 Hi everyone, thank you so much for watching. My name is Raif Derrazy and in this video I'm excited to interview our special guest Dr. Monica Gandhi to discuss her findings and the potential current and future benefits to long-acting ART for people living with HIV as well as wraparound care. We'll get into exactly what all that means. We'll also touch on her newly released book and just get to know her as a yet another tireless, extremely passionate individual working to help end the HIV epidemic. But first I will start by introducing our esteemed guest. Monica Gandhi, MD, MPH is a professor of medicine and associate chief in the division of HIV, infectious diseases, and global medicine at the University of California, San Francisco, UCSF. She is also the director of the UCSF Center for AIDS Research, CFAR, and the medical director of the HIV clinic Ward 86 at San Francisco General Hospital. She serves as the associate program director of the ID or infectious disease fellowship at UCSF. Her research focuses on HIV treatment and prevention optimization HIV and women, adherence measurement in HIV and TB, adherence interventions and the interplay between COVID-19 and HIV. She served as the co-chair of the international AIDS conference in San Francisco, Oakland in 2020 and has recently worked on COVID-19 mitigation and vaccination strategies with a book on the COVID-19 pandemic called Endemic, a post-pandemic playbook now released from Mayo Clinic Press. Dr. Monica Gandhi, thank you so much for joining me. I'm so excited to have you here. Thank you so much for having me. Absolutely. So I guess just to start off, I'd love to get some insight in how you originally became involved in HIV cure research and what made you stick it out? Yeah. So you know, I have actually wanted to be an HIV doctor since I was 12. So that's just a commentary about how long I've wanted to be in this movement. I was, that was the year 1981 and that was when these cases of AIDS were first described in mainly young gay men and it was really heartbreaking and I had to grow up first and then I went into medical school and then did an infectious disease fellowship and residency out here at UCSF because I was interested in working at the epicenter of the epidemic, which was San Francisco at the time. And I eventually grew up at UCSF. I became the medical director of Ward 86 and that is just a very special place because 1983 is when we first opened our doors. So that's just a mere 18 months after the description of the epidemic. And I watched people, my first year of internship go from not having any medications in 96 to the end of the year, having these anti highly active antiretroviral regimens almost to rise from the dead. And it was incredibly important to see these advances in antivirals and biomedical advances and to see people live. And it was so heartbreaking before that. But even if you're on antiretroviral therapy and you're taking it and you're taking your pill every day, it doesn't mean that you don't want to be cured. And I, like anyone in HIV for a long time, became very interested in cure on the scientific advisory board for one of the cure initiatives, the Hope Collaboratory, but here at UCSF. But I just as an HIV doctor, I'm interested in eventually getting to a cure so that we just wipe the face of the earth of this because 39 million people are living with HIV and it's far too many. And so what, what was unique and significant about Ward 86 in particular in the beginning? So it is, it's a very special place at the very beginning. I wasn't there, but it started in 1983. And it was really a place where there was just tragedy really to play out like anything at the beginning of HIV, we didn't have anything to give people yet. And so it was so hard. And there was so much that was needed to just help people live longer or even pass the dignity that we started this model of care. And that model of care that was started in the 80s was, we call this San Francisco model of care, but the idea was a one stop place where you could get everything to happen. You could get your oncology care and neurology and psychiatry and cardiology and social work and everything happened at one place because you're dealing with so much and there's not treatment and you really just want one place to go and it feels like home. And so we continued that model of care even when we got the HIV medications in 96. I became medical director in 2014, but we've started a lot of programs at Ward 86. We started a program for women, women living with HIV in 2008. 2010 we started everyone should be treated with HIV treatment regardless of T cell count. That became the norm in 2012, but we started it here. We started in 2014. Prep, we started that same year rapid starts of HIV medication, the rapid program. We started in 2017 a program to help people who are older because we were so grateful that people were living to be older, but they needed older people's care, a more geriatrician care. And so that's called the golden compass in 2017. And then in 2019, we started a program for those who are homeless because that's third of our population. We only have a publicly insured population at Ward 86. And then finally we started using long acting this year in even in patients who have a hard time taking meds. Amazing. And just to give some context, are a lot of these things that were started with Ward 86, were they actually started at Ward 86, meaning like were you a front runner for all these things providing proof of concept so that other places can do the same thing? Yes, I really think that does describe Ward 86. It's very innovative and a lot of these programs were kind of the first example. So for example, rapid was really started at Ward 86 in the city of San Francisco, starting meds right away when someone gets diagnosed. I would definitely say that golden compass was one of the first aging programs. And then our pop-up clinic, there is another program in University of Washington, but we were the second program for just designated care for the homeless. And then this year, just even starting using long acting antiretroviral therapy