Great Progress in Doctor’s 30 Years of Treating HIV
In 1989, when Jody Borgman, MD, began his internal medicine residency at Einstein Medical Center Philadelphia, AIDS was a relatively new disease. There were few treatments. Death rates were high.
That year, about 35,500 people nationwide were diagnosed with AIDS, caused by human immunodeficiency virus (HIV). Nearly 800 of them were in the Philadelphia area.
For a young doctor, it was a fascinating and challenging time.
Dr. Borgman began treating patients with AIDS and with HIV infection as a resident – and he has kept it up for the last 30 years. His staff at Einstein’s Immunodeficiency Center recently recognized that service by presenting him with a commemorative plaque. Dr. Borgman, who is certified by the American Academy of HIV Medicine, has been medical director of the center since it opened in 1994.
“Treating HIV has been an integral part of my entire medical career,” he says. “Throughout the 80s, it was on the nightly news every single day and we were still learning a lot about what it meant and what could be done about it and who was going to get infected by it.”
Fear in the ‘80s
In those early days, he recalls, “people were very scared.”
“It certainly was still associated with men who had sex with men and IV drug users, so there was the social stigma associated with it,” he says. “And people were worried that this was going to be the reason that they were going to die. A lot of them were very young, so there were very traumatic experiences for many patients at that time.”
There was good reason for fear. In 1989, the death rate of people diagnosed with AIDS was almost 50%, according to the Centers for Disease Control and Prevention (CDC). Of the 24,035 U.S. adults with AIDS who died in 1989, more than three-quarters were adults ages 25 to 44.
Problems With Early Medications
The Food and Drug Administration (FDA) approved the first medicine to treat AIDS, azidothymidine (Retrovir), commonly known as AZT, in 1987. It was followed by others in the same class, known as reverse scriptase inhibitors.
“Unfortunately, we knew they weren’t very effective,” Dr. Borgman recalls. “People would often develop resistance to those medicines. We would try different combinations, and in a few patients they would work better than in others, but in most cases they weren’t very effective.”
Many patients already showed symptoms of AIDS when they came to Einstein for treatment. Some had taken the HIV blood test for other reasons and were in earlier stages of infection. The test, approved in 1985, also allowed blood banks to test for the virus, eliminating blood transfusions as a source of infection.
“And there was lots and lots of research by that time, so there was this thought that we were getting closer to having better medications available,” Dr. Borgman says.
One milestone was the announcement in 1991 by star point guard Magic Johnson that he was retiring from the NBA because he was infected with HIV.
“He said that I’m going to deal with this and try to help other people, too. And he really did,” Dr. Borgman says. “And he was an inspiration. In every one of our exam rooms, there’s still a picture of Magic Johnson. We used it a lot more in the earlier days saying, ‘Look how good he’s doing. You know, we can do this.’”
Advances in the ‘90s
Then came simpler HIV tests, and new medicines, notably the first protease inhibitor, saquinavir, approved in 1995. Doctors started combining classes of drugs in a treatment regime called highly active antiretroviral therapy (HAART).
“We found that the combination was very effective in controlling the virus,” Dr. Borgman says. More and more patients could suppress HIV enough to avoid developing AIDS.
“The problem was the drugs were very difficult to tolerate. The earliest combinations were up to 16 to 18 pills over the course of a day. Pill sizes were large and there was a lot of intolerance and a lot of side effects. So many patients had a hard time staying on these regimens for prolonged periods. And that was a really big struggle for us.”
But the next class of drugs had fewer side effects. Gradually, the number and size of pills got smaller as different drugs were combined.
The Game Changer: One Pill a Day
The big breakthrough came in 2006, when the FDA approved Atripla, a combination of three common HIV drugs that required taking only one pill a day.
“That was news on the street,” Dr. Borgman recalls, “and people heard about it and said, ‘Oh, I can take one pill a day. I want that medicine.’ So that was a really big deal. It really changed the treatment of HIV.”
