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All Podcasts How COVID and HIV/AIDS Can Help Us Get Ready For (or Avoid) the Next Pandemic

How COVID and HIV/AIDS Can Help Us Get Ready For (or Avoid) the Next Pandemic

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Description

Dr. Bob calls up AIDS researcher Carlos del Rio and longtime AIDS activist Gregg Gonsalves to explore what the HIV/AIDS epidemic of the ‘80s and ‘90s can teach us about COVID-19 today. They discuss the politicization of both viruses, how the role of activism compares, and how the 30-plus-year quest for an HIV vaccine helped advance the COVID-19 vaccines. Plus, what HIV/AIDS can show us about what it means to return to “normal.”

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Find Gregg Gonsalves @gregggonsalves and Carlos Del Rio @CarlosdelRio7 on Twitter.

 

Keep up with Andy in D.C. on Twitter @ASlavitt and Instagram @andyslavitt.

 

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Transcript

SPEAKERS

Gregg Gonsalves, Dr. Carlos Del Rio, Dr. Bob Wachter

Dr. Tony Fauci  00:00

Given the fact that we now have the virus in our hands, it is quite possible, in fact, it’s invariable that we will develop a vaccine for AIDS. The question that remains to be answered is, will that vaccine be effective in protecting individuals against infection with the virus and we don’t know that. But that’s exactly where much of the research is going on at the present time. We don’t know a lot about AIDS, but we also know an incredible amount about it from our experience over the past three or four years. And hopefully, our recent advances of being able to isolate, identify, and characterize the agent together with the advances in understanding the natural history and pathophysiology of this disease will allow us over the next year to come back to you and tell you that we now not only have hope and hypothesis, but that we have a real prevention and indeed a real cure.

Dr. Bob Wachter

Welcome to IN THE BUBBLE. I’m Dr. Bob Wachter. Does that voice sound vaguely familiar to you? It should. That was Dr. Anthony Fauci speaking in 1984. Let’s see, 21 plus 16. That was 37 years ago, when he was a young, precocious Director of the National Institute of Allergy and Infectious Diseases has same title as today. He was 44 years old at the time. And he was talking about this new disease called AIDS that had burst onto the scene with the first reported cases a couple of years before that. And he was describing the path of science and how we were going to be looking for treatments and for vaccines.

Dr. Bob Wachter 

It was the early part of my career as well, in medicine, I actually had a chance to meet Dr. Fauci a few years after that, and he was already a legend in healthcare, remarkable leader and scientific leader in the field of infectious disease. And he and his colleagues at the NIH and colleagues in academia and pharmaceutical companies set out to try to figure out this puzzle of this new viral pandemic. And one of the things that makes our experience in the past year in COVID so remarkable is we came up with answers at an incredibly rapid pace, and an HIV and AIDS tragically, that did not happen. So although here, Tony was talking about searching for treatments and searching for a vaccine.

Dr. Bob Wachter  02:39

It’s now almost 40 years later, we still do not have a vaccine for HIV. It was not for another 10 years or so that we developed effective treatments. And of course, within a few years, we had remarkably effective treatments that completely changed the nature of HIV and turns it into a manageable chronic disease to the point that we now I still can’t believe this, we now have a geriatrics aids clinic at UCSF for older people who have had AIDS now for decades and are living perfectly well with it all having to take medicines every day. So aids there are a lot of parallels between the emergence of HIV and AIDS and some major differences between what aids,  the experience with AIDS and with COVID.

Dr. Bob Wachter 

Some of the differences include that aids was uniformly fatal that attended to strike a very specific group or set of groups. COVID is much more general, although we’ve seen the COVID also preys on certain groups and elders and people of color and others. So there are differences. There are similarities. But I think there’s a lot to learn, in thinking back on the experience that we as a country and we as a world had in attacking this remarkable pandemic that struck us in starting in the early 1980s. One theme that blends through both pandemics is the importance of government and government getting it right.

Dr. Bob Wachter  04:01

And as you’ll hear the role of activism and AIDS was really important because government largely ignored HIV and AIDS for the first several years, the President did not utter the word AID in a speech until seven years after the pandemic had begun, which is pretty remarkable. And I don’t have to tell you that we’ve had, we had our own challenges with government in 2020. And its response to COVID. So as we thought about that, we thought there were a lot of things that we could learn in going back now 40 years and thinking about the history of HIV and AIDS.

Dr. Bob Wachter 

We know that some of our listeners lived through that and some of them did not. And so we thought it would be useful taking a step back thinking about what happened then and what its relevance is to now. And we were lucky enough to find two folks who have been essential leaders in the fight against COVID but also had an interesting history as it came to HIV and AIDS. One of them Carlos Del Rio was already Professor already working in healthcare at the time. Another Gregg Gonsalves, as you’ll hear, was younger at the time, but was just coming out and was an activist in the early years of the AIDS epidemic, so two very different perspectives, but I think really interesting perspectives.

Dr. Bob Wachter 

And that’s why we thought it’d be useful to spend an episode talking about the lessons for COVID from HIV and AIDS. And so our guests today are Gregg Gonsalves Greg is a global health activist and epidemiologist. He’s also assistant professor at the Yale School of Public Health, and Associate Professor at the Yale Law School. And as you’ll hear, Gregg has been an AIDS activist and worked on HIV AIDS and other global health issues for over 30 years, and has taken that activist mindset and applied it to COVID. Carlos Del Rio is a distinguished professor of medicine and the division of infectious diseases at Emory University School of Medicine. And he’s also professor of Global Health and Epidemiology at the Rollins School of Public Health at Emory.