in patients who have challenges to adherence, that is also something that we just completely innovated in its novel to us. And we're trying to get out the information so other people will do it. Well, I will say I'm also, I'm part of hope as well as a lot of my viewers know as on the community side as a cab co-chair. Will I be seeing you in San Francisco? Yes, I will see you in September when we have our next advisory board meeting and it is a really important collaboratory. I'm so glad that you're there to help us because I do think someday we'll get to cure. It's a little harder to get to cure than treating and prevention, but I have faith. I have hope that we're going to get there. And we'll be at the Buck Institute, which actually focuses on aging. Yes, which is that's the brilliant thing is that to be an HIV, you can be at the beginning of the process where you try to cure someone if they've just been diagnosed. And then you also, because we're so lucky that we have these antiretrovirals and people are living normal lifespans, then you have to think about aging. And it's so important to think about aging. And that's what our Golden Compass program does. It has kind of four parts of the compass, but they're all about heart care and mind care and bone care and geriatrics care and getting your social circle wider and having social groups and then navigating to basic services. So Golden Compass is really important and aging is really important issue in HIV. Okay, well, I am going to do some content in San Francisco and focus some of it on aging since that's why we're there. So maybe we can follow up there or at some point in the future on the Golden Compass. Come to our clinic. Let's see. Would you take a moment because one of the reasons why I thought about bringing you on is because I was reading, I was going through some articles recently and I saw one in the body pro in which you were talking about your successful execution of wrap around care in San Francisco. So I'd love for you to kind of describe what that means to our viewers and what you were able to find as far as effectiveness. Yes. And so the idea of wrap around care just means, I mean, I actually like to think of it because we embrace the patient, but it really is that you have the care of the provider, but then you have everything all at once in that same clinic like a Hollywood movie. But, you know, the social work and the neurologist and the psychiatrist, but there's a lot of social support. And what happened during the pandemic, during the COVID pandemic, is that people lost insurance, they lost jobs, they lost friends, they lost housing. It was a really hard time. And this wrap around care, a model of care was incredibly important because we helped get housing referrals, we helped get people into more social support services that they needed during this time. And wrap around care just means what the model of that is, is the Ryan White Care program. Meaning, if we look at the history of Ryan White, he was a little boy who acquired HIV from hemophilia, triplet transfusions and in, and in he was unable to enter his school when he was 11 years old in Indiana because parents locked arms and they wouldn't let him in to his school. And in 1990, he died at the age of 18 and he died of AIDS. And that year, August of 1990, Congress passed the Ryan White Care program. And that is been re-ratified this year. It's probably the best example of a bipartisan disease program where you provide wrap around care for low-income patients. And that wrap around care means social work, means social support, it means having a pharmacist there to help you with your medications if you have too many medications, decreasing those numbers, it's just kind of one stop shopping. And then the other thing I think that we may have helped inspire, because again, I really think this came from Ward 86, is not just the Ryan White Care program, but PEPFAR, the President's Emergency Plan for AIDS Relief, internationally, also uses a care model where you come to one place and you get everything. You get your heart care and your hypertensive care and your HIV care and your diabetes care and your malaria care. Everything happens at the same time. And so I think it's a model of care that's very important for people living with HIV. And we like to think that it really did originate at Ward 86 and I think that's likely true. Amazing. Okay, so I want to put up a little chart here because I, and before I do, I realize that you focus on people who are unhoused, people who have drug use issues, mentally ill, et cetera, traditionally considered difficult to treat. Yes. And so I came upon this chart recently and I just clicked into my head when I was going over my notes with you. And it shows here that since the mid-70s, you see this light blue line shows people who are in a mental hospital versus the dark blue line, people who are in prison. And somewhere in the 70s, this line inverts and suddenly you have prison population increasing and those in mental hospitals decreasing dramatically. And I'm not saying, I don't think the chart is saying that one for one, the mental hospital is now in prison and vice versa before the 70s. But there is something interesting to note here to see that as the population in mental hospitals has gone down, those mentally ill, that criminalization in people in prisons has gone up dramatically as well. So I wonder if that's part of the problem and our ability to give good care is that instead of dealing with the root causes of mental illness, that we're just criminalizing people and throwing them in jail? Yes, I completely agree that this is a huge problem. So if you think about criminalization of any activity, there's criminalization of sex work and criminalization in Uganda right now with an anti homosexuality law of just being gay, literally, you could go to jail. There's criminalization of all sorts of activities that really have to do with marginalization. And those who are mentally ill are marginalized. And it's somehow it seemed easier for the United States sometimes, and this happened, yes, in the 70s and early 80s, to