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Fighting Stigmas Associated with Infectious DiseasesFrom HIV to Mpox

Learning Objectives
1. Explain how harmful stereotypes and social rhetoric led to the stigmatization and inadequate care of gay and bisexual patients during the HIV epidemic
2. Describe how the responses to the COVID-19 pandemic and mpox incorporated lessons learned from the HIV epidemic, leading to less stigmatization and better patient care
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Audio Transcript

Intro: Welcome to Stories of Care, a podcast from the American Medical Association and the CDC's Project Firstline. The relationship between gay and bisexual men and public health is one that has been forged through the experience of the HIV epidemic. The proliferation of the mpox virus among this population has thrust this historically fraught relationship into the spotlight once again. What can we learn from past epidemics that have affected the gay and bisexual community.

In this episode, we are joined by Dr W. David Hardy, the director of infectious diseases at Cedars-Sinai Medical Center in Los Angeles and an associate professor of medicine-in-residence at the David Geffen School of Medicine at UCLA. He shares about his experiences during the initial response to the HIV/AIDS epidemic, the mpox response, the COVID-19 response, and how when health care professionals do not understand how pathogens spread and get people sick, this can lead to fear and sometimes stigma of patients.

Megan Srinivas, MD: [00:01:10] Thank you so much for being with us today, Dr Hardy. Your experiences throughout the last few decades of being an infectious disease physician in the face of so many different epidemics is really astounding and will give us such a great perspective. Can you kind of tell us a little bit about your initial career, kind of launching into the world of ID in the midst of an HIV epidemic?

David Hardy, MD: Definitely. I'm happy to be here. I entered the infectious disease world as a specialist, trained specialist in the early 1980s. I completed my medical school training in 1981 just as the first cases of AIDS were being described in the MMWR of the CDC and the New England Journal.

I had already made a decision to enter infectious diseases. And at that time, the world of infectious diseases was primarily all inpatient therapy. Very little outpatient therapy at all. In fact, I can remember there really were no outpatient ID clinics in those days, a patient either survived their infectious disease in the hospital and went home well, or they had, or they died. In most cases, they would die. What happened with HIV was that I, and I had made a decision to do ID but not had really specialized it to HIV yet until my internship. I. Sorry. Until my residency, when I moved from Texas to Southern California, to a UCLA, a county teaching hospital. And at that medical center, I was aware of the fact that the immunology clinic, which was primarily about allergies more than immunology at the time, was starting to see these patients with this rare and unusual immune deficiency that was manifesting by severe and life-threatening and rare opportunistic infections.

Because this new disease was both infectious diseases in terms of its manifestations as well as its etiology initially because it was transmissible, I was attracted to it. And it was also the time that I was coming out as a gay man, during my residency. So, there were two reasons, both academic, scientific, professional and also personal reasons that I got attracted to this. At that time, you know, what was happening is that the immunologists in the hospitals I was working in were the ones who stepped up and started taking care of these patients.

The infectious disease doctors oftentimes would shy away from this, and it wasn't always clear why this was happening. It wasn't universal. Some places it was happening, where the ID doctors would step up, but in many places it was the immunologist. In Los Angeles, certainly it was that way. In, in New York, it was certainly that way. But the thing that kind of struck me was that why was this happening? Why did the ID doctors not be interested? And I think, you know, this is where the first indication that stigma was starting to raise its ugly head.

You know, one of the other problems was, was that at that time there was, you know, of course always competition for NIH grants. And by the mid '80s, when the NIH finally started providing research funds for HIV, there was a competition of old, older, bacterial diseases that were the mainstay of infectious diseases and this new disease called AIDS, that had just been found to have an etiology of HIV and the funding trend started to shift. Away from the bacterial and fungal diseases and to this new disease. And many of the more old-timer infectious disease doctors got very threatened by that. And they did not want to have that be a threat to their NIH grants.