Dr. Bob Wachter 

He’s also Executive Associate Dean for Emory at Grady Health System, the big and fantastic public health hospital in Atlanta. And he’s the co-director of the Emory center for AIDS research. They are really thoughtful about the lessons from HIV AIDS, the things that are similar, and some things that are really quite different. And I suspect somebody will be doing a podcast 20 or 30 years from now, with some new infection that has emerged and talking about the lessons from COVID that are relevant to this new and emerging pandemic. Let’s hope it’s 20 or 30 years from now, and not 5 or 10 years from now. So with that, I think it’s a really interesting episode. And I really enjoyed talking to Gregg Gonsalves and Carlos Del Rio, so we will ring them up right now.

Dr. Bob Wachter  06:45

Hello.

Dr. Carlos Del Rio 

Hey, good morning, everybody.

Gregg Gonsalves 

Hello.

Dr. Bob Wachter 

Nice to see both of you. I know Carlos, Gregg, I don’t know that we’ve ever met.

Gregg Gonsalves 

I don’t think we’ve met either, Bob. Nice to meet you.

Dr. Bob Wachter 

Yeah, nice to see you. Thank you for doing this. Alright, let’s go ahead and get started. I want to talk about what your lives were like at the beginning of HIV AIDS. So I’m going to take you back to 1980 to 1983. And tell us about where you were and the first times that you heard about this emerging infection, what you thought when you heard it, so maybe I’ll start with Gregg.

Gregg Gonsalves 

So I graduated from high school in 1981. So the advent of the AIDS epidemic and my imprints into adulthood, coincide with each other. It also coincided with me coming out as a gay man. In the New York City area, I grew up on an island outside of New York, went to college in Boston, at least for a few years. And so my coming out, the Reagan administration, the AIDS epidemic are seared in my mind is sort of the seminal event of my young adulthood. And so, to be honest, for the early years in college, I didn’t think about HIV. It was something I saw on the papers.

Gregg Gonsalves  08:01

But you know, there’s no internet, there wasn’t sort of a bombardment of sort of external information for people in a closed college environment. But fast forward a few years. And once I dropped out of college and was sort of living as a young gay man in Boston, the epidemic started to impinge upon my life, and I met somebody who is HIV positive in the middle of the 80s. First person I had met, was convinced he was going to be dead in a few years. And when searching for information, which led me to act, I’ve been sort of determined that directory most of the rest of my life.

Dr. Bob Wachter

I guess I’m surprised that coming out as a gay man at that time, that it wasn’t a dominant issue for you. And you’re sort of thinking about how you having to make decisions about how you lived your life and your sex life and all that kind of stuff. What explained that sounds like it took a few years for it to really embed itself in your consciousness, what was going on?

Gregg Gonsalves 

I think the fact if I been in college in New York City, or a larger metropolis, I was at Tufts University in the suburbs of Boston. You know, my social life is really defined by that campus community. You know, my cousin who died in 1996 from AIDS, was living in New York at that time. And I think it would have been a much different experience for somebody who’s a slightly older, was not basically in sort of a post childhood era of cloistered relationship with my family, which I went to see back, you know, every spring break or winter break.

Gregg Gonsalves 

And so I think, I do think there was a sort of generation of gay men who were my age, who, for the first few years basically had that sort of idyllic relationship to their coming out, which really was where AIDS was not a big thing, but it happened. It moves pretty quickly. It takes over sort of the story of my generation.

Dr. Bob Wachter 

Yeah. Carlos, how about you? I don’t think you were to graduate from high school, right about then. So where were you?

Dr. Carlos Del Rio 

No, but it was so story of my life, I mean, clearly 1983 I started my medicine residency and I started medicine residency at Emory and I, I came to Emory for residency because I wanted to be a cardiologist and I wanted to work with J. Willis Hurst. But HIV was starting and it just became fascinating. And it became fascinating because you know, this new patients that were coming in that we didn’t know what they had, and that they were my age, and they were very rapidly dying. And it was just really, you know, fascination of science. And, yes, it wasn’t what it is today with the internet. But at some point in time, like every week in internal medicine, I had a paper and you can read about it, and you can learn about and having been here in Atlanta, you know, was having the CDC and many of the IAS officers working on this were my friends.

Dr. Carlos Del Rio  10:46

But then really a defining moment was, I was starting my second-year residency, and I got traded, there was a funny thing happened. But Hopkins wanted, a resident at Hopkins wanted to come to live in Atlanta for personal reasons. And instead of quitting and coming here, she was told to come and do a residency here, and then somebody from Emory would be traded to go over to be at Hopkins. So I arrived at Hopkins as a second-year resident, and my first month in service, John Bartlett was my attending. And that then changed my life and made me go into infectious disease and go into HIV. So I mean, the early years of HIV define where I am right now.

Dr. Bob Wachter 

Yeah. And John Bartlett for our listeners was one of the most prominent infectious disease specialists of his generation and wrote the textbook that everybody used during training to understand sort of how to treat various infections. Did you have any choice in being traded? I never heard that story before.

Dr. Carlos Del Rio 

No, it was it was the weirdest thing.

Dr. Bob Wachter 

We were told that you’re leaving Atlanta, you’re going to Baltimore.

Dr. Carlos Del Rio 

Basically, it was like a baseball trade. But again, you know, as scary and as crazy as it was, it was a defining moment in my life going to Hopkins really was very critically important in where I am right now. And you know, and the people I work with, and, you know, the people I got see and what they were doing in HIV at that point in time over there was really defining in me wanting to do an HIV career. So yeah, I mean, I tell residents don’t be afraid of things like that. It was pretty scary and at the same time, it was incredibly rewarding.

