPR of 1 to 128, etc. I noticed that happening in summer of 2023. And then I noticed the price going up at the local pharmacy.

Paul Sax: [00:13:20] Combination, combination of shortage and price gouging.

Eamonn Vitt: [00:13:23] Right. And they're related. When there is a monopoly, right? There's no alternative producer to pick up the slack, etc. Right. It's kind of an econ 101 lecture. Anyway. So I see the price going up 400, 500, 600. I feel like I'm trying to buy, you know, cigarettes in Brussels in 1916 or something. I don't smoke, but it's pretty classic. And I work with mom-and-pop pharmacies and I can talk to them. A couple of years ago, I heard on a podcast by a guy named Zdogg, who I love. He's a West Coast-

Paul Sax: [00:13:58] Yeah, I know him.

Paul Sax: [00:13:59] Yeah, he's a very interesting guy. He had a fellow named Alex Osmanski on his show who had just launched the company called Mark Cuban Cost Plus Drugs. Alex Osmanski, it was his idea. He's an interesting guy. He's a radiologist. He did an internship at the Brigham. Then he got a PhD in math at Oxford. He's a sharp fellow. Anyway, he started this company to help prevent price gouging of generic drugs. I heard him on a podcast. Very interesting. Again, reminded me of my punk rock roots in that if you drill down to the basic parts and can isolate these somewhat crystalline black and white issues. Foundationally, you have to fix those things first, if you're to expect any downstream improvement or improvements in patient care. Otherwise, you're trading in the ocean kind of thing.

Eamonn Vitt: [00:14:54] He said some interesting things on his podcast, including that he cold emailed Mark Cuban about starting this company. By December 2023, growing increasingly frustrated with this whole situation. Again, for me, it's every day. In January, early in 2024, I was reading fine print on these weird FDA emails that I subscribe to. And I noticed that a company based out of New Jersey/Pennsylvania, had pursued temporary permission to import the French equivalent of penicillin G benzathine from France. The company is called Laboratoires Delbert. It's called EXTENCILLINE. It's pretty much the same thing as BICILLIN® LA. It has some soy products in it. I'm familiar with these medications. I've worked with Doctors Without Borders back in the day, where I would play a role in ordering, predicting consumption and ordering tens of millions of euros of mostly HIV drugs, but all kinds of medications. So I have a sense of what the price of things are. So I was really happy that this company somehow navigated FDA bureaucracy. And so I emailed them and asked them how much it would be per dose. They responded quickly, and they said 500 USD per dose for the 2.4 million units. And that was the Eureka, or shall I say, voila moment when I said, ah, I got you guys because I know how much this costs in France. Right. I had an idea.

Eamonn Vitt: [00:16:25] So I picked up the phone into my terrible French called a pharmacy on Rue San Gil, near an apartment where I used to stay, and I was given a price of €12. That's quite a delta. So this company on the U.S. side is buying it for €12 and selling it for $500. Arbitrage. We know the economic terms. It's not illegal, but to me it's unethical. The intersection of medicine and commerce is very messy. Again, purpose to this is going to be a whole thing. I acknowledge that. I understand that all kinds of arguments for for patented drugs, this is a generic drug. Anyway. So when I read this price, I corroborated it with phone calls to Paris. We looked up and the French national formulary, you can find the price. So I reached out to people in public health, people in the government, people in the press. I did not get the traction I desired. To you and I, this is a huge deal. I realize people have other things to think about, but it was a real, you know, real gotcha moment. I had written Cost Plus Drugs previously on the form on their website about this issue, in the summer of 2023. Did not hear a response. So after speaking with some reporters not getting the traction I need, I remembered this podcast that Dr. Osmanski mentioned. He sent this cold email.

Eamonn Vitt: [00:17:47] So I spent some time writing a quite a sanguine email address to Mark Cuban's publicly available Gmail address, which is crazy. Hit send. And unbelievably, he replied in two minutes, which is crazy. It's amazing right? On many levels. And he looped me in with the CEO. By the end of the day, the emails are going back and forth, and I learned that Cost Plus cannot make the drug because Cost Plus now apparently is a building, a facility where they can produce drugs in shortage. I was initially asking them to make it. Apparently you cannot make penicillin or cephalosporin or beta lactam drugs in the same building as other drugs for purity reasons. I learned all kinds of things on this journey, and then I sent a follow up saying, hey, this company is doing this. You guys should do the same thing. And I reached out to some contacts with Doctors Without Borders to find out who they buy their stuff from the borders people intensely vet any producer. They're a very punk rock organization. No one's pulling a fast one on them. And so I trusted who they work with for many years. All spring, Mark, David, and Alex applied to the FDA for this carve out to import it temporarily under the rules where a shortage permits importation. And then in the summer, we got the great news that they got the green light from the FDA.

