Where have we come with HIV/AIDS? Reminiscences of a career

In 1981, I had the honor of seeing the first cases of HIV infection in Los Angeles as a product of my having worked with UCLA professor Michael Gottlieb. This disease has been a focus of my career and the many conferences and meetings through the decades have allowed me to see how science advances and how one disease has the potential to change medicine.

As a resident at Stanford in the late 1970s, certain diseases were very difficult to treat in particular serious fungal infections, often among immunosuppressed patients (lymphoma, leukemia, some rheumatic disease patients). Also diagnosing and managing viral infections was difficult as but a few antiviral were available and only a few years earlier, in 1986, did the antiviral acyclovir become available for managing herpes virus infection of the brain (encephalitis).

As HIV was identified and the spectrum of associated diseases uncovered, the pharmaceutical industry, perhaps in conjunction with the many activists for AIDS, advanced, did a whole class of agents became available not only for the HIV-infected but also for many other, especially cancer, patients medicine. No longer were systemic serious fungal infections deemed seriously hard to treat.

Other investigators developed techniques for measuring the quantity of virus in the blood, a technique that came to be known as determining a “viral load.” This was subsequently extended to hepatitis B and C infections, to a respiratory infection called respiratory syncytial virus (RSV), and may be used for other viral infections in the future.

What is especially encouraging is the number of antivirals that were identified or modified for treating HIV, with well over 40 combinations now available (in the developed world, this advance begs to be transferred to the developing world). During much of my career in clinical medicine, HIV antiviral constituted about one-half of all antiviral available for human viral infections, a number now diminished somewhat by the many advances in treating HCV infection.

The world has changed so much since those days in 1981. The first identified cases, in homosexual men, met resistance for “first-page publication” from senior editors of Morbidity and Mortality Weekly Reports, the weekly CDC publication that we used to notify the world about these new cases of pneumonia (Pneumocystis in gay men).

In 1987, I worked full-time caring for indigent patients several years later in Dallas, after finishing training, and at the time not one nursing home in the Dallas-Fort Worth area would take an AIDS patient, a leading downtown church decried AIDS as “The Wrath of God,” and of course myths evolved, typified in the Dallas Buyers Club, a film I could not finish because being on the treating end with my colleague Daniel Barbero, we were a part of the medical establishment de facto pilloried by the movie.

The truth is that in Dallas in 1987 a small and dedicated staff worked endlessly trying to care for patients who were often ostracized by their families, who had to come in for thrice-weekly infusions of antifungal therapy for simple thrush, and who had only one antiviral become available for their treatment AZT. In retrospect, we were probably breeding resistance to therapy, and only with the later development of AIDS cocktails and triple combination therapy was it possible to control HIV infection.

The instances of outright discrimination were rampant, in my own career I saw patients deprived of housing, met a Russian woman who managed AIDS control in Azerbaijan who said it had recently been illegal to treat patients with HIV or other sexually transmitted diseases, heard participants from LA at a meeting in Holland decrying the discrimination patients found within churches.

The tools of prevention made a big difference in managing this disease and prevention is far broader than most realize. It is not simply abstinence from sexual activity (which the Brazilians informed the Bush administration “does not work”), and to think of it as merely the use of barrier protection is similarly simplistic. As I taught students throughout the latter years of ward teaching, it entails blood safety, counseling, good surveillance, treating other sexually transmitted infections, ensuring access to circumcisions (uncircumcised men are far more likely to transmit infection because of a certain cell (“dendritic”) in the foreskin in infected men, allowing women the right to vaginal microbicides (especially women whose husbands or partners have other contacts, often as a consequence of working away from wives for extended intervals), partner protection, and the use of antivirals, known a “PREP” or pre-exposure prophylaxis.

One other mode of prevention that few think of is providing sustenance to poor people. David Wilson of the World Bank has shown in 3 areas of Africa that simply making cash payments to the poorest of the poor often prevents their engaging in casual sex-for-pay and lowers the HIV rate.

How often I imagine do we challenge the traditional teachings of the church? I remember a stellar Dominican nun in El Salvador who was adept at working with the poorest of the poor AIDS patients. Our imperative is to love and provide for our patients, and in doing so, we meet them where they are philosophically and religiously, and treating a sick and dying AIDS patient demands a particular skill at pastoral care.

On a mission trip to Guatemala, I remember visiting an American priest in Guatemala who spent his time building schools, especially for girls, for he felt the country could not advance unless women were educated.   I use this example when I see the inevitable wall some in secular society have of the church as being unresponsive to needs in society.

In my career, I have been blessed to keep and maintain clinics with the poorest of the poor, immigrants who cannot afford a $20 co-pay, to patients that walk to Houston from Central America, to a poor-African American man who acquired infection from his spouse because he refused to use any barrier with her in expressing his affection for her, to several homeless schizophrenic women with HIV infection, a group that posed some of the greatest challenges for anyone caring for HIV patients.

Comparing HIV to COVID-19 infection is inevitable. HIV infection was uncovered in a small group of patients (rather ignobly referred to once as the 4H club: homosexuals, heroin addicts, hemophiliacs, and Haitians), while in reality, most cases occurred in Africa and among heterosexuals (where also it was often referred to as the “homosexual disease” in an attempt to shift the “blame” rather akin to syphilis in olden days being referred to as the Spanish disease by the French, the French disease by the Germans, with an endless carousel of names). COVID-19 though has affected many more strata of society, although as limitations in vaccine supply becomes evident, it parallels what HIV has become, a disease affecting millions, especially the forgotten million in the developing world whose status denies them both access to medication for HIV or vaccines for COVID-19.

In the end, the philosophy of Mission Doctors Association contains the mustard seed, as we in the organization continue our care for the poorest of the poor we building a society that forgets pegging blame (be it on a risk-factor group for HIV or an ethnic group of COVID), and work diligently and constantly to improve the lot of the indigent in society and in doing so, build the kingdom we pray for in our faith.

Wayne Shandera, MD

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