Dr. Bob Wachter  12:13

Well, you’ve had such a spectacular career, I hope Emory got a couple of draft choices or something like that trade. But yeah, it’s actually a good lesson for young listeners that sometimes these things feel like they’re cataclysmic. And yet, it turned out to be an incredibly important thing for you and your career. And it’s worked out incredibly well. Maybe one more question for you, Carlos, since you were practicing at the time, and actually started my residency in 83′, as well, so we were the same year, but somehow UCSF could not get rid of me. How scary was it? You were taking care of these people and you we didn’t really know how it was transmitted at the time.

Dr. Carlos Del Rio 

It was incredibly scary. I still remember putting an arterial line in a critically ill patient in the ICU, which ended up dying of pneumocystis. But at that point in time, we didn’t know this was somebody who was an injection drug user who came in with bilateral pulmonary edema. So we have no idea that this was actually pneumocystis. And this new disease, and you know, back in those days, as you remember, we didn’t use gloves or anything to do that. And I put the line and then the arterial line came over, you know, that was released, and it came all over my face. And literally, by the time that we discovered this virus and the tests that appeared, I was having night sweats, and I was, you know, having chills, and I was sure that I had HIV, and I was one of the first persons actually tested.

Dr. Carlos Del Rio 

Because I said, you know, I’m sure I have this infection, and I didn’t, so it was very scary. And it was very concerning of all of us that were drawing blood, and they were seeing patients that way. But I would say that at the same time, a big difference to what it’s like today is that we can touch the patients, we can hug the patients, we can offer human kindness to the patients. And to me the hardest thing about COVID is having all this PPE and having this fiscal separation for the patient, that just makes it so hard to be with somebody who’s dying and not be able to just basically, you know, give them a hug.

Dr. Bob Wachter  14:09

Yeah. Although I have to say, you know, you said we can touch and we can hug the patient in those early days. I remember there was a period of time where we really didn’t understand how it was transmitted.

Dr. Carlos Del Rio

Oh, totally.

Dr. Bob Wachter 

You know, there was worry that just coming into the room was I going to get it just from being in the room, I don’t think it was completely clear that it wasn’t airborne. And there were all sorts of theories floating around about how it was being transmitted in those early days.

Dr. Carlos Del Rio 

And the stigma was also unbelievable, you know?

Dr. Bob Wachter 

Yeah. So maybe I turned back to Greg and talk a little bit about the stigma and how HIV felt different than COVID it by virtue of the fact that it was striking, you know, we’ve talked a lot about in COVID, about disparities. But by and large, it can hit everybody, everybody was at risk. In HIV, it became fairly clear relatively quickly that if you were not a gay man, and then a little bit later an intravenous drug user. You were not at very high risk and maybe almost zero risk. So how did that change the nature of those early years with HIV AIDS compared to COVID?

Gregg Gonsalves 

Well, it’s interesting, you know, Larry Kramer, I think on a 60 Minutes interview in the 1980s, talk about AIDS being a disease of disposable people. And so, I was pretty clear that as my friend Greg Bordeaux Whitson, or professor at the Art Institute of Chicago said, was the […] words in the junkies, right? It was people who were despised by society who were getting this. And one of my in retrospect clear memories is this recording of Larry speaks the president press officer in a recording in the White House laughing about the disease as if it was a big joke to everybody assembled around President Reagan.

Gregg Gonsalves 

It was pretty clear that the disease was ignored, the efforts to combat it were delayed. Remember, President Reagan didn’t say the word HIV until seven years into his term, and that we were fighting for our rights as gay men, but also for our lives. And it really determined the trajectory of the LGBT community over the next, you know, two decades, the idea of gay marriage really came out of the visibility of AIDS and gay men who had no choice but to sort of take our case to the American people, because the American government didn’t really give a damn.

Gregg Gonsalves  17:06

I do think, you know, when we think about COVID, yes, everybody can get it. But when you look at the disparities and deaths, when you look at the disparities and who’s getting infected, when you look at the disparities and who’s getting vaccines, you start to think again about who’s disposable or who gets to the front of the line for care, treatment and prevention in the context of COVID. Very much in the way, in the old days. This is a disease of the forgotten.

Dr. Bob Wachter 

It struck me I have written some about this, it struck me that one of the things that happened with HIV AIDS was that it did hit a group that had a preexisting social consciousness, and a group identity and to some extent, a tradition of activism, fighting for rights in various ways. And then AIDS just became the issue folded into that preexisting sensibility and political structure where it’s not quite the same for COVID. Is that accurate?

Gregg Gonsalves  18:13

Well, you know, remember, it’s a, it’s a very nascent social movement, you know, the gay rights really starts to come of age in the 1970s. And, you know, the stigma against gay men was pretty, pretty ferocious throughout the 80s, as well. And a lot of gay men did not want to come out and to fight city hall or fight the White House. And Larry Kramer railed against them in the early years saying, you know, you’re sitting at home watching your friends die and doing nothing. So the stigma kept a lot of people in the closet and died in silence right there. A lot of gay men who died without their families knowing they were gay. Family wouldn’t that their lovers and their partners see them attend their funerals.

Gregg Gonsalves 

So this was highly stigmatized, just as sort of the gay rights movement was sort of finding its feet in the early 70s. You know, it’s interesting that we talk about COVID. And, you know, I wonder why there isn’t a similar social movement. But it’s interesting, and I talked about this yesterday, a little bit in the context of the Conference on Retroviruses and Opportunistic Infections. Many of the people who are fighting COVID right now, are infectious disease doctors and researchers, but also the AIDS activists from that era. They’re all back for their second pandemic, right? And it’s fascinating to be watching people who ordinarily think about HIV treatment and research.

