Page 1

FA L L / W I N T E R 2 0 1 9

Caring for People with HIV


FALL/WINTER 2019

HIV & AIDS

8 13 14 19 20

Staying Positive Two longtime HIV+ patients share their stories

Alumni in the Field Shireesha Dhanireddy

A Call to Compassion Early years of AIDS at Georgetown

Alumni in the Field Craig Hendrix

Women and HIV Leading the way with WIHS

24 25 26 30 33

Alumni in the Field Eric Daar

Resilience, and Remembrance Faculty Point of View

Global HIV Response Reprioritizing the local

HIV Education Hands-on learning at Georgetown

Alumni in the Field Robert Redfield


8

30

20 2 3 34 39 40

From the Editor Check Up News & Research

On Campus Alumni Connections Reflections on Medicine

From the Archives: Georgetown demonstrates a new tank respirator in the hospital lobby during National Hospital Day in 1952. Known as the iron lung, the ventilating machine allowed people with polio to breathe if muscles around the lungs became paralyzed. Many patients spent months or years immobilized in the apparatus.


A publication for alumni and friends of the schools and programs of Georgetown University Medical Center

Editor Jane Varner Malhotra

Contributing Staff

The Long Walk Georgetown is a community. It exists as a place, but also in time, and is shaped by the world around it as well as by those who study and teach here, who cook and clean here, who care for the dying and catch the newborn babes here. Although the campus has some walls and gates, the Georgetown ethos seeps out into surrounding neighborhoods and beyond, touching this beautiful city, rowing its rivers, walking its alleys. I live near American University a few miles away, and set out early one morning for a short walk. I fell into step with a woman who was out for a longer walk, and we began talking. It turns out she had retired from a long nursing career at Georgetown Hospital, where she worked in clinical trials for HIV and AIDS. She shared a painful chapter of our university’s history with me. It was the first I’d heard of the Thursday Night Clinic—an effort to care for the people dying of AIDS, despite pressure from some hospital leaders to keep those patients out, or at least out of view. She told me how at first the patients were young gay men, and their numbers grew quickly. Next came people who used intravenous drugs. Then in poured the sex workers. All God’s children, broken, dying, alone. So many that it became a day-long clinic, she said, shaking her head, and the stigma was pervasive. My teenage children can’t comprehend the social transformation we have undergone since those years. When they witness vestiges of it today—hatred and bigotry towards the LGBTQ community—they are shocked and angry. And that gives me hope for a continuing bend in the justice arc as future generations embrace openheartedness and inclusivity. Accompanying people with HIV offers a way to embody the true values Georgetown aims toward: reaching out to care for the marginalized, developing science and technology in health and medicine to support these efforts, and living generously in service to others. Today we have people aging with HIV, and the first glimmers of what seemed at one time unimaginable: a possible path to a cure. Our faculty, students, patients, and alumni are working around the world and around the corner to help stop the spread of the disease, to care compassionately for those who carry it, and to research and design the most effective treatments of tomorrow. In the end, what emerged powerfully from the walk with the retired nurse was her pride in those stalwart people at Georgetown who champion the suffering, who touch and care for people who may be abandoned by their own family, church, workplace, society. A few of these many leaders of conscience—who sometimes work quietly behind the scenes—can be found on the pages of this magazine. It is our privilege to share a slice of these stories. Jane Varner Malhotra Editor

2

G EO RGE TOW N MEDIC INE

Molly Benedict Chelsea Burwell (G’16) Kate Colwell Jupiter El-Asmar (F’17) Allan Hutchison-Maxwell (G’14) Patti North Camille Scarborough Karen Teber

Design Director Robin Lazarus-Berlin Lazarus Design

University Photographers Phil Humnicky Paul Jones

Executive Vice President for Health Sciences and Executive Dean Edward B. Healton, MD, MPH

Dean for Medical Education Stephen Ray Mitchell (W’86), MD, MBA

Georgetown Medicine is published by the Georgetown University Office of Advancement Communications. Visit the magazine online at https://alumni.georgetown.edu/medicinemagazine. The magazine welcomes inquiries, opinions, and comments from its readers. Address correspondence to georgetownmedicinemagazine@georgetown.edu or: Jane Varner Malhotra, Editor Georgetown Medicine Office of Advancement P.O. Box 571253 Washington, DC 20057-1253 For address changes contact alumni records addup@georgetown.edu or 202-687-1994. For up-to-date information on Georgetown events and alumni news on campus and around the world, visit Georgetown Alumni Online: alumni.georgetown.edu. © 2019 Georgetown University

Cover illustration: Stephanie Dalton Cowan


C H E CK U P

NEWS & RESEARCH

Top: Adobe Stock

A Cup of Medicine n n Fung-Lung Chung can’t wait to find out if his mother’s belief in the healthpromoting properties of the hot green tea she served after meals will be scientifically validated by a new Georgetown clinical trial. Green tea contains catechins, a group of flavonoids that possess antioxidant properties. Chung and other Georgetown researchers have found evidence that catechins can stop the spread and even the development of liver cancer, which is on the rise worldwide. Chung, PhD, a Georgetown University basic science research and oncology professor, studies the impact of catechins in preventing DNA damage in liver tissue using a catechin-containing extract called Theaphenon E (TE). Aiwu Ruth He, MD, PhD, oncologist and associate professor at Georgetown Lombardi Comprehensive Cancer Center, is leading a clinical trial based on findings from Chung’s research. She is enrolling people with liver cirrhosis (or inflammation and scarring), who are at

substantial risk of developing tumors. Every year, 3 to 5 percent of cirrhotic patients develop liver cancer. “There is no way now to prevent liver cancer from developing in patients with or without cirrhosis. This is a huge unmet need,” He says. “And to think that a possible preventive compound is not a drug, but a natural compound in a much-beloved tea is fantastic.” Chung’s lab found a biomarker, γ-OHPdG, a type of DNA damage in liver tissue that appears to predict prognosis of liver cancer. Chung and his team, with He, showed that higher levels of γ-OHPdG were strongly linked to shorter survival and low recurrence-free survival. The investigators then found that administering TE to mice suppressed the levels of γ-OHPdG in livers. It also reduced or blocked liver cancer development by more than 80 percent to 100 percent. Chung and He were invited to present the findings to the National Cancer Institute’s Division of Cancer Prevention in

2017. The findings were also published last year in the journal Hepatology. The two researchers sought federal funding for a clinical trial aimed at preventing recurrence in patients who had their cancer surgically removed. The National Cancer Institute (NCI) chose a more ambitious approach, instead funding a study to test whether green tea could stop liver cancer from ever developing in patients with cirrhosis. He’s new NCIfunded trial is being conducted with Georgetown Lombardi’s clinical partners, MedStar Georgetown University Hospital and MedStar Washington Hospital Center, and at the University of Puerto Rico. Phase I of the study is designed to confirm the extract’s safety and to identify the best dose. The study will also assess if taking the green extract capsules can decrease the levels of γ-OHPdG in the livers of enrolled patients. n

The Healing Power of Communication Journalist Katie Couric and John Marshall, MD, director of Georgetown Lombardi’s Ruesch Center for the Cure of Gastrointestinal Cancer, discuss the importance of communication among doctors, patients, and caregivers during the inaugural Edward M. Kovach Cura Personalis Endowed Lecture at Georgetown in August. “It makes a huge difference for patients and their families to have caring, compassionate doctors,” Couric said.

FA L L / W I N T E R 2 0 1 9

3


C H E CK U P

Partnering for Health in Almost Heaven about healthy decisionmaking and substance abuse prevention. Angela Brown, Clay County Health Department nurse practitioner, welcomed the help from Georgetown students during the health fair. “We wouldn’t have been able to draw blood for 82 people, measure height and weight, and counsel them,” she says. People in the region are slow to trust newcomers and accept help, Wilkinson says, so “our goal is to slowly build a relationship and increase our footprint in the neighborhood.” In previous years, the students educated home health aides on how to help their patients. This year, the county health department connected them with two families to visit and bring some healthy food. In one home, a woman who cares for her grandchildren explored how to modify the foods she likes to eat to keep her diabetes in check. “She said this was the first

When record-breaking floods brought hardship to her West Virginia hometown in 2016, a Georgetown professor responded by establishing an ongoing education partnership between the School of Nursing & Health Studies and Clay County.

time someone talked with her about what she liked to eat and helped her talk about recipes, instead of telling her what not to eat,” Wilkinson says. The group also met with county health officials, the mayor, and local business leaders to discuss the economic and health challenges their town faces. Clay County has almost 11 percent unemployment, more than twice the national rate, and 23 percent of its residents’ incomes are below the poverty rate. The county also has one of the highest opioid addiction rates in the country, which has contributed to more than half of the county’s children being in foster care. The impact of the immersive education experience is transformative.

“The students are often overwhelmed by the needs of the community. They may see health disparities they have never seen in their own community, and it shapes their view on health care,” Wilkinson says. “I had one student who said she wanted to do concierge medicine, but when we were sitting in this rural community, she began to cry and said, ‘I can no longer do what I thought I wanted to do.’” Seeing the students grow and being able to give back to her home state has made the trips “my favorite part of my faculty role,” she says. “The trip is physically tiring with very long days, but it’s rewarding to watch students explore their perceptions and watch those perceptions change in real time.” n

What’s Fueling Pancreatic Cancer? “To effectively control tumor growth, you have to know the molecular network that drives that growth. This study takes a good look under the hood, and gives us the key drivers that could be targeted to shut that engine down.” — Chunling Yi, PhD, associate professor of oncology at Georgetown Lombardi Comprehensive Cancer Center, and senior investigator in a study decoding a chain of molecules that are critical for the growth and survival of pancreatic ductal adenocarcinoma—the most common and most lethal form of pancreatic cancer.

4

G EO RGE TOW N MEDIC INE

Bottom: Nathan Krah, University of Utah / Top: Associated Press

n n An ongoing collaboration with a community in West Virginia has provided students in Georgetown’s online master’s degree program in nursing with insight into rural health challenges. After a devastating thousand-year flood in her home state in 2016, Melody Wilkinson, DNP, professor and director of the Family Nurse Practitioner Program at the School of Nursing & Health Studies, began bringing graduate students there to help and learn from residents of Clay, West Virginia, a former coal mining town. The partnership continues to grow. Wilkinson returned this year with a group of nine graduate students who had prepared for six weeks before the trip, creating health promotion projects and learning about the needs there. At the end of April they spent three days in Clay, where they worked at a health fair, picked up trash, painted a building, and spoke to school students


Research and Education: Synergy in Community n n Since its launch eight years ago, the annual MedStar Health-Georgetown University Research Symposium brings together researchers, residents, academics, and collaborative partners from across the region to showcase work throughout the two entities. This year’s one-day conference was attended by more than 1,000 participants and featured over 400 presentations. Academic research submissions varied from clinical to translational and from epidemiological to health services, revealing the wide range of work being conducted across the GeorgetownMedStar community. The program grew out of a mash-up of two separate but related offerings several years ago, one from the Center for Innovation and Leadership in Education (CENTILE) based at the university’s Medical Center, and one from MedStar Health. “By bringing the CENTILE-sponsored Colloquium for GUMC Educators in the Health Professions to the same day and venue as the MedStar Health Research Symposium, we created a unique opportunity to seamlessly link reports on

innovations in education in the morning with an afternoon of presentations on new discoveries in research,” said Aviad Haramati, PhD, director of CENTILE and professor of integrative physiology at Georgetown. “What emerged was a synergistic experience, which also resulted in more participants being exposed to both programs.” The event reflects the Georgetown mission of caring for not only for the whole person but also for the whole community. Neil Weissman, MD, School of Medicine professor and chief scientific officer for MedStar Health, acknowledged the challenge and the opportunity this presents in Washington, D.C., which has some of the worst health statistics in America. Convening can help make a difference, says Weissman. “That’s what the research symposium does. It helps bring people together. It shares information. It makes us feel and then act as one community.” n

Cons of Probiotic Labels

Bottom: iStock / Top: Bigstock/elenabsl

n n

Shopping for a good probiotic? Reading the labels may not provide enough information to weigh the options, according to a research team led by Georgetown University Medical Center. In their study, published in the Journal of General Internal Medicine, investigators found that just one of three bottles was labeled with enough information to link the product to medical efficacy as supported by clinical evidence. To get a thumbs up from the Georgetown researchers, the labels had to name the strain of bacteria or yeast

designations, and the product had to contain enough to be a beneficial dose. Also, at least one controlled human study supporting use of the probiotic had to be listed on PubMed, a web-based search engine for biomedicine and health studies. The good news? “It may be counterintuitive to consumers, but we found that products with fewer strains and lower cost were more likely to be supported by evidence we could trace,” says the study’s senior investigator, Dan Merenstein, MD, professor of family medicine. Of the 33 bottles linked to

evidence that the probiotics inside were clinically beneficial, none had any mention of those studies on the label. “I think it’s a lot to expect consumers to check the evidence, but trustworthy guides can help them find products backed by evidence,” Merenstein says. “Companies could greatly help this process by labeling products with strain designations, dose at expiration, and proper indication of usage.” n

FA L L / W I N T E R 2 0 1 9

5


C H E CK U P

Priming Cells for Better Cancer Treatment n n New research has uncovered a mechanism thought to explain why some cancers don’t respond to a widely used form of immunotherapy called “checkpoint inhibitors” or anti-PD-1. In addition, the scientists say they have found a way to fix the problem, paving a way to expand the number of patients who may benefit from the treatment. Immunotherapy, which enables the body’s own immune system to attack cancer, has not yet met the promise it holds. While it has been a major advance in the treatment of cancer, up to 85 percent of patients whose cancer is treated with checkpoint inhibitors don’t benefit, according to estimates. In a new study published online in Nature Immunology, a research team led by Samir N. Khleif, MD, director of the

