Getting to Zero: How to Cure an Infectious Disease
By: M. J. Stephen
Tags: Infectious Disease, Public Health, HIV

Inside the dungeon, the underground studio with its cold black concrete walls and naked white bulbs eerily dangling from the ceiling, it’s time to start pedaling to the line. Demetre is going to take us there, to the line that separates life from death.

He gets on his exercise bike, and the other riders follow. Music with a heavy beat roars from the speakers, and a video showing a woman in a billowing white dress against the backdrop of the expansive American Plains projects from two large screens. The smell is crisp, the air a touch cold. Now the flywheels of the bikes slowly come to life, a mesmerizing whirl of air mixing with palpable nervous energy.

It’s Friday night, and it’s time to die.

Demetre has on a black tank top and black spandex shorts. His head is shaved, and staring out at the other riders are deep-set liquid eyes. As his legs start pumping, muscular and lean, you can make out the blur of tattoos on his arms and torso. There’s a fish, a fly, and snakes. A skull adorns his right bicep, at once haunting but also wracked with sadness. An eagle with talons extended dives down his left pectoral. Just below it, a single word in bold type announces: WARRIOR.

Over the next hour, with muscles straining, sweat flying, Demetre leads his combatants in this near-death experience. As sharp and imposing as his presence is, his voice is other — deep and resonant but full of warmth and encouragement. He takes the riders up and down hills, standing on the bike with arms raised up, and then crouching low with head down. It is through the ride, and the accompanying pain, that the objectives are reached — unleashing the inner monster within all of us, shedding the timid self of the daylight hours, putting on a mask of aggression. But the aggression is not for its own sake. The ultimate goal is to get up to that invisible, mystical, line of terror. Here is life on one side, there is death on the other.

In the gothic darkness of the underground studio, the music continues. A heavy sweat builds up on the riders, and a tension with it. The average heart rate in the room soars, heading toward two hundred beats a minute. That’s about three beats a second. But these aren’t palpitations. These are steady, strong beats with a purpose. To go to that line.

Up and down they go, with Demetre calling out for the others to follow him. They reach a final hill, and ratchet up the tension on the flywheel. It’s time to go. In unison they all stand up. It is now their legs cramp with lactic acid, their brains sear with pain. A final count to ten, and then release. “Come back to the living!” Demetre calls out.

There’s a cool down, and some deep, heavy respirations in the room while the breath of life expels the humors. Demetre walks around, unfazed, handing out water and encouragement. Then some plastic cups come out, and an elephant-handle-sized bottle of vodka. A final ablution takes place, a reaffirmation of our place here on Earth. The burn of the alcohol in the throat is one final reminder of the fragility of it all.

Today in America, living as a gay man with the shadow of HIV never far off, is probably the closest thing there is to a community of people living near that line of life and death. Demetre’s in a good position to help, as he knows both about being gay and having HIV. And like a modern-day Catcher in the Rye, his life’s work is all about pulling people back from that line. Hopefully a lot of people.

***

The Demetre we are talking about is Demetre Daskalakis, and he’s not just a spin instructor in a gothic Lower East Side fitness studio. He’s a Harvard-trained physician and the assistant commissioner for New York City’s Department of Mental Health and Hygiene (DOHMH) Bureau of HIV Prevention and Control. When he’s not leading fitness classes, he is working tirelessly to get New York City to zero.

Zero’s existence as a number has been debated. It certainly does strange things. It’s the only number when you multiply with it, you get the same number each time. But don’t talk too much philosophy with Demetre. He understands the bike ride theory of life better than anybody. Keep pedaling, keep moving forward, otherwise you fall over.

Demetre will tell you biology isn’t mathematics. Things in biology can begin and do end. Obtaining zero is possible. History bears this out. The most famous example is smallpox, which goes back some twelve thousand years. It likely started in China, then spread to Europe and later to North America and Australia. It killed three out of every ten people it encountered, many of them children. Tens of thousands died over the years.

