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HIV InSite Interview with Donald I. Abrams, MD

Donald I. Abrams
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Osher Center for Integrative Medicine
UCSF Divisions of Hematology and Oncology

Heather Dron, MPH, HIV InSite: What were you doing when the epidemic started (the early 1980s)? What was the first indication that this might be a new epidemic?

Donald I. Abrams, MD: I was actually driving to the airport on my way to spend a month as a visiting oncology fellow at the bone marrow transplant center in Seattle. I heard something on the radio about an epidemic of cancer in gay men, and I said, "What is that?" I kept pushing the buttons to hear, because I just got the end of the story, but I couldnt hear anything else. Being a gay man, I was very interested in this issue, whatever it was. So, I got up to Seattle the next day and began a 1-month stay as a visiting fellow at the Fred Hutchinson Cancer Research Institute, and I ran around outing myself asking everyone if they had heard about this epidemic of cancer in gay men, and nobody knew what I was talking about.

At that time you were a fellow at UCSF?

I was a hematology/oncology fellow at UCSF. I was just about to begin the second year of my fellowship. I was also going to begin lab research, but before I began my research I was going up to do a clinical month in Seattle. Then, when I came back in August 1981, I began working in Harold Varmus's lab. Harold Varmus and Mike Bishop had a retrovirology lab at UCSF and I had arranged that I would come back and start working with Harold Varmus in the retrovirology lab. I had given a presentation on a patient who I thought might have a virally induced malignancy. So, though I didn't really want to work in a lab, they figured that I should talk to Harold Varmus. We had a few meetings and we decided that I would work in his lab, which was a retrovirology lab, of all things.

"I guess because I was a young doctor and wasn't working in a particularly academic setting, I didn't think that maybe this was something novel, or that I should write it up. So I didn't."

Going back a little bit, because Paul Volberding always laughs when I tell this part of the story, in 1979, when I was still an internal medicine resident at the Kaiser Foundation Hospital here in San Francisco, I was working with the hematologist in his clinic. He used to send me all these young gay guys with swollen glands. My job was to try to figure out whether they had lymphoma, cancer of their immune system... and they didn't. At first, I did all the blood tests to see if they had some kind of infection, and they didn't. Then, I sent them for biopsies and they all came back benign and reactive. After the first 5 patients that I saw had their biopsies and were benign and reactive, I stopped doing biopsies on these gay men with swollen glands, and just said, oh you are benign reactive. I guess because I was a young doctor and wasn't working in a particularly academic setting, I didn't think that maybe this was something novel, or that I should write it up. So I didn't. That was in 1979, and that was probably the beginning of the epidemic.

During my medical training, toxic shock syndrome and Legionnaire's disease had both come suddenly out of the blue and were very quickly figured out. So I figured, well, if this is something novel, then we'll figure it out pretty soon.

When I came back, though, Paul Volberding had just become the first full-time oncologist at San Francisco General Hospital. Paul knew that I wasn't crazy about working in a retrovirology lab and he also knew that I was a gay man. He had just seen his first case of the gay cancer at San Francisco General and he thought I should get involved. So Paul and Marcus Conant set up a Kaposi sarcoma (KS) clinic at UCSF, and I was sort of the fellow representative at the beginning of the clinic.

What attracted you to this field/subject?

Well, again, to me it was a mission. I was a gay man, and this was my community that was being decimated, and they were having a cancer and I was an oncologist. It just seemed that I was where I needed to be. It was all very synchronistic.

Why did you persist in pursuing AIDS in spite the early challenges?

"In spite of the challenges? It was because of the challenges; I'm someone who likes to be challenged. There we were, it was like a big detective story."