Tony and Jeannie Loop Immuno-Oncology Laboratory at Georgetown Lombardi Comprehensive Cancer Center, shows that the condition of immune cells (T cells) prior to anti-PD-1 therapy is a crucial determinant for the ability of cancer to respond. “If the immune cells are not in the appropriately activated state, treatment with anti-PD-1 drives these T cells into a dysfunctional, nonreprogrammable state, inducing resistance to further immune therapy,” Khleif explains. In order to prevent the immune system from attacking normal cells, the body has a way of protecting these cells. Cancer cells often adopt this system of checkpoints in order to put the brakes on immune surveillance so they can continue growing. Checkpoint

inhibitors release those brakes. New drugs function as antibodies, removing protection so that T cells can recognize and attack tumors. Khleif says researchers already know the tumors that respond more readily to checkpoint inhibitors are those that have already engaged the immune system, such as melanoma and cancers that express many mutations. The question is why the agents don’t work on immunologically “quiet” tumors. The team also found a strategy to overcome resistance to immunotherapy. “When we first activate T cells by using a simple vaccine, or remove the dysfunctional T cells, we found that the checkpoint inhibitor

therapy works better,” says Khleif. The animal model and patient tumor sample findings are being developed for clinical trials in patients. Cancer vaccines based on a patient’s specific tumor are also being explored as a way to prime the tumors for treatment. “In the past, some of these vaccines have been used after checkpoint immunotherapy. Our findings suggest that the vaccines should be used first, or at least in conjunction with anti-PD-1 therapy,” says Khleif. n

“While the amount of money awarded in the Oklahoma case is significant, what is most important going forward is that the proceeds from the litigation be spent building the type of health care system necessary to prevent, treat, and sustain recovery for those with substance use disorder.” — Regina LaBelle, JD (L’92), program director for the Addiction and Public Policy Initiative at Georgetown’s O’Neill Institute for National and Global Health Law, responding to the August settlement against Johnson&Johnson in Healio Primary Care

6

G EO RGE TOW N MEDIC INE

Bottom: Dan Bejar / Top: iStock

Justice and the Opioid Epidemic


Shining a Light on Drug Industry Influence n n

Bottom: NoDerivs 2.0 Generic (CC BY-ND 2.0)

As the impact of the opioid crisis continues to unfold, Georgetown convened health professionals in June for a hard look at what is happening now and what can we do better going forward, as a country and increasingly as a global community. Opioids: Conflicts and Controversies brought together 200 physicians, nurses, pharmacists, social scientists, lawyers, students, and a few state attorneys general for the conference offered by Georgetown’s PharmedOut project. The event was led by Adriane Fugh-Berman, MD (M’88), professor of pharmacology and physiology at Georgetown University Medical Center. She launched PharmedOut in 2007 as an education and research effort to help shed light on pharmaceutical industry marketing practices and foster evidence-based, cost-effective prescribing. What is one thing Georgetown alumni should know about the opioid crisis? “A key part of the tragedy of the opioid epidemic is that physicians participated unwittingly in creating it,” says Fugh-Berman. “It was started by industry, but doctors weren’t suspicious enough about the reframing of pain, so we became the agents of industry in creating this epidemic. It is our obligation to help stop it, not only in the U.S. but also to prevent the epidemic from being exported to other countries.” PharmedOut is working to defend the CDC Guideline for Prescribing Opioids for Chronic Pain, which Fugh-Berman says is under attack by industry-funded third parties including “pain advocacy” organizations, which continuously shutter and reopen under different names. Like the Jesuits, Fugh-Berman is not afraid to go to the tension places and challenge the powerful. In addition to opioids, PharmedOut focuses on pharmaceutical marketing messages covertly placed in articles and talks, product

advertising that is disguised as education, and the corporate invention of diseases like low libido. “Being the first out there can be challenging for an institution, but this program fits with our Georgetown principles like work in the service of others, and care for the whole person,” she notes. “PharmedOut has many firsts. We were the first to write an article in the medical literature exposing drug rep tactics, first to survey family medicine residencies about the

“It was started by industry, but doctors weren’t suspicious enough about the reframing of pain, so we became the agents of industry in creating this epidemic.” influence of the pharmaceutical industry, and first to publish a study on relationships between physicians and medical device reps—to name just a few.” Individual donations and grants help fund the program. Support for their work continues to grow, and Fugh-Berman says the impact is outsized for the small organization. “It enables us to punch above our weight. It’s the best investment in a donation anyone can make!” She hopes it will help them go international on the opioids issue, because she sees similar patterns unfolding in other countries. “If we can help prevent this epidemic from devastating India, China, and Latin America, that would be a good use of the rest of my life. But it’s a big project—I can’t do it alone.” n

Nicotine delivery: What’s the deal? The effort of Altria (formerly Philip Morris) to purchase 35 percent of e-cigarette manufacturer Juul Labs should serve as a wake-up call for the careful monitoring of competition in the U.S. nicotine delivery market, says David Levy, PhD, professor of oncology at Georgetown Lombardi Comprehensive Cancer Center, and others writing in BMJ (Open Access) in September. “Altria has agreed to provide Juul Labs access to its consumers through Juul coupons on its cigarette packs, as well as provide Juul Labs access to its database of more than 10 million smokers,” the authors note. The article raises important questions about FDA regulations, market segmentation, retail channels, and global impact.

FA L L / W I N T E R 2 0 1 9

7


HIV & AID S

Staying Positive Two longtime Georgetown HIV+ patients share their stories of survival By Chelsea Burwell (G’16)

Like an unassuming wave gaining strength under the ocean’s surface, HIV, or human immunodeficiency virus, crept in and swept thousands off their feet in the 1980s and 90s. The three-letter disease rattled the normalcy of lives, shortened life expectancies, and unearthed a stark divide that pushed diagnosed people to the most isolated margins. Nearly as important as HIV medical treatment for patients’ vitality and quality of life was the level of empathetic care and community offered as they navigated the epidemic. With the courage and guidance of Georgetown’s medical community, coupled with major advances in treatment, two patients were able to reclaim their lives, become advocates for those living with the virus, and work to eradicate “the lonely disease.” Expanding Horizons At one point, reaching the age of 50 seemed unfathomable to Marcia Brown. For decades, she sequestered her diagnosis from loved ones and existed within the boundaries of the HIV community, privately contending with the disease. But the diagnosis was neither the first nor the last hurdle in her life’s journey. Raised in northern Virginia among seven siblings, Brown’s academic gifts and the love of her family and teachers catapulted her into a world of opportunities. In the mid-1960s, she attended her junior and senior years of high school in Hanover, New Hampshire, as part of the burgeoning A Better Chance (ABC) program, which placed young people of color in high-performing schools to cultivate their academic merit. Living next to Dartmouth College gave Brown a window into campus activism, particularly Black student activism in the U.S. and around Nigeria’s Biafran War, which ignited her interest in African diasporic connections and international affairs. Over the next decade, Brown was accepted to Stanford University, took a hiatus from school to participate in activism back in Virginia and give birth to a daughter, and later returned to complete her English degree. Inspired by a year-long study

8

G EO RGE TOW N MEDIC INE


abroad experience in Kenya during her junior year, she continued at Stanford to earn a graduate degree in international development education. She then joined the United States Agency for International Development (USAID), working in Washington, D.C., and throughout the African continent. When her mentor offered her a two-year assignment in Zambia, Brown enthusiastically accepted. However, as she and her daughter were getting settled in the country, Brown found herself in the thick of the nation’s first exposure to HIV and AIDS. “Entire families were being wiped out,” she recalls, thinking back about how many close friends she lost to the newfound disease. “It was a very frightening and sad time for everybody. That was my first time hearing about HIV.” Then, in 1987, while living happily and in a loving relationship, she received the news that she never could have fully prepared for: she was HIV-positive.

Stephanie Dalton Cowan

A Search for Care After the diagnosis and the end of her work contract, Brown and her daughter returned home, where she began adjusting to a new way of living—stealthy and cautious. “At the time, my brother and father were both very ill, so that gave me more reason to withhold my status. I kept it underground, and I really didn’t know what to do,” she says. She focused her energy into raising her daughter and continuing her work in international development. When it came time to seek HIV care, Brown initially forwent the limited treatment options being offered by physicians, and turned to complementary care which included alternative and natural medicine. However, as her health began to deteriorate, she soon realized that she needed to seek other forms of care. “I met with one doctor, a white male physician, and it was very clear that he was only accustomed to having gay white males as his patients, so it just wasn’t a good fit for me,” she remembers. As a heterosexual Black woman in the late 1980s, Brown felt that she was an anomaly in the pool of patients with the infectious disease, knowing no other women who were HIV+. Physicians struggled to keep up with the curve. According to the CDC, between 1988 and 1990, African Americans were being diagnosed with more new HIV cases than white people for the first time since the epidemic emerged in 1981. Two years later, HIV became the second leading cause of death for Black women ages 25-44. “It was a miracle that my body was able to keep going. For a very long time, I was walking around with little immunity,” she adds. With the turn of the decade approaching, Brown sought advice from the few friends she decided to reveal her status to,


in hopes of finding more emotional support and more inclusive health care.

Strange Awakening Around this same time, Richard Strange, an IT professional who enjoyed keeping up with the latest medical science research, began educating others about the infectious disease. “I first heard about the virus when news reports appeared in the early 1980s,” recollects Strange, who grew up in London but settled in D.C. “Before it was known as HIV, it was called GRID, or gayrelated immune deficiency. But then after a few years, scientists saw that the disease was impacting a wider community.” Outside of multiple cases among gay men, new HIV diagnoses were being reported by hemophiliacs, people who injected drugs, and those of Haitian background, causing a sweeping stigma among the populations. After reading extensively about the disease, Strange shared the latest HIV research and emerging knowledge about transmission with others he knew. “I thought I was well-informed and I knew what was regarded as risky behavior. I avoided that, and told everyone to get tested yearly,” says Strange. “I assumed that because I was following all the rules, I couldn’t get infected. But I realized that if I was telling others to get tested, I should too. So in December 1992, I walked into the Whitman Walker Clinic in Northwest D.C. to finally get tested.” Age 51 at the time, Strange was certain that his results would come back negative, but to his surprise, he learned that had contracted the infectious disease he had warned so many friends and colleagues about. “To this day, I don’t know exactly how I got infected, but I couldn’t argue with the data. I knew I had to act quickly,” he says. Strange turned to Georgetown University after he confided in a close friend, who was a doctor. “I called him up and said, ‘I can’t believe it, but I’ve just tested positive. What would you do?’” he recalls. “And he said, ‘Well, if I was in your position, I would want to be treated by Dr. Princy Kumar.’” Just days after reaching out to her, Strange was in Kumar’s office as a new patient. “She’s been a wonderful doctor and friend ever since.”

If you ask her, Princy Kumar, MD (R’90), was destined to work in the service of others. From following her calling to be a physician, to advocating for those battling infectious diseases, Kumar’s tireless work and commitment to her patients has made her a game changer in the field of HIV and AIDS research and compassionate health care.

10

G EO RGE TOW N MEDIC INE

Stephanie Dalton Cowan

Destined to Serve


HIV & AIDS

Growing up with eight other siblings, the Georgetown doctor remembers her father’s lessons on being self-sufficient and giving unto others. “Seven of us are doctors in different specialties. It was my father’s vision, who told us that as a physician, your profession is not work. It is a service to the community. Its reach in impacting the community is beyond that of any other profession.” As a medical student, Kumar was intrigued with microbiology and learning that most infections have a definite treatment which leads to cure. Her understanding of the field was tested as AIDS became an epidemic. “HIV was a completely different paradigm. We were in the dark much like the public—we didn’t know what caused it, how to treat it, or how to prevent it from spreading. However, this reinforced my father’s perception of being a physician—why medicine is a calling and why it is important to step out of our comfort zones to help the affected community.” Landing at Georgetown as an infectious disease fellow in the midst of the AIDS crisis in 1988, Kumar encountered the shocking reality of how the epidemic was affecting thousands of people. “There was no treatment for HIV at the time. Patients had no hope,” she recalls. “Many of them were stigmatized, and I believe I was called to take care of them.” Kumar’s predecessor at Georgetown—Phillip Pierce, MD (M’75, R’80)—led the charge to provide comprehensive care to HIV-positive patients on Thursday nights. “We called it the Thursday Night Clinic. We had likeminded specialists who really wanted to be of service.” However, Kumar admits she and Pierce were met with much resistance from fellow physicians who did not want patients with HIV in close proximity to their patients. “There was an immense lack of knowledge about HIV during this time, so we really had to struggle to provide the necessary care for our patients,” she says. Fear rooted in misconception was a major factor in why the Infectious Disease Division was eventually moved from the main hospital building. Besides providing medical care, the young doctor saw that patients needed something more to combat HIV. “It was really difficult to see how young, previously healthy people were devastated by this disease, and most of all the shame that they felt from having it,” Kumar says. “People didn’t want to be associated with anybody who had anything to do with HIV. It was truly a lonely disease.”

Trials and Community In the early 90s, after a lengthy search for better medical care, Marcia Brown was recommended to Mary Young, MD (R’87, W’89), a colleague of Kumar and fellow Georgetown physician

who was developing the Women’s Interagency HIV Study (WIHS), an NIH-funded cohort study devoted to helping women impacted by HIV. “They provided a safe space for us. We felt loved and respected there, and they provided excellent and compassionate clinical care,” Brown shares. A growing community of patients living with HIV led to a stronger need for support, advocacy, and engagement. Georgetown responded to this call by creating the NIH AIDS Clinical Trials Group (ACTG). Given Brown’s display of leadership and diagnosis management, Kumar turned to her to help revitalize the District’s ACTG Community Advisory Board. Over the years that followed, Brown began to serve on other advisory boards, including the George Washington University’s Center for AIDS Research Board as chair and community coordinator. Many people with HIV visited the National Institutes of Health to participate in clinical trials of new treatment options for HIV and AIDS. For Brown, the experience of finding a drug to improve her health was bleak. “Going up to NIH’s huge campus in Bethesda, I felt very much alone,” she says. “It was overwhelming, and still, no one in my family knew my status. I had to come up with reasons why I was leaving the house so early in the morning and trekking to Maryland.” Though NIH’s pioneering research drew people from across the country, Brown remembers never seeing other Black women or even people of color at the clinical trials. Participating in numerous studies, she felt at times that she was losing the battle to AIDS; she later had a second devastating diagnosis, learning that she was also battling cancer. But the tides changed for Brown after participating in one clinical trial and receiving the good news from Young that for the first time, her HIV was undetectable. As for Strange, he believed clinical trials were essential to make progress, and his philosophy on participation was “If not me, then who?” With the counsel of Kumar, he began participating in trials almost immediately after being diagnosed. At that time, the primary FDA-approved drug treatment was Retrovir, or AZT, which required as many as six dosage intakes a day.

