Thoughts on a Monday morning.

Human Immunodeficiency Virus

I was sitting across a table from my friend and fellow Grady doctor a few evenings ago. This was simply some social downtime for both of us without much of anything on our agenda for the evening. I wish I could say that we talked about any and everything but work. That would be untrue, so I won't say that.

We did talk about other things but we talked about aspects of our careers--which to me is fine because we are both fortunate enough to love what we do. And when you love what you do for a living, all of it is a continuum, is it not?

I think so.

So anyway. This friend of mine works with HIV positive patients. And not just any HIV positive population. She works with a very challenging population of people who for many reasons both complicated and simply unfortunate have a lot of difficulty adhering to medical recommendations. And, see, this isn't exactly an extremely unusual thing for any of us Grady doctors--that is, the part about people having trouble sticking to what is asked of them--because we work in a sometimes resource poor and psychosocially challenging environment.

And no. I am not saying that this applies to all of our patients at Grady. I am not. I am just saying that the kind of poor and the kind of hard knocks I see at Grady Hospital are not like any I have seen at any other place I've worked. I've also never seen such resilience.

So, yeah, all of us Grady doctors rub our foreheads in frustration or shed a few tears here and there over ducks that just can't seem to get into a row despite our best efforts.

But. . . you know? HIV treatment is different. Because, see, the problem with giving you some antihypertensives and you not taking them is just that your blood pressure will just be high and that's that. But at least when we do give you the pill back, it will still work. But, again, HIV treatment is different. Different in that, unlike with high blood pressure, a little bit of treatment can oft times be worse than no treatment at all. The follow up and follow through require motivation and insight and ideally, some kind of support system. And you know? There are people out there who do have all of that and who slug it out until they win. There sure are.

Then there are the others. The ones who live on streets only blocks away from our HIV/AIDS Ponce de Leon Infectious Disease Program but who, on those streets, have all sorts of stones being hurled at them when they're out of there. The things like poverty, yes, but also drug strongholds and low literacy, too. And that sucks. Especially when you're one of the doctors on the front lines trying to reach those individuals like my friend.

See, with HIV you have to remember that it's a virus. And the treatment is aimed at smacking this virus down into some submission even if we can't yet "cure" it . . . technically. But the problem with that is it's a virus. And viruses and bacteria can be pesky and slippery and malleable. Give them a little taste of the treatment drug and then withdraw it? That gives it time to armor up and figure out a way to render your drug no better than a placebo.

Kind of like showing your hand in a game of spades or letting somebody see your stealthy 'Z' on a game of Scrabble.

The best antiretrovirals are the stealthy 'Z'. And sure. Thanks to technology and science, just like Scrabble there are a few more high value letters after your first line moves fail you. Kind of like dropping 'J', 'X', or 'Q'. But after you use those up, you're pretty much stuck with one-pointers or worse--a blank tile altogether.

So what do you do?

We were talking about how some HIV doctors are reluctant to treat any and everybody--especially high risk people who might not comply with medications. The idea behind that being that creating resistance is worse, possibly, than someone going untreated. It's always a catch 22, and no one has a perfect answer.

So I asked my friend, "How do you do it? What can you do?"

And my friend said, "Sometimes you break through. And when you do, it keeps you going."

And so I listened as she explained to me about us trying to figure out the whys when it comes to people not being on treatment instead of lamenting about people as if they are hopeless. Because those breakthroughs affirm that just when it seems that way, someone comes waltzing in with an undetectable viral load and climbing T-cells to prove otherwise.

And that keeps people like her in the game. Slugging it out with them.

I thought of her today because caring for our population can be tough sometimes. There are days where you feel like a person drying off a car during the middle of a rainstorm.

But then, sometimes. . . there is a breakthrough. The pieces come together. You drop your 'Z' on a triple letter row without using up all your tiles. You break through. The speed bumps get discovered and flattened down, the resources found, and the results are positive and right before you.

So we stay in the game. We keep our eyes on the ball and we stay in the game.

For some Grady doctors and people period, the game is harder than it is for others. But thank God for people who are hard wired for the hard games with their fast balls and major need for excellent hand-eye coordination.

And thank God for the breakthroughs that keep them and all of us in the game.

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Happy Monday.