There was also the fact that, these patients were so sick and there was so little experience that most of the academic centers around the urban areas [is] where they landed in almost all situations. Some community hospitals also were part of this, but not as much as academic centers because the expertise of academic centers was really necessary to take care of cases of pneumocystis, cerebral toxoplasmosis, and these other odd infections that only occurred very, very rarely. And so, you know, this clash between a very, very academic, conservative, white coat heavy, I would call it, academic contingency of physicians was clashing with the gay community. And there were many, many times I can remember certainly when I was a resident and fellow at UCLA, that that clash was very, very perceptible.

Srinivas: You've really described so much in that, in just in, in that answer alone, I would love to unpack each of these little topics. So you touched kind of on how this was just coming about when you first started as a resident. And how your personal background of having just come out yourself made you even more interested.

Which alludes to the whole stereotype that it was gay men who was getting this disease back in the '80s. How did that stereotype come about and how did you see it manifesting in, in the clinic in which you were working as a resident?

Hardy: Certainly. Well, you know, I think the way the first cases were reported by the CDC through their MMWR publication, in Los Angeles and San Francisco and New York, is that in those first cases, were all being recorded among gay men. Now, at that time, the word that was used more commonly for gay men was homosexual men or described as men who had homosexual activity. And so, the word homosexual, I think carried a certain connotation with it that does not come with the word gay.

And of course the CDC was trying to be scientifically correct and scientifically linguistic. And so, they used the word homosexual. I think it's almost like the way that in the 1970s persons stopped using the word negro and started using the word Black or African American, where there was sort of a more social way to describe a minority group with a term that was a little softer and not quite so clinical.

You know, that was part of what happened is that the CDC was being very clinical, but not necessarily understanding, and I don't think they entirely did, what the prejudice, the stigma against gay men was really all about. You know, these were the days that not too long before that a former Miss America Anita Bryant had been trying to stop homosexuals from becoming teachers or to eradicate them from teaching school. There were referendum around the around the country in which --

Srinivas: Was that, was that before the epidemic even broke out?

Hardy: Late 1970s. Late 1970s.

Srinivas: Oh, wow. So, then this, the epidemic probably only heightened that messaging.

Hardy: It was true, it was true. You know, California was one of the battlegrounds where this was occurring, and there's a whole history about what was happening in California and especially in Florida and other states around the country. Anyway, into this comes this very severe disease. Homosexual men first, but then later other people were coming into hospitals very, very sick. Very, very ill. Needing expert infectious disease care. And the clash that really occurred there I think was one that was sort of what I would call stigma on top of stigma. There was already an existing stigma against homosexuals, primarily because of the fact that they were from a community that was very little known to most of the very conservative, white coat doctors who were caring for them. And so there was a really different sort of way to try to interpret this. You know, this was also, I think, the genesis of why so many young physicians in the United States, in other parts of the world too, really were attracted to come into HIV care initially.

Because it was caring for individuals who did carry stigma that many of the older attending physicians and more established physicians had to be taught about. That it was okay to take care of homosexuals, that it was okay to speak to them, that it was okay to let their partners sleep in the same room when the person was not doing well or was dying just like they did with heterosexual couples.

And this was actually, you know, crossing a lot of boundaries and breaking a lot of new territory that had not really been ever looked upon or confronted in the medical care system.

Srinivas: Yeah. And there are a couple things there that you mentioned that I would love to dig into. One of the things that I've actually heard people discuss is the terminology issue that you brought up and how the word homosexual has so much more of a connotation to it than gay.

And I know right now in the ID world, especially if you're looking at notes, people tend to write, you know, men who have sex with men. Does that also have a connotation to it?

Hardy: The reason that they coined that was because in certain communities such as, particularly the African American community and some of the Latinx community, the word gay does not carry a positive connotation at all. And in fact, many men who have homosexual same sex relationships do not consider themselves to be gay. This is something where the CDC was trying to really be more inclusive and more descriptive of saying men who have sex with men, to try to include all individuals who might be at risk for transmission of HIV.

And it was hard to come up with a term that wasn't, you know, kind of clunky. Men who have sex with men is kind of clunky. But it tends to be much more descriptive and more universal than gay.