From Surviving to Thriving After volunteering for five new drug trials at NIH between 1993 and 1998, Strange discovered that his immune system seemed to be genetically in his favor and might be able to withstand the virus with few drugs or none at all. In 1999, he joined a multiyear study of how a small portion of patients could control the virus without drugs. “For a year and a half, I took no drugs at all and the virus was either undetectable or only came back at a fairly low level,”

FA L L / W I N T E R 2 0 1 9

11


12

G EO RGE TOW N MEDIC INE

Stephanie Dalton Cowan

he says. Now, at the age of 78, Strange’s current viral load is undetectable. “In many places, there’s a great stigma around being gay, let along having HIV,” says Strange. “Even though people are somewhat more accepting here now, the fear of stigma keeps people from disclosing their status. But, I also realized that as an HIV-positive person, I have a responsibility not to infect others.” Considering how his health status could affect his relationships and even beloved hobbies like hiking, Strange decided in 1993 to share his HIV diagnosis with his closest friends. “My friends and I enjoy being outdoors, and I said to them, ‘I’ve got something I need to tell you. I just tested HIV-positive, which means that in any of our outside activities, if I ever get cut, you have to let people know to be very careful.’” Now, more than 25 years since his diagnosis, Strange continues to be a proponent for medical advancement in HIV research despite being aged out of eligibility for many trials. “If we’re going to make progress, we should all play our part in furthering scientific knowledge and getting more effective diagnoses and treatments,” he asserts. He has served a total of 12 years as a volunteer member of the community advisory boards for two NIH-funded HIV research studies. After nearly four decades of HIV research and care, there are still gaps in understanding the virus as well as prevention methods and medications. “Even with the progress we’ve made, the social aspects of the disease can be very ostracizing,” says Kumar. “The hard part is whether patients remain engaged in care. It’s not so much about access, but about other factors in their lives. Are they willing and able to take the medication? Are they still distrustful of the system?” For Brown, addressing the needs and rights of HIV-positive patients and advocating for strong researcher-community relationships are paramount. Having overcome two earthshattering health diagnoses, she remembers what it was like to feel alone and overlooked at certain points of her journey. But now at almost 70, she stands tall—as a mother, grandmother, friend, advocate, survivor, and thriver—with a legacy that she can be proud of. “There’s nothing else that I have on a bucket list. Everything else would be icing on the cake from here,” says Brown. “What I really hope to see is the next generation benefit from all of the good things that life has to offer, while also feeling their worth, value, and power in all of their relationships.” n


HIV & AIDS

ALUMNI IN THE FIELD

Shireesha Dhanireddy Based in Seattle, Shireesha Dhanireddy, MD (C’95, M’99), completed her internal medicine residency and infectious disease fellowship at the University of Washington. After her fellowship, she joined the Madison Clinic, the largest HIV clinic in the Pacific Northwest, where she is now medical director. She spends two-thirds of her time in patient care, and the rest working on student, resident, and peer education as well as research focused on improving health outcomes in vulnerable patients. Through her clinical work at a county hospital, she developed an interest in the health of people who inject drugs. “Outcomes are not optimal. As providers, we could improve our approach by addressing substance use disorder in addition to their other medical issues,” says Dhanireddy. Her current clinical research looks at the intersection of the opioid crisis, injection drug use, and infectious diseases. Dhanireddy seeks to provide wrap-around care—including patient navigation and opioid agonist therapies (medication-assisted therapies such as buprenorphine)—to help people who inject drugs to treat their drug dependence and focus on other health issues. She hopes that this packaging of interventions will help reduce some of the barriers to care still facing people with HIV and other infectious diseases in the community. With a deep commitment to providing care for those who are marginalized, Dhanireddy reaches vulnerable patients through creative approaches. In response to a lack of services available to unhoused women engaging in street-based sex work in the north end of Seattle, Dhanireddy partnered with the non-profit organization Aurora Commons in 2018 to create the SHE Clinic (Safe Healthy Empowered) to provide co-located primary care, including HIV prevention and sexual healthcare. Run from the back of a mobile van, the SHE Clinic offers sexually transmitted disease testing and treatment, HIV testing, opioid agonist therapy, and contraception. Shortly after the clinic began operations, a new cluster of HIV cases was diagnosed among the population it serves. The SHE Clinic has been integral in providing HIV testing and prevention services as well as coordination to connect newly diagnosed women to care. Dhanireddy’s approach of meeting people where they are includes development of a new outpatient antibiotics program

for people who inject drugs. Similarly, she introduced a new STD self-testing model for patients in the HIV clinic to allow low-barrier testing, resulting in exponential increases in testing and treatment rates. “Today, HIV can be treated with one pill once daily. Other medical conditions, like diabetes and hypertension, are much harder to treat. When treating HIV, the aim is to minimize toxicity, focus on comorbidities, and provide a more comprehensive care model and not just focus on the specialty,” she says. Dhanireddy is committed to the education of future HIV and infectious disease providers as well. She implemented an

Nate Gowdy

“The HIV is the easiest thing to treat; their other conditions, like diabetes and hypertension, are much harder.” HIV training pathway in the internal medicine residency program at University of Washington, providing opportunities for residents to serve as primary care providers for people living with HIV, in an effort to increase HIV provider workforce in the region. She also participates in a distance-learning program of the Mountain West AIDS Education and Training Center to support health care providers working in rural areas where HIV is less commonly seen. Using live video, the weekly sessions provide clinical consultations between community providers and a panel of HIV experts. Dhanireddy names two infectious disease physicians at Georgetown who inspired her to pursue the specialty: Princy Kumar, MD (R’90), and Joe Timpone, MD (M’95, R’88). “My training as a Georgetown medical student laid the groundwork for me to succeed during residency and fellowship,” she adds. “We had high expectations for work and ownership in the care of our patients, and being present at the bedside. It is only through being present with patients that we learn how to care for them as people with complex medical and social needs.” n —Jupiter El-Asmar (F’17)

FA L L / W I N T E R 2 0 1 9

13


HIV & AIDS

A Call to Compassion The Early Years of AIDS Care By Jane Varner Malhotra

In his fourth year of medical school in 1985, pulmonologist Chip Read, MD (M’85, R’86, W’89), was acting intern in the medicine wards at Georgetown when he met the young patient he’d never forget. The 17-year-old was suffering from Cytomegalovirus colitis, an AIDS-related diarrheal illness. And he had a do-not-resuscitate order.

“He knew he had AIDS. His family was supportive, which was atypical, and it helped him be more at peace with his diagnosis. And amazingly, he was a DNR. He knew he was going to die, and he knew he didn’t want the CPR.” Read pauses, taking a deep breath. “He was so at peace with his life, as brief as it was. When he was discharged home, I wrote him a letter to say I’ll always remember him as I go forward in my career.” He died shortly after. The patient came from a strong, loving family, Read says, with three boys and three girls. “The next year as a resident I took care of his middle brother who died of AIDS under my watch. Then during my fellowship the third brother came in with Pneumocystis and died. The family lost all their sons, like we were in a war,” he says, shaking his head. “We were in shock, seeing a young healthy population being wiped out.”

A Time of Fear The first reported case of AIDS at (now MedStar) Georgetown University Hospital occurred in 1980, when a

14

G EO RGE TOW N MEDIC INE

previously healthy gay man presented with Pneumocystis pneumonia and died two weeks later. As the AIDS epidemic swept through American communities during the next decade, health professionals at Georgetown sought to provide compassionate care in a time of widespread anxiety and stigma that today can be hard to imagine. The disease was spreading rapidly among healthy men, often very young men, withering them away, and the survival rate was zero. Was it airborne, or could it be caught from door knobs and water fountains? Little was certain, but as the mysterious illness emerged, fear came with it. At hospitals across the country, including Georgetown, meal tray deliveries were sometimes left outside the patients’ rooms. Chaplains were hesitant to enter rooms too, recalls Sal Jordan, S.J., a nurse and chaplain at Georgetown University’s hospital in the 1980s and 90s. His training in psychology helped him understand the fears that care providers faced, and also the complex needs of the patients who were often stigmatized and alone. “I often think of those years as my

best work,” he says softly. “It brought me in front of a totally new group of people I’d never had contact with before. If I had not been a nurse, I could have been more fearful of AIDS work.” “The patients would ask me, ‘Why don’t our chaplains come in? We see them at the nurses’ station, but they don’t come into our rooms.’ I would explain that they are fearful of AIDS and of how it’s contracted.” HIV wiped out the immune system. For many with decades of infectious disease experience, those years were difficult beyond words. The epidemic turned the profession upside down, says nurse historian Ella Curry, PhD, who spent nearly 25 years at Georgetown in infectious diseases.

By 1990, the hospital’s clinic for people with HIV moved to dedicated space in the Kober-Cogan building.


at Georgetown “We had incredible physicians who had lived through the discovery of penicillin and believed the medical field had mastered infections. But HIV shook that ground. It was challenging everything we knew, because it was attacking the immune system in a way that antibiotics and antivirals we’d come to rely on were no longer effective. It became a real challenge at the bedside for all health care professionals.” Outside many rooms on the hospital’s seventh floor were yellow isolation carts indicating an infectious patient. The carts held footies, head gear, gowns and masks for visitors entering the room, and double-gloving became the new protocol. “I never faulted any of my staff who didn’t want to go into the room,” says Curry. Rather, she would have a conversation with them to consider the impact of their actions. “It telegraphs to our patients that they were in the category of the untouchable.”

Clipboard: iStock

Balancing Act In the early years of the epidemic, before coming to Georgetown, Curry cared for AIDS patients in the Boston area. The challenging work inspired her to study health care ethics, world religions, and human responses to plagues at Harvard Divinity School. Her transformative experience in ethics training proved critical for her continued work in AIDS care. Grief and loss were palpable, she says. In those early years, the infectious disease division alone was losing nearly two

patients a week. “Under the leadership of nurse manager Jill Cunningham, Adult Medicine’s seventh floor west in the hospital’s Main Building became a haven for many patients with HIV,” Curry says, adding that her beloved colleague passed away in 2016. “Jill was very intentional in creating an atmosphere of welcoming and open care to patients with HIV. She hired nurses who shared that approach. Georgetown University Hospital never had a dedicated AIDS unit per se—such units were both a benefit and a problem. It’s a benefit because you get highly specialized care 24/7. But the downside is that if someone knows you’re a patient on 7-West, then they would know that you must have HIV. For us it was always a balancing act in terms of nondisclosure of the disease.” A desire for privacy complicated the disease from the start. Curry recalls that as it emerged, HIV seemed to take hold in a few distinct populations known as the four H’s: hemophiliacs, Haitians,

During the height of the epidemic, Georgetown established LifeLine Support Group for people with AIDS and their families—one of the first patient support groups at the hospital.

homosexuals, and heroin users. Gay men formed the vast majority of people with the disease. In addition to fear about HIV itself, many men did not want their families to know they were gay. Discrimination against the LGBTQ community and American cultural norms of those years meant many kept their sexuality private—at work, in school, and at home. Stigma caused many patients to ask that their diagnosis be kept from friends and family. “It was very difficult to see young healthy people just be devastated by this disease, and most of all the shame that they felt from having this disease,” remembers Princy Kumar, MD (R’90), who leads the infectious disease unit today. “So much has changed. At that time, it was an extremely stigmatizing disease. People didn’t want to be

FA L L / W I N T E R 2 0 1 9

15


HIV & A IDS

Nurses Curry and Jordan, S.J., used their respective training in ethics and psychology to support patients, families, and colleagues during the AIDS epidemic.

associated with anybody who had anything to do with HIV infection. It left people lonely and desperate and wanting some form of companionship.”

The Thursday Night Clinic With so much public fear and misunderstanding about transmission of the virus, no hospital in the District wanted to be identified as the AIDS hospital during those pretreatment years, recalls infectious disease specialist Mary Young, MD (R’87, W’89). “They thought other patients would be afraid to come to that site. So at Georgetown, the choice was made to create a discreet full-service clinic on Thursday nights to care for those with HIV,” Young says. The vision for the comprehensive clinic came from Phil Pierce, MD (M’75, R’80), who drew together a team of people from the hospital in 1986 to make it happen. It was open from 6-9 p.m. each Thursday evening, in Gorman next to the old student health center. Kumar notes that the evening hours worked well for patients because most needed a companion to help them get there, too weak to come alone. It also worked for the many volunteer clinicians who were more available to donate their time after hours. Team members not only

16

G EO RGE TOW N MEDIC INE

shared medical insights at weekly meetings but openly discussed complex ethical dilemmas they were facing, Pierce says. Although many university and hospital leaders were not outwardly vocal about their support, they helped make the clinic happen in subtle ways, says Young. An obstetrician would do pap smears and exams. Caregivers from pulmonology, phlebotomy, and psychology participated as well. “They all created an interdisciplinary whole-patient care clinic with streamlined, fast-tracked service,” says Young. “A patient came in with a cough and fever on a Thursday night, and Chip would get them scheduled the next day for a bronchoscopy at the hospital.” The gay population in D.C. had mixed feelings about coming to Georgetown for their care, recalls Read, with many wondering if they would be treated with dignity at the Catholic hospital. He and doctors Kumar, Young, and Pierce made a concerted effort to go out into the LGBTQ community and assure physicians that their patients would be welcomed, and could expect comprehensive and compassionate care. Georgetown’s work in clinical trials offered additional appeal. James Lavelle, MD (W’86), the late cardiologist and researcher who also worked in the Thursday Night Clinic, led the university’s close partnership with various pharmaceutical companies to develop new HIV therapies. After his death, Kumar continued his vision by further strengthening those partnerships, including NIH, by creating the infrastructure for the research unit. “Through this effort, Georgetown has been involved with the development of almost every single HIV medication,” Kumar adds, transforming the lives of countless people living with HIV. “Dr. Kumar turned our clinic into a powerhouse of research,” Young recalls. The nursing team provided a strong anchor to patients with complex problems, says Pierce, recalling the impact of

caregivers there including Pamela Harding, Anne Byrnes, and Karla Pillote.