Gregg Gonsalves 

Now talking about new scaling up of mRNA vaccines or the latest data on the monoclonal antibodies or other sorts of treatments for COVID-19. We were trained in an informal way by many people like Carlos and others in infectious disease medicine and science. And we banded together, you know, 40 years later to do some very similar work. Less than sort of an antagonistic way with our medical counterparts from the early years now more or less by their sides fighting this the same battles around. […] researching for vaccines for diagnostics for treatments for COVID-19.

Dr. Bob Wachter  20:06

Yeah, it’s interesting in terms of activism in the groups, we hear a lot about the disparities around racial and ethnic groups. I’ve been hearing lately from colleagues, who are geriatricians, who say that one of the, if you think about the death, so many of them have been among older people. And as I hear that, and that’s actually right, it’s a little surprising that there’s been I haven’t seen very much activism or lobbying among groups that represent older individuals, does that struck you? And what do you think is going on there? Because you would have, you’d have thought that there’s an existing huge political force that could have come out and been very forceful, but it has not been at least to my knowledge.

Gregg Gonsalves 

You know, where is the AARP? Right? You know, there’s lots of groups that are representing seniors in this country. What’s interesting to me is that sometimes this comes down around class lines, I’m in Connecticut, pretty wealthy state, but the state with pretty wide disparities in health and income. And if you’re in Greenwich, or some of the richer communities in our state, and you’re elderly, by the vast majority of elderly people are vaccinated right now over 70%. But if you’re in Waterbury, or Bridgeport, or poor community, 30% of the elderly are vaccinated, right? And so the people who had most risk are not just the elderly, it’s the elderly who have no access to resources, or political power, and have already been living in sort of a health crisis of chronic disease and other sorts of health outcomes, which preceded the COVID-19 pandemic.

Gregg Gonsalves 

And so it’s hard to understand why we haven’t seen more opposition to what was happening last year across the board. What was interesting to me and my friend, Julia Marcus, who’s an epidemiologist at Harvard Medical School, and I’ve talked about it a little bit, it’s the Black Lives Matter movement is happening in parallel last summer, we remember all the protests. And you know, everybody remembers “Defund the Police” but nobody remembers the second part of that phrase, which was “Invest in our Communities”. And I think, in a certain way, some of the Black Lives Matter movement was really about redressing the sort of imbalance in resource allocation to communities of color across United States.

Gregg Gonsalves  22:13

You know, first and foremost around healthcare. David Satcher, the former Surgeon General, wrote a paper several years ago talking about how there’s 80,000 excess deaths among African Americans every year in the United States pre-pandemic. And so I think there’s an acknowledgment that there were two health crises going on last summer one was around police violence, but the other was sort of just the health disparities that make COVID so much, much worse in communities of color.

Dr. Bob Wachter 

Carlos, anything you want to add to that?

Dr. Carlos Del Rio 

You know, I would just say that, to me, growing up with HIV, and learning from the community and the advocates and, you know, act up and all the different organizations. I think, as a physician, I became also an activist, and I realized the importance of activism. But the great majority of physicians are very reluctant to get into political discussions, are very reluctant to get into activism. And I think, again, I’ve been during this pandemic, very active and in pushing and pushing our politicians, and I’ve had physicians in the HIV community primarily say, thank you very much for doing this. But I’ve had other physicians saying, what are you doing, you’re destroying your career.

Dr. Carlos Del Rio

So it’s, you know, it is a lot of physicians are not very comfortable in being activists. And I will say that a lot of patient populations are not being comfortable. And, you know, HIV has really also lost a voice now that is moving to a disease of poverty, and African Americans so and you know, what you have is a disenfranchised community that, quite frankly, is not, you know, used to advocate for themselves in the activism, and I agree, the Black Lives Matter was a call to do something. But we need more activism in this country, we need more people, you know, saying this is our right, this is what we need.

Dr. Carlos Del Rio 

I mean, I’m kind of surprised to not see more activism around, you know, getting vaccines to the disenfranchised communities, I would think that a lot more political activism is in this country. And if I find this is the early days of HIV, you know, I miss Larry Kramer act up and others, you know, going after Tony Fauci and going after, you know, Jim Kern, etc, etc, because, again, that is important. It is really critically important that we realize that public servants are there to serve the public and you know, we need to demand action, and we do need to demand response.

Dr. Bob Wachter  24:24

Yeah, for those who weren’t around at the time, I mean, the volume was high. The street theater was extraordinary. I remember when they lowered a huge condom over conservative congressman Jesse Helms’ house. You know, it was I helped put together the International AIDS Conference that was in San Francisco in 1990, and wrote a book about it, in part because what had begun as a classic scientific conference became part political convention, part street theater protests, I was actually in charge of letting the police who were on horseback underneath the Moscone Center in San Francisco know whether they should come out and break up the riot. Which we thought might occur during the conference, and it was uncomfortable.

Dr. Carlos Del Rio 

Again, but that’s also I mean, I, you talked about the International AIDS Conference, I tell everybody, whether you’re a basic science researcher, you need to go to at least one International AIDS Conference, because it is not just a scientific conference, it really is a convention. Yeah. And it really is where you can get, you know, you’re presenting your poster at the same time that the sex workers are protesting for the rights, and this happens, and that happens. And again, it was Durban 2000, where, you know, this call to Antiretroviral therapy access is globally happen.

