The Centers for Disease Control and Prevention predicted in 2016 that if current rates continue, one in two African-American gay and bisexual men will be infected with HIV, the virus that causes it AIDS, during their lifetime.
In Atlanta, the epidemic was particularly acute. Now, it may be worse.
Dr. Carlos del Rio, co-director of Emory University’s Center for AIDS Research, put it this way: “Downtown Atlanta is as bad as Zimbabwe or Harare or Durban.”
If you’re wondering how this is possible, given the success of lifesaving antiretroviral medication, given the decades of research and education, you’re not alone.
Dr. David Malebranche, an associate professor of medicine at the Morehouse School of Medicine who has been working with HIV prevention and treatment for the past 16 years, has spent nearly his entire adult life considering the disturbing trend. As a self-described “same gender loving man,” he can confirm the cost of both the progress and failure in educating Black men and preventing the virus.
Even so, Malebranche’s reintroduction to Atlanta’s HIV epidemic in 2001 was like stepping back in time .
“It was like being in New York 15 years ago,” Malebranche said recently. “We would hospitalize people for opportunistic infections that people in New York hadn’t seen in years.”
In many ways, he said, that speaks to the essential issue of why Black men who have sex with men have long endured the brunt of the epidemic. In the gay rights movement, which coincided with the HIV movement, it can be overlooked that Black gay men are, in fact, Black men first.
“We can have Kumbayah moments around our shared sexual identities, but racism still happens every single day,” Malebranche said. “You have to acknowledge it as a factor. The white gay community is just as racist as their heterosexual counterpart.”
According to Malebranche, 1998 was the first year that Black and Latino gay men outpaced white gay men in rates of new HIV infections.
" Nothing has changed,” he said. “That’s why there are so many people upset with CDC and other places who look at things as business as usual. It’s one thing for the CDC to continue to splash these stats year after year, but what are they going to do about it? More importantly, what are we going to do about it?”
Malebranche, 48, considered one of this country’s foremost experts on HIV among Black gay and bisexual men, was 12 when the epidemic broke out.
He had graduated high school in upstate New York when he first learned of it, but it wasn’t until the summer of 1987 that he really came to understand the gravity of the epidemic.
Malebranche had just completed his freshman year at Princeton and had returned to Schenectady for a summer custodial job at Ellis Hospital, where his father worked as a surgeon.
At a meeting with all custodians, they were warned to be careful cleaning patients’ rooms, particularly those who fit into the four “risk groups” for HIV: hemophiliacs, homosexuals, Haitians and heroin users. Malebranche fit in two of those. His father was a native of Haiti. And though he was 18 and hadn’t had sex yet, Malebranche was attracted to other men.
“It was scary,” he said.
After he earned an English degree from Princeton in 1990, Malebranche spent a year in Chicago and Atlanta before starting medical school at Michigan State University, Magic John-son’s alma mater. He was there when the basketball Hall of Famer announced in 1991 that he was retiring from the Los Angeles Lakers because he had been diagnosed as HIV positive and warned it could happen to anyone.
“The whole campus was in a tizzy,” Malebranche said. “I was getting tested but the level of awareness shot up, particularly in the heterosexual Black community who were now seeing themselves possibly susceptible.”
In the summer of 1994, Malebranche transferred to Emory University School of Medicine. By then, AIDS had become the No. 1 killer of all African-Americans ages 25 to 44.
As a Black gay man, HIV was the stubborn weed in Malebranche’s landscape that would not go away. It was impacting him personally and professionally. He had friends who had tested positive as well.
He was in the midst of an Internal Medicine third-year clinical rotation when it struck him how severe the spread of the virus had become. Thirteen of his 20 patients were HIV positive. To make matters worse, the medications weren’t as well developed and the social climate was even further behind the evolution of the science.
“Nurses and doctors were double-and triple-gloving just to talk to patients and their attitudes were just stank,” Malebranche said. “If you were straight, you were innocent. If you were an IV drug user or gay, you brought HIV on yourself. You weren’t seen as a victim. There was the ‘HIV innocent’ and the ‘HIV guilty’ in many medical professionals’ eyes.”
The more he saw, the more he was inspired to bring care and compassion to the field.
“I thought, ‘I can do this better than them,’” he said.
After graduating medical school in 1996, Malebranche headed for the New York Hospital-Cornell Medical Center in New York City for his residency. There, he found there were only a handful of antiretroviral medications to treat HIV: AZT, Zerit and a few others.