The Impact of Stigma By 1990 the Thursday Night Clinic moved to a separate building, KoberCogan, and the hours expanded as more and more patients arrived in need. Besides gay men, people who use intravenous drugs and sex workers were arriving in increasing numbers, and it became simply the Thursday Clinic. Eventually the disease touched everyone, but the early predominant groups carried a stigma that challenged some of the

With Georgetown support, Mother Teresa set up the Gift of Peace Center in Washington, D.C., in 1988 to provide hospice care for people with AIDS. (Above, with President Timothy Healy, S.J.)

espoused Catholic values of the archdiocese and in turn the hospital. “At first there was vocal animosity towards this program,” Pierce says, but the caregivers would not be deterred. He notes that the initial grassroots effort gained administrative backing over time and ultimately was welcomed and supported by the university’s president, Timothy Healy, S.J. During those years, the university’s relationship with the LGBTQ student community was evolving. In the 1980s, the Gay Rights Coalition of Georgetown University Law Center filed suit against the university to seek official and equal status for LGBTQ student organiza-


Doug Mills/AP

tions, under the D.C. Human Rights Act banning discrimination based on sexual orientation. After nearly a decade of legal action, including motions before the Supreme Court, the university finally consented as the courts sided in favor of the students. “There seemed to be a big change after that,” Pierce recalls. “Shortly after, doors opened up for us and suddenly the hospital administration asked us how they could better support us. That’s when they gave us a dedicated space in KoberCogan.” Through the clinic, Father Sal Jordan and Peggy Magee set up one of the hospital’s first patient support groups. The Georgetown staff who volunteered there were an exceptional group, says Father Sal. “A lot of it was on the quiet side without much publicity or anything. I always considered it my most essential work as a Jesuit. I was very fortunate to work with the nurses, doctors, and social workers through the HIV clinic—how loving they were, and nonjudgmental.” Societal judgment around being a heroin user or being gay had an outsized negative impact on research and care for people with the sexually transmitted disease, says Curry. “We lost a decade due to stigma. In the 90s we were dealing with the fallout from the 80s,” she explains. “There was this false sense of security in the early years because people heard and read that only certain groups were at risk. People would see those categories, and when they did not see themselves on the lists, they would believe themselves not to be at risk and also that it was not their concern.” She pauses. “And we live with the legacy of that still.” Curry recalls the many times patients begged them to not document anything that would reveal they had HIV, including one high-ranking government official who planned to tell everyone that he

had TB. “He thought that was more acceptable. Don’t put HIV on my death certificate, he said.” As if the disease itself weren’t devastating enough, the stigma around how it was acquired made it far worse, says Curry. “Living with that level of fear of discovery evokes a lot of negative entropy, in terms of someone ever achieving a sense of wellbeing.”

Helping Families in Turmoil Many families struggled as their sons quickly declined in health and often at the same time revealed their previously private sexual identity. “I remember one whose father was a top lawyer in his hometown, mother a nurse, an aunt a nun,” says Father Sal. “Their son’s illness created lots of turmoil for them. He didn’t even want to go home for Thanksgiving.” Father Sal convinced him to go and reconcile with his conservative Catholic family, and agreed to accompany him and help bridge the divide. “He had just a few months left to live and had lost a lot of weight. We drove home to his family an hour away and spent Thanksgiving there with them. My presence was a big help to him and to his family, just by offering understanding and support. A month later he died in a Washington hospice care facility about 3 in the morning, and his family called me to be with them at his bedside. I was glad they were reconciled.” “Far too many people had been banned from families once their diagnoses were known,” says Curry. “They wanted to be with nieces and nephews again but were forbidden to touch them.” For some, they were invited to family occasions but were seated at a separate table alone, with disposable plates and cups. Curry remembers a sentinel event that greatly impacted the Infectious Disease team. A young man with advanced AIDS who had insisted on keeping his diagnosis from family, came in to the hospital critically ill and was placed on

a respirator in the ICU. He had been living his dream of working for the government in the nation’s capital, and when his parents and brother arrived from the Midwest they were completely stunned by their son’s sudden illness. Some members of his care team believed the family should be told of his underlying condition, and frequent ethics consults took place for staff. How can the family make decisions about his care when they don’t know his diagnosis? But Mary Young, his physician, honored her promise to him of nondisclosure. “After he died, Mary had a meeting with family and explained everything,” Curry says. “She explained why we withheld the information. They were enormously relieved to know that there was something to explain his critical illness, and that he was being cared for by a team like Mary’s, who honored their commitment to the patient. But the family grieved that he never trusted them with that information. His mom said

President Bill Clinton greets AIDS patient Larry Singletary while visiting Georgetown for World AIDS Day in 1993.

they could’ve helped him carry that burden. She was heartbroken that his decision had deprived him of their prayers and their love and support.” From that point forward, Curry says, their practice changed. They shared parts of the story with new patients in similar circumstances, and had them identify at least one person they could trust who

FA L L / W I N T E R 2 0 1 9

17


HIV & AID S

would know their situation fully, and who could make decisions for them when they were no longer able. Magee and Father Sal organized a yearly Mass of remembrance in the hospital chapel, where the names of all the patients lost to HIV were read— 80 to 90 per year during the peak. “We lost a lot of patients,” says Young. “Protease inhibitors combined with older nucleoside drugs turned the tide, people stabilized, people reversed course. Some are still alive today. But 1987 to 1995— those were really rough years.”

A Generation of Medicine Shaped by HIV Watching their teaching clinicians stumble into the AIDS epidemic, not knowing exactly what to do as they lost patient after patient, left a lifelong impact on medical students at the time. But they shared in the privilege of caring for an especially vulnerable group of individuals, accompanying those in great need, even in high-risk scenarios. Mary Young remembers the pregnant woman who came in with pneumonia,

18

G EO RGE TOW N MEDIC INE

received an HIV diagnosis, and was transferred to her team for care. It was a second marriage for her husband, who had done a lot of international travel and who also presented with HIV. By then they were treating patients with AZT, which she took and gave birth to healthy twins. “Both parents had significant infections,” says Young. “She died in 1994. But he got on new inhibitors and responded, and lived long enough to raise their children. People who could make it to 1995 had a good shot of surviving.” Kumar recalls the leadership shown by Mother Teresa, who came to Washington, D.C. in 1988 to set up the Gift of Peace Center to house and provide care through end-of-life for people with AIDS. Mother Teresa told Pierce that she saw the population as analogous to the people on the streets in Kolkata, India: homeless, frail, and abandoned by their families. Located in Northeast D.C., the Center was staffed by Mother Teresa’s order of religious sisters, the Missionaries of Charity, and supported by the Archdiocese which provided a former orphanage

for the site. Per Mother Teresa’s request, Georgetown University agreed to provide linens, remove waste, and provide a case manager as well as physicians to volunteer there—contributions that are now equally shared by MedStar Georgetown University Hospital and continue today under Kumar’s leadership as the medical director of the Gift of Peace. Despite the overwhelming medical and societal challenges of the time, Georgetown’s Catholic and Jesuit values gave hospital caregivers the language and grounding to do their work, caring for the marginalized despite widespread fear and stigma, says Young. “It was an honor to work with that team. They humanized the illness, and recognized the person behind the disease, someone with hopes and dreams and family issues—with much more going on that just the illness you see. They were treating the person above all, not just the disease,” she says. “The people who showed up for this work exemplified cura personalis, that deep compassion. They were ready to risk their life to care for others.” n

Lisa Helfert

Current and former Georgetown colleagues in HIV and AIDS care who shared their memories for this article: Phil Pierce, Ella Curry, Princy Kumar, Mary Young, and Chip Read. Not pictured: Sal Jordan, S.J.


ALUMNI IN THE FIELD

Craig Hendrix

During some of his first clinical experiences as a medical student, Craig Hendrix, MD (M’84), witnessed the tragic conditions for AIDS patients, with Washington, D.C., an epicenter of the epidemic in the U.S. After graduation, Hendrix did his internal medicine residency at Johns Hopkins and was a fellow in infectious diseases and clinical pharmacology, before fulfilling his remaining six years of scholarship commitment to the Air Force. Based in

topical microbicides to locally prevent anal and vaginal intercourse-related transmission. His team continues to work on topical drugs, oral drugs, long-acting injections, and implantable devices. “One question I often get is why there are so many different prevention methods. One pill a day works great for some people, but for others it may not. From surveys and behavioral observations, some people will only want the drugs at times of potential exposure.” In this way, Hendrix hopes that providing more options and easier treatments will help them reach a larger population. “For HIV, the evolution of drugs for treatment is remarkable. The simplicity of regiments nowadays makes taking them much easier and complications much fewer. We have more formulations and less frequent dosing.” Being a part of this dramatic evolution in HIV treatment, including the rollout of highly effective prevention, has been an extraordinary privilege, says Hendrix, “from the early days of losing so many patients, to a current life expectancy the same as a person without infection.” For five years Hendrix has led the clinical pharmacology division at Hopkins, transitioning drugs through phase I and phase II clinical trials, and for some treatments proven to prevent HIV such as Truvada, being part of advancing them to phase III studies and licensure. Looking back, he sees how the challenging years in medical school at Georgetown makes a difference in his work today. “At Georgetown we had extraordinarily good hands-on, well-taught experiences in clinical medicine,” says Hendrix. “Those years were precious and it was impactful to have a solid clinical foundation. I appreciated how hard I worked at Georgetown to be at the bedside.” n

“For HIV, the evolution of drugs for treatment is remarkable. The simplicity of regiments nowadays makes taking them much easier and complications much fewer.” San Antonio, Texas, he managed the HIV evaluation program, working with patients who had been identified as HIV-positive by the military force-wide HIV testing program. The vast majority of the HIV-infected service members were in very early stages of infection, Hendrix notes. Through this extensive testing, the military created a large natural history database of patients and their dependents, who would return every six months for check-ups. After five years in San Antonio, he returned to Washington to work on HIV prevention at Walter Reed Army Institute of Research, along with some clinical work at Hopkins while still on active duty. By 1997, he had transitioned into full-time faculty at Hopkins in clinical pharmacology research. “My first work at Hopkins involved understanding how drugs used for HIV treatment got into the male genital tract,” says Hendrix. “There was concern that some drugs didn’t penetrate and might leave HIV to replicate locally and still lead to transmission. This was largely debunked and, subsequently, the concerns about transmission were proven untrue based on epidemiology.” He later worked on drugs for HIV prevention through pre-exposure prophylaxis, or PrEP, with an emphasis on

—Jupiter El-Asmar (F’17)

Above: Hendrix leads a session on HIV prevention in Tijuana, Mexico’s Zona Centro with students from Universidad Autonoma de Baja California and University of California San Diego.

FA L L / W I N T E R 2 0 1 9

19


HIV & A IDS

Leading the Way on Women and HIV By Molly Benedict

At first presentation in the 1980s, the United States AIDS epidemic emerged mainly among men who have sex with men and within the drug using community. There was little mention of the virus among women, and rumors about women’s immunity spread. In 1988, Cosmopolitan magazine published an article falsely claiming that women’s ability to contract HIV was connected to their physical position during sex. Misinformation and stigma around HIV and women continued to grow. Medical professionals saw a much different story playing out. Doctors were diagnosing HIV-positive women from every age and socioeconomic group, primarily in women who had sex with men. HIV did not discriminate. Almost 10 years after the start of the U.S. epidemic, the first conference on HIV in women convened in 1990 in Washington, D.C. At the same time, a dramatic increase in AIDS cases among women of color prompted a push to fund a major study of HIV in women. In response, the National Institute of Allergy and Infectious Disease, the National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Drug Abuse, and the National Institute of Dental and Craniofacial Research sought proposals from sites nationwide to participate in the Women’s Interagency HIV Study (WIHS, pronounced “wise”) to investigate the biology and impact of HIV on women’s health.

20

G EO RGE TOW N MEDIC INE

When the call for proposals came out, Mary Young, MD (R’87, W’89), was working as an assistant professor in infectious diseases at Georgetown. Having encountered women in clinic being diagnosed and living with HIV—and recognizing the gaps in the medical research—Young knew Georgetown should participate. WIHS began in 1993 as a national multi-center, prospective, observational cohort study of HIV-infected or at-risk women. Young served as the principal investigator leading the Washington, D.C., site, which represented a collaboration among three universities (Georgetown, Howard, and George Washington), the Montgomery County Health Department, the Inova Juniper program of Northern Virginia, and the District’s Whitman Walker Clinic. The collaboration and diversity of clinics allowed the study—which continues today—to collect data from women seeking care in a variety of practice environments. With Georgetown as the funded member, the coalition of universities and clinics began enrolling women from as far north as Baltimore and south to central Virginia. Participating women clustered primarily in the Southeast and Northeast quadrants of D.C., where HIV was prevalent in the region. In 2016, Young retired from the WIHS project, but she left a well-oiled machine for her successor, Seble Kassaye, MD. Drawn to Georgetown by its commitment to the underserved, Kassaye previously worked with women living with HIV and specifically focused on HIV and pregnancy, and prevention of


perinatal HIV transmission from mothers to infants. WIHS continues to thrive under her leadership.

Reaching Out to Build Community At the beginning, the founding institutions of WIHS worried that the D.C. clinics would struggle to enroll participants, according to Young. The majority of women with and at risk for HIV were women of color, predominantly Black and Hispanic women, living in underserved communities and often uninsured. Without insurance or convenient clinics, many had not regularly interacted with health care providers in medical spaces. And because of past injustices and mistreatment, many in the Black community also harbored mistrust of the medical establishment and research in particular, says Young. Aware of these concerns, Young and her team worked to create a welcoming place of comfort and trust for women in the study. With assistance from community outreach coordinators at George Washington University, WIHS researchers met women in their communities to establish a base level of trust. The outreach workers were either from the underserved communities themselves, or were known, friendly faces the women felt comfortable talking to. With the help of the outreach team, Young was able to recruit the first group of D.C. WIHS participants. She also included community leaders in clinical trial design and decision-making.