Dr. Carlos Del Rio 

And as a result of that, you know, I think we should be very proud that an HIV is the only disease where the burden of disease and where the therapy is actually matches. No other disease has that. And now we’re having discussions, Gregg, myself and others about how do we do that now for vaccines, right? We need to be sure that, that we don’t have this apartheid around vaccines in which vaccines go to the rich and not to the poor, we need everybody to have access, just like we did in HIV.

Dr. Bob Wachter  26:01

We talked already about the AIDS activists to some extent piggybacked on the nascent gay rights movement. The other thing that was different, it strikes me between COVID and HIV AIDS was, if you were diagnosed with AIDS, you are going to be dead in a year, maybe 18 months at the outset. Whereas COVID is much more probabilistic. You know, you might do badly, and there’s a chance and obviously, depending on your risk group that influences that, but decent chance you’re going to do okay, how much do you think that influenced things? Because if people didn’t live through that error is almost hard to imagine, for Carlos and I taking care of patients in the hospital, you would see a 22-year-old man come in, and you knew for sure he would not live to see 24 with a 100% certainty. What do you think, Carlos? How important was the fatality piece of it?

Dr. Carlos Del Rio 

I mean, the fatality piece was just huge. I mean, I just, you know, sometimes just cried about seeing so many of our people that actually, you know, later on, you know, became my patients and became my friends. And I saw them over a long period of time, because it wasn’t immediate, that they died, you know, you frequently took care of them for a long period of time, and you would lose them because there was not much to offer them. You know, AZT didn’t appear until much later. And quite frankly, AZT wasn’t very good. I mean, you know, it was pretty crappy medication. It was really until 1996, that we had really effective antiretroviral therapy before then we were just not really being able to do much.

Dr. Bob Wachter 

Let me put a punctuation mark on that, that the first cases of aids were reported in 82′-83′. And it was not until 1996, that we had anything to offer other than treatments to prevent some of the infections, but to actually fundamentally attack the disease. So 14-15 years later.

Dr. Carlos Del Rio 

So for many of us, I mean, it was really hard to practice it was it was very emotionally consuming, and really very hard. You really had to have, you know, a mission, you really had to understand what you were doing, you really had to had a lot of hope. And I think research helped a lot of us realize that, you know, there was discovery and there was making progress. COVID puts that on steroids, right? Really quickly. And it has happened so quickly. But the reality is that what you’re saying is absolutely true. The great majority of people with COVID don’t die.

Dr. Carlos Del Rio  28:17

But it also I still think it’s a little bit like a Russian roulette. You know, when you get when somebody gets infected, you don’t know you’re going to be that 10% that’s going to die. And you know, I get calls over and over people said, you know, my 30-year-old, you know, son, who has diabetes just got diagnosed with COVID. And should he do this? And now he’s got a fever, and do we give antibody? Do we do this? Do we do that? And maybe the person is going to do okay, but you also have that sense that if they don’t they start getting worse at some point in time, there’s really not a lot we can do.

Dr. Carlos Del Rio 

And the course can be who gets a cytokine storm and who doesn’t who ends up dying? It’s still pretty much I mean, we have some risk factors, but a lot of it could still be, you know, unknown. So I think that there’s a sense of, of anxiety still being diagnosed today, quite frankly, even now, if you happen to be over the age of 60. I think the anxiety goes up significantly, you know, the older you get, the worse it is.

Dr. Bob Wachter 

Greg, let’s talk a little bit more about politics for a second. So, you mentioned that Reagan did not utter the word AIDS in a speech till 6-7 years into the epidemic. And obviously, we lived through the Trump administration’s response last year. What were the parallels and what were the differences between these botched federal responses?

Gregg Gonsalves 

I think the Reagan restrictions operating in sort of negligence, right? I think like they didn’t give a damn about us. And it was sort of ignore the AIDS epidemic. While you know, a Democratic Congress was starting to institute important programs for HIV while the NIH research program was getting built up in the 1980s, so there was sort of real progress to be made despite what was happening in the White House. Now, over the past year, it’s been sort of, it’s not negligent, it’s actually it was a sort of malignant, deliberate set of policies that were destined to make the epidemic worse.

Gregg Gonsalves  30:20

As President Trump said in the interviews that he did with Bob Woodward in 2020, he knew this was a catastrophe. And he decided to play it down. You know, essentially, we’re talking about activism. But, you know, the scientific community, the public health community, clinicians, researchers, even bench scientists, along with activists had to sort of fight the White House, not to do the right thing, but to stop doing the bad things all last year. And Carlos and I were writing op eds, back and forth. The mobilization of the scientific community in clinical community last year was extraordinary. I mean, you know, Akiko Hirosaki, who’s an immunologist here at Yale, speaking out directly as a bench scientist, Carlos and the rest of his clinical colleagues doing the same.

Gregg Gonsalves 

But mathematical […] like Marc Lipsitch at Harvard and others really basically saying, I’m going to walk into the public domain and do something that I’ve never done before in my life. And, you know, and it wasn’t just the sort of old established researchers and clinicians, it was young people. You know, Julia Marcus, as I said, at Harvard, talking about how we think about risk in the context of COVID, really filling the gap, in a way which I hate to talk about silver linings of the pandemic. But I couldn’t be more proud to be a public health researcher, to be, you know, colleagues, with people like Carlos and Rochelle Walensky who before becoming a CDC director, you know, it’s on the front lines, talking about what needed to be done about COVID.