With fewer pills, people were more likely to take them. And that led to another improvement, Dr. Borgman says. “If you go on and off and on and off your pills, you’re going to allow the virus to change and become resistant. And then the medicines are not going to work anymore. With Atripla, we started seeing a lot less resistance and that meant people were really taking their regimens on a regular basis.”
As treatment has become more successful, HIV has been transformed. Today, it’s a chronic illness – and not the worst one at all.
The 2010s: Simple, Successful Treatments
“As far as treatments go, HIV is the simplest thing,” Dr. Borgman says. “I’m seeing patients not just for their HIV but for all their medical illnesses. And 90% of the time the conversation starts with ‘HIV is the least of your problems. We’ve got to get your diabetes under control, we’ve got to get you to lose weight, we’ve got to help you with your asthma, you’ve got to stop smoking.’
“All these other chronic illnesses are the things that are going to shorten patients’ lives, so their ultimate demise is going to be because of their other medical problems, not HIV.”
In a lot of ways, I’m blown away by how far we’ve come.
Almost 40 years into the epidemic, we’re able to completely control it.
— Dr. Borgman
Besides protecting their own health, people who take their HIV medicines have so little of the virus in their system that they are unlikely to infect others.
But prevention is always best. That’s why Einstein promotes the two-drug combination Truvada for prevention as well as treatment of HIV infection. Known as PrEP, this regime involves taking one pill a day to suppress HIV for people who have a high risk of being exposed to the virus.
The FDA approved PrEP in 2012 for people who may be exposed to partners with HIV or who use injection drugs. Taken every day, it’s nearly 100% effective in preventing HIV infection.
Spreading the Word About PrEP
Getting more people to take advantage of PrEP is the next challenge.
“Part of it is information,” Dr. Borgman says. “We need to continue to get the word out there. You know, the people most at risk for it are young. The highest risk group consists of men who have sex with men. They’re otherwise healthy, except for maybe sexually transmitted illnesses. There’s some fear of taking medicines, fear of costs, or they may not feel that they’re at risk.”
The Immunodeficiency Center has two staff members who promote PrEP on a regular basis, Dr. Borgman says.
A social worker spreads the word to medical practices in the Einstein network. A community educator takes the message to the community. “He goes to barbershops and grocery stores and a library and just sets up a table and talks to try to engage people in PrEP,” Dr. Borgman says. The next step will be an advertising campaign on social media and dating apps targeting men who have sex with men.
A Few Disappointments
Dr. Borgman acknowledges some disappointments in the last 30 years of caring for HIV patients. Despite much research, no vaccine has turned out to be successful. And HIV suppression has become so good that many men who have sex with men have stopped using condoms, leading to a surge in other sexually transmitted diseases.
The biggest disappointment, Dr. Borgman says, is that even today 15% or so of the Immunodeficiency Center’s 1,000 patients don’t stay in treatment. The reasons vary, but often are related to psychiatric illness or addiction. For this reason, some of them develop AIDS, now known as Stage 3 HIV. “But it’s so much less now,” he says.
Today, about 1 million people nationwide are living with HIV. Of course, people with HIV are still dying. But many are living normal lifespans. In 2015, nearly half of the deaths in this group came at age 55 or older, according to the CDC. Many of Dr. Borgman’s patients are age 60 and older, with a few in their 80s.
It’s been a rewarding journey, Dr. Borgman says.
“It’s defined my career. It’s been an absolutely fascinating intellectual experience, just seeing the developments that have come out of this and what we can do for patients. In a lot of ways, I’m blown away by how far we’ve come. Almost 40 years into the epidemic, we’re able to completely control it.
“A cure is even starting to be a possibility. I don’t know if it will be five years or 10 years or 15 years, but I do think we have patients now that eventually will be cured.”
Learn more about Einstein HIV care.
Top photo: Aviva Joffee, Program Director of Einstein’s Immunodeficiency Center, presents the plaque to Dr. Borgman.