To continue easing women into the medical study, WIHS established their office apart from the hospital, to create a more relaxed and welcoming atmosphere for the women they sought to enroll. Once enrolled in the study, participants engaged meaningfully with WIHS researchers, nurses, and staff. “Together we created a wonderful kind of participant-researcher interaction, rather than just researchers coming in and doing something. There is a real sense of collaboration with the women,” Young says. At the start of the study, participants received food vouchers, transportation to appointments, and help with childcare whenever possible. At lunch-and-learns, women would get together and hear results from the study, or discuss advances in research with WIHS staff. Before treatment advanced, community advisory groups gathered to learn pain-relieving massage techniques. The group also gathered for Thanksgiving and Christmas parties. A true community formed as the patients and staff lived the Jesuit value of cura personalis—care for the whole person. “They weren’t research subjects to us,” says Young. “They were individuals we really cared about. We celebrated their successes and mourned their losses. It was and is a real ongoing community.” This culture of collaboration continues today, and has been key to the longevity and impact of WIHS.

FA L L / W I N T E R 2 0 1 9

21


HIV & AID S

In 2016, Kassaye became principal investigator of the D.C. branch of WIHS, which has tracked thousands of HIV-infected or at-risk women since the national study began in 1993.

Due to the study’s observational nature, women do not receive clinical HIV treatment at their WIHS appointments. In a typical visit, they answer a long questionnaire and are provided with pap smears and basic gynecologic care. Participation can be long, taxing, and invasive. “It’s very involved, but the participation is high and that to me speaks volumes about how much trust, acceptance, and eagerness is there to participate in this study,” Kassaye adds. “WIHS wouldn’t be successful without it.” Over the years, women have recommended family members and neighbors, providing a varied and deep level of data. Due to the longevity of the study, mothers and daughters have enrolled, and some participants who were first enrolled in 1994 continue to come to their appointments today.

with their health providers. Their candor gives researchers a more complete picture of women’s behavior. “We maintain a non-judgmental, very welcoming environment for the women. It does so much for maintaining the trust. At times, some might not make it to their doctor’s appointment, but they’ll come to their WIHS visit,” shares Kassaye. “This is the U.S. study for HIV in women. There is no other equivalent, so it pushes the boundary from how things are being affected on the molecular level to how people’s lives are being affected on the population level,” she says. “The biggest effect of the study has been pulling in different scientists from multiple disciplines—from geneticists, to neurologists, experts in aging, behavioral scientists, social scientists. We cover the spectrum of not only HIV’s effect on the body but also within the population—its influence on how people live and their quality of life.” WIHS questionnaires gather data on medical and psychosocial issues in participants’ lives. Every survey includes questions about medications taken, consistency of dosage, and care. Some questionnaires included sections on depression, sexual violence, housing, and childcare issues—deep personal questions that can be especially difficult to answer for patients who are already feeling vulnerable. The study also includes physical examinations and tests, in which patients may disrobe, be measured, have body fluid samples taken, and undergo many tests. Nonetheless, the patients continue to come back, sometimes from great distances, and they recommend their friends and neighbors. Relationships form the backbone of WIHS, and this allows the researchers to capture the personal impact of HIV on women. This information is useful in analyzing how family structure and psychosocial environment affect women with HIV and their ability to stay in care and on medication. Over time, the surveys are able to paint a reliable portrait of the life of a woman infected with HIV. Furthermore, the surveys help researchers understand the effect of HIV infection on family relationships. In terms of collaborative research, the data WIHS has gathered is invaluable. In addition to all of the survey responses, researchers have collected almost 30 years of bodily fluid and tissue samples. “WIHS has both blood samples dating back to 1993, and good epidemiological data about the women,” Young says. “Researchers could come to us and say we want to study some disease, and we want to look at the blood samples that you have from 1993 and by the way can you tell us about the women? WIHS has all that information for them.”

Since the study began, WIHS has captured an abundance of valuable information on women living with HIV—including information that some women weren’t comfortable sharing

22

G EO RGE TOW N MEDIC INE

Insight Through Diversity WIHS’s focus on women—particularly women from underrepresented groups—might be its greatest achievement.

Lisa Helfert

Creating and Sharing Research


Historically, women and members of minority groups have been underrepresented in clinical trials. Study findings were often extrapolated across genders and races, resulting in approvals for treatments and medications often based on data derived from studies that primarily enrolled males, the majority of whom were white, says Kassaye. WIHS has provided the opportunity to understand the long-term effects of HIV treatments on women in more specific and less represented groups, like Black women. Through WIHS, new information on the medications’ use, side effects, toxicities, and dosing have emerged. “If those groups are underrepresented in the clinical trials, the observational studies that we conduct provide an opportunity to really look at how the pharmacogenomics of these medications may vary among different groups,” Kassaye adds. “We also look at disparities and how well people do, for example with medication. Variations may be due to social and structural impediments.” Kassaye’s team recently published results in JAMA Open Network from a national multi-center WIHS study looking at the struggles of daily living for HIV-positive women. For many, the challenges make it difficult to manage the disease and maintain a low viral level.

Lisa Helfert

Staff like Glo Lamb Woodfork help nurture the sense of community at WIHS. She has welcomed visitors to the WIHS office for 15 years. “I greet everyone with a hug,” she says.

Challenges such as unstable housing and lack of social support constitute ongoing barriers to effective and sustained viral suppression, she notes. “Day-to-day survival is a priority over putting a pill in your mouth for a number of our participants, and that is the public health challenge we must address.”

Reaching universal treatment and viral suppression will require wraparound services that can effectively address women’s social and mental health issues, Kassaye says. “The truth of their lives is a lot less rosy than a few lines of statistics in a summary report can reveal,” she adds. “When you see a grandmother, her daughter, and her granddaughter come into the clinic for HIV treatment, you realize there is much more we need to know.” The study also gives doctors the ability to further understand HIV’s long-term effects and the co-morbidities affiliated with the disease. Early on, some clinicians feared that women infected with HIV would experience much higher rates of cervical cancer, but gynecological monitoring and care through WIHS has helped disprove this theory.

The Future of WIHS As the work of WIHS continues to shed light on improving care for women living with HIV, the study is transitioning into a new phase. This year the National Institutes of Health merged WIHS with the male-focused long-term HIV study known as the Multicenter AIDS Cohort Study (MACS), to form the new MACS/WIHS Combined Cohort Study1. While this move comes with many benefits including the opportunity to look across gender, it poses challenges as well. Above all, Kassaye wants to ensure that the women are not forgotten as the study proceeds. “I think what made WIHS unique before was that unwavering focus on women,” she says. “We must continue to be able to answer questions that are relevant to women and women’s health today and into the future” In the past 26 years, WIHS has collected invaluable medical and psychosocial information on women living with and at risk of contracting HIV. Over the same time period, HIV treatment has made tremendous advances, shifting the disease in the public consciousness from a brutal death sentence to a manageable chronic condition. But Kassaye is quick to note that HIV remains an epidemic that affects over a million people in the United States, and research must continue. “We can’t become complacent,” she asserts. “People should be aware of risk. We can’t lag in terms of educating our youth. They must be aware and able to protect themselves as well. Approximately 39,000 new cases of HIV are diagnosed per year, a number that has remained steady since 2013. It’s better than before, but we still have a long way to go to completely end the HIV epidemic and stop new infections. I think education and awareness are key elements that everybody can participate in.” n 1

The research described is supported by a grant from the National Institutes of Health (#1U01HL146205-01).

FA L L / W I N T E R 2 0 1 9

23


HIV & A IDS

ALUMNI IN THE FIELD

Eric Daar Eric Daar, MD (M’85), cared for his first AIDS patient as a Georgetown medical student on rotation. After graduation, he returned to his hometown, Los Angeles, to pursue a residency in internal medicine at Cedars-Sinai Medical Center. Located in the middle of West Hollywood and at the center of the gay community, the hospital quickly became a hub for the HIV epidemic in the 1980s. “We saw the disease evolve into a global pandemic before our eyes. The disease was affecting my peers, mostly men in their early 30s. It struck close to home,” says Daar. During residency and the early years of his infectious disease fellowship, Daar cared for many patients with HIV and conducted lab work in HIV-related clinical virology. Soon his research interests resonated with what he saw in patient care. During his fellowship, he was a lead author of a New England Journal of Medicine article characterizing the virology during the early stages of HIV infection. “In the beginning, we were just trying to support young people who were dying,” he remarks. “Now, if someone living with HIV is doing well on treatment with viral suppression, they don’t have to worry about developing the complications of AIDS. In addition, they can be assured that they won’t transmit HIV to their sexual partners, and with evolving therapeutics it’s possible that in the near future one may only need as few as six days of treatment a year.” Now a professor at the David Geffen School of Medicine at UCLA, Daar is chief of the Division of HIV Medicine at Harbor-UCLA Medical Center and principal investigator with the Los Angeles Biomedical Research Institute. He currently leads a multinational study to identify and characterize people with acute infection. The study looks at how very early treatment of HIV infection impacts the size of the viral reservoirs which develop early in HIV infection, and is recognized as a major obstacle to potentially curing people of their infection. His work focuses on catching the disease early and intervening with therapies that could make patients more responsive to potentially curative interventions in the future. In other studies, he tracks patients over time to understand the impact chronic HIV infection has on neurological and cardiovascular complications of infection, which have until recently taken a backseat to the immunological pathology.

Since the early days of the epidemic, much more is understood about how researchers and clinicians can better partner with people living with HIV. “We’ve learned the importance of working with the community,” Daar says. “We need to solve human problems with the help of those affected.” Advocacy played a major role in advancing HIV research and treatment, he adds. “It changed government behavior and even shifted the FDA perspective, making rapid drug development possible. Working with the community continues to be important in overcoming obstacles. We need to address substance abuse, psychological diseases, homelessness, and healthcare disparities by close linkage with the affected community. This is a problem for everyone, not just those living with HIV.”

“We’ve learned the importance of working with the community. We need to solve human problems with the help of those affected.”

24

G EO RGE TOW N MEDIC INE

Some tools for HIV prevention can have benefits for other public health concerns. “Many HIV and hepatitis C outbreaks have occurred where simple interventions like needle exchange programs would have helped,” Daar notes. Amidst the devastating losses from the epidemic, Daar also sees some remarkable outcomes. “Defining the biology of HIV, and the relative rapidity of the drug development process, have been extraordinary. The pace of progress—from being universally fatal to universally treatable—came out of new collaborations among government, industry, non-profits, and universities.” Georgetown made a profound impact on his career, Daar says, as both a physician and researcher, giving him the opportunity to train with infectious diseases faculty like Tom Cardella, MD (C’60, R’65), at D.C. General. “My four years at Georgetown were instrumental to everything that I am, and everything that I’ve become.” n —Jupiter El-Asmar (F’17)


FAC ULTY POINT OF VIEW

Resilience, and Remembrance By Michael Plankey, PhD

Washington Blade photo by Doug Hinckle

1982

New Haven. Bone scan, liver scan, gallium scan. A gallium-67 scan was always the death sign. I lost countless numbers of gay men who died shortly after I finished their scans. I knew who I was so each death in this community of men kept the voice in my head screaming ‘Don’t you dare come out’ alternating with ‘No more deaths.’ I remember where I was standing in the hospital when scientists thought the cause of these deaths was related to poppers use—inhaled nitrites. I felt hope, but it was quickly dashed. It would not be that easy. 1990 Preoccupied with my clinical epidemiology training, I was distracted as the next wave of deaths hit just as combination therapy was failing rapidly. 1995 I moved to Washington, D.C. for a post-doc fellowship. I was encouraged by a few new friends to work on the NAMES Project for the 1996 display of the AIDS Quilt in D.C. (It would be the last time the entire quilt was displayed here). On my hands and knees, I helped nail the panels down each morning and fold them up each evening. Along with all of those nails, my tears were in that ground, too. As I passed through the stages of grief, the Quilt helped me accept. I became an openly gay professional with many friends living with HIV due to new a ‘cocktail’ therapy. 1998 By the end of my fellowship, I was reintroduced to HIV, this time in a more positive way: I took a job working with Jim Goedert, Bob Biggar, and Phil Vigro with the National Cancer Institute’s Viral Epidemiology Branch. HIV, hepatitis B and C. Hemophiliacs. Gay men. Women. Pathogenesis, clinical outcomes, genetics, behavior, and mental health. I had come out, but I also came into this impassioning work. 2006 Deciding to work at Georgetown was not easy for me. I needed to contend with its long history of unkindness toward gay men and women, particularly gay men with HIV. Despite my trepidation, I decided to come to Georgetown. I was determined to find a successful voice here. I have accomplished this through my research, teaching, and mentoring. Most importantly I have become a fearless advocate for assuring the humanism of HIV both scientifically and institutionally at Georgetown. 2019 My most important work over the last five years has been to discover how HIV+ men find and use their resiliencies to live well despite their infection. It’s my ‘owned’ adaptation of cura personalis.

For all who have passed away from HIV-related causes— caring for you, being your friend or partner has made me stronger. I remain confident that my ongoing scientific work contributes to the wellness of those still living with HIV. n A clinical infectious disease epidemiologist and professor in the department of medicine, Plankey is senior co-investigator for the Baltimore-Washington site of the Multicenter AIDS Cohort Study and Women’s Interagency HIV Study Combined Cohort Study. He is faculty advisor for the medical school’s LGBTQ and allies group Hoya Med Alliance founded in 2008, and for Georgetown Medical Review, the student-run academic journal launched in 2016.