Gregg Gonsalves 

And so what’s interesting to see is that the politics might have been street theater, and you know, the disposable people that Larry Kramer talks about in the 1980s. But it was a huge coalition of people that push back against the Trump administration last year, which I think is the unwritten story of the pandemic thus far, because it could have been a whole lot worse without people who basically sort of put their careers on hold, put their work on hold, and pivoted to COVID in their research lies in their clinical lives, but also in their sort of day-to-day interaction to the media, with politicians, etc.

Dr. Bob Wachter  32:16

Carlos, maybe take that run with it in terms of what we’ve learned in the scientific world from COVID and differences, do you think between now between AUDS and COVID, I’m struck that we still don’t have a vaccine for HIV, I don’t know if that’s, it’s probably not for lack of trying. I mean there’s some fundamental differences in the viruses too. But what do you think the big differences in the scientific response now versus 30-40 years ago were?

Dr. Carlos Del Rio 

Well, you know, I think there’s some similarities and some differences. I think, you know, the drug discovery process in HIV initially started looking at drugs individually. And it was really a moment of brilliance with people […] said, you know, maybe we need to put drugs together and make combinations and look at how you create synergy, which is something that in virology nobody had thought about doing was that was not something that was part of our virology. And yet, that’s how we got to combination antiretroviral therapy. In viral treatment for COVID we are in an infancy, right? We still have very little to offer antiviral wise.

Dr. Carlos Del Rio 

And maybe when you start thinking about HIV, how do you combine antivirals? How do you put them together in a different way, we don’t have anything oral really that we can use as an antiviral. The monoclonal antibody story I think it’s interesting because a lot of the work in HIV around developing a monoclonal is and monoclonal is for prevention and other things broadly neutralizing antibodies has clearly opened the field  and in COVID now we are using a monoclonal therapy for both treatment and prevention.

Dr. Carlos Del Rio 

And then, you know, let’s not forget about the HIV, the quest for an HIV vaccine yesterday at his Croix plenary, after Gregg spoke, Tony Fauci told us how, you know, the NIH, the VRC, the vaccine research center, was put there to develop an HIV vaccine, yet they started working in other vaccines, and they have been critical in advancing the COVID vaccine.

Dr. Carlos Del Rio  34:01

So again, goes to this whole issue that, you know, the research in one area, it’s actually benefiting out of the areas and the research doesn’t necessarily stay within its field. I mean, research spills into other areas, in ways that I mean, nobody would have predicted oh, when we build the, when we started working in HIV vaccines, is because we’re going to get a COVID vaccine. But that’s has been the story. You know, the knowledge there has allowed us. I mean, you know, the platforms that we develop for HIV, for example, you know, the viral load platforms that exists globally, that we use for monitoring our patients were critically important in doing COVID tests.

Dr. Carlos Del Rio 

And if we hadn’t had that infrastructure of PCR machines around our hospitals or clinics around the world, we would have not been able to do the COVID testing that we’re able to do. So it’s sort of interesting to see those synergies that occurred within diseases and those things that that nobody would have predicted initially, right?

Dr. Bob Wachter 

And can you in lay language tell people why we were able to discover a COVID vaccine in 10 months and 40 years later, we still don’t have one for HIV AIDS?

Dr. Carlos Del Rio 

Well, I think first of all, let’s put it this way, it’s an easier virus. I mean, I in COVID, we know that people, as you said before, recover, so it’s not uniformly fatal. In HIV, we don’t even know what an effective response to HIV is, right? We don’t know what protects you from HIV, we’re looking for that. But if you take antiretroviral drugs that are used for prevention, we just completed study, the AMP study giving monoclonal antibody for prevention and trying to figure out if we can come up with some sort of mechanism that prevents the transmission, but all the vaccine studies done up to now have failed and they have failed primarily. Because, you know, the virus escapes and HIV escapes and the immune system, the virus plays this trick of escaping the immune system almost constantly.

Dr. Carlos Del Rio 

So the immune system has not been able to control HIV, except in very, very few lucky individuals that are […] controllers, which are a very small percentage of people with HIV. In COVID, as you said, people have recovered. So it’s pretty easy to say, Well, those that recovered develop antibodies against this protein, which was a spike protein. And then you know, genetic, […] biology allowed us to, within, you know, days of discovering the virus, sequence that protein, and then it was a matter of how do we get that protein into the immune system. And then different platforms were used, the mRNA technology had been researched for years to try to deliver other vaccines.

Dr. Carlos Del Rio  36:18

So it was a matter of getting the genetic material inside an mRNA. And then delivering that and then doing the clinical trials, which by the way, were done within the HIV clinical trials infrastructure, the HIV vaccine trials network was one of the leads in developing the vaccine, and many of us working in HIV vaccine. So all of a sudden, clinical trials have suddenly shifted to doing COVID vaccine clinical trials. So I think it was a much easier virus to look at a lot of resources thrown to it. But also, I would say, an incredible, you know, private public partnership.

Dr. Carlos Del Rio 

And I would say of all, you know, a lot of mistakes. If we can enumerate 1000 mistakes. So the Trump administration, in response to this pandemic, I would say that putting together operation Warp Speed, bringing the different companies funding that, the way it was done. I think it was a Manhattan kind of project to get an COVID vaccine, and it worked. And I’m very pleased that,  that actually led to a successful vaccine or multiple successful vaccines.

Dr. Bob Wachter 

Yeah. Maybe the last few questions, We’re now entering a phase where we’re going to have to figure out what normal is. And when we say it’s now back to normal, or is it normal-ish? And what does that mean? Are there any lessons from the experience with HIV AIDS that help inform that? Obviously, it still is there, but the life of someone from an at-risk community is very different now than it would have been in the mid-80s. So, Gregg, what are the lessons that we can take from AIDS that may be relevant to the move toward normal and COVID?