“We were still tinkering with the doses, and patients were almost as likely to die from the meds and their complications as they were the disease itself,” Malebranche said.
He remembered holding the hand of a 28-year-old as he died of AIDS-related lymphoma, then going home despondent.
“I was a wreck,” he said. “He was exactly my age. He died in front of me, and I couldn’t do anything about it.”
Once triple therapy, the three-cocktail regimen introduced in 1997 to fight the virus at its different stages, started, people began to do a lot better. The only caveat: It involved a lot of pills and a lot of side effects.
“We had an inpatient service dedicated to HIV back then,” Malebranche said. “When you were on that rotation as a medical resident, it was always busy.”
Remarkably, by the last year and half of his residency the inpatient ward devoted to HIV had become a ghost town.
“There were always people sick, always people dying. When patients started taking that triple therapy cocktail, they started getting better and weren’t coming to the hospital like before,” Malebranche recalled.
But still they were coming, if in fewer numbers, and their care often fell to Malebranche. He wasn’t double-gloving but he was constantly aware of the personal risks.
In the fall of 1997, he was in the second year of his residency when he noticed one patient’s IV had been connected too long. The patient had a T cell count of 40 and viral load of 500,000. A normal tcell count is between 450 and 1100 and the viral load should be less than 20, the standard of care when on treatment. He had multiple infections and had been in the hospital for weeks.
After a full day at the hospital, Malebranche was tired. It was 9 p.m. He could change the IV or go home. He decided to change it and was almost done securing the new one when he stuck himself with a needle he was using to stitch it in place.
“I froze,” Malebranche said. “I tied the last stitch and calmly excused myself. Walked to the sink, took off glove and saw my blood. I washed it and squeezed the blood out.”
Instead of notifying the chief resident, he went home.
The next day, Malebranche told his chief resident he might have been exposed and started post-exposure prophylaxis or PEP, a 30-day three-drug regimen to reduce his chances of contracting the virus.
“That was one of the hardest months of my life, but the one thing it did for me is it helped me understand why some patients weren’t taking their medicine,” he said. “I have the utmost respect for anyone who has been a longterm survivor, because those early medications were really toxic.”
One of the meds he took three times a day on an empty stomach with a liter of water. The other two, he took twice a day. They caused headache, nausea and a metallic taste in the mouth.
“It was so bad, I threw the last dose in the garbage,” he said.
Malebranche left New York City in September 2001 to become a clinical investigator at Emory University, and to begin work at the Ponce Clinic in Midtown.
What he found there was shocking.
He had arrived just as new rates of HIV infection among Black gay men had begun to spike in 2000.
Why the spike? Racism, class and a
general lack of empathy on the part of law and policy makers who hadn’t been touched by the virus, Malebranche said.
Perhaps not surprising, the political climate remained very conservative even in progressive cities like Atlanta.
Malebranche cited Grady Hospital, the only safety net hospital and Level 1 trauma institution in Atlanta. Local, state and federal funding had flatlined, while the number of uninsured was skyrocketing.
“When policies’ focus isn’t on health or preventing HIV, and prioritizing health equity in Black communities isn’t on politicians’ agendas, the funding doesn’t reach the people who really need it,” Malebranche said. “As the face of HIV became darker, funding started to dry up and a racialized HIV epidemic continued.”
While white gay-specific organizations were still being funded, specific attention for at-risk Black men to get tested and treated was lacking.
Moreover, Black health initiatives and gay health initiatives left Black gay men in limbo, since neither targeted at the intersection of race and sexual orientation. By the time public health officials started truly sounding the alarm about HIV among Black gay men, the epidemic was already entrenched in their communities.
Then came Atripla, the first single-tablet regimen which in 2006 won FDA approval for the treatment of HIV.
“That changed the game,” Malebranche said. “People could take one pill a day and be done with it, just like high blood pressure.”
Today, he said, newly diagnosed patients can choose from six different one-pill-a-day regimens to achieve HIV viral suppression. Once that is accomplished, not only are patients less at risk for contracting opprotunistic infections, they are substantially less likely to pass on HIV to a sex partner.
But in some ways, Malebranche said, progress plays a part in continuing the epidemic.
“Back in the day, if you saw your friend dying or on toxic meds that made them sick, it left an impression on your mind,” he said. “Since you don’t see people dying as much or their stories in the media, it leads people to believe that it isn’t as bad as it used to be. As a result, some prevention efforts and community education/awareness campaigns lack the sense of urgency they once had.”
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