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Chapter Two: “It’s the Virus, Stupid”

C.J. Trent-Gurbuz

In August, 1981, a young Haitian girl was admitted to the George Washington University (GW) Hospital intensive care unit with respiratory failure. Gary Simon, MD, PhD, diagnosed her with diffuse pneumonia, called a thoracic surgeon to perform an open lung biopsy – the standard of practice at the time – and left a message; Simon was in the operating room and was then heading out for an anniversary dinner with his wife. He thought the patient might have Pneumocysitis carinii pneumonia, now known as Pneumocystis jerovici, and the newly described “acquired immune deficiency syndrome.”

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“[The surgeon] called me back about 7:30, 8 o’clock that evening,” Simon recalls, now sitting in his office. “He did the open lung biopsy, and it turned out to be Pneumocystis.”

At the time, clinicians didn’t know about HIV, or human immunodeficiency virus; rather, they noted an unusual presentation of a pneumonia that was virtually limited to patients with a severe immunodeficiency. “The first reports of the acquired immune deficiency syndrome was in June of ’81, and this was August of ’81,” says Simon. 

He treated the girl with pentamadine, a then-unlicensed drug that had to be shipped to the hospital from the Centers for Disease Control and Prevention (CDC). It wasn’t enough; she died not long after her diagnosis, retroactively recognized as the first identifiable case of HIV in Washington, D.C. It was a sentinel moment for the District, and the epidemic merely expanded its cycle of infect and kill. By the end of the year, the CDC estimated that the virus had infected tens of thousands of people.

“These patients were profoundly immunosuppressed.  In fact, prior to the identification of the viral cause of this syndrome, this condition was defined by certain abnormal immune parameters.  We, like many of our colleagues, including those at the National Institutes of Health, tried drugs to stimulate the immune system,” Simon recalls. “None of them worked.  Two years later the virus that was initially named LAV (Lymphadenopathy associated virus), then HTLV-III and finally HIV, was identified.”

As political culture phenom James Carville’s “It’s the economy, stupid” dominated the news cycle, Simon – first intrigued, then immersed in HIV/AIDS research – and his colleagues adopted their own mantra: “It’s the virus, stupid.”

“The first drug to show any benefit was an antiviral, azidothymidine, AZT in ’85, ’86,” Simon explains. “This drug was originally considered for the treatment of cancer; it could halt the virus’ progress, but only for a little while because of the development of resistance. A decade or so later, a remarkable thing happened.”

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Meanwhile, one of Simon’s former students at the GW School of Medicine and Health Sciences (SMHS), Alan Greenberg, MD ’82, MPH, had returned to his hometown of New York City determined to follow in the footsteps of his professor. “He made a big impression on me,” Greenberg recalls with a smile.

Greenberg completed a clerkship and then matched for his internal medicine residency at St. Vincent’s Hospital in Greenwich Village. “I went as a young, ambitious, idealistic doctor to help the community and walked right into the beginning of the HIV epidemic in lower Manhattan,” he says. “It was both a time of great heroism on the part of the patients, and a time of great loss because many [of the] young men we took care of did not survive their infections or presenting symptoms.”

It wasn’t what the young doctor had envisioned; he went to medical school to help people, and he found himself frequently practicing palliative care, often helpless to prevent the death of patient after patient. “Each generation has its moments,” he says. “For one generation, it was 9/11; for another generation, it was Zika, and for another, Ebola. Things happen in society that generate a sense of purpose and mission, and you can try and make your small contribution to one aspect of the ills that plague the world.”

Fighting HIV/AIDS was Greenberg’s mission – and his efforts would culminate when he once again crossed paths with Simon.

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As research marched on, significant strides were made with antiretrovirals, medications used to treat viral infections and retroviruses such as HIV. The number of drug companies sponsoring studies multiplied, as did potential drug therapies. By the middle of the 1990s, when the number of those infected topped six figures, a breakthrough changed the landscape of HIV/AIDS care.