just criminalize it instead of doing all the hard work that it takes to treat people and give them the help they need. And so I think there is no doubt that what happened with those who have mental health concerns is that if you make that a criminal activity and criminalize it instead of getting people treatment, then people are at risk for everything, including all the bloodborne pathogens that are at risk for HIV and STDs. They're at risk for hepatitis C. And there is a concentration among those who inject drugs and among those who are homeless, and among those with mental illness, especially in the city of San Francisco of HIV infection. And it's such a tragic response, I think, to what people need because there are underlying concerns that lead to mental health issues, and you can't just you can never treat that in a prison. So I'm actually watching right now criminalization of lots of things around the world. And we're kind of having this backlash and this really disturbing anti-LGBTQ sentiment arising that trans laws that are anti-trans laws, I should say, and in some places in the South and Southeast of this country, the South Africa was going to decriminalize sex work and they have not moved on that because of these kind of political forces at play. So it's very disturbing to see in 2023 these very disturbing ways of criminalizing people's kind of behavior, which they're just trying to live. Yeah, two things. I'm really glad you brought up marginalization. And then I'm also glad that you brought up not just issues here in the US because so often this type of content and the type of content that I see on YouTube is very US centric or Western focused. And the reality is it's a global issue and it needs to be covered more and I really want to focus on that. So thank you for bringing that up. Regarding the marginalization, yeah, I want to add to that because that popped in my head the fact that states like Tennessee, Florida, Texas, I know there's a case now going on where there's religious Christian folks who are saying that they don't want to have to provide prep through their health care because it's infringes on their religious freedoms and how that is really just about attacking marginalized groups, which also speaks to the stigma of HIV because it's not it doesn't just affect marginalized groups either. Right, right. I mean, actually, and to go on what you just said, if we think internationally, you know, the latest UN aid statistics were just released for 2023 in terms of number of people living with HIV, 39 million people around the world. And there are places where half of the epidemic is what's called generalized epidemic, it's in heterosexual populations, and half are in what we call key populations. So mental assets with men, commercial sex workers, trans women, trans or more trans women than men, like sort of these very marginalized populations that are getting zero support that is very hard for them to come out very hard for them to seek care if they're have to hide that because you're in a place where there's criminalization. And it's really disturbing to see that go on internationally, which is sort of mirroring what you just said is going on in the south of this country, which is these laws that are just making it harder to get trans care, to get gender affirming care to get to get something as simple and basic as HIV prevention tools, which, you know, we have had prep since 2012 in this country, so to make it harder or not possible to get it on insurance is just really terrible because you need to be able to prevent an infection with these easy to use tools, either a daily pill or an injectable. So it's, you know, I know things come in in waves, but at this very moment, we're sort of in a disturbing backlash cycle. I don't know if it's from COVID. And we really do need to come back and focus on people's health and meeting them where they are. And the fact that just being who you are may expose you to an infection. So we have to try to help you with that. Yeah, every time you speak, I come up with three more things that I want to talk about. So I'm trying to like, focus in what I'm doing here. No, but yeah, and even just something as simple as education and representation for LGBTQ plus people, even that is being is being reeled in. And the fact that we're trying to get it to a place where it's where you're ubiquitously giving good healthcare to all is like, we got to go all the way back down to the beginning, which is just basic education to kids at the start. So we've got our work cut out for us lately. So, okay, back to some good news about your work that you've been doing lately with long acting, ART, namely Cabo Tegrovir. Can you talk about that a little bit? I know it's an injection that after you, you give it twice within the first four weeks, then after that, it's every eight weeks. I know that that's something that you were using for your the folks living in your area. Yeah, so there's sort of two types of injectables actually, there's one that's been approved for PrEP. So, you know, preventing HIV, and that's intramuscular Cabo Tegrovir by itself, it's an integrase inhibitor. And then the one that's approved for treatment is that same drug intramuscular Cabo Tegrovir paired with a friend, which is an NNRTI called rilpivirine, and those two put together are given for treatment as combination treatment. And the thing about the treatment with Cabo Tegrovir and rilpivirine, it was only studied in populations in the clinical trials who could take oral HIV medications every day and who were very logically suppressed. And that is not all of our patients because people have substance needs, they have housing insecurity, they have substance use, they have food insecurity, and they're real, real barriers to taking a pill every day. It's a challenge when you're when what are you competing with like getting food? I mean, that's that's like taking a pill every day is your second concern when you're when you have these other substance needs. These are really populations with adherence challenges. And, and we wanted to try the long acting Cabo Tegrovir and