Joel Blankson has been treating patients with HIV and AIDS at Johns Hopkins since 1995, when he was an intern in the Department of Medicine.
"Back then, patients would come in with severe disease, and there were times we couldn't do anything for them," says Blankson, professor of infectious diseases at the Johns Hopkins University School of Medicine.
Now, with a single pill a day, people with HIV can keep viral loads so low that the virus is not transmissible. This exquisitely attainable goal, a global health strategy known as U=U, or undetectable equals untransmissible, allows them to live full and healthy lives.
"It's the difference between getting people ready to die versus getting them ready to live," Blankson says.
From the earliest days of the HIV and AIDS epidemic, Johns Hopkins has led clinical care, research, and education locally and around the world.
There from the beginning
In 1982, just months after the first cases of a previously unknown cancer were reported, Johns Hopkins epidemiologist B. Frank Polk began studying the disease known at the time as GRID: gay-related immunodeficiency disease.
The following year, Johns Hopkins began outpatient treatment of patients with the still-mysterious ailment in the Moore Clinic, originally a research clinic. Over the next few years, the number of patients increased exponentially, and in 1988, the Johns Hopkins Hospital became the second one in the nation to provide inpatient care for patients with AIDS, after San Francisco General Hospital in 1983.
Richard Chaisson served as director of the AIDS service and led both the inpatient ward and outpatient clinic from 1988 to 1997. "In those early days, the service was overwhelmed with previously healthy young men and women with life-threatening complications of AIDS, and we struggled to learn how to treat them more effectively and support them through a harrowing illness," he recalls.
"The Division of Infectious Diseases at Johns Hopkins embraced HIV at a time when many other university hospitals were trying to avoid it," says Joel Gallant, who arrived for a fellowship in 1990, was a professor from 1992 to 2013, and recently returned as a partially retired adjunct professor. "From the moment I came to Johns Hopkins, HIV and AIDS has been my focus," he says.
The institution always made a point of sharing its knowledge about the virus and about patient care, he says.
John Bartlett, chief of infectious diseases from 1980 to 2006, was another early and active supporter of HIV and AIDS care and research at Johns Hopkins. His commitment inspired others to come to Johns Hopkins to study the virus and care for patients, and to develop research and care infrastructures in communities reeling from the disease.
Bartlett established programs in Maryland prisons and county health departments to bring Hopkins' expertise to patients unable to come to Baltimore. In 1990, he published the first edition of Medical Management of HIV Infection, considered a go-to resource for treating patients in the U.S. and around the world. The guide was regularly updated by Bartlett, Gallant, and Paul Pham.
"Hopkins has really been there from the beginning," says Joyce L. Jones, assistant professor and medical director of the John G. Bartlett Specialty Practice. "Both addressing the immediate patient care and psychosocial needs, as well as advancing the research."
Research and treatments
In the early years, care was focused on treating AIDS complications, including opportunistic infections, and on keeping patients as comfortable as possible as they grew sicker.
A breakthrough came in 1996 with the introduction of drug combinations known as highly active antiretroviral therapy (HAART), which dramatically reduced deaths by blocking the virus from replicating.
However, the treatment required an exacting regimen of many pills, taken multiple times a day, and it didn't work for everyone. It also came with severe side effects, such as nausea and kidney stones, says Blankson.
Care for patients with HIV is very different now, says Jones.
"A vast majority of people can achieve that sustained, suppressed viral load with one pill, once a day," she says. "And we have injectable treatments as well—people come in once a month or once every two months to get an injection, and that treats their HIV."
Caring for the Bartlett Specialty Practice's 3,000 patients involves more than suppressing their viral load. Chronic conditions including diabetes, cardiovascular disease, and hypertension are more common in people with HIV and the underserved population of the clinic.
Psychiatry and social work are routine aspects of care, Jones says, with support that includes help with medication adherence and guidance for younger patients as they transition from pediatric to adult care.
"HIV is still disproportionately impacting certain populations," says Jones. "So we're making sure we continue this legacy of wraparound services and support, connecting patients with what they need and deserve."
Rapid tests, first available in 1992, allow for standard HIV screening for emergency-room patients, unless they opt out—a best practice identified by Johns Hopkins research that enables those who test positive to be treated sooner and reduces spread.
Another game-changer was the 2012 introduction of pre-exposure prophylaxis (PrEP), which protects people who are HIV-negative.
Learning how the virus behaves
Meanwhile, Johns Hopkins researchers and epidemiologists have been diligently studying the disease and how it is transmitted, leading to dramatic improvements in both treatment and prevention.
CFAR, the Johns Hopkins University Center for AIDS Research, began promoting interdisciplinary HIV and AIDS research at Johns Hopkins in 1998, and was revamped and expanded by Chaisson in 2012 after a lapse in funding.
Over the years, he says, it has supported hundreds of young investigators who went on to have long careers in HIV research.
"Hopkins has been a leading engine of discovery in HIV across a large range of disciplines, making significant advances in virology, immunology, therapeutics, prevention, and public health interventions," says Chaisson, CFAR's director.
Pediatrician Deborah Persaud's research is finding that very early interventions for babies born with HIV can limit HIV reservoirs and create remission without antiretroviral therapy.
She, Bollinger, and others have also led studies showing that breast-milk transmission of HIV to newborns can be reduced by giving doses of nevirapine to both mothers and babies.
Robert and Janet Siliciano, husband-and-wife Johns Hopkins professors, have focused their research on HIV reservoirs that contain latent virus. Most recently, they showed that a full HIV cure is still out of reach because the virus in these reservoirs can rebound.
Blankson is now studying patients whom he calls "elite suppressors," who are able to keep their viral loads low without medication. "We think they might be a model for a cure of HIV where you don't have to eradicate the virus, but you can control viral replication without drugs," he says.
"The Hopkins HIV research footprint is huge, and the global impact of this work over many decades has been incredibly important," says Robert Bollinger, Raj and Kamla Gupta Professor of Infectious Diseases and associate director for medicine at the Center for Global Health.
"Internationally, a lot of what we have done recently is implementation science," he says. "We worked for decades to identify tools that work, for both prevention and disease management. More recently, we have focused on how to optimize the uptake and the real-world impact of these tools."
Gallant, who has been treating people with AIDS at Johns Hopkins since 1990, says the progress has been nothing short of remarkable.
"It's definitely a happy story," he says. "If you were forced to live with one chronic disease, this would be the one to choose. The treatment is so easy, safe, and effective that you can truly live a normal life despite having HIV."
This article appears in the November/December 2024 issue of Dome