Eamonn Vitt: [00:19:21] The FDA was extremely helpful. You know, Mark Cuban Cost Plus is incorporated as a public benefit corporation, which is super interesting, which means they're the corporate charter has some sort of guardrails in it, or parameters about how the business is going to be run. You know, it's not a nonprofit, but they have a 15% cap on their markup. So it's kind of the ethos of the company, which is super interesting. And again, reminds me of Fugazi, the band who only charged $5 per show and had a cap on that. And it was a fair price, right? So anyway, fair pricing and transparent pricing. This band, Fugazi and Mark Cuban Cost Plus. There's a lot of very interesting parallels, right? When you have a fair price, you have price transparency. It's fairness. You're also creating what's called an externality, which is effects in the community at large that come from how you're running your business operations. And there's also what's called a non-economic benefit in economics, when there's a price and a purchase of transaction, you know, there's another upside to it. So when you go see your favorite band or a work of art, it's meaning. You get meaning from it. Our whole profession is based on meaning. So Cost Plus Drugs imported it, selling it for 30 USD for 2.4 million units.

Paul Sax: [00:20:39] That sounds more reasonable.

Eamonn Vitt: [00:20:42] Yeah, in line with the European cost. And part of the process was I dug into all the CDC publicly available data. You know, what's the consumption going to be? How many thousands of cases per year if it's primary or secondary, early or late, and it's going to be one shot, you know, if it's late latent, it could be three shots. We'll say 10% of the population is going to self-report penicillin allergy. We're not going to give it to them. Apparently the military is still giving this to recruits. I learned about this, the DoD. It's called the peanut butter shot. And this is like full metal jacket type of stuff. So you're talking hundreds and hundreds and hundreds of thousands of doses. The back of the envelope calculations were saving over $200 million. If all these entities were to pay $500 instead of 30.

Paul Sax: [00:21:28] Yeah, yeah. No, it's amazing.

Eamonn Vitt: [00:21:29] Which is amazing. Yeah. So and that's the story. I got the shipment this summer. I have it with me right here. You can buy it from the company.

Paul Sax: [00:21:38] You're keeping it in your?

Eamonn Vitt: [00:21:40] Yeah. This I can afford to stock, you know, and I have no conflict of interest. I don't work for Cost Plus, I don't take a dime from them. I'm just fascinated with their ethos. And the fact that they got this done is incredible.

Paul Sax: [00:21:51] Yeah. I mean, I'm glad you mentioned that you don't work for them. You're not a consultant for them or anything, and neither am I. But it has been kind of revelatory. There have been some other antibiotics that we've turned to them to get, in particular a drug called linezolid, which still is sometimes sold at the original brand price, but not on Cost Plus Drugs. So anyway, fascinating story.

Eamonn Vitt: [00:22:17] And albendazole. Yeah for sure. I read your blog post about the linezolid. Great story by the way.

Paul Sax: [00:22:23] It's unbelievable.

Eamonn Vitt: [00:22:24] [laughs] I've been in that situation many, many times, almost every weekend, I feel like. But yes it's unbelievable. And so price transparency is I think what our whole talk is about.

Paul Sax: [00:22:35] How practically though, I mean you're as you said, you know, low overhead operation, you control everything. But if another practice, say, a practice that is struggling with getting benzathine penicillin for their patients wanted to do this, there's an urgency to treating people with active syphilis. And, you know, Cost Plus Drugs is a mail order pharmacy.

Eamonn Vitt: [00:23:01] Yeah. The timing. Right. I mean, mail order is not ideal, of course, especially not in my practice so much. But in previous jobs you have the human there. You want to treat them while you have them.

Paul Sax: [00:23:12] Yes. Totally.

Eamonn Vitt: [00:23:13] And during pregnancy, same thing. Like that's why the biopsychosocial thing is very applicable to syphilis. It's kind of the poster child along with HIV of course. Right. I have not had any luck connecting with the important people who order these drugs. I've tried. The doctors are too busy. It's almost. They don't have the bandwidth. I totally get that. And then in New York City, you're just dealing with bureaucracy, whether it's public or private, whether it's the corporation, the XYZ health, 2000 corporation, it's really difficult. So one can go on the Cost Plus website through the provider side and order it, and the price is so low. Patients could order it to themselves. I'm not sure about the logistics of that.

Paul Sax: [00:23:57] Yeah, they'd have to get it administered. But it is really a fascinating story and I credit to you for solving this problem. I have a couple of other questions. You know, you mentioned purpose, too. And just for the people who don't follow the HIV field closely, purpose one was a study of lenacapavir for PreP in women that was reported this summer and published in New England Journal of Medicine, showing it was 100% effective, giving a twice-yearly injection of lenacapavir for PreP in high risk individuals and women in Africa. And then purpose two, just recently we heard the results, it was almost that effective in men who have sex with men and trans women. And we haven't seen the full data yet, but we have the press release. But there's going to be a huge controversy with this treatment.

Eamonn Vitt: [00:24:44] Absolutely.

Paul Sax: [00:24:44] There is already. What do you predict as far as?