rilpivirine, even if they weren't taking oral antiretrovirals like in the clinical trials and had virologic suppression. So we started the demonstration project. Soon after the drugs were approved in January of 2021. And we put anyone who wanted the injectables on it, even if they had high viral loads, even if they were homeless, even if they were using substances, if especially if they just couldn't take the pill every day. And we had some really good success. We published this in the annals of internal medicine on July 4th. So just a couple of weeks ago, 2023, that even the patients who started out with viremia, they all suppressed with their viral load except a couple. So we had about a 98.5% virologic suppression rate in a really hard to treat population. So we think that's really heartening. We think that's showing success with the long actings. It's a way to get around the barriers of having it to take a pill every day, all those adherence challenges. And we encourage other groups, we call this our splash program. And we encourage other groups to try the long actings in viremic patients. Don't reflexively think that there's nothing to be done for patients who have adherence challenges. There is something with these long acting, we think they're very, very exciting. So we're going to keep on going, now we have about 200 people on long acting. Well hats off to you and your team for not just doing a study, because you thought it would be important, but actually looking at what the needs are of the community and reflecting that and meeting people where where they are what they need and using a practical application of the drugs that can actually benefit the people that you're serving and not just a select set of people who are already undetectable or what have you. Thank you, thank you. We feel really excited for these patients. I will tell you one thing, is that one thing when we were doing it is people would say well beyond like the effect on viral load, which was good. What did the patient say? And people like I had one patient who had a very high viral load over 10 million actually a really low T cell count. He had never been suppressed in his life. He got suppressed immediately on this therapy called his mom, he hugged me, he hugs the clinic, the nurse manager, and he went back to work. And he hadn't been able to work for a while. Patients who have never been very logically suppressed in their life, if this is the first time this has happened, it is so empowering and motivating. So we've had a lot of good interviews with people that say this is this is really important. Amazing. Yeah, I can imagine the psychological impact of that alone can have a ripple effect into the rest of their lives. I know just you saying it made me emotional. I've heard of other long acting injectables as well, coming down the pipeline, if not already like once every six months or so, are you considering expanding that and trialing that out? Yeah, it's a great question, because the cavatigravir and rotivarine are given at the most every two months you first we first give it every four weeks, then we give it every eight weeks. But there is a drug approved called Lenocapavir, which is a capsid inhibitor. So brand new class of drugs that kind of prevents you from the virus from getting a jacket on top of it called the capsid. So the virus falls apart, which is what you want. And it got approved in December 2022, but only for patients with multi drug resistant HIV. So lots of resistance to the other drugs. However, we being word 86, we're always kind of trying stuff. And we did. So we have put Lenocapavir with cavatigravir in some of our patients, because the problem with rotivarine is that you can't use it if you have resistance to rotivarine. And if you've used a faverin or cystiva was called or E triple in the past, you know, you can get resistant pretty quickly. So there's a lot of what's called N and RTI resistance. So even though cavatigravir is great, you can't use it in patients who have N and RTI resistance. So we've been pairing up Lenocapavir with cavatigravir for those patients. And we linked with two other centers, one at UCSD, one at Case Western, and we're going to, they are also doing this. And we have about 20 people on it. And we're going to put forth a case series and say, look, we, you can do this. Like I, I, if your patient really wants injectables, and we have this brand new one out, you can put them on injectables that they can't take oral ART, even if for pairing doesn't work, we can use Lenocapavir. Amazing. I did not know that. This is so hot, brand new information. You're like one of three people who know. And we're going to get more long actings. And someday I want like, we all want a regimen that's every six months or maybe every year or an implant. Like it's just, it's incredible to see the advances in HIV. And then we need to care. Yeah. And not just hope, but also a toolbox of options, because I was having this conversation with some fellows at AIDS funds a few months ago. And we were talking about how, for example, for someone like me, an injection every month or every two months, for me in my mind and my schedule and my life and my realities, I would rather take a pill every single day because I already take like a dozen pills every day for supplements and fitness and things like that. And the idea of having to make an appointment with a doctor every month or two is like way more stressful for me. And I don't have problems with adherence. So I would rather take the pill, whereas someone else might want the injectable. So just having those options is key. Yes. If that's what it is, the options, like some people, yeah, like you said, like you, it's fine to take an oral pill. Some people absolutely reminds them they have HIV. They just don't want to put it. I have one patient who she felt just so stigmatized that it reminded her she had HIV that every time she'd try a pill, she would actually throw it up, like she would just get nauseated. And then she got on injectables and is doing great. So everyone has their own reasons or their own, but you need that choice. And