FA L L / W I N T E R 2 0 1 9

25


HIV & AID S

Global HIV Response Reprioritizing the Local By Lauren Wolkoff (G’13)

In towns and cities throughout Kenya, the drivers of the ubiquitous boda boda, or motorcycle taxis, gather each month to talk about wide-ranging issues. Sometimes the topic is police harassment, other times it might be about how to access better banking systems. Discussing their risk of HIV ranks pretty low on the list of priorities. Yet researchers at Georgetown University Medical Center feel these types of grassroots gatherings may hold an important key to engaging communities around HIV and other health issues. Together with partners on the ground, they regularly attend—without any agenda except to listen. “When you engage people in what is actually important to them, and listen to what they are saying they need, you find you can often engage them over health issues as well,” says Sylvia Ojoo, MBChB, DTM&H, MRCP, associate professor of medicine and faculty codirector for the East Africa region for Georgetown’s Center for Global Health Practice and Impact (CGHPI). Through an ongoing project, CGHPI researchers seek to tap into and strengthen these types of communities of practice in Kenya, Malawi, and Eswatini. Their aim is to link health service delivery at the grassroots level with policymaking at the national level. This approach flips the conventional script on how to approach complex health topics. Rather than deciding what they want to talk about and then convening a meeting about that topic, the researchers are working with local stakeholders to identify where conversations are already happening—and listening closely to the topics that matter to the people in the room. The motorcycle drivers, for example, may not immediately identify their health as a major concern. “And yet we know they are concerned about traffic deaths. From there, we ask them what are some of the other causes of death, and at that point they may mention that HIV is one of them,” says Ojoo, who is based in Nairobi, Kenya. “Our interests eventually begin to intersect because they see that we are listening and trying to help with things that may be completely unrelated to health.”

Communities at the Center The notion of communities taking the lead in identifying their own needs is not new or radical. In fact, more than three decades ago, the global HIV response drew tremendous strength and momentum from the fact that it was, at its core, community-led and -owned. “The HIV response worked, not because it was medicalized, but because it was about Background image: The densely populated Kibera district in Nairobi


people,” says Mark Dybul, MD (C’85, M’92, H’08), co-director of CGHPI and professor at the School of Medicine. “In the beginning, before we ever had effective antiretroviral therapy, we had a massive community-led response with communities coming together from the U.S. and around the world. Their creativity and innovation were driving the response.” Dybul, the 2012 recipient of Georgetown’s Timothy S. Healy, S.J. Award, previously served as executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria and as U.S. Global AIDS Coordinator, overseeing the implementation of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). In these roles, he saw how community demand and action galvanized political response, paving the way for high-level partnerships, political buy-in, and, ultimately, substantial funding from donors and countries alike. In fact, spending on HIV from 2000 to 2015 is estimated at more than a half a trillion dollars, according to a 2018 analysis by the University of Washington. After a prolonged wave of momentum and progress, however, Dybul now argues the global HIV response “has hit a wall.”

Treatment and Prevention In some ways, the response has fallen victim to its own success. The surge of interest and energy was undeniably transformative in terms of producing data, driving research, yielding better treatments, and building capacity in countries. But it has also had the effect of recalibrating the response towards the priorities of people outside of the communities they seek to serve. The initial grassroots groundswell has given way to a different paradigm—one in which the partnerships and funding drive the priorities, Dybul says. And while treatment options today are better than ever, the needs of communities have faded into the background—with both prevention and service delivery suffering as a result. “HIV prevention was a big deal when treatments were not available—it was one of the best weapons we had at our disposal to prevent new infections,” says Deus Bazira, DrPH, MPH, MBA, associate professor of medicine at the School of Medicine who joined Georgetown earlier this year as codirector of CGHPI along with Dybul. An expert in health systems strengthening in emerging economies, Bazira’s field-level practical experience spans two decades and more than 15 countries. Before Georgetown, he led an extensive program implementation and research portfolio at the University of Maryland, Baltimore, where he founded and

directed the Center for International Health, Education, and Biosecurity at the Institute of Human Virology. Over time, the global HIV community shifted the emphasis away from prevention to increasing access to treatment, as antiretroviral therapies became more readily available. The most recent UNAIDS report, published in July, shows that progress in reaching key populations with effective prevention approaches has stalled. These groups include people who inject drugs, gay men, transgender people, sex workers, and prisoners. The report casts doubt on the ability to achieve the United Nations’ goal to end the HIV/AIDS epidemic by 2030. Notably, young people are not being reached effectively by current prevention efforts, a fact Dybul cautions will lead to a “massive resurgence in the epidemic” in the near-term if not addressed swiftly, given demographic trends. The population of sub-Saharan Africa is expected to double to 2.4 billion people by 2050, according to projections from the United Nations Population Fund, and the majority of them will be young people. Bazira says that the challenge of reaching young people means thinking differently about prevention efforts. “We need to understand that they are living in a different world. They interact via social media, and they are living as part of a global community. Some of the strategies in behavior

Kenya’s boda boda drivers gather informally but also organize monthly meetings to discuss issues in the community.

change communications that worked in the 1990s and 2000s are probably not the way to approach this generation,” he says. How can we meet this challenge? “We need young people to be engaged in designing new prevention interventions,” says Bazira. “We need, for once, to ask them what they can do to make sure their generation remains AIDS-free.”

Reframing the Response The CGHPI-led initiative in Kenya, Eswatini, and Malawi offers an opportunity to reframe the HIV response by taking


HIV & AID S

the work back into the communities, enriched by the advances and the lessons from the past three decades. Known as Business Process for Impact (BPI), the initiative seeks to ensure that communities are at the center of articulating their own challenges and generating their own solutions. The guiding premise is that the best solutions are those that are driven locally. BPI identifies existing community groups that have come together organically around issues important to them, and systematically links them to other communities. Through these connections, they can share best practices, as well as send their ideas and conversations up the chain to policymakers in order to bring about change.

Growing up in a community ravaged by HIV and AIDS inspires Bazira’s work to promote global health equity.

“The goal is that if good ideas are developed in one community, they are more readily shared across communities, and that they are brought up to the policy environment in each country to have even greater impact,” says Charles Holmes, MD, MPH, faculty co-director of CGHPI and visiting associate professor of medicine at Georgetown. From community to community and country to country, the CGHPI researchers know that evidence-based interventions that put people and their communities at the center of an HIV plan are more likely to be accepted and thus more successful. Soon the CGHPI researchers will integrate principles of BPI into HIV interventions in Central Africa and the Caribbean, in places where the HIV epidemic seems intractable. Supported by a multimillion dollar award by U.S. Centers for Disease Control and Prevention, through funding from PEPFAR, the work is intended to support selected countries to achieve and sustain epidemic control of HIV, tuberculosis, and malaria through a program called TIDE, or Translating Data and Evidence into Impact. “These are regions where the HIV response still has a way to

28

G EO RGE TOW N MEDIC INE

go, and innovative successful approaches need to be optimized,” explains Bazira. “We won’t have true global public health protection on the HIV front until the epidemic is over, and it won’t be over until we close the persistent gaps.” As with the motorcyclists in Kenya, the idea is not to convene community members around a certain topic, such as HIV, but to go where they are already gathering and let their agenda be the guide. “These groups already exist and meet regularly because they have a structure that they have defined for themselves,” says Ojoo.

From the Field Up Though overseen by Georgetown and funded by the Bill & Melinda Gates Foundation, BPI is not about Western entities imposing a solution based on what might work elsewhere. To the contrary, the goal is to establish a process—a blueprint of sorts—that can support communities and countries in working out their own solutions. “The days of people flying in thinking they have all the right ideas are over. Of course, there is room for sharing expertise across universities, national programs, and communities. But it cannot be a unidirectional process,” says Holmes. Georgetown’s role in this endeavor is essentially to provide the scaffolding—the financial and technical support—to ensure that community voices are better heard, and that the innovation taking place at the grassroots level has the best chance of shaping national systems and policies. “We are involved, and frequently on the ground, providing some of the resources that are needed to facilitate greater sharing, and to strengthen the community systems that are already in place. But a lot of the frontline work is done increasingly by the national stakeholders themselves,” Holmes says. “We don’t go in to countries saying that we are from Georgetown, or from Washington, D.C., and we know what you need to do. We say, ‘This is our process. Does it resonate with you? How do you see this working? What is your solution?’ And then they create it,” echoes Dybul, who is the principal investigator on BPI. One universal truth that has surfaced is that there are no universal truths. In Kiambu county, Kenya, for example, Georgetown partners are meeting with groups of young people, mostly adolescents and young adults. These young Kenyans express concerns about finding jobs once they are out of school, or if they are out of school, just being able to make ends meet. “The risk of getting infected with HIV doesn’t even come up among the first three priorities for them,” Bazira says. In terms of their health, he explains, their main concern is the risk of getting pregnant or getting someone pregnant. They are not thinking about HIV, even though they may be at risk. “You have to understand where they are coming from, and


how to work with them as partners to find solutions. If you simply come with some boilerplate of a prevention strategy that may have worked somewhere else, and you assume it will work here, you will be in for a rude surprise. That is our challenge for scaling up so-called best practices,” Bazira says.

perhaps because it is too densely packaged or technical. “We need to do a better job of understanding what the data needs are of each group, each layer of the communities of practice, and delivering just the data that is absolutely essential,” Dybul adds.

Designing for Human Need

A Sustainable Response

In international development, there is popular label for grounding both research and solutions in the needs and wants of the people for whom they are meant: human-centered design. Done well, it encompasses a truly multisectoral approach— integrating elements from anthropology, behavioral science, market research, and data science. As a discipline, human-centered design has been used for decades in marketing to figure out what consumers want— understanding people’s incentives, their challenges, and what types of messages resonate with them. The same principles apply in health care, Dybul says. “As a physician, I can tell you that if you listen to a patient, not just their words but also their body language, they will tell you exactly what is wrong with them before you order $1,000 worth of tests. But it takes time to listen and to meet them where they are.” Human-centered design is not just about the patient experience, however. There needs to be engagement at all levels of the community in order to ensure the right linkages are happening and to bring about accountability. For example, Ojoo notes that the head of state in a given country may not be getting the necessary information to make decisions about health care expenditures. “Maybe nobody has ever told them that if you fail to treat HIV properly, this number of people will die, and this would be the cost to your national economy,” Ojoo says.

At the heart of all of these efforts, ultimately, is sustainability. By building communities of practice, emphasizing humancentered design, and optimizing data use, the vision is for communities and countries to be better situated to address their own HIV burdens over the long term. “Countries know that the global fight against HIV has to be won, but they also know that they are going to be the ones who have to sustain epidemic control once we cross that line,” Bazira says. Georgetown’s location helps ensure that the insights and evidence gathered in the field make their way to the desks of global policymakers. The university’s mission to improve the human condition and solve problems for the greater good means researchers are not concerned with protecting the status quo in international development. “We are in the business of generating knowledge, and then putting that into practice through service,” Bazira says. “And we are not scared of working ourselves out of a job.” n

Making Sense of Data For communities to play a central role in designing their own solutions, they need better access to data. This does not mean more data—to the contrary, there is already too much data available for local communities to digest. In HIV alone there can be as many as thousands of indicators for one country. Through BPI, researchers are focused on pairing relevant data with the relevant audience—whether it be a community business group or a county governor. “Technical people like us consume a lot of data that would be meaningless to the motorcycle rider. But if you could tell them that last month they had fewer deaths, and here are the causes, they can then refocus their attention on what matters to them,” says Ojoo. “Whatever it is they are interested in, they can monitor.” At the same time, countries are collecting and reporting magnitudes of data that will never make it to policymakers,

THE TWELF TH ANNUAL

Georgetown University Medical Center Convocation Monday, November 18, 2019 n n n

Colloquium on HIV/AIDS 10-11:30am Convocation Ceremony with Wafaa El-Sadr, MD, MPH, MPA 2019 Cura Personalis Award recipient 2:30-4pm Reception follows For more information: gumc.georgetown.edu

FA L L / W I N T E R 2 0 1 9

29


HIV & AIDS

HIV EDUCATION

At Georgetown, learning about HIV is a hands-on experience By Christina Frank

One evening at the Hoya Clinic in 2017,

Jack Pollack (M’20) volunteers regularly at the student-run Hoya Clinic.

a medical student volunteer performed a rapid HIV test on a patient, and it came back positive. The volunteer clinic manager that night was Jack Pollack (M’20), a second-year med student at the time. “I had a quick meeting with our faculty supervisors, Dr. Saulters and Dr. Quinn, and the other students on how best to share this information and make sure we had the next steps planned out as well,” says Pollack. “The supervising physicians led our team seamlessly through the process as they prepared to break the news to the patient and do the confirmatory diagnostic testing. The experience was so important in terms of preparing us to handle similar situations going forward.” While learning about the biology and modes of HIV transmission in the classroom is invaluable, students and faculty agree that the numerous hands-on clinical experiences available to students at Georgetown are a critical part of health and medical school education, particularly when it comes to HIV. According to the D.C. Department of Health, as of 2017, 1.9 percent of the city’s residents were living with HIV, a figure that is considered above the epidemic level. This puts Georgetown in a unique position to serve the community—a mission that aligns with the school’s Catholic, Jesuit principles of service and cura personalis, caring for the whole person and for every person uniquely and fully.

For over a decade, Mary Beth Levin, MPH, has led a course on service learning, offering second-year medical students the opportunity to do community outreach. Levin is an associate professor in the department of family medicine and faculty advisor for the Georgetown Medical AIDS Advocacy Network (GMAAN), founded by medical students in 2008. Under her guidance, students have volunteered on the mobile unit of the local syringe exchange, performing a number of tasks: conducting street outreach; providing patient education on HIV, viral hepatitis, overdose, and wound care; entering data; and making treatment referrals for substance use disorder. Outside of class, they’ve educated their peers and held bake sales and bottled water drives in support of the program. In 2012, GMAAN students went to the emergency department at MedStar Georgetown University Hospital to suggest a new approach to broaden the scope of HIV testing. Within six weeks, the students had secured an annual grant from the

30

G EO RGE TOW N MEDIC INE

Lisa Helfert

Learning Through Service


D.C. Department of Health that allowed them to provide rapid oral opt-out testing in the emergency department using CDC guidelines. The grant ended in 2017, at which point GMAAN began to offer HIV and STI testing at the university’s student health center. GMAAN has also partnered with One Tent Health, a community-based organization that offers free pop-up testing at local grocery and convenience stores in selected D.C. neighborhoods. One Tent was founded in 2016 by Mackenzie Copley (C’15), who got the idea during his senior year at Georgetown. Currently there are over 1,000 student volunteers from local universities including Georgetown, George Washington, Howard, and American universities, as well as the University of Maryland. Since 2017, nearly 400 people have been tested, including students and members of the community. In Levin’s six-week selective course, called “HIV: Cultural Competency and Community Activism,” activism and advocacy are stressed. As a result, students have participated in rallies, made phone calls to senators, and lobbied on Capitol Hill to advocate on an assortment of HIV-related issues. “When given the opportunity, students embrace these formative experiences that will shape them for the rest of their lives,” says Levin. “We are preparing the next generation of leadership in the fight against HIV.”