Gregg Gonsalves 

Well, it’s interesting. You know, what was normal? For the three of us on this discussion right now is not normal for a lot of people around the world, the New York Times did a piece called America’s Hidden Epidemic, it was like five or six years ago, what was it about? It’s about HIV. It’s about HIV among African-American young men in the south. And, you know, you didn’t have to look very far to find that hidden epidemic. And the point is, is that I think the lesson from AIDS is, is that you either fix the underlying conditions that gave rise to HIV and allowed it to perpetuate and now, you know, making Carlos’ neck of the woods, some of the most highly affected areas of, of the country, with rates, rivaling you know, some in Sub Saharan African some of the counties in the south.

Gregg Gonsalves  38:33

Unless we deal with the underlying sort of structural features of our public health and healthcare systems that sort of let HIV perpetuate itself. Even in this country, even the concept of highly active antiretroviral therapy, we’re not going to deal with the sort of aftermath of COVID in any way that prepares us for the next pandemic, you know, 3% of our health budget goes to public health in this country, right? 3%. We lost 60,000 public health frontline workers after the Great Recession in 2008. They never came back. The American public health, the Public Health Schools Association says we need a quarter of a million people to staff public health around the country pre pandemic.

Gregg Gonsalves 

And so there’s a whole sort of chaotic public health sector that’s been grossly under invested in over the past 40 years, we still have a patchwork of a health care system. And we don’t have a social safety net that is able to catch people when they fall. Everybody who works in AIDS knows that treatment is one part of keeping people healthy, they have to have what we call the enabling environment to sort of protect them, to keep them in care to get them linked to care to get successful viral suppression. Betsy Bradley, who’s now the president of Vassar was a public health professor her deal for a long time and wrote a book called The American Healthcare Paradox. And she said, let’s look at other countries around the world who have better life expectancy than we do. What is the difference there?

Gregg Gonsalves

And it wasn’t our health care spending, it’s about the social safety net and the social determinants of health that keep people from getting sick in the first place, and support them when they’re ill. And so those are the lessons we need to learn that health is not just a pill antibodies, and that the fundamental nature of health is social economic and political. And, you know, infectious disease may always be with us, but epidemics are human creations. And I think that’s where the lesson of HIV for me and I think, you know, you start with Ebola you saw it with COVID-19. And it’ll be the same for the next pandemic.

Dr. Carlos Del Rio  40:19

So I would just add to that, you know, early years of HIV, it was primarily gay, white, middle class men got this disease. And I remember having a discussion one day with Jim Curran and saying, what do you think is going to be the future of this disease, and Jim said, like any other STD is going to move into the minority populations into the poor? Well, COVID has happened the same way except that in steroids, right, and speed, the first persons with COVID were travelers were who are people who could afford to go to Europe and here and there, but then it rapidly like a nanoseconds moved into the most vulnerable populations. And I think if this teaches us something, is that epidemics move into the vulnerable populations.

Dr. Carlos Del Rio 

And as Gregg said, if we don’t deal with that, if we don’t deal with structural racism and with social vulnerabilities, then, you know, that’s the same population impacted by diabetes, by hypertension, by stroke. And we have to deal with once and for all, I hope that our society, the way to get out of COVID is by you know, there was a viewpoint in JAMA by Williams, talking about a new kind of herd immunity, and a new kind of herd immunity should be that we provide the social equity that allows people to have safe jobs, good housing, safe food, and other things that will decrease the vulnerability to multiple diseases, not just to COVID not just to HIV, but to many other illnesses that right now.

Dr. Carlos Del Rio 

You know, we’d rather pay for dialysis in somebody with diabetes and paying for them to have you know, access to healthy food for To start with, and then we need to decide what we’re going to do. And I hope that the end of COVID is a better look at our society, equity is not just health equity, it is beyond health. And because health is much more than pills and medicines that Gregg said.

Dr. Bob Wachter  42:04

Absolutely. It’s incredibly important point. Let me end with just asking you to reflect on the losses and the number of people that have passed from this, the numbers get so big that it can be a little bit numbing. Are there lessons from what you experienced with HIV AIDS that have helped you process the number of people have died of COVID, and sort of more in the losses and keep the losses front of mind, while you’re dealing with numbers and data and curves, and all those sorts of things?

Gregg Gonsalves

I think we have to be wary of PTSD. I’m serious that the people that live to the AIDS epidemic. And if you’re in your 20s and 30s, you don’t, unless you fought in the war, you don’t see your friends die week after week around you. And I think you know, it probably more even acute for health workers during the COVID pandemic, you know, the sheer level of death that you saw, and the idea that you can sort of put it behind you and to integrate it and move on is probably not feasible, and that this psychological toll on all of us, but particularly people who are on the frontlines, not just in the healthcare professions, but in the professions that were devastated by this warehouse workers, plant workers, grocery store workers, others.

Gregg Gonsalves 

It’s going to be with us for a long time to come. And so, yes, we can grieve, but we have to realize that there’s going to be a huge amount of psychological damage and mental health consequences of this pandemic that are going to outlast it long after the virus is suppressed around the world.

Dr. Bob Wachter 

Carlos, can you reflect on that and rub it in with us?