that's where we're getting to in HIV. And that makes it feel just more open and free. And then when you're vaccinated, we need to cure. Those are the two other things we need. Another hurdle for ending the epidemic is trust from the community for healthcare. And we saw this completely aggravated as you touched on during the COVID pandemic and the way we handled that as a society. How do we undo that damage? And how do we strengthen those bridges moving forward? Well, this is a great question because the book that I just wrote, which is endemic, like you said, the post pandemic playbook by Mayo Clinic Press. Actually, the entire premise of the book is we should have learned more from HIV to deal with COVID because what we did in HIV, and I'm not saying this was from the very beginning, HIV was hard to, but relatively early on, at least there was kind of a unity between researchers and clinicians and doctors and patients and advocates and community health organizations. We got on the same page and we would march together and like we were just sort of more unified than we were with COVID. And beyond that, we involved community, like community, you're on the Hope Collaboratory community is essential, nothing, you know, nothing without us, right? And, and then also we, we used a harm reduction approach and the harm reduction means in the context of HIV is there were some people like politicians who were saying, you know what, there's a new sexually transmitted disease to stay away from each other. Something wrong with you. There's, oh, it's out there. You're causing this. Just stay away, abstinence only, which is a terrible way to do public health. Just say no is a really dumb public health message. And it didn't work. And, and instead, if you were like meeting people where you were, where they were, you'd say, okay, totally get there as a new STD. Let's talk about how to stay safe within that context. Oh, the pills have come around. Oh, undetectable equals untransmittable. You don't need to worry about it if you're undetectable. You're not going to pass it on to anyone. Like it was a progressive sort of meet people where they were. And with COVID, there were a lot of things that happened where people said, you know, stay away from each other for indefinite period, which caused loneliness, closed schools for too long in some states. And we obviously lost trust because there's a very clear decline in trust in public health agencies that occurred not over time, but during the COVID pandemic. So it wasn't like started, you know, didn't happen in 2018. It happened now. And now we're down to about, there was that Harvard study, published in health affairs that were down to about 30% of Americans trust the CDC. So that's not a good place to start from. So I am very interested in trust in building back trust in public health in telling people, I'm sorry, what was hard. I'm sorry, what we did wrong. I'm also really interested in biomedical advances just because that came from the HIV world. So if we got antiretrovirals, that seemed like a miracle to me. And if we got the COVID vaccines and the treatment, those were the miracles we needed. I thought that was just really important. And I didn't understand after we got the vaccines and treatments, that we were still saying, stay away from each other, wear a mask, don't go to a restaurant. That was what that was supposed to do, unlock the key to normal life. So really, it's how HIV could have informed COVID. That's what the book is about. How do we gain trust? How to say I'm sorry if things went awry, where there were too many politics in public health, and then kind of a 10 point plan at the end of the book about the next pandemic. I'm so glad that I didn't realize that that's exactly what the book was about. And I'm so glad that you wrote that. I think it's so needed. I mean, even I, there were points during the pandemic where I was like, I feel completely misled. And I feel distrustful because I'm a rational, try to be objective person. I didn't get carried away with it, but I can understand why so many people did, including friends and family. I remember like mainstream media was giving certain facts. And then you had alt media, like Joe Rogan and YouTube channel, virologists that popped up out of nowhere and Twitter experts who were spouting other stuff that at first you're like, I don't know about that. But then a lot of what they were sharing turned out to be true. And because of that, everyone bought into everything else that they were saying, well, if this is true, then everything else they're talking about must be true like AIDS, denialism, et cetera. It's, it was such a good point because if public health just pushed one message without any nuance, without any kind of a holistic view, everyone get a booster from six months on and get six boosters from six months on, as opposed to kind of the nuance which other countries did. If you're older, you're on immunosuppressants, get lots, you know, get repeated boosters. If you're young and healthy, we can stick with this. You know, like we were just so bent, at least public health here was so bent on a, I mean, maybe this is uniquely American on a just say no or a just do it, you know, don't ask questions, just do it messaging that it didn't end up being nuanced. And then you'd have someone say the opposite on Twitter, like you said, and it have it have a grain of truth in it. Like there are side effects of the vaccines and repeated doses in young men wasn't being recommended anywhere else because there is a low rate of heart inflammation. So you just don't need to just be non nuanced. And I think we got that non nuance. I think it's from being American, but it also, for me, it was kind of like public health and the infectious disease community wanted to didn't let Trump understandably. But what they did is they whatever he said, they'd go the opposite. So he said, open schools. Okay, we're going to close schools. And it was just too reactive. And it wasn't nuanced and any epidemic is nuanced. Yeah. And I think you're right also in the, the public deserves an apology. And we deserve