Awards of Courage
Donald I. Abrams, M.D.
Honoring with Pride 2000 Honoree
Donald I. Abrams, M.D., has been in the vanguard of the struggle to develop effective treatments for AIDS since the disease first emerged. His name is synonymous with the introduction of community-based clinical trials for AIDS therapies, which he pioneered in San Francisco as Chairman and Principal Investigator of the Community Consortium, an association of HIV health care providers established in 1985. Dr. Abrams has been the principal investigator for the Consortium’s Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) site since 1989, and he was one of the original investigators in the AIDS Clinical Trials Group (ACTG) collaboration. A charter member of the Antiviral Advisory Committee of the Food and Drug Administration, Dr. Abrams was also an early member of amfAR’s Scientific Advisory Committee and a founding medical editor of the amfAR HIV/AIDS Treatment Directory (since renamed the amfAR Global Link). He is now Assistant Director of the AIDS Program at San Francisco General Hospital and Professor of Clinical Medicine at the University of California, San Francisco. He is the principal investigator of a recently concluded NIH-funded safety trial of marijuana in patients with HIV infection. Dr. Abrams has served on the Board of Directors of the Gay and Lesbian Medical Association since 1993 and is currently President.
In 1979, I was still in my internal medicine residency at the University of California, San Francisco Medical Center. I was working with a hematologist there, and we started to see a number of young, otherwise healthy gay men who had chronically swollen glands. Even after doing biopsies, I still didn’t know what was happening, but these men all were doing some drugs and had a lot of sexually transmitted diseases, and it just hit me that probably they were in the fast lane. My advice to them was that they should slow down and see if their lymph nodes would go away.
In 1981, when we started seeing our first patients with Kaposi’s sarcoma and pneumocystis carinii pneumonia, I began to wonder if the men with swollen glands two years earlier were now developing these more serious, life-threatening manifestations. So I wrote a grant to the University of California — I think it was for $10,000 — to do tests on patients with this syndrome, lymphadenopathy. Because I was a member of BAPHR, Bay Area Physicians for Human Rights, the local gay doctor group, a lot of the gay doctors in the community knew that I was doing this, and they began to send me the increasing numbers of patients they were seeing with this swollen gland syndrome. That’s how I became one of the first people to recognize persistent generalized lymphadenopathy as related to more life-threatening diseases.
At the time, I was working in the retrovirology laboratory of Harold Varmus and Mike Bishop. But once I started the lymphadenopathy study, the patients started calling the laboratory all the time. It was very frustrating for my colleagues and for me, and finally I just told Dr. Varmus that I was going to have to move on, to go back to doing clinical work. So I started seeing and treating all the first patients who had Kaposi’s sarcoma at the university hospital.
In 1985, Diane Feinstein, who was then the mayor of San Francisco, decided that it would be important to keep physicians in the community up-to-date on what was going on at San Francisco General Hospital, where I moved after completing my fellowship. So the County Community Consortium came together. Paul Volberding, chief of oncology at the hospital, went to the first meeting, and he noticed that the people in attendance were, for the most part, my friends from BAPHR, so he suggested that I attend the next few meetings in his place. Little did we know that this group would meet every month for what is now 15 years. Initially, I would simply inform the providers in the community about clinical trials that were open and available, so that they could refer patients. I would also brief them about conferences that I had the luxury of attending, because I was an academic physician. I really felt this was a duty to my community. And after six or nine months, people started saying, "Well, Donald, it’s fine and well to hear about all the studies you’re doing at the AIDS program at San Francisco General Hospital, but we could do research in our clinic, in our private offices as well, you know." I totally agreed. There was so much that was unknown in 1985, we really knew nothing — so everything anyone did was essentially research, and should have been done under controlled conditions.
In addition, as an academic clinician and as a gay man, I knew that I personally would have burnt out very quickly, if all I could do was tend to the hundreds of people who were slowly dying before our eyes, every day, every week, every month. What gave me, personally, some relief was the knowledge that I was contributing to our overall knowledge base by conducting clinical trials, and I wanted to share this sense with my colleagues in the community, the people who were out on the front lines providing care, day in and day out. I felt they should be allowed to know that the patients they were seeing were making a difference as well.
So we designed a randomized clinical trial, which was turned down by the government but ultimately funded by a drug company. We had 69 different physicians participating in the study, and we enrolled over 400 patients. The Community Research Initiative in New York also participated; they did toxicity and safety evaluations. There was a lead article about the study in the New England Journal of Medicine, and it led to the approval by the FDA of inhaled pentamidine as the first prophylaxis for pneumocystis, and it proved to the government that community-based clinical trials can work.
Now, in the year 2000, sometimes I look back on those days, and I can’t even remember how much pain and numbness there was, as a result of constantly seeing people die. I’ve certainly not been immune to loss myself. Between the ages of 25 and 39, I lived with four different men, and they’re all dead. The last one was my partner when he died, in 1989, and it certainly was a tremendous education in what it’s like to love somebody who is dying — an education that will live with me until my own dying day. And in addition to my own lovers, I’ve lost many, many friends and thousands of patients. You know, I still see ghosts. I still see someone on the street, and I think, "Oh my God, that looks just like — ", or, "Is that — ?" I still get confused. It is truly unsettling to consider the contributions that could have been made to society by all of the people we have lost in this epidemic. And I guess one of the difficulties of having watched this epidemic closely for nearly 20 years is that I know that patterns repeat. Now, in this era, with this new sense of optimism, with people saying AIDS is under control, that it’s a manageable disease, I look at my friends and my patients that are doing so well on their regimens and I just say — can this go on forever? I hope so, but I wonder.