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Having turned 60 years old this past year and approaching 30 years as an HIV/AIDS specialist, I erroneously believe I have seen it all in the field of HIV medicine.
Having started in private medical practice as an idealistic young HIV specialist and transitioning into the non-profit world, The World Health Clinicians, Inc., essentially to survive managed care as a disillusioned but still idealistic older humanitarian, I initially found myself in an unfamiliar world, seemingly without the tools needed to navigate it (that is, aside from my medical school colloquial lesson, “See one, do one, teach one”).
Having started practicing HIV medicine in the pre-AZT era and now researching gene therapy as a possible functional cure for HIV, I’ve taken the road less traveled, while exuberantly participating in history-in-the-making.
Having traveled the journey of the “HIV spectrum” from HIV as a death sentence from AIDS, to HIV as a chronic, manageable, treatable, lifelong illness in the developing world (ie, the United States), to HIV as a death sentence from AIDS in the developing world of Zimbabwe, to HIV slowly becoming a manageable, treatable, but far from a lifelong illness in Zimbabwe with WHC’s non-profit initiative, BEAT AIDS Project Zimbabwe (BAPZ), I am sobered and humbled by the contrasting spectrum from one world to the next.
Having watched and participated with one generation dying from AIDS and successfully coming together with other researchers to change the shape and face of HIV so that, paradoxically, the current men who have sex with men (MSM) generation could falsely believe that “HIV is no longer a big deal,” I am deeply saddened by this modern-day generational epidemic but empowered to understand and reverse it.
Having been on the forefront of HIV/AIDS stigma and discrimination, as a gay man and HIV physician who lost my first long-term stigmatized companion of 16 years to AIDS-related lymphoma and co-founded the anti-stigma campaign, HIV Equal™ to fight the overwhelming HIV stigma still experienced today in the United States, especially in the black/African American and Latino/Hispanic MSM and transgender communities, and throughout Zimbabwe in all communities, I have developed a unique perspective on and will commit the remainder of my life fighting HIV stigma in the developed and developing worlds.
Having the perspective of treating more than 3500 diverse HIV-seropositive individuals in Connecticut (where WHC and its non-profit comprehensive HIV and LGBTQ medical clinic, CIRCLE CARE Center, is located) and having worked in beautiful Victoria Falls, Zimbabwe, I have developed a unique perspective about those who are poor or disabled and entitled in the developed world versus the same who have no entitlements in the developing world. A quarter of the individuals in Connecticut are on Medicaid, 30% are on Medicare, 70% are MSM, and 99.6% have undetectable HIV-1 viremia, while being surrounded in the US by 1.1 million Americans living with HIV, 66% of whom were linked to care, but only 37% of whom are retained in care, and even less, 25%, have undetectable HIV-1 viremia,1 meanwhile in Zimbabwe, where essentially nobody has private insurance or the equivalent of Medicaid, BAPZ has more than 8,500 on limited HIV antiretroviral therapy, but 75% have undetectable HIV-1 viremia and the loss to followup rate is 0.26%.
Having journeyed from sending discordant HIV+/HIV- couples to Italy for experimental sperm washing and artificial insemination procedures to have children, to blindly sending AZT/3TC/ABC to a positive couple in Zimbabwe in 2001 long before definitive proof was available demonstrating HAART for prevention of mother-to-child-transmission (PMTCT) of HIV and without the availability of any CD4 cell counts or viral load tests, to the upcoming 14th birthday of my HIV-negative godson, Gary L., in July in Zimbabwe, to the breakthrough knowledge of HIV “Treatment as Prevention,” to the UNAIDS worldwide “90-90-90” goal to end HIV by 2030, I am truly enlightened and believe that anything is possible if one is seriously motivated and incessantly persistent.
Having personally taken the seemingly endless journey from Louise Hay’s “Power of Positive Thinking” in the pre-AZT days, to HIV monotherapy with one antiretroviral agent, to sequential monotherapy, to dual therapy, to triple therapy with 35 pills daily, to triple therapy with the first non-nucleoside reverse transcriptase inhibitors (NNRTIs) to triple therapy with the first fixed-dose combinations (FDC) of nucleoside reverse transcriptase inhibitors (NRTIs), to triple therapy with the first ritonavir-booster protease inhibitors (PIs), to mega-HAART with 6 HIV medications, to FDC with triple NRTIs and two pills daily, to structured treatment interruptions, to the first FDC with one pill once daily, to four classes of HIV drugs with entry inhibitors, to five classes with integrase inhibitors, to three TDF-based FDC with one pill once daily but long-term renal and bone toxicities, to recent TAF-based FDC with less renal and bone toxicities, to the first and only FDC that HIV has, to-date, been unable to develop drug resistance in treatment-naïve patients, to, in contrast, the current extremely treatment-limited, resource-limited setting in which BAPZ supports the Zimbabwean Ministry of Health with 4 NRTIs, 2 NNRTIs and 2 boosted FDC PIs (8 generic ARV as compared with 40 single and FDC available in the US), I am committed to sharing the lessons we learned and attempting to avoid the mistakes we made over 35 years in BAPZ and HIV Equal’s work in Zimbabwe and beyond.
Having this unique and diversified worldly perspective on the field of HIV/AIDS, throughout my own past 30 years as an HIV/AIDS specialist, I have been enlightened, provoked, amused, stimulated, sobered, encouraged, and amazed. Do not be shocked if Zimbabwe or another developing nation becomes the first nation in the world to achieve the UNAIDS “90-90-90” by or before 2020, long before the US or another developed nation.