transparency. And we got a little bit of it with regards to the vaccines. I remember them saying, Oh, once you have the vaccine, then you're good, you're not going to get COVID, it'll protect you. And then infection started to happen regardless. And then we're like, Okay, well, we were learning as we go, we're just figuring things out. But if that, that mentality needed to be expanded to everything and not, I think a lot of times the issue that I have with, with healthcare, and especially when it comes to HIV is treating us like we're dumb for, for lack of better words, like we need a really black and white answer. And that if we, if we're given anything else, it's going to be too much. We won't be able to handle that. And don't you think that's, I so agree with that because the other thing this book is, it's actually trying to be common sense. So remember how they like close the beaches and close the parks in California? Like, that didn't make sense. Like everyone knew that it was safer to be outside. This is just common sense. And like pulling up your mask, like remember the restaurant, you'd have to wear it in, then you go to the table, then you take it off, then you put it back on. This is not common sense. It's literally just common sense. So that is the last part of the book. It's kind of a 10 point plan. And the first step is accelerating vaccination and global equity and vaccinations because we learned from ART that if you don't give it globally and equitably, that's like, we're all going to fight against that. And we did in the, in the early 90s for, and the late 90s for ART access of global equity and vaccinations. But the minute you have vaccines, stop, ease the restrictions. In, in everywhere in Europe, they said, just get vaccinated. We go, that unlocks the key to normal life. Here we said, yeah, get vaccinated, but also mask and stay away from each other and socially distance. We're going to close the restaurant. So we're going to, and what changed? Like, tell people that something's going to change. And then the other parts of the plan are keeping the outside open, because that's best in a respiratory pandemic, really evaluating when you need to close schools, because that's very important for children. If deep cleaning doesn't work, stop deep cleaning, because it lowers the trust. If, if something doesn't work, it lowers the trust reassess testing. And then ultimately, the last part of it is get antivirals for, for viral infections. Paxilovid is a really important advance, but we need more of the antivirals because COVID's never going to leave. And then coming back full circle, that's the last part of it is building trust. And we're in that phase right now. And we have to build trust. And I see no issues with people just coming out and saying, I am sorry it was hard. And I'm sorry where we were confusing. And I'm sorry when we were back and forth. And I'm sorry when we treated you like you didn't understand, because people understand. Yeah. And I think the biggest thing for me, since I've joined Hope in particular, is realizing just how much more information about HIV and living and growing with HIV, aging with HIV, that there exists. And I knew that my primary care physician never talked to me about nobody ever talked about. And, and I, and I, and I get it from a doctor's perspective of, I just want to give you the easy, like this is your diagnosis. You can live a long, healthy life. Here's your medicine. You have nothing else to worry about. But the reality is it's so much more nuanced than that. Like you said, and there's so much interesting science there. And I think that people will understand it. You just, that's actually a big, that's a big part of this book is it's called education and harm reduction instead of coercion. Like don't use coercion, just talk to people. Honestly, they'll understand. It's not rocket science to like how to avoid respiratory problems. Totally. And so that's why I'm bringing folks like you on to my channel is because I want to move away from, okay, so there is a place and there's a need for HIV 101 talking points and information. I find that most interviews kind of reach just like a surficy level. And that's as far as you can get in like 10 minutes. And, and, and there, a lot of people still need to hear that. But there is a lot of us who are like, okay, I've heard this like 20 plus times. I get it. There's got to be more to it. So I want to bridge that gap between HIV 101 and experts, which we're not going to understand unless we're like you expert. Yeah, this is a great podcast for that very reason, because you can break it down. You can make it understandable. And something happened with public health during the pandemic where they acted like, you know, Americans were children. And by the way, we were no, we were the one of the most political places, as you know, during the pandemic, like everywhere else was just kind of not everywhere, but a lot of other places were just more calm and nuanced and just better about their epidemic. And we were just all over the place. Like I remember when when Iceland, the Nordic countries, not only do they keep schools open, but the after the vaccine came out, Sweden, Norway, Finland, Iceland, when they started seeing breakthrough infections with the Delta wave, they said, you know what, actually, look, there's, there's very little severe disease. So I'm, I know that they're not preventing all infections, but they're preventing severe disease. So this is what we wanted because we never would have, we would never would have developed a vaccine against a cold. So this is actually what we wanted, the preventing severe disease, go about your day, go about your lives. Great, great success story. Here in the Delta wave, there was all this agony, like, we didn't expect this to happen with the vaccines. Wait, we see breakthrough infections. Okay, go back to masking. And it just was so all over the place. And the province town, the province town, the P town party in July of 2021 was like fun. It's P town, it's inside and people got infected, but they also were not hospitalized. They stayed