Human Immunodeficiency Virus Medicine

In the 25 years since I completed my infectious diseases training, I have practiced human immunodeficiency virus (HIV) medicine in both an academic medical center and a community-based clinic. My path might be hard to replicate today, but I’ve learned lessons that may be useful to those pursuing a career in this still-exciting field. In the early 1990s, I was an infectious diseases fellow who felt drawn to HIV in different, darker times. We had little to offer our patients except management of complications, prescription of nucleoside analogues with modest, time-limited benefits, and—when our efforts failed—preparation for death. Still, students, residents, and fellows flocked to this seemingly depressing field. From a medical and scientific perspective, no patients presented with such fascinating differential diagnoses than those with advanced HIV disease. While often emotionally devastating, our work was often more of a “calling” than a career choice. We were responding to a global crisis, caring for sick and dying patients who were stigmatized and marginalized by society. The camaraderie among healthcare workers was rare in other disciplines. Finally, this was history. Having started medical school in San Francisco in 1981, I witnessed the birth of a new disease, the identification of its cause, and early attempts at treatment, and had the hope—though still dim at the time—that the future would bring better treatment or even a cure. Few physicians have the potential to witness both the beginning and the end of a disease during the span of their careers. As horrible as that era could be, I feel privileged to have experienced it as a physician. My approach to fellowship would be frowned on by program directors today. I wrote no grants, had no research focus, and was oblivious to my sources of funding. When faculty asked me to work on a clinical trial, a cohort study, or a review article, I said yes, finishing my fellowship with a modest list of publications that had only HIV in common. This strategy worked: Having not secluded myself in a laboratory, I was well known to faculty and clinical staff and was asked to become director of the HIV clinic as an assistant professor. Hopkins had no specific faculty tracks, but it was understood that I would combine clinical work with teaching and research. During my 21 years on faculty, I maintained an approximate 50/50 split with respect to clinical time. I managed to get promoted twice without ever having written a grant. My early projects emphasized the natural history of opportunistic infections; later I focused on clinical trials of new antiretroviral agents. With time, I was viewed as the local antiretroviral therapy (ART) expert and was asked to participate in a variety of projects, including multicenter and multinational research networks. I couldn’t remain ignorant of my funding forever. My salary was cobbled together each year from a combination of Ryan White funding, support for clinical and administrative responsibilities, trial revenue, and grant support from collaboration with colleagues. Finding salary support in academic medicine is always stressful. Not having to write grants was a luxury, but it kept me dependent on the grants of my colleagues, which had an annoying tendency to come to an end. I left Hopkins in 2013 in part for lifestyle reasons, but I also worried that if trends continued, the varied career I had enjoyed for 2 decades would eventually be replaced by full-time clinical work. I was not replaced at Hopkins. The model that had worked for me had become less viable. Fellows now do what I had avoided: They find a research focus and keep it funded. Faculty members have a harder time dividing time as a clinician, educator, and researcher and generally have careers that conform to a specific academic track. I moved to Santa Fe in 2013 to direct the HIV and hepatitis clinic within a larger community-based healthcare organization. When an HIV job became available in the city I wanted to live in, it was an opportunity that could only happen once. I viewed this as a major career transition, but my work didn’t really change: I was still seeing patients about half the time, running a clinical trial unit, teaching, and serving as a reluctant administrator. Still, there were important differences, including some advantages. I no longer had to find my own salary support. Because we were a small, less bureaucratic organization, we were more successful at getting clinical trials approved and enrolled than I had been at Hopkins. I published more than I had during academic life, and our research efforts were a source of revenue for the organization rather than a money-losing activity. Finally, I found that I had more clinical and administrative support and a stronger voice in the clinical operations of the organization. The disadvantages were those that come from leaving academics. I was still teaching, but I had less opportunity to learn from my colleagues. In my small city with no academic institution, I no longer had the same wealth of expert consultants to call on for my patients. Whether in academics or the community, people debate the future of HIV medicine. ART is now easier and more effective than the treatment for almost any other common chronic disease. Is there a future for drug development in an era when we can treat most patients with well-tolerated, often single-pill regimens? Will there be a role for HIV experts in the future, or will generalists take over? The answer is unclear, but even today patients do better when cared for by experts [1, 2]. Drug development continues, largely driven by the desire for long-acting regimens and new modalities for biomedical prevention. A cure is being aggressively pursued. In today’s political climate, funding for HIV care and research is unpredictable, but because HIV care is so inextricably linked to control of the epidemic, we hope it will remain well-funded as a public health measure. Although my career path in HIV medicine may be hard to replicate, I’ve learned lessons that still apply. Some are more relevant to academics, but regardless of where you practice, our field is hungry not just for HIV clinicians, but for young educators, researchers, and advocates to replace the old guard, who are now retiring or moving to industry. Get yourself out there. In academics, a criterion for promotion is reputation outside your institution, either through publications or teaching. If you’re not churning out ground-breaking research papers, say yes to speaking opportunities, no matter how small. It just takes one influential audience member to say, “I heard Dr X give a fantastic talk at a local meeting. Let’s invite her to speak at our national conference.” Speaking can also be a source of income. While lucrative industry-sponsored tours are a thing of the past—at least in academics—continuing medical education talks can help establish your teaching reputation while compensating for our generally low salaries. Writing is important too. If you’re not publishing original research, editorials, review articles, case reports, and online chapters demonstrate your commitment to scholarship and help establish your credentials as an HIV expert. Consider industry connections. Funding from the National Institutes of Health is declining, and much of the research in our field comes from the pharmaceutical industry. Participation in industry-sponsored trials is not possible everywhere and may not be a quick path to promotion, but it involves you in drug development and sometimes results in authorship, presentation of data at conferences, or participation on scientific advisory boards. Get involved. If all you do every day is prescribe the same ART regimens and congratulate patients on their undetectable viral loads, you risk boredom and burnout. In HIV care, we have always been advocates and activists, as important now as it was in the 1980s. Work with local organizations or health departments to improve access to treatment and prevention. Join the HIV Medicine Association. With their help, visit your legislators’ offices to educate them about HIV-related issues and legislation. Learn how HIV care is practiced in resource-limited settings by volunteering in another country. People today may go into HIV medicine for different reasons than they did in the 1980s and 1990s. For some, it’s not a calling; it’s just a well-considered career choice … but a great choice. In the clinic, we treat people with an otherwise fatal disease, preserving their health and longevity with safe, effective therapy. People who aren’t diagnosed or in care still get hospitalized with fascinating and life-threatening complications, but we can now treat them and restore health with ART. Prevention isn’t just abstinence and condoms anymore; biomedical modalities are cutting-edge interventions that continue to evolve. The search for a cure is thrilling, but challenges facing cure research mean that we won’t be putting ourselves out of business anytime soon. Finally, HIV medicine is about much more than a single disease; it’s about sexuality, politics, economics and economic disparities, stigma, global health, and human rights. It’s also the greatest pandemic of our time. You don’t go into this field just to prescribe ART, but to embrace a depth, breadth, and diversity found in no other field of medicine. Supplement sponsorship. This work is part of a supplement sponsored by the Infectious Diseases Society of America. Potential conflicts of interest. The author has received consulting or advising fees from Bristol-Myers Squibb, Gilead Sciences, Merck & Co, Theratechnologies, and ViiV Healthcare/GlaxoSmithKline. His institution has received research support from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen Therapeutics, Merck & Co, Sangamo Biosciences, and ViiV Healthcare/GlaxoSmithKline. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.