In spite of the challenges? It was because of the challenges; I'm someone who likes to be challenged. There we were, it was like a big detective story. We had a new disease, and nobody knew what was causing it. Paul Volberding and I used to get on the phone and speculate. Was it steroids that people put in their rectums because they had hemorrhoids, or was it people who were taking too many artificial tanning treatments and suppressing their immune system? We were just going crazy trying to figure it out. I started running around collecting lymph nodes. By now, I was a fellow and working on the hematology/oncology clinic as well as in the lab, and also moonlighting at Kaiser where I would see these young gay guys with swollen glands. I was running across town collecting lymph nodes and storing them in my freezer at Harold Varmus's lab, because I wanted to probe them to see if there was evidence of a retroviral oncogene. I was a klutz in the lab. I came out of the clinic, and I'd never really worked in a lab, and I had no skills. The Bishop and Varmus lab had 32 postdoctoral fellows from around the world, each with their own project trying to make their name as a retrovirologist. When I kept telling people, "I need help. I think this is a retrovirally induced malignancy disease," everyone said, "Uh huh, sure, that is what the clinician thinks." So I was collecting all these lymph nodes and saving them in Harold Varmus' freezer. Finally, when I left the lab because I got so busy trying to figure out the lymphadenopathy syndrome, I got a little grant at UCSF to do studies on these lymph node patients. I decided I was over the lab and I left because I couldn't convince anyone to look for a retrovirus in these specimens. That was in 1981.

List some major successes and/or missteps of HIV/AIDS advocacy and research efforts.

The biggest advance was highly active antiretroviral treatment, which in my mind was in 1996 when we introduced protease inhibitors into the nucleoside analogue regimens. That was the turning point in the epidemic. That was when we changed it from a rapidly fatal disease into the current chronic manageable disease that it is today. We traded off death in exchange for some side effects from the drugs. You know, I was raised as a cancer doctor, and we use drugs that really have serious side effects.

How long did it take you to realize what a turning point that really was?

For me, having treated patients for the previous 15 years with therapy for KS, one of the interesting things when we first started to use protease inhibitor regimens was that I saw KS completely, absolutely disappear for the first time. So, I didn't really have to wait for the change in survival statistics to appreciate that this was a very potent regimen that we were using.

Now, are you working primarily as a clinician or as a researcher?

Now I don't work in AIDS anymore. I work in oncology, both clinical and research. At the time, I was also doing both, clinical and research.

What about advocacy?

"Patient advocacy from the HIV world has really done a lot to shape patient advocacy in cancer."

What comes to my mind about advocacy was that I was the chair of social policy and action when the International AIDS Society meeting was held in San Francisco in 1990. It was the first year, and they used to have three tracks. The first was basic science, the second was clinical science, and the third was epidemiology. That was the first year in which we added social policy and advocacy, the policy- and patient-centered track. Louis Sullivan was Secretary of Health and Human Services, and he came to speak at the meeting. We had ACT UP at that time, and when he spoke, the activists just roared. It was awful, the guy couldn't speak, and they were screaming and throwing chairs at the Moscone Center, and for me that was depressing. We had worked so hard to have a great conference, and we did. Here we had a high-ranking official from the government, and maybe the government deserved to be abused like that, but it didn't seem right at the time.

I think that, being an oncologist now, the patient advocacy from the HIV world has really done a lot to shape patient advocacy in cancer. Particularly with women breast cancer, and maybe men with prostate cancer, really have taken a lesson from the HIV/AIDS world in advocating for better treatment, but I don't think that they quite do it as loudly or as violently as in that experience.

What is most important lesson you have learned over these 25 years that HIV researchers and policy leaders should keep in mind as we move forward?

It is to definitely involve the patient in the plan, some representative of the community that is most impacted.

Do you think that HIV has fundamentally changed the way that we think about and research infectious disease?

Probably not, because infectious diseases usually have a more rapid pace, but I'm not an infectious disease specialist.

What are some of the findings from HIV research that benefited research into other diseases?

As a cancer specialist, the opportunity, which is not a good word but it is the word, to study the development of malignancies in people who are immunocompromised will help us understand that situation in others who are immunocompromised for reasons other than HIV. As somebody who is interested in virally induced malignancies, we see in HIV patients other malignancies arising as a consequence of dual infection, with, for example, Epstein-Barr virus, or human papillomavirus, or maybe even hepatitis viruses. This provides a really good opportunity to study and perhaps figure out how to prevent or treat diseases in people besides those with HIV.

Any other comments about what it was like to be part of this community?

In the old days, Paul and Connie Wofsy and I used to know all of the patients in San Francisco by name. There was a time when all the people that were involved in caring for patient with AIDS around the world knew everyone by name too. It was a tightly knit group of investigators and people who were really committed and on the front lines in dealing with this total unknown. It was, as you mentioned, a challenge, but it was really exciting to think that you could actually do something that might make a difference. It was such a frightening time.