safe. They didn't get really severe disease. And instead of saying, that's great, we acted like we didn't know what vaccines did. And I don't know what happened because again, in other countries, they were just more clear about the messaging and explained everything. And it was just so much better. So we need trust. We need to get back to that trust because God forbid we have another pandemic, hopefully in a hundred years. Yeah, it's just a matter of time really. Yes, but I hope it's a long time. But yes, we need to get back trust because right now we're not we're not in a good place. And so speaking to the HIV community, especially during COVID, I've got a lot of questions, a lot of comments about like, what are my risks as someone who has HIV? If I'm undetectable, if I'm not, what about long COVID? What about long term effects? And I noticed that you had some experience with that. So I'd love to hear any, any information that you have around that. Yeah, you know, we did. Yes, we did some a lot of work actually on the interaction between HIV and COVID. I think to make a long story short, in general, if you have a low T cell count and your viral load is high, you are more at risk for severe COVID. That's for sure before the vaccines. But if you had a high CD4 count and you were on and suppressed, then you just kind of had risk like everyone else. And one thing is that, and I'm very intrigued by this, but I do think to know for fear was protective. There's now two studies, one in the VA system, one that just came out that showed if you were on to know for fear containing regimens that probably protected you from COVID. And a lot of people are on to know for fear probably because it inhibits the same polymerase. So that was one advantage that a lot of people are on to know for fear. Then you get to the vaccines and the vaccines work. They work in people without HIV, they work in people with HIV. You may need more boosters, especially if you're immunosuppressed with HIV with the lower CD4 count. You may need boosters more, but the vaccines absolutely work. They raise an antibody and a T cell response. And then finally, I would say that people with HIV, their lives got really disrupted during this time. And that was really hard too. There were higher rates of a lot of anxiety and depression because it was just a miserable time for everyone. That was true across the board. And in terms of long, yeah. And in terms of long symptoms, I mean, we do have to remember that HIV is a retrovirus. So unfortunately, it does stay in your body, you know, RNA gets made into DNA in your body and then the DNA gets inside your chromosome and it stays there until we can cure it. And that's why we're going to cure it. And we're going to get there. But, you know, five cures total. I mean, we're not there yet, but we're going to get there. But it does stay in your body. RNA viruses like SARS-CoV-2 will eventually go away because they can't be made into DNA to stay. And so there was just a recent study that Paxilovid just got shut down for long COVID symptoms and antiviral because it didn't work. Because that makes sense. It's not the virus is still replicating in your body. So it's really the inflammation that usually occurs after severe COVID that make people have lingering symptoms. And we've seen that with influenza and we've seen that with sepsis and all sorts of severe infections. So we've been seeing the incidence of long COVID go down as the incidence of severe COVID has gone down. And severe COVID went down because of immunity. Because so much, so many of us have immunity from a variety of reasons, from natural and infection and vaccination. And the second is because Omicron was less virulent than the other, its cousins before it. So that altogether, the long COVID incidence is going down. But if you still have those symptoms, I would really encourage you to talk to your doctor about Metformin because it is the only drug that has the best, I think that has the best data behind it on reducing the inflammation. So absolutely say, Hey, I just heard this podcast and Metformin looks like it's going to get rid of my long COVID symptoms at least in 40% of people. So I would just really think about asking your doctor about that. Can you spell that? Yeah. Metformin is M-E-T-F-O-R-M-I-N. And it's a diabetes drug, but it's giving, you know, HIV really helped us with COVID because if you have inflammation, we've been studying inflammation in HIV for a long time. So someone thought to try Metformin with the inflammation after COVID. And it was really effective in these, what are called the COVID out trial. So this just got published in the Lancet. And so Metformin for me is kind of drug of choice if I have some of the lingering symptoms until we get other data from other trials. Great. That's amazing. Yeah, I still, I will, I've read an article recently that those with HIV have been shown to have recurrences of long COVID as well, more likely than if you don't, if you're not living with HIV. And I have definitely had weeks where I suddenly just completely depleted. And I have no other explanation to say maybe it's long COVID, although I can't prove it. Yeah. And the energy went down. So if that came back again, I would do Metformin. I would, and I would talk to your doctor about that. And then Paxilovid, that trial closed down, you know, because that doesn't look like it's going to be a therapy. And then there are other therapeutics in development and understudy. Amazing. Great. Okay. In your intro, I just want to touch on this briefly, since we're running, we're getting to the, to the end here. But in your intro, you mentioned that you also focus on women in HIV. I'd love to hear a little bit more about that. Yeah. Actually, when I first started out, when I was an infectious disease fellow, I wanted to do global HIV, but I was at UCSF. And at the time, we didn't have a lot of global HIV. And someone said to me, work locally, think globally, who is the population in this country that gets the least attention? And it was, it was women, because there was one thing about, especially gay men, they had more support