Srinivas: No, you're right. When, in my work down in South America, I did some work around stigma discrimination against the LGBT population in Brazil, and it was definitely, you know, we'd ask the question, would you consider yourself gay? And people would flat out say no. But then if you asked if they'd ever had sex with a man, if it were talking to a man, they'd say, oh yes, yeah, once or twice. It was a very different answer. So that makes sense. And it's good to know that that doesn't necessarily have the same negative connotation.

Hardy: Right. Although, you know, I think it's something that's really used only in terms of medical terms, epidemiologic terms, not really the kind of thing people talk about in colloquial [terms], out in the community.

Srinivas: Yep. No, that makes complete sense. So then being a physician at this time. You're talking about the rhetoric that's already existing in the setting of then these new stereotypes coming out with, about HIV patients. Being a gay physician yourself, did you find that many of your colleagues treated you differently in this setting?

Hardy: You know, some did and some didn't. You know what I found, for example, and this is I think of a surprise to many people, is that when I interviewed for my infectious disease fellowship at San Francisco General Hospital, the now departed Chief of Infectious Disease there flat out told me that his infectious disease department at SF General would not, would not train individuals to take care of patients with HIV. He clearly said if I wanted to study bacterial meningitis or bacteremia or cryptococcal meningitis without HIV, he would be happy to have me in his fellowship. But when I voiced the fact that I was so interested in studying this new disease, he flatly said, not in my hospital.

That person later became a maven of HIV infection about four years later. You know, it was again, following the money in many ways of where the research funding was being directed. But even home and when I became an attending at UCLA School of Medicine, you know, I heard comments from my infectious disease colleagues, how other physicians were speaking about HIV behind my back. Making allusions to the fact that I would really enjoy a colonoscopy more than anyone else because I was a gay man. Or the fact that the patients who were dying in the ICU were my patients, even though I was not necessarily even taking care of them. So even within the ranks of my own infectious disease division, there was stigma simply because of the fact that I was a gay man.

Srinivas: Did you find that other people in the medical world—in your department or even in other departments across the country that you knew—that people were hesitant to come out, to admit that they were gay themselves because of this type of stigma that was happening, these things that you were facing?

Hardy: You know, I think, I think it was sort of interesting, what was happening around the country, was the fact that in many of the urban centers where most of the patients were being seen, gay men and others, was the fact that the gay physicians in those cities really stepped forward in many, in many ways. It was primarily because it was their patients who had been seeing them previously for nothing more oftentimes severe than an STD, all of a sudden had a whole practice or a very large part of their practice who were now needing to be hospitalized.

What was happening, I think, in the hospitals was the fact that gay physicians did tend to come out more because there was a feeling of the fact that they had more of a responsibility, more of a connection, more of a better understanding about what was happening in this epidemic.

Plus they were medically, and in many cases, infectious disease trained. So, you know, like myself, I think I found many colleagues in many of the academic centers around the country really coming together,

Srinivas: You touched on NIH funding earlier as changing kind of the direction of San Francisco General, which now we know is honestly one of the big epicenters for studying HIV.

And it's interesting to me that the actual practitioners had such a close-minded view, at least the ones at the top. But that the NIH was willing to be so malleable. Which is, we often don't think of government structures as the ones who are leading progressive change. What were your perspectives on seeing that happen? Why did that happen?

Hardy: You know, I would, I would chalk it up basically, and interestingly, to one person. The reason that the tide turned in terms of federal research was because of Tony Fauci. Tony Fauci, you know, whose division at NIAID was really the focal point of research in this area and who had the money to do this, looked upon this as, I think, a important part of what his division, which was really based upon immunology and infectious diseases, it was their responsibility to look into this. He saw the necessity of the expertise that he and others in his institute could offer to this. When it became clear that HIV/AIDS was not going to be a flash in the pan, like some previous infectious diseases, like Legionnaire's disease, for example, and that cases were being discovered all over the world and among an increasing number of different populations of people, he saw the importance of why his institute's expertise was really needed. And, you know, he and other well-known individuals, even including Elizabeth Taylor, you know, sat in front of Congress and talked about both the scientific as well as the social and humanistic reasons why the federal government should start funding this research into this disease.

Srinivas: Wow. That's, I mean, that's impressive. To think that just having the right person in the right position can really change the entire trajectory of how a disease is dealt with.