“There was the development of ‘the cocktail,’ a combination of drugs that not only stopped the virus but, to everyone’s surprise, led to a restoration of the immune system,” Simon says. “It was truly remarkable. All of us thought that simply controlling the virus would not be enough. The immune system was irrevocably damaged. We were wrong.”

Once use of the cocktail was widespread and the immune system was able to improve, he adds, patients started to live longer.

“People living with HIV are on medication like they’re on high blood pressure medication, and they have to keep taking it. That’s the key to managing HIV,” Simon says. “If you take [your medication], the odds are overwhelming that you’ll do very well. I tell patients that ‘You shouldn’t spend your retirement money, because you’re going to live a long time with this.’”

Many of his patients who managed the virus with handfuls of pills gradually saw the number reduced, as researchers, having unlocked the power of antiretrovirals, could create better therapies.

“I have many patients now that I’ve been following for more than 20 years, since the early ’90s,” Simon says. “While those patients were taking two pills six times a day and other pills in different regimens, we now have once-a-day medications.”

As Simon witnessed and contributed to research chipping away at what was once a death sentence – his focus on antiretrovirals and combinations of agents has continued to the present – Greenberg struck out his own path, one that would take him around the world.

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Greenberg, at the tail end of his residency in the late ’80s, found himself drawn to the CDC’s epidemic intelligence service, a post-doctoral training program for disease detectives. “It’s still a very prominent program where they take clinicians and PhD epidemiologists and train them to become field workers to investigate disease outbreaks,” Greenberg explains. “The EIS officers act as first responders who go in and try to figure out various infectious and non-communicable disease epidemics, the extent of the epidemic, how it’s being transmitted, and how to implement measures to stop it from spreading.”

So strong was the pull toward preventive medicine that Greenberg decided to devote the rest of his career to HIV prevention, traveling to and living in sub-Saharan and West Africa between bouts in the Big Apple, Boston, and Atlanta. When he returned to the United States permanently after 20 years of back and forth, having treated many patients and spearheading HIV research programs – as well as welcoming children with his wife (his greatest personal accomplishment, he says) – he became the chief of the AIDS epidemiology branch for the CDC in Atlanta.

“Toward the end of that experience, I was contacted by Ruth Katz, who was the dean of the school of public health here at GW,” he says, leaning back to stare out of the expanse of office windows onto the bustling street below. “She said, ‘How would you like to consider coming home?’ and I said, ‘I have three generations of my family living here in Atlanta, I’m head of AIDS epidemiology.’ She said, ‘How about breakfast?’ And I said, ‘OK, I can do breakfast.’”

Her pitch: move back to Washington, D.C., and help build the public health school at his alma mater.

“That was a very meaningful line to me,” Greenberg says, “and my wife said, ‘That sounds like you.’”

And that’s all it took.

What Greenberg wasn’t expecting, however, was to encounter an epidemic that rivaled what he saw in West Africa. Washington, D.C., in the mid-aughts was home to a crisis-level HIV epidemic, with inadequate resources. In 2007, the Washington Post reported that nearly four residents were diagnosed with HIV every day, a huge number given the population at the time topped out at only 600,000 and the city itself spans less than 70 square miles.

Building upon decades of experience, Greenberg formed a partnership between the now Milken Institute School of Public Health at GW (Milken SPH) with the D.C. Department of Health (DOH) to conduct HIV surveillance, which continues today. Along with Milken SPH and DOH colleages, he also helped improve the National HIV Behavioral Surveillance System: “We have mobile vans, and we go to venues around the city and do street-recruited, community-based HIV surveys, and all of this is done in support of the CDC’s work with the Health Department,” he explains.

Despite that experience, the full impact of his work had yet to arrive – until a reunion with his former mentor.

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“We were doing HIV work obviously for a long time, and then Alan came on board,” Simon says. “We’ve been friends from the moment he came here. We meet almost every week, we talk three times a week, and we socialize together. He and Michelle and [my wife] Vicki and I. We’re really close friends.”

The two, linked by their passion for HIV/AIDS research and prevention, wanted to do more; it was just a matter of time.

“Alan had this great plan of how this was going to evolve,” says Simon. “Mine was more to just get things up and running, to get an integrated research program that was more than just the isolated little pockets of HIV research that were ongoing in downtown D.C.”