groups, especially in the city of San Francisco, they had more support around them, but women felt really marginalized. And so I started, I joined a study called the Wai Study on wh, who it's, you know, observational study of women with HIV. And I did a lot on sex differences, how women may have different side effects to medication, they may have different levels of the HIV medications, higher levels that would, that would lead to more side effects. And I'm really interested in reproductive health and reproductive justice and also mother to child perinatal transmission. So I got real, I was really in that field for a long time. And then I moved more towards now kind of HIV optimizing HIV prevention and treatment for everyone. But for a long time, I was in the women's role and I loved it. Speaking of global HIV as well, I noticed sometimes in my analytics, I have upwards of sometimes as much as 20% of people from India who watch my content. And I love to think that it's just because I'm amazing. But I think the reality is that there's just so little content out there that they have to come to someone who lives in California to get information about HIV. That is so true. So I work in India and I work in some areas of Sub-Saharan Africa, but India is sort of where my heart is because I'm Indian American. And you are so right that there is this ongoing stigma of living with HIV and it's, and it's gay men. I will get so many emails that I have no, they're all from Indian people and they, I don't know where they are. And they'll just say, I, this happened to me and they'll like name a sexual situation or something. Did I get HIV? And I will always write back because there's no one that this, you know, kind of out there to give information. So yes, I think that this is very interesting. You know, India has so many people that even though the prevalence isn't high, it just has such a vast number of living with HIV because there's just, it's now surpassed China and population. We are so populated, populated is India. Okay. Oh, I'd love to touch base with you on that because I definitely want to expand my coverage as well. I get, I get tons of reach out reach outs too. And actually from people requesting, I finally started a telegram group that is for people living with HIV with different categories like immigration and fitness and nutrition and stuff like that. And a lot of that is so great. I will actually recommend this to people because especially in India and then the areas of Southern Africa, especially right now with some of these countries like Uganda, you need to go outside the country for this. You need to get online and go find content elsewhere. It's really an honor for me to be part of your series because you're doing a lot of good work. Thank you. Okay. So let's see what, okay, this is totally off the wall, but what are some of your hobbies and interests outside of work? When you're kicking your shoes off, you're done with your day of work if that ever happens. Well, I do work a lot and I like work, but I will say I like reading. So this is real, this is not a background. This is like, these are real books. And I like reading. I like movies. I like theater. I actually just, I really like dark books, like I'm reading Dostoevsky right now. So I just like, I like, I like reading actually. And then I have two sons who are very wonderful children and they're kind of older. They're 15 and 13 now and they are my best friends. I love that. I'm a mama's boy too. Oh, I want them to stay that way forever. So you've given me hope that hopefully with their later in life, they're going to stay with me. Mama's boys, that's what I want. Well, is there anything we haven't covered today or anything you'd like to share with the viewers? No, you know, I would say I just have a lot of hope for HIV. I'm glad we're both on hope, but it's not just, I know we'll get to cure, I know we'll get to a vaccine, but I also am just really hopeful about what we have now, which is really good treatments, really good preventions. We need the political will. This is what UNH said yesterday this week. They said we can get away from, we can absolutely get there, but we need the political will. We need more investment. We need people thinking about this. We need to come back to HIV. Now that COVID simmering and we need to rejuvenate our attention to HIV, in my opinion. 100. And Monica, I would so love to bring you back on to this channel at some time in the future. So we talked about building trust and bridging that gap, but the thing that we didn't mention is really visibility and role models within the healthcare community. And so you coming on to the channel and having this really open conversation with me is part of that. So you're contributing to that. So thank you for that. But yeah, I'd love to bring you on to talk further. There's so many topics that we kind of like just scratch the surface on. That sounds great. I will see you again another time then. Thank you. And where can people go if they want to follow you and or your work? I am on Twitter with follow what that means, but it's Ammonica on the L1 word 9, M-O-N-I-C-A-G-A-N-D. And then the book is available. And then I just try to talk a lot at HIV meetings. I hope I get to see you all at some meeting or another meeting. Yeah, I noticed when I, if I search for you on YouTube, it's not hard to find Z-DogMD, his YouTube channel. Some great interviews there. We're going to talk again in August. Okay, awesome. So yeah, podcast, but I just, yeah, I really want to go back to talking about HIV. I kind of, as everyone's kind of simmering with COVID, it's just sort of now people want to, I want us to bring our attention back to this important HIV. All right. Well, everyone at home, please comment below your thoughts and questions. I'm happy to follow up with any questions you might have with Dr. Monica Gandhi. And yeah, thank you so much. Be sure to like this video. If you liked it, subscribe, hit that bell icon so you get a notification every time a new video comes out. And that's been happening a lot more lately. And I will see you all soon. Cheers.