Hardy: Yes, yes. I mean, this is where I think, you know, Tony Fauci, I think was already a well-known researcher. With HIV, he became a real humanistic researcher. He sat down with the activists. He invited them into his office at NIH, even though they were protesting outside his office and, you know, having die-ins and putting up posters in front of the NIH buildings. Instead of rejecting it and calling them all crazy loons, he enveloped it and brought it in and talked to these people as anyone who has an important point would do.

Srinivas: I mean, now what, 40 years later, we're facing new epidemics that, once again bring about Dr Fauci into the formula, both between both COVID as well as, honestly, monkeypox. Once again, relying on government structures to create the messaging and public health awareness. Have you seen things from your initial experiences with the HIV epidemic? Have you seen us learning from that in the way that we're packaging things now or dealing with them now?

Hardy: You know, tremendously. You know, what I would say is that certainly, initially, with COVID, there was not nearly the same degree of fear or stigma, against the persons who were coming into hospitals with COVID. Now the situation was different because it was a generalized epidemic and not really focused on one group of individuals, at all. It was, you know, discovered to be transmissible by airborne routes as opposed to by contact or by fluid mechanisms of transmission. And you know, the other thing that was different with COVID is that people came in the hospital and died rather quickly.

As opposed to have, with HIV there was usually a series of multiple hospitalizations and then they would die. After a series of different opportunistic infections. But with COVID there was still the same kind of fear oftentimes of the patient and the discrimination that occurred, although much more briefly with COVID, because we had much better ideas about transmission routes and how to prevent them, about not wanting to treat the patient, you know.

Just like I remember in the world, in the days of HIV, individuals either ran toward this or ran away from this. And the persons who were running away from it would come up with all kind of different reasons and excuses. I might be pregnant, was what some women were saying. Or I have small children or elderly people at home. I don't want to bring it home to them, with HIV. The same thing happened with COVID, as well. Initially. But again, you know, I think by that time there was so much more understanding that it's not the patient's fault they're sick, and that as infectious disease people, we know how to prevent transmission through the measures that were used during COVID.

So, you know, it was much more of a logical response than was ever seen with HIV. And that's a tribute to the fact that we learned a lot in those 40 years.

Srinivas: Did you see in those 40 years, we've clearly learned a lot, but did you see any of the same follies repeat or things that we could have done better?

Hardy: You know, a little bit. You know, when HIV was first out there, the idea by how it was transmitted, because we did not have an etiological agent until late 1983. And so, during those very early years when everything and anything was being described as the possible etiology of this severe immune deficiency. All kind of crazy ideas popped up. You know, for example, there was one immunologist who thought that HIV was caused by a man being exposed to another man's semen, that there was this some sort of anti-semen antibody that would occur and cause an autoimmune effect in terms of destroying T-cells.

You know, we look back at that now and say, how crazy was that? The CDC at one time even hypothesized that it was an amyl nitrate, poppers, that was causing HIV through different sort of chemical destruction of T-cells. And, of course, never proven. The period of time that there was, there was fear of transmission was longer, I think, with HIV because we did not have an etiologic agent for a while. And until it was really mapped out about how transmission was occurring through blood and only certain body fluids, you know, there was a lot of fear.

The advantage with COVID is that we had an etiologic agent very quickly and that etiologic agent was actually already known as a different virus to this one, the SARS virus. So, things happened much, much more quickly with SARS because we had much, much better technology. The virus was sequenced within a matter of 10 days by the Chinese and that sequence was distributed internationally through the internet.

So, you know, the therapeutics and vaccines could be developed, you know, as fast as we all know they were. So, times were different, although there was, I know, always a period of time, with, even with COVID, and our enhanced technology and understanding of transmission in which fear was always there. Always there.