Rotations and Reform

Left: One Tent Health / Right: Alamy

Students have played a big part in making other types of clinical opportunities happen, as well as effecting change in how LGBTQ health in general (which encompasses HIV) is taught in the classroom. Michael Plankey, PhD, professor in the division of infectious

diseases in the department of medicine, is faculty advisor to Hoya MedAlliance, Georgetown’s LGBTQ and ally medical student group founded in 2008. Plankey had always wanted to set up a clinical rotation at Whitman Walker Health, the HIV and primary care clinic in D.C. that focuses on LGBTQ health. The idea didn’t become a reality until 2017, when Evan Cooper (M’17), then a fourth-year year medical student and president of the Hoya MedAlliance, told Plankey he wanted to do a rotation there and asked how to make it happen. “It felt like manna from the heavens, because I had been wanting to do this,” Plankey says, “Students are quite powerful in getting what they want from their medical education.” After completing the rotation, Cooper took a proposal to the medical school’s Committee on Medical Education, which resulted in the establishment of a four-week rotation offered to medical students in their fourth year. Rather than a selection by lottery, students apply for the opportunity by demonstrating their interest in LGBTQ health. “We really want students who have a passion for this specific area of health care,” Plankey says. At around the same time as the rotation fell into place, two medical students set out to examine the entire curriculum’s treatment of LGBTQ health. Tim DeVita (C’14, M’20) and Casey Bishop (M’18) combed through lecture captures and lectures given in the preclinical years to see what content existed regarding LGBTQ health and where there were gaps. Using standards and competencies set by the Association of American Medical Colleges and Vanderbilt University, they found that Georgetown’s medical school curriculum completely covered seven LGBTQ health competencies, partially covered eight competencies, and did not cover the remaining 15 competencies.

Left: Founded by Georgetown undergraduates, One Tent Health brings HIV prevention to D.C. communities, offering free screening outside of grocery stores and laundromats. Right: Medical students helped establish a Georgetown rotation in LGBTQ health at D.C.’s Whitman Walker Health.

FA L L / W I N T E R 2 0 1 9

31


HIV & AID S

Second-year medical students in Levin’s “HIV: Cultural Competency and Community Activism” course lobby on the Hill on an HIV issue of their choice.

The unmet ones tended to be in mental health and endocrinology. They set about tackling the deficiencies. With the administration’s full support, Bishop presented their work to the medical school’s Council on Diversity Affairs and requested that the competencies be added to the curriculum. The methods and findings involved in the project were ultimately published in the journal Medical Education Online in 2018 with the title “Queering Medical Education: systematically assessing LGBTQI health competency and implementing reform.” “Georgetown has really been enlightened in terms of its LGBTQ clinical medical education,” says Plankey.

Battling Stigma Despite significant strides in HIV treatment and perception, stigma surrounding HIV is still present. Professor Melody Wilkinson, DNP, director of the Family Nurse Practitioner Program at the School of Nursing & Health Studies, makes a point of addressing biases and stigma in her classes. “We specifically teach the students how to have difficult conversations with patients, particularly when it comes to HIV and other STIs,” she says. She does this via lectures, but also by simulating clinical situations. A student may have to take a sexual history, for example, or talk to a patient about PrEP (pre-exposure prophylaxis), or tell someone their test came up positive. “By challenging them and mentoring them as they sit in that uncomfortable space, they’re learning how to navigate difficult conversations with patients.” The first step, Wilkinson says, is for students to confront their own discomfort and their own barriers and develop the tools necessary to move forward with those types of conversations.

32

G EO RGE TOW N MEDIC INE

“We all approach every encounter through our own lens and our own experience. And providers themselves may have bias that they carry into the room that can create barriers and make situations challenging. I’ll still hear students, when they start to take a sexual history, assume someone is married to a member of the opposite sex. Our job is to help them pause and realize that the words they are selecting may be related to their own experience. And those words in and of themselves may carry judgment, though not intentionally.” Wilkinson believes that thinking of the whole person in this way underpins everything about a Georgetown education, and says it’s one of the reasons she chose to work at the university. “In graduate nursing, we use a very holistic model. So it’s never about simply walking in, providing a medical assessment and filling out forms,” she says. “We want to know how the individual is feeling, and that is true not only when we talk about HIV. That’s true when we talk about diabetes and hypertension and childhood illnesses. “Georgetown attracts students who are interested in service. We are training highly skilled, evidence-based clinicians, who operate from the framework of Jesuit values that places them in areas where there are health disparities.” Maya Jackson, MD (M’18), credits Levin’s course with opening her eyes and inspiring her to engage in advocacy. “Prior to my enrollment in the class, I was naïve in my thinking about HIV and AIDS,” says Jackson. “I hate to admit that I was one of those people who thought HIV and AIDS affected a certain type of person, and part of that was because of the stigma that is attached to HIV within my family and within my community.” In 2006, Jackson’s cousin died of AIDS-related complications, but she was told he died of brain cancer. It was not until her sophomore year of college that she was finally told the truth about his cause of death. Even after receiving this news, however, her perception of HIV did not change. “I still believed that it was a disease that affected a certain type of person. I now understand that HIV is not a disease that is restricted to a certain class, ethnic group, or sexual orientation.” When told that she would have the opportunity to lobby in support of a bill related to HIV, Jackson selected the Stop AIDS in Prison Act based on her desire to help vulnerable populations. “As an African American woman, I was appalled and horrified by the statistics on HIV in the African American community and specifically the prison population.” The lesson Jackson learned reflects what Georgetown’s School of Medicine hopes to impart to its students now and going forward. “We as a nation have to combat this disease,” she says. “We cannot shy away from discussions about HIV and AIDS any longer.” n


ALUMNI IN THE FIELD

Robert Redfield As director of the U.S. Centers for Disease Control and Prevention since 2018, virologist Robert Redfield, MD (C’73, M’77), is optimistic about the future of HIV treatment. “Never underestimate the possible,” he says. “We’re going to bring an end to the HIV epidemic in America. We’re going to do that by putting the science into action. We’re going to get people diagnosed, get them into treatment, and get them to stay in treatment. For those at risk, we will get them access to healthcare and PrEP, and we will show the American people that we’re applying what we’ve learned since 1981.” After receiving his medical degree from Georgetown in 1977, Redfield pursued his residency and fellowship at Walter Reed Army Medical Center and had his first assignment within research in 1982. His task was to study viruses which could cause significant problems for active duty military personnel, either through blood transmission or as a sexually transmitted disease. He spent much of his time learning about a new syndrome called AIDS. All active duty personnel diagnosed with AIDS and their families were referred to Walter Reed, and Redfield became their primary physician. “The story of HIV is a very exciting one for the power of science,” says Redfield. “In 1981, we had a new syndrome with no etiology affecting young people in their prime, and modern science couldn’t help them. By 1984, we knew the cause to be HIV. We knew how it was transmitted, and we knew how to diagnose it with a blood test. Two years later, we began looking at how we could therapeutically intervene. We can now expect a 20-year old with HIV to live another 53 years.” In 1983, he was working with a colleague at NIH to validate a hypothesis from the University of Chicago claiming to have uncovered the cause of the virus. Although they found the hypothesis to be inaccurate, Redfield then collaborated with Robert Gallo at the National Cancer Institute later that year to develop an etiology for AIDS. Their work was grounded in the fact that Redfield’s experience with patients at Walter Reed was unique. Around 30 percent of his patients were women, and around 50 percent of them were married. He found that the spouses of his AIDS patients also had low T-cell counts. The researchers sought to

isolate the new retrovirus and determine conclusively if HIV was a sexually transmitted disease. After two decades at Walter Reed, he left the military and co-founded the University of Maryland’s Institute of Human Virology with Drs. William Blattner and Robert Gallo, and he served as chief of infectious diseases and vice chair of medicine at the medical school there. Just last year, he assumed his current role leading the CDC.

“As we encourage those at risk for HIV to seek care, we need to meet them in their journey. This means clearing the path of stigma, finding more comfortable ways of delivering health services, as well as learning from individuals already in treatment so the journey becomes easier for others who follow.” —Redfield in June 2019 CDC press release

Redfield credits Georgetown for providing him with a strong pre-clinical and clinical foundation, and finds that its Jesuit identity truly sets it apart. “I had great clinical training, and Georgetown instilled in me to do that training with purpose, to use our skillset to impact the lives of all people in an equitable way,” says Redfield. “It was a great place to learn the art and science of medicine.” “Georgetown was critical in terms of my formation as a young adult and young physician,” says Redfield, noting that he is a member of the university’s a cappella singing group the Chimes. “The Jesuit tradition is important to me—women and men for others and a commitment to health justice and equity, seeing the gifts of science applied equitably. Georgetown taught me that science and medicine are made to impact public health.” n —Jupiter El-Asmar (F’17) Above: Redfield and Tedros Adhanom Ghebreyesus, WHO Director-General, met in the Democratic Republic of the Congo to discuss international Ebola response.

FA L L / W I N T E R 2 0 1 9

33


ON C AM P US STUD ENT POINT OF VIEW

The Hidden Costs of Medical School By Lawren Wooten

M

y kindergarten teacher once told my mom that I don’t do well with free time. The same could be said of me today. For the past five years, I have been in school and working, sometimes both full time. Like many pre-med students, I took “time off ” after college. I served in AmeriCorps and then completed a post-baccalaureate year of graduate coursework. Then, in order to pay for medical school applications, I worked full time for surgeons while earning an accelerated master’s degree, which I completed in September of my first year of medical school. I like to be busy—or so I think. Has it become the norm out of necessity?

According to the AAMC, more than half of the 2018 matriculants to American medical schools had a parental income in the top 20 percent. There are many obstacles on the road to medical school, but money can be the ultimate challenge that prevents students from applying or attending. In fact, students often take out loans just to cover their applications. The Medical College Admissions Test (MCAT) costs $315. American Medical College Application Service (AMCAS) costs $160 plus $39 for each medical school primary application. Most schools automatically send a secondary application requiring an additional $50-$150. After months of research, I applied to 17 schools and submitted secondaries to 12; these numbers are considered low. By the time Georgetown accepted me, I had

34

G EO RGE TOW N MEDIC INE

spent over $4000 on application fees, the MCAT, travel to interviews, and deposits. Instead of buying groceries, health insurance, and gas, I paid to apply to medical school. I graduated from an Ivy League university with less than $10,000 in debt. After completing the post-bacc courses and my master’s degree, I was $60,000 in debt. Now as a medical student, financial insecurity persists. I constantly worry that money will prevent me from reaching the goal I have had since kindergarten. According to the Association of American Medical Colleges (AAMC), average medical school tuition and fees are around $60,000 per year. Many students mitigate the financial burden by attending more affordable state universities. As a D.C. resident, this was not an option for me. Certainly, access to federal loans benefits those of us who need them. But just like with credit cards, postponing the need to pay tuition from our empty pockets can provide a false sense of freedom. In addition to tuition and fees, we have living expenses and additional academic costs. In order to live near campus, many Georgetown students pay $1500+ per month for a share in a group house. Some courses require e-textbooks only available on Apple devices. Students on clinical rotations must pay for their transportation and parking. To secure a residency position and practice medicine, all medical students must complete the multi-step United States Medical Licensing Exam (USMLE). Medical schools do not (and in my opinion should not) teach to the


Lisa Helfert

On the job: As a busy medical student, Lawren is grateful that her part-time work at the Hoya Kids Learning Center is also fun.

test, but this means students have to supplement with outside resources like prep courses, which range from hundreds to thousands of dollars. The actual exam is $600-$1,000 for each of three steps. Several residents told me that as fourth-year medical students, they spent nearly $10,000 on the application and interview process. To be nationally competitive as candidates, they felt the need to take most interview opportunities offered—sometimes as many as 12. Flights and hotel costs for each trip add up, forcing some to borrow additional funds. These costs mean many medical students max out federal loan eligibility and resort to private loans with higher interest rates. With all these costs on top of tuition, many graduate with more than $300,000 in debt. In America, the average MD in their first year of training will earn $51,000—often less than the cost of one year of medical school. I didn’t know

how expensive this career path would be. Across the country, most medical students come from wealthy families. According to the AAMC, more than half of the 2018 matriculants to American medical schools had a parental income in the top 20 percent. This data point is telling—and helps explain why the American medical student community as a whole is relatively homogenous. At Georgetown’s School of Medicine, for example, 14 percent of students are from populations underrepresented in medicine. As a result, a person of color is often the only one in a room full of students, faculty, or staff; this can also be the case for students who do not come from wealth. For me, the combined stress of finances, academic demands, and being an “only” in the room is exhausting, isolating, and detrimental. It can be difficult to find peers or faculty who sympathize with these struggles, so

a small but important student cohort ends up with minimal or no community support. For example, I was advised against working while in medical school, but the income is a necessity for me. I believe medical schools could diversify their classes and improve student wellness by addressing these financial stressors, particularly by decreasing fees for applicants, lowering student tuition and fees and increasing non-loan financial aid. These actions would provide greater financial equity to applicants and students, and increase the level of diversity in medicine. In my opinion, medical schools have an opportunity and a duty to actively address this challenge if we are to produce caring and diverse doctors. n Lawren is in her second year at the School of Medicine, and enjoys doing the hokey pokey with Hoya Kids, and playing cello.