Dr. Carlos Del Rio 

No, I couldn’t agree with Gregg more. I mean, I think that all for all of us. It’s the loss. And it’s the loss of friends of colleagues. You know, I think about colleagues who work in in HIV that we’ve lost this this past year, you know, David Katzenstein, and you know, James Hakim, you know, Geeta Shamji, I mean, so many people that we’ve lost unnecessarily, to COVID. And I just think about, you know, how hard it is to, even now when I’m in the hospital, and I see somebody and then, you know, the next day I’m rounding a team says, we’ll Ms. such such died yesterday. And you know, it’s a 60-year-old person that I remember the last time I talked to him to his family, and many of them, you know, did not speak English, they were Spanish speaking.

Dr. Carlos Del Rio  44:15

And I was the only one that communicated with the family, it’s just incredibly hard, I would say that I’m very concerned that at the end of this, there are going to be many people that are going to, you know, hang the coat  and say, I’m done. You know, I’ve had enough of doing what I’m doing. And it’s been exhausting. And I think it’s been, you know, I mean, right now, I think many of us are still going on adrenaline, but at some point in time, the epidemic is going to be over and you know, our glands are going to be, it’s not gonna be more adrenaline to keep us going. We’re gonna need a major, you know, recovery time. Personally, right now, my time of solace is listening to music and I try to listen to music as much as I can. And classical music for me has been a, it’s something very special that I do and therefore allows me to have some sort of relaxation.

Dr. Carlos Del Rio 

But it’s really important that we do not forget that at some point in time, a lot of people are going to be very, very, very hurt by this. And I think about our residents. I mean, I’m finishing my career, but people are starting, this has been particularly hard for our house staff and for our students. And it’s going to be really difficult for them to process this as they go through their career. For those of us in HIV. I mean, we talked about the early years and all the loss, but at the same time, I was lucky enough to see, you know, successful antiretroviral therapy, the miracle of people living in that I think was the healing of HIV, hopefully, the vaccine and other things would be part of the healing of this pandemic. Because for the good of everybody, I think we want to say, you know, we want to see this end at some point in time soon.

Dr. Bob Wachter 

That’s for sure. Thank you both. That was terrific and instructive. And it definitely brings back a flood of memories for me, most of them not happy but gratifying in a way, because I think we were doing something important. And we learned a ton. And as you pointed out, some of those lessons, I think, are quite relevant to COVID. And I hadn’t really thought through the vaccine thing in this depth, but clearly, with all the work on HIV has accelerated some of the scientific advances we made for COVID. So it saved a lot of lives that way. Thanks very much. And thanks for all the great work you’ve done for the last year.

Dr. Carlos Del Rio  46:18

Good talking.

Gregg Gonsalves 

Thanks, Bob.

Dr. Bob Wachter 

That was Finlandia from John Sibelius. Carlos says it’s a piece he’s enjoying listening to a lot these days. Well, for me, that was absolutely fascinating, in part because I lived through it, and it brings back a lot of memories, some of which I’ve airbrushed, I think they I remember the incredibly interesting parts, the really scary parts, and the tragic parts are still in there. But I have to say after 40 years, some of the rawness and the pain has gone down. So I’m not sure that’s a good thing. But time heals, as they say, it was a crazy time. And it was a scary time. And seeing that many young people come in and come in that sick that scared and, and all didn’t die. I mean, you could be sure they were all going to be dead within 18 months, is really something.

Dr. Bob Wachter 

As I tell some of our residents now, though, there are tremendous life lessons that one learns in training in that kind of environment. And I think about some of the people that I trained with and how their careers were markedly influenced by their experience and our experience, taking care of HIV and AIDS patients and thinking about the science and thinking about the policy. You’ve heard from some of them on this podcast, Julie Gerberding who went on to become head of the CDC, and Steve Hahn, who went on to become head of the FDA, and several others were people that trained with me during that era. And we’re our lives and our careers were clearly shaped by living through that crucible.

Dr. Bob Wachter  48:11

So thank you to Gregg Gonsalves and Carlos Del Rio for reliving those days with us and drawing some really interesting and I think useful lessons from air experience back then and what we’re all going through now. We have a number of other terrific shows coming up on IN THE BUBBLE. We have our capelin artists, one of the most interesting people I’ve met in my career in medicine, he is an ethicist in terms of his card-carrying credentials, but he’s also just a fascinating person who has opinions, smart, interesting, engaging opinions on everything complex and controversial in medicine. And as I’ve been saying, for several months, I think the issue of immunity or vaccination passports, or authentication will be the most interesting issue of the summer.

Dr. Bob Wachter 

Part of what I do for a living is train medical students and residents in medicine. And the transition from layperson to doctor is always fascinating. But it’s been particularly fascinating over the past year, as students and residents and fellows have had their trading transformed by the experience and taking care of patients with COVID or by COVID, disrupting their training and all sorts of ways. I already mentioned that happened to me during my training with HIV and AIDS and it’s happening to a new generation of students and other trainees now, for this one, I decided to go local and in one case very local, chose a medical student who has lived through the disruption of the past year and the medical student is on the line who happens to be my daughter.

Dr. Bob Wachter 

Chose a resident at UCSF who has both had his training disrupted and also taking care of many COVID patients. That’s Jack Penner, who’s a very thoughtful and articulate person. He’ll describe the experience of residents. And then Katherine Lucy, who is our Executive Vice Dean and the Dean for our medical education programs here at UCSF and a national leader in medical education will talk about the impact on trainees and also what it means for the future of medicine. And a lot of people are still struggling with issues about the kids. It might be getting them back into school, it might be dealing with camp, it might be, I’m vaccinated the kids are not, what do we do on an airplane? There are about 100 versions of what do we do with the kids. And we will cover that in another special episode of IN THE BUBBLE. And so a lot of great stuff coming up in the next several weeks. hope you’ll join us and until then stay safe.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

 

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