Srinivas: You know, and as you're telling these stories about, you know, what hypotheses existed as to how HIV was passed, it makes me want to laugh. But at the same time, we still have those same myths circulating about COVID and how that's generated, how it's passed, even surrounding the vaccine. So, there is that whole reality of, we're going to look back 20 years from now probably and laugh about COVID too. Hopefully we can laugh, because hopefully we'll have it under better control. But one of the things too that you're, as you're discussing all of this, that comes to mind is you're talking about the whole conflict between who wanted to take care of the patient during the HIV epidemic and with COVID that some of that conflict existed, but not as much. And part of me wonders if it has to do with our government jumped in right away and said, Hey, regardless of your insurance status, regardless of anything financially, we will cover this. We have passed legislation that's going to make sure everybody can get the care they need.

That didn't happen for HIV until really, Ryan White. So how did you see hospitals dealing with taking care of HIV patients and their perspective as far as wanting to allow people like you to do everything they needed to do to take care of these patients?

Hardy: Sure. That's a, you know, that's a very important difference that occurred as well, you know, and it was remarkable how long it took. The disease was occurring in gay men, in persons who injected drugs, in individuals who were transmitted through sexual contact. So, you know, by those three transmission routes, people already had prejudice against those individuals to begin with. And again, that's why I call it, you know, stigma on top of stigma. Not only are these persons, you already have a prejudice or many health care workers already had prejudice, but now they were sick and they were dying and they had a great need for those person's expertise. And that really made people feel very uncomfortable initially.

So, you know, I think the difference between then and now has been dramatic. The federal government jumped in, even President Trump, you know, made all therapies affordable or payable by the government, because of course they also developed them. And the same thing eventually happened with HIV. However, you know, the pharmaceutical industry was the one that really jumped in and started developing anti-HIV agents. The first one was starting to be developed in 1985. AZT was licensed in '87. And it took a while for that to happen. It took a while, you know, a long while.

And of course we still don't have a vaccine for HIV, whereas, you know, within 9 months or shorter we had, you know, authorized vaccines for COVID. So not only was the technology so much different back then than it is now, but that there was just a different will, a different political will, to get one disease under control and the other one, uh, let's think about it, but not until there's enough feeling that this is a good thing to do. You know, and one, and they were both very huge pandemics. You know, one discovered immediately, one discovered after several years. So again, the time was also a different situation.

I'll just make a simple point as a, as an example, we didn't have PCR until 1995. And, of course, it was PCR that actually cracked the code for COVID within a matter of days. You know? And it took a long time. It took a long time. And it was one of the reasons PCR was developed was so that viruses like HIV could be sequenced and followed.

Srinivas: Yeah, I'm going to date myself a little bit, but I remember in school learning PCR is this brand new technology and it's going to revolutionize the way we look at biology. To where we are now, it's quite remarkable, honestly, how fast science has gone. But with that different rhetoric, that different mindset and approach back in the '80s, what did you see within the health care systems? I mean, you as a practitioner wanted to take care of these patients. Did you have pushback? Did you have support? What was happening?

Hardy: Oh, there was, there was. You know, there was a, there was a series of publications in the late 1980s in which the whole idea of whether or not residents of all training programs should even be exposed to persons with HIV. Now at that time, we have to remember, there were no treatments. The death rate was very high. And there was, there were many editorials and the results of surveys that were written and published in the late 1980s, actually asking fourth year medical students and residents in training what their feelings about taking care of HIV positive persons were, which were primarily gay men, but also about gay men in general.

And there was a very clear trend towards fear. Towards I don't think I should have to take care of these patients because I don't want to get infected. We should let the older doctors do it who may be more adept at doing it. There was a feeling that, there was a hesitancy to take care of gay men. Because remember the HIV antibody tests had just become available in March of 1985 and not everyone wanted to get the test. And so, the use of the test became very controversial. There was a situation in which health care providers wanted to use it to identify who, which patient had the virus, but persons who might be at risk said, why do I want to find out if I'm positive or not? All that's going to tell me is that I'm going to probably die. So, there was a very strong, you know, debate of whether or not persons wanted to get tested or not. So, you know, I think what was happening, again, another tension, between [the] health care world and the patient world was really evident there.

Many training programs wanted to limit how many HIV positive patients would be admitted to their teaching hospitals. I know at UCLA, the vice chair of medicine department at the time told myself and my, and my mentor Michael Gottlieb, that we would be limited as to how many patients we could admit to the hospital because, as he said, I don't want to destroy our training program for internal medicine.