Eamonn Vitt: [00:24:48] Yeah, I alluded to that earlier. Right. Taking it back to music, the intersection of art and commerce is always a mess. The intersection of medicine and commerce, it's the same thing. Right? So you're going to have people like us, providers, people in need. Medicine is beyond economic sort of thing. Anthropologically. I absolutely love medicine. I'm the luckiest human being in the world. It is full of meaning. And when you work in resource limited places, it is full of impossible choices. We could do another discussion about that, about the decisions a Doctors Without Boarders worker has to make in the field. Or if you're in Arctic Alaska. The decisions you have to make if you're going to fly someone to Anchorage or not. Right. It's totally insane. Very fascinating. You and I have just been talking for however many minutes about a generic drug. That is simple. That's why it's Duplo Legos, not the advanced builder set. Right? It's for kids, that situation. This that you're asking about is a whole other fascinating can of worms. I read the Gilead, their press release. Of course, I want to see all the data and be difficult, skeptical, annoying doctor and criticize it. Whatever. Um, what's going to happen with you and I is we're not going to be comparing it with HIV. The background HIV, right? That's not going to happen. We're going to be comparing it with emtricitabine tenofovir, which Cost Plus Drugs, again who I do not work for, now sells for 16 USD a month. That's one six. That's going to be the choice. My patients are for the most part are very adherent compared to my previous New York City jobs. So it's going to be a very complex decision making. The insurance companies, we know what they're going to say. We know what Gilead is going to say. And I encourage government support for these sort of preventive therapies and therapeutics. It's a therapeutic therapy too, right?

Paul Sax: [00:26:45] Yeah, but this is a much bigger area for lenacapavir.

Eamonn Vitt: [00:26:48] It's huge. Right. And but the thing is, if Gilead charges X, every dollar that's spent towards X is a dollar that's not going towards something else. Right? That's really how I think about it. Right. So if the government's going to pay 42,000 a year instead of, you know, 40,000, that $2k could be used to keep the door clinic open on Saturday mornings, right? So that's to me, that's really where the rubber meets the road kind of thing. And then in resource limited countries, I've worked in South Africa, I've worked in Uganda, I've worked in South Sudan. It's a whole different thing. It's going to be interesting. It's fascinating.

Paul Sax: [00:27:29] I think it's going to be especially important in places where oral PReP hasn't really worked. We look at the adherence data from purpose one over time to the oral regimen. It's terrible. And so lenacapavir twice a year injections in women who are at high risk for HIV and Africa makes a ton of sense.

Eamonn Vitt: [00:27:52] Yeah, and of course, you and I would concur that the rich countries should help the poorer countries, I don't think that's controversial, but and how it plays out in my practice is going to be and yours is going to be extremely interesting. My patients are very tuned in. The days of informational asymmetry between doctor and patient are over.

Paul Sax: [00:28:13] [laughs]

Eamonn Vitt: [00:28:13] They don't have to get a, you know, Harvard Med ID card and go to the library to read about the latest stuff, right. It's great news. 

Paul Sax: [00:28:19] Yeah, this is great news. And this is a great story you told. I got a final, final few questions. Okay. Lightning round. 

Eamonn Vitt: [00:28:26] Yes, lightning round.

Paul Sax: [00:28:27] Quick questions, quick answers. All right. What would you be doing if you weren't a doctor?

Eamonn Vitt: [00:28:31] I think I'd be a struggling musician struggling to write bad novels about my life as a struggling musician. 

Paul Sax: [00:28:39] What do you like to do in your free time?

Eamonn Vitt: [00:28:40] I don't have any. Neither do you. I have two young kids. I have a solo practice. I'm on call 24 over seven. I'm a big reader. I'm a long-distance runner. That's really it.

Paul Sax: [00:28:55] Those are two things.

Eamonn Vitt: [00:28:56] I'm in dad mode. 

Paul Sax: [00:28:58] Ideal vacation? Not that you get vacations, but your ideal vacation location?

Eamonn Vitt: [00:29:03] Ideal vacation? Yes. And I tell my solo solitary employee every year, when you have your own practice, it's great. You can go on vacation whatever you want. The downside is you'll never be on vacation. We went to Taiwan in August for a bit. My wife and two kids. Unbelievable. It's like Japan at 50% off. I highly recommend it. The food is incredible. Very affordable.

Paul Sax: [00:29:26] And last question because it's an ID podcast. Your favorite antibiotic?

Eamonn Vitt: [00:29:31] Penicillin G benzathine, naturally.

Paul Sax: [00:29:35] [laughs] I didn't have to ask.

Eamonn Vitt: [00:29:36] I like Doxy a lot too lately.

Paul Sax: [00:29:38] Good, good. Anyway, I want to remind everyone that this episode of this Let's Talk ID podcast was produced by the Infectious Diseases Society of America and edited and mixed by Bentley Brown. And I have been talking with Doctor Eamonn Vitt, who is a HIV specialist and primary care doctor in New York City, where he has solved for now the cost and shortage issues for benzathine penicillin. Thanks so much, Eamonn.

Eamonn Vitt: [00:30:07] Thank you.