FA L L / W I N T E R 2 0 1 9

35


ON C AM P US

Learning Society Magic

For five years, transforming student experience through community building

A

s you walk into the library, nervous and excited to start your new life, you see house names at wooden tables beckoning you to sit with your new family. Colorful banners bearing the names of legendary faculty flutter against the wall. A man with a twinkle in his eye greets you and encourages you to compete for the yearly house cup. No, you’re not at Hogwarts School of Witchcraft and Wizardry. Dean Ray Mitchell welcomes students to Georgetown University School of Medicine by sparking a little magic through the learning society support model, launched in 2014. For the last five years, when medical students choose Georgetown, a learning

society community welcomes them in. At the White Coat Ceremony, first-years are presented a pin that inducts them randomly into one of five societies: Harvey, Rose, Stewart, Hufnagel, and Knowlan. At a school year kickoff barbeque, older students give out t-shirts in their society color to help new students find their tribe of 40 from each class year,

36

G EO RGE TOW N MEDIC INE

plus five faculty advisers. Over the next several years, students mentor one another in pursuit of mindfulness, resiliency, professional authenticity, and leadership. Dean Mitchell originally proposed the learning society model to provide a social and mentor-rich environment and a sense of cohesion for the 800 medical students. After a group of faculty and students agreed that such societies would improve the School of Medicine experience, the students took over, preparing by-laws and a structure for student leadership. “We originally planned just four societies,” Dean Mitchell recalls. “But one of the senior students, Matt Carpiniello (M’15), reminded us of the studies that show the number of people one can get to know well would not exceed 150, so we added a fifth.” Within each learning society are four academic families of 10 students each. They spend time together and share faculty and staff advisors and professional identity formation. Margaret Krackeler (N’16, M’20), student director of the advisory council that plans society events, says her experience of Harvey Society’s power to bring people together inspired her to get involved. Mary Furlong, MD (G’91, M’95, R’00), faculty director of the Hufnagel Society as well as senior associate dean of curriculum and director for the Office of Medical Education, wishes that she had

the chance to participate in the society model when she was a student at Georgetown. “The societies provide a great opportunity for students to get to know each other—in the context of their academic work and socially—and I love the fact that students also have a direct connection to faculty who are also members of the societies,” Furlong says. Society members bond through teambased academic lessons, service activities, reflection and speaker events, career development workshops, happy hours, and friendly competition: the more people per society who attend events, the more points the society stands to earn towards a trophy at the end of the year. Krackeler remembers feeling her academic family grow closer and less anxious through fun, stress-relieving contests. “It’s a way to channel our competitive spirits that provides a good balance between the rigors of academic courses and life,” says Krackeler. Research shows that social support systems are key for the wellness of medical students facing perfectionism, impostor syndrome, and isolation. Across the country, medical students report pressure from being evaluated in comparison to peers, especially during clinical years. The fear of looking less prepared than others can discourage students from asking for help. “The societies create a shared sense of vulnerability that allows for connections between different people,” says Erica Meninno (M’20), former reflection chair. “That’s ultimately what we’re all working toward—to feel connected and feel a sense of love and compassion for one another.” n

Dave Mohebbi (M’22)

By Kate Colwell


What’s Behind a Good Night’s Sleep?

Researching placebo effects in insomnia treatment By Kimberly N Uweh, PharmD

Jon Krause

W

hen I was a child, my grandmother told me that healing begins in the mind, but I objected, saying that healing starts when you take medicine. Fast forward 20 years later and I am a pharmacist, learning about mental health, psychiatric medications, and inconsistent patient response. That’s when it finally clicked: my grandmother was right! Many psychiatric patients take their medications as prescribed, but recovery is hampered by their belief that they will not get better, and this may be further complicated by a negative relationship with their doctor. To begin my journey to understand this problem, I earned a highly coveted postdoctoral fellowship for the GeorgetownHoward Universities Center for Clinical and Translational Science (GHUCCTS) TL1 Award Program. I have the privilege of being mentored and trained by pioneering sleep researchers Ihori Kobayashi, PhD, assistant research professor, and Thomas A. Mellman, MD, professor, both in the Department of Psychiatry and Behavioral Sciences at Howard University College of Medicine. Mellman is principal investigator for the study I’m working on, and director of both GHUCCTS and the Sleep and Stress Research Program at Howard University. When I began my fellowship, I didn’t know the clinical implications from unresolved sleep issues that persist for months and develop into insomnia. Insomnia is the most prevalent sleep disorder in the United States, and approximately one in five Americans develops the condition each year. Thirty percent of the U.S. adult population suffers from acute term

insomnia and ten percent of the population experiences chronic insomnia. Many patients resort to hypnotics and experience side effects, and do not obtain relief from their medications. Sleep is essential to basic human functioning but on a deeper level, sleep is an opportunity for every living being to restore and heal itself. The benefits of sleep include stress reduction and improved memory, along with lower occurrence of diabetes, mood disorders, obesity, and heart disease. Many people miss out on the benefits of sleep, and seek medical help for insomnia. Our current sleep treatment practices rely too heavily on the sole use of sleep medications, which come with side effects and potential for dependency. Our patients need and deserve more than prescription drugs to overcome their sleep issues. In pharmacy school we learned that if patients were compliant in taking their medications, they would be fine. When this did not seem to translate for patients with insomnia, I remembered my grandmothers comment on healing beginning in the mind. I researched mind and body medicine, and arrived at the question of how placebos benefit patients during clinical trials. Perhaps this was the missing link. At our next weekly lab meeting, we were reviewing participant cases from our ongoing double blind randomized clinical trial. All reported that they were doing great. Then a light bulb went off in my head! Could some participants be experiencing a placebo effect? After our lab meeting, I pitched my fellowship project idea to my mentors: examine the

characteristics of placebo effects during an insomnia clinical trial. I got the green light. My goal is to gain insight into the extent to which a patient can get better while receiving a placebo and also how it compares to a drug. We have our study participants complete questionnaires and sleep diaries throughout the clinical trial. And we use polysomnography, a multiparametric test and diagnostic tool to record brain waves while our participants sleep overnight in the lab. Understanding placebo effects taking place in my lab’s clinical trial for insomnia serves as an opportunity to maximize utility of placebos in future insomnia treatments based on mind-body medicine. From taking in my grandmother’s seeds of wisdom about healing to then becoming a clinical pharmacist, I have gone full circle as a researcher in this area. The occurrence and benefits of placebo effects are established in disease states such as pain and depression, yet there is currently limited research in sleep disorders. By conducting foundational research, I hope to use my interest in mind-body medicine to become a pioneer in understanding placebo effects in insomnia. n Completing her second year as a GHUCCTS fellow, Kimberly enjoys healing people through art and science. She is also an aspiring fashion designer.

FA L L / W I N T E R 2 0 1 9

37


ON C AM P US

Honoring A Legend work, and encouraged students and faculty to remember that they are part of a new era of achievement in medical education, research, and patient care. During the event, the medical school Class of 2015 dedicated their class gift to establish the new Donald M. Knowlan Endowed Scholarship. To close the night in style, Dean Ray Mitchell announced the medical school’s new Knowlan Medal which will be given annually to the best clinical teacher among graduating students. n —Allan Hutchison-Maxwell (G’14)

For more information about donating to the scholarship in Dr. Knowlan’s honor, please contact Mark Antonucci, mark.antonucci@ georgetown.edu or 202-687-6807.

Christina Hanna (F’08, M’14)

T

he 18th Annual Founders Day event in April honored the contributions of Donald “Coach” Knowlan, MD (R’60, W’82, H’04), doubling as a 90th birthday celebration with 200 of his closest friends, former patients, colleagues, and alumni. Knowlan’s tenure at the medical school has seen many advances in patient care and clinical training. A faculty member since the early 1960s, he credited the excellence of his colleagues for his success. Along with his faithful service to Georgetown, Knowlan served as physician to the Washington football team for over 25 years. He shared colorful highlights from his years in medical education at Georgetown, reminding all that frequently it’s the teacher who learns from the student. Knowlan reiterated that Georgetown continues at the forefront of preparing students for clinical


A L UM N I CON N E C T I O N S

What’s (not) in my white coat? Interview by Patti North

Lisa Helfert

In this installment of our series about the tools Georgetown alumni carry in their white coats, Nauman Siddiqi, MD (M’05, R’08) offers a twist. The interventional cardiologist at MedStar Union Memorial Hospital in Baltimore performs cardiac catheterizations and transcatheter aortic valve replacements, and said goodbye to his stethoscope years ago. Not only do I carry nothing in my white coat, but I hardly ever wear a white coat. I spend every day in the cath lab, wearing scrubs and a surgical gown or lead apron, doing heart catheterizations and valve replacement procedures, with no outpatient or hospital duties. I performed over 900 total procedures last year, and together with three colleagues, care for more than 3,000 patents who come through the cath lab each year. At the moment, cath labs with interventional-only cardiologists like us are quite unique, but the “sub-sub” specialization that I represent is the future of health care. When I graduated from Georgetown, a cardiologist who didn’t carry a triple-head Harvey stethoscope and ECG calipers would have been rare. Now I require only one tool: the cath lab. The patients are seen by an experienced team of general cardiologists located throughout the Baltimore area, and then are transferred to the MedStar Union Memorial Hospital. This “hub and spoke” model allows us to be better proceduralists at a

lower cost, while getting the best possible outcomes for our patients. With the transradial approach for cardiac catheterization, complication rates have been significantly reduced, patients recover in a lounge-like setting, and some even go home the same day after coronary stenting. In terms of aortic stenosis, only a few years ago these patients required open heart surgery, long hospital stays, and even longer recovery periods. Now with transcatheter aortic valve replacement, they are moderately sedated, but not knocked out, and often able to go home in 1-3 days. Using a small team of high-volume operators at a highvolume center, the procedures have better outcomes for our patients and significant cost savings. Not only that, we are able to recognize subtle trends very quickly and can make adjustments that benefit the patient almost in real time. Healthcare delivery has changed, so what you define as a tool doesn’t necessarily fit in your white coat anymore. n

FA L L / W I N T E R 2 0 1 9

39


Reflections on medicine with

Julie Silver, MD (M’91) I grew up in Northern California and was initially an engineering major in college. I liked math and science but didn’t want to sit at a desk all day. I liked to interact with different people. Medicine was the right mix. For medical school, Georgetown was my first choice. I fell in love with the campus. Georgetown offered a mix of training hospitals. In patients we saw tremendous socioeconomic diversity, ethnic and racial diversity, acute and chronic condition diversity, national and international patients. We treated prisoners too. During the time I trained in D.C., around 1990, we saw a lot of trauma. As a rehabilitation physician, it helped me understand the effects of gun violence. At the VA hospital, filled with patients with AIDS, an attending neurologist asked us what we thought filled the hospital when he was in training. Tuberculosis—surprising since by then there were so few cases. I learned about my specialty while on rotation at the VA, because we’d walk to the National Rehabilitation Hospital for lunch. I went to a table of doctors and asked them what they do. The specialty grew out of many who suffered from paralysis from polio, and from helping returning World War II veterans. Today the field includes sports medicine, cancer and stroke rehabilitation, traumatic brain injury, and more. Physiatrists are increasingly interventional—trained in electrodiagnostic studies such as EMGs and nerve connection studies. We do joint and trigger point injections. My primary clinical and research focus has been musculoskeletal and cancer rehabilitation.

I’ve seen a culture shift in professionalism during medical student training. There used to be no expectation to limit student work hours, and no repercussions for being disrespectful to students. We have a new normal—academic medicine has collectively decided to treat patients, medical students, trainees, and all people with dignity and respect, regardless of where someone is in the organizational hierarchy.

40

G EO RGE TOW N MEDIC INE

I got interested in workforce gender equity research when I became associate chair of my department. More than 60% of our faculty come from underrepresented groups. We worked to support them all equitably, but external barriers limited access to leadership roles, speaking opportunities, grant funding, and journal publishing. My research focuses on using data to

document disparities for women in medicine, and address them scientifically. Medical society recognition awards demonstrate the extent to which women are often not valued for their accomplishments. In one study, in a specialty with more than 40% women, for the most recent four years the society gave no awards to women—the inexorable zero. I direct a women’s leadership CME course at Harvard. We focus on teaching leadership core competencies, including equity, diversity, and inclusion. All leaders should be familiar with the evidence base on these, and using data to understand what’s happening at their institutions, addressing gaps scientifically, and transparently showing results.

To address gender discrimination in medicine, we should be thinking like scientists. In one study, we compared how often men versus women were mentioned and their work described in one medical society’s newsletter. In more than a third of their newsletters from the last five years, zero women were mentioned, for a specialty that is 42% women. In 100% of the newsletters, men were mentioned. People develop reputations by someone acknowledging their work. At Georgetown, I used to study in empty classrooms by Dahlgren Chapel. I loved seeing people celebrating weddings and baptisms, the cycle of life, the commitment to serving

humanity that Georgetown represents. It reminded me why I was studying, to make a difference in peoples’ lives, to make the world a better place. n

iStock / Wikimedia Commons

Associate Professor and Associate Chair, Department of Physical Medicine and Rehabilitation, Harvard Medical School


I found a home at Georgetown. — Psychiatrist H. Vincent “Vin” Kelly (C’, M’, R’) When he finished high school in , the fastest kid on Long Island had track scholarship offers from top schools around the country, allowing him an education his family could otherwise not afford. He chose Georgetown for many reasons, including the prospect of a post-graduate education in medicine. His lungs fueled not only his racing endeavors but also a long singing career, including  years performing the national anthem before Georgetown basketball games. “In medical school, Georgetown taught us to be clinicians, focusing on being with people—our patients—as our lifelong devotion and profession. When I think about my whole life, it has been % influenced by my connection to Georgetown. As my wife Cathie O’Connor Kelly once said, I found a home at Georgetown.”

To join Dr. Kelly in supporting future students at the School of Medicine, please contact the Office of Planned Giving at -- or email plannedgiving@georgetown.edu. Top photo: The two-mile relay team (left to right) Kirk, Lippmeier, Peyton, and Kelly


NON-PROFIT ORG. US POSTAGE Georgetown University Office of Advancement Communications University Box 571253 Washington, DC 20057-1253 USA

BEHIND THE SCENES Mansa Gurjar, PhD, a postdoctoral student in Georgetown’s biology department, is studying neurodevelopmental defects that can lead to hearing loss. Learn more about her work at gumc.georgetown.edu.

PAID PERMIT NO. 3901 WASHINGTON, DC