Srinivas: So, this wasn't about the finances, this was purely because of perception.

Hardy: Exactly, exactly. And you know, there, on a more granular basis, you know, on the day-to-day sort of care of the patients, again, there were nurses who stepped up, some of them gay, most of them not, who really wanted to take care of patients. You know, there were several, several different AIDS inpatient units all over the country. San Francisco, New York, at Cedars-Sinai in Los Angeles and other small community hospitals all over the country where individuals who wanted to be a part of this volunteered to work on those units.

And so, you know, the quality of care really changed. Instead of being, in those days, where the patient was basically alone in their room, people either had to dress up in basically a space suit of all kinds of protection from different forms of transmission because no one really knew what it was. And even after it was that way, people still wanted to dress up in all those different space suits. It was just to have some sort of sense of security. But things really did start to change after the fact that, for example, when Rock Hudson in 1985 died, his good friends Doris Day and Elizabeth Taylor hugged him publicly. Touched him. And kissed him on the cheek. Indicating that they had understood and were told by scientists how the virus is being transmitted. And they were trying to be examples that these people needed love, care, understanding, not rejection. You know, and again, health care workers are on that frontline.

Some health care workers will believe the importance of human-to-human contact as being part of the healing or even dying process. Others were just simply very scared and walked away from it. And I think that's why in many ways, those hospitals that created an inpatient unit did a great service because the health care workers who worked there were volunteering to work there and wanted to work there. Not that they had to work there or take care of patients in the general hospital.

Srinivas: All these stories about Elizabeth Taylor makes me really, really respect her legacy even more. I mean, I'd heard stories, but seeing you sharing them and seeing the animation that comes to your eyes when you can tell the power that she definitely had with her actions. I feel like we should call this episode the Elizabeth Taylor episode.

Hardy: In many ways. Either that or the Tony Fauci episode. Or both?

Srinivas: There you go. We can call it the Tony-Taylor episode. But one thing that you highlighted there that I'm really intrigued to learn more about is the patients themselves. I mean, they know, unfortunately, that the stigma is circulating. They have been relegated to a certain number of beds or only certain staff that are willing to work with them. How did you see this impacting patients every day? I mean, especially with those that had long hospitalizations with HIV, people sometimes staying there for 8, 9 months at a time.

Hardy: Yeah. You know, the other thing that happened, and just to kind of contrast then and now. When I was a trainee, it was not considered to be good medicine to send a patient home from the hospital until all their problem lists had been resolved. Either resolved or easily followed up on an outpatient basis. You know, one of the things that was very different then is that, for example, if a patient had a persistent fever or had a fever. They didn't go home until that fever was diagnosed and treated it, if possible. What happened with HIV is that fevers were very common and that we couldn't always come up with an etiology for the fever or a treatment. And so initially patients were left in the hospital for months, months and months. Trying to figure out what's going on with them. And health care workers were heavily, heavily frustrated. They were, they were challenged by these patients to the point that they started blaming the patient for the problem.

What was happening in, certainly during the '80s and '90s was the fact there was a recognition that it was okay to send the patient home with a fever, with certain symptoms that were going to continue because they were chronic and continue outpatient evaluation or even home therapy. And this is where, you know, a time that home therapy, intravenous antibiotics, for example, even sometimes home chemotherapy for different cancers, was pioneered. Because patients wanted to get out of the hospital. Administrators were very ready to send them home as well. They were costing the hospital more money than they were making for them.

And you know, it was really a humane thing to do. Because in a situation in which persons knew they were destined to die within a fairly short period of time, having them at home and out of a hospital environment was really humanistic. So, we learned to practice medicine differently because of HIV and it, you know, this sort of idea of using home treatment as a better way to treat patients has been seen in other areas. For example, if a patient's neutropenic because of chemotherapy or other kinds of immune suppressive medications, we don't even put them in the hospital because there's a greater chance they'll be infected with a highly resistant organism, a bacteria. So, you know, we have learned from that that home care is okay, and in fact, oftentimes preferential not only scientifically, but also for the patient's wellbeing.

