HIV and ID Observations

“Dr. Sax, what’s it like to have lived through two pandemics as an ID doctor?”

The question came from a brand-new intern during afternoon sign-out. I took a breath — because wow, were they different.

HIV: It Felt Like A Calling, One Miraculously Rewarded

I started my internship in 1987, six years after the first cases of AIDS were reported. The median survival of someone newly diagnosed with AIDS was 12−18 months. When, at the end of my three-year residency, I chose Infectious Diseases as a specialty, part of the rationale was to follow what felt like an urgent mandate:  HIV was about to become the leading cause of death among young men in the United States.

(I also liked antibiotics, microbiology, and taking patient histories about travel and pets. You know, the nerdy ID stuff.)

This catastrophic new disease taking the lives of young people in our country didn’t just present a medical challenge. The stigma was brutal. Many clinicians reinforced it by asking how someone acquired the virus, even when the information was in the chart or had no impact on treatment. “How many partners?” “IV drugs?” “Why didn’t you use condoms? I sure hope you do now.” Patients loathed the inquisition and the implied accusations; most of them already felt deeply stigmatized by their diagnosis.

One gastroenterologist, after doing an endoscopy, memorably told a 28-year-old patient of mine with candida esophagitis, “You don’t look like someone who has AIDS. How did you get it?” She remembers that 30 years later, and so do I.

It’s hard to convey just how ubiquitous, and punishing, this stigma was back then. “We can’t have those people taking up an ICU bed,” a cardiologist grumbled to me in 1990. Those people. Some surgeons looked for any excuse to avoid operating on a patient with HIV. Hospitals deliberately downplayed HIV as an area of expertise, not wanting to be branded an “AIDS hospital.”

I’m embarrassed to write that even some ID doctors followed this unfortunate plot line, expressing concern that HIV might ruin our specialty. Why take care of someone with advanced HIV disease when there was nothing that you could do to treat the underlying problem, the virus itself? Send them back to their primary providers for palliative care once you’ve treated the toxoplasmosis or pneumocystis, they argued. Small in number (fortunately), this group of ID doctors did not distinguish themselves during this period.

Because they were wrong. There was plenty we could do, and it wasn’t just diagnosing, treating, and preventing the opportunistic infections. We could also help alleviate chronic symptoms, manage polypharmacy, provide a longitudinal, compassionate care team, and — this part was critical — we could follow closely the research on antiretroviral therapy gathering steam in the laboratories and clinical trials.

When successful HIV treatment arrived in 1996, we could then celebrate with our patients the transformation of their previously fatal disease into something quite treatable. Rejoice!

Today, remarkably, HIV is easier to manage than many chronic conditions. In a quiet signal of triumph over the inevitable downward course of untreated HIV, residents who admit someone with stable HIV to the hospital — usually for a completely unrelated reason — list HIV way down on the patient’s problem list, something in the background that deserves mention but is rock-solid stable.

COVID-19:  A 2-Year Siege That Drained and Divided Us

March 2020 reversed that script. Critically, this time, we ID folks weren’t alone; the whole medical center mobilized.

Energy to respond clinically was both collaborative and, at least initially, sustaining. In those first months, we worked together with critical care specialists, emergency room personnel, the microbiology lab, nursing, respiratory therapists — everyone on the front lines of patient care chipped in to get it right.

Another big difference was that, due to the mode of transmission, the fear was everywhere: every PPE donning felt like bomb-squad duty. Is it weak of me to admit that each time I entered the room of a suffering, coughing patient with COVID-19 in the spring of 2020 that my heart rate quickened? That I repeatedly checked my N-95 mask for the proper seal? Cursed with a giant nose, I had always considered this feature of my anatomy a cosmetic challenge, not a life-or-death issue — but it sure made fitting an N-95 mask difficult.

(Too much information? Sorry.)

I remember a woman from the Dominican Republic, struggling with COVID, telling me — through an iPad interpreter — that she drew strength from memories of going to church as a child. Her faith, she said, was helping her fight the virus. I listened, nodding, but from the far side of the room. The connection felt intimate; my posture and location, not so much.

Hallways were eerie and quiet — administrators were remote, many non-essential clinicians sidelined and doing only video visits, all elective surgery canceled, and family and friends of patients barred from visiting their sick loved ones. That last one was particularly heartbreaking. What a terrible time.

Then, the summer of 2020 in northern cities like Boston teased us with a very welcome pause, as COVID practically disappeared. Phew, time for a deep breath, everyone. I remember postulating hopefully, wishfully, to a close friend that perhaps the virus had already targeted the vulnerable, either from immunologic or genetic factors still to be determined; maybe it was done wreaking havoc on society at large.

I was so very wrong. The next 18 months brought us an autumn/winter surge almost as bad as the first one. Delta the following summer filled ICUs with the unvaccinated; Omicron then infected everyone else within weeks, making the Christmas holidays in 2021 a blur.

We in ID watched each of these waves unfold, following the scientific advances closely, and doing our best to communicate this knowledge to our patients and an increasingly weary public who just wanted this virus gone. Monoclonal antibody treatments came and went as the variants mutated — each antibody challenging to obtain with limited supply, and as difficult to deploy as they were to pronounce.

(It will be quite the trivia question one day to ask ID doctors to say, or spell, bamlanivimab, casirivimab, and imdevimab.)

Alas, our hard work put us in growing conflict with a world ready to move on. Anytime we modified our guidance due to evolving evidence as the disease changed, our words were seized as a signal we weren’t to be trusted. Ivermectin enthusiasm and anti-vaccine rhetoric spiraled into mass delusion. Two extremist camps battled it out in the press and social media — the group that insisted the whole thing was a fraud from the start versus those who refused to acknowledge that the disease had lessened in severity over time.

We knew that the truth lay somewhere between these two groups — yes, COVID was still with us, causing some unfortunate people to become severely ill or leading to long COVID, but no, it was nowhere near the threat it was in the first 2 years. Somehow, conveying this message led to increasingly cantankerous pushback from both camps.

What began with a collaborative spirit to fight a global pandemic evolved into a political fracture that still hasn’t healed. It was the toughest 2 years of my career, and I’m still not over it.

Some Lessons Learned

Back to that intern’s excellent question, because in our workroom, I probably didn’t give it sufficient thought when I answered, motivating this post.

Yes, they were different. There’s no better example of how different than to look at what happened to Dr. Anthony (Tony) Fauci. Celebrated for leading the response to HIV, pilloried for the same leading role with COVID, he eventually needed a security service to protect himself and his family — one of the saddest commentaries on our divided world one could imagine.

But both viruses exposed societal ignorance and healthcare inequities. The best responses involved teamwork, compassion, rigorous evaluation of the latest research, and nuanced communication.

And both reinforced the fact that our work is never boring, that’s for sure. ID is still the best job in medicine, even when it breaks your heart.