So, the two, along with Sylvia Silver, DA, professor of microbiology, immunology, and tropical medicine at SMHS, met one afternoon. Silver’s office, on the fifth floor of Ross Hall on the GW Foggy Bottom Campus, was snug but had enough room for the three to tackle one pressing question: “What can we do to really galvanize the HIV response?”

“We were three people, so we did what most people do; we’ll have a meeting,” Greenberg recalls. “We tried to get together all the people that we knew who were faculty members at GW who were working on HIV research. We literally had a pizza and sat around a conference room and exchanged ideas.”

And so was born the GW AIDS Institute, which was chartered in 2006. The initial members – GW faculty only – realized they had a lot of research interests in common but were working in isolation. When they started meeting with AIDS researchers and colleagues from Georgetown and Howard universities, and subsequently became the D.C. AIDS Institute, the same phenomenon occurred: “What we rapidly realized is a lot of us have more in common scientifically with each other as AIDS researchers and AIDS clinicians than we have with other colleagues in our own schools,” Greenberg says. “People liked being together – it was like magnets, you know?”

Although D.C. lacks universities with the large research portfolios of Johns Hopkins or the University of California at San Francisco, there was, Greenberg says, important research happening in the city.

“We had the idea that if we could link all these institutions together, we’d have enough funding to qualify for one of the Centers for AIDS Research (CFAR) that even GW on its own wouldn’t do,” he explains. “What we pioneered was the citywide model: Our job, our mission is to conduct research that helps fight the AIDS epidemic in partnership with government and community, to really look at it as a citywide issue rather than a university-specific issue.”

Greenberg and Simon, as co-directors, first received a five-year starter grant – a D-CFAR, or developmental CFAR – from the NIH in 2010. On the heels of the initial five-year award, the team earned the full CFAR designation. Their virtual consortium now includes more than 200 academic HIV investigators from GW, as well as from Georgetown, Howard, American University, Children’s National Health System, the Veterans Affairs Medical Center, Whitman Walker Health, and the D.C. Department of Health.

“The CFAR has been an incredible experience,” says Greenberg. “The signature part of the CFAR is its pilot awards program. The idea is that young investigators will get some seed money to do some of their research, and then generate data and publications that’ll allow them to submit NIH grants to become full-fledged investigators in D.C. We’ve been able to create a community of HIV research scientists in D.C. to help support the Health Department’s mission in ending the epidemic.”

Although Greenberg and Simon may view themselves as small cogs in a larger machine, their contributions – whether seeing a patient through diagnosis to treatment, funding research projects, conducting their own research, or merely acting as a bridge for collaborations – have had an indelible impact on HIV/AIDS. Between 2007 and 2016, new cases of HIV declined by almost 75 percent, and last year, Greenberg says, there were only 371 new cases. It is, he adds, “real, profound progress.”

“It’s been quite a run,” he says. “I think the greatest experience I’ve had is helping to foster the next generation of scientists and public health professionals, trying to help people understand how they can make contributions and then trying to create structures and environments that will enable them to realize their dreams.”

Simon, meanwhile, looks back at his role in fighting the epidemic with, if not optimism, appreciation. “It’s been sort of a personal odyssey,” he says. “My former chairman of medicine [once] described what it was like when isoniazid came out for tuberculosis. So, I guess in the mid-’90s, I had that same experience. All of a sudden, this disease, which was basically universally fatal, was treatable to the extent that patients were getting better, not just in terms of controlling the progression of the disease, but they were actually getting better. And that was an astounding time.”

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“Chapter Two: 'It's the Virus, Stupid’” is the second of several installments of “Observation: On HIV/AIDS,” highlighting the pivotal role the George Washington University (GW) School of Medicine and Health Sciences has had on HIV/AIDS treatment, research, and education in Washington, D.C. This series features several GW researchers and clinicians, shining a spotlight on how the virus has touched their lives and how they continue to work toward an end to the epidemic.
“Observations” is a new online, long-form nonfiction series covering SMHS areas of academic excellence.