Srinivas: Yeah, definitely. And as we're talking about all of this and the stigma surrounding both the patients and the practitioners in this situation with HIV in the '80s, it makes me think about monkeypox epidemic that really just emerged over the last year. And some of the things that, that we've seen as far as headlines, we've seen some of that stigma pop up again, unfortunately. How do you see the monkeypox epidemic evolving compared to how the HIV epidemic did, and are we learning from our past mistakes in that evolution?

Hardy: Yeah, you know, I would really call it night and day. And I would hand a lot of it to the CDC. You know, the CDC, our national public health organization, approached monkeypox entirely differently. Of course, the two diseases are very different. The death rate with monkeypox is much, much lower. It is not an immune deficiency disease caused by an infectious agent. Both are virally mediated, of course, but the biggest difference is that when cases of monkeypox were being described, the sociopolitical term was used, that was used to describe the persons who had it was gay. Not homosexual. And you know, that disease outbreak was much more centered in the gay community than even HIV was. You know, it's, it's almost 95% gay men that are having this disease. Some women, some heterosexual men, many transgender women. But it's different than the way HIV was being seen in many different sort of transmission groups.

But the CDC, you know, immediately acted on this. Some thought it was too slow in terms of rolling out the vaccine stores that were already available and the treatment medications with tecovirimat. But the federal government responded. And they responded rather quickly because you see that this disease, the number of cases is, in most places around the country is very, very small.

So a response that quick and that efficient can work. You know, and again, I think the, the stigma with monkeypox existed, but only briefly. Only briefly. You know, the good thing was, is there was a vaccine available and there was a treatment already available. And so I think, you know, one of the things that always made HIV treatment difficult was because practitioners were made to be, to feel impotent. They had very little to offer these patients. And of course, as individuals who liked to take care of patients and be successful, you know, we couldn't. For many, many years, we couldn't. And you know what oftentimes resulted from that, even from practitioners who wanted to do this, was a real sense of failure. A real sense of the fact that no matter what I do, this patient's going to die. And the idea that oftentimes we became, instead of infectious disease warriors, stamping out infections where we could, like we did in, before HIV happened, we were much more like oncologists. We were treating people who were destined to die. We threw all kind of things at them therapeutically. Sometimes it worked. Most of the time it didn't. And most of our patients ended up dying. And that was a hard thing for doctors, particularly, who were used to winning, had to come to terms with.

Srinivas: Yeah, that had to be one of the biggest mental blocks and so tough for everybody in the health care industry to deal with, let alone the patients and their families feeling so hopeless with this unknown.

This has been such an enlightening conversation. Thank you so much for sharing all of your stories. Is there anything, if you wanted to leave one last message to our listeners about where we were, where we're going, anything that you would like to touch on? What would be your last message?

Hardy: You know, as I kind of look back on the 40 years that I've been a physician, I, and also in the world of infectious diseases, every time I happen to hear the fact that medical centers, medical schools, training programs want to de-emphasize training in infectious diseases or in public health. You know, it just frustrates the heck out of me to say, you will pay for that. Because the world of infectious diseases has to continue to work, has to continue to be around, has to continue to have proponents and trainees and practitioners because we do not know what the next pandemic is going to be.

You know, we deal with microorganisms that can mutate and evolve so much faster than we can. And by the time we figure out oftentimes that the new infection has occurred, we are already behind the times, tremendously. So, you know, I get frustrated when there's this idea that we know everything and have antibiotics for everything that could possibly ever be out there. And in reality we don't. We don't. There will always be a new infectious disease. And we have to look at it through a public health lens rather than, the individual always time. The public health lens is the one that really has saved us so many times, over and over again, through all these pandemics.

Srinivas: Yeah, I couldn't put it better myself, honestly. Part of the passion as to why I went into ID myself. So, thank you so much for everything you have done and for everything that you shared with us today. It's been a true pleasure to have you on the show.

Hardy: It's been my pleasure. Also, thank you very much for allowing me to do this.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.75  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 0.75 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.75 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.75 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 0.75 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 0.75 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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