The beginning of the end for smallpox started in 1796, when the English doctor Edward Jenner began experimenting with a vaccine made from a related virus, cowpox. It worked, and in 1801 he published The Origin of the Vaccine Inoculation. Less than two hundred years later, in 1978, the last death from smallpox occurred. For now, the world is at zero with smallpox.

The goal for New York City is to get HIV to this same zero.

But how are we going to get to zero with no vaccine and no medications that can cure? Demetre thinks he has the answer, and he puts it simple formula:

Science + Community + Political Will = Zero

It’s an equation that is not mathematical, doesn’t make sense, but maybe we can get to zero because we’re dealing with public health and not abstract numbers. Public health is not about discovery in the same way science is in the laboratory. There are no Erlenmeyer flasks with blue liquid, no pipettes, no goggles. Public health is about getting the world to move toward your vision. To do that takes a tremendous amount of Will — and Energy.

New York City believes it has found its key will and energy in Demetre Daskalakis.

***

What Demetre is trying to do isn’t as hopeless as it might seem. In fact something similar was recently accomplished with tuberculosis. TB was very common in this country as recently as a hundred years ago. It was also easily spread, and there were no available medicines and no vaccine. But with a big dose of public health it was controllable.

The disease tuberculosis originates from a tiny bacterium responsible for the most infectious deaths in the history of humanity. As of today, it still infects almost two billion people, about a third of the world’s population. It was the scourge of nineteenth-century Europe and America, and accounted for one out of four deaths during this time. From Mimi, the heroine in Puccini’s La bohème, to characters in Eugene O’Neill’s plays and Fyodor Dostoyevsky’s novels, tuberculosis found its way into every aspect of our culture.

The unmasking of TB began in 1882, when the German bacteriologist Robert Koch definitively announced that the white plague was due to bacteria and not bad “humors.” Across the Atlantic in New York City, one physician, Dr. Herman Biggs of the Department of Public Health, took this information and translated it into some good. As in most dense cities during the nineteenth century, in New York TB was the leading cause of death from all causes. It was completely out of control, with a rate in 1850 of 431 deaths per 100,000 people per year. (today the rate in NYC is 7).

This was the status quo until Dr. Biggs went to work. He set up a system of free sputum analysis, where all patients in either public or private hospitals could find out if their lungs were infected. He opened up TB wards in hospitals throughout the city, where patients were quarantined. He had circulars printed in English, but also German, Yiddish, and Italian to educate the burgeoning immigrant population on how to cover their coughs and dispose of sputum in a sterile way.

He also advocated for some things that gave the medical establishment fits of apoplexy, like insisting that all cases of TB be reported to the city’s public health department so they could be followed and all of their contacts tracked down. The New York Academy of Medicine pushed back hard, calling his recommendations “mistaken, untimely, irrational and unwise,” as well as “offensively dictatorial.”

But Dr. Biggs persisted, and convinced lawmakers from upstate New York as well as the Tammany Hall government in New York City that these steps were necessary. And they worked. The city saw the rate of TB deaths per 100,000 plummet to 237 cases in 1900, 126 by 1920, and 46 by 1945. This was all without any antibiotics and no effective vaccine.

From this success Dr. Biggs famously stated that ultimately you got the public health you paid for: “Public health is purchasable. Within natural limitations, a community can determine its own death rate.” But who is going to be our modern-day Herman Biggs, today, right now, with HIV in New York City? Many believe it’s Demetre.

***

The story of what Demetre is trying to do cannot be told without some knowledge about the people he’s trying to treat. They are mostly members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. Estimated at 3.5 percent of the population of America, for a long time they were simply not allowed to come out of the closet.

In 1950 that was some five and a half million people forced to be silent about who and what they were, or risk loss of employment, family, and standing. Being openly gay was cause to be discharged from the military, to be fired from your job, to be tracked by the FBI. Bars that catered to the LGBTQ community were commonly raided and shut down. The 1952 edition of Diagnostic and Statistical Manual, the standard text for psychiatrists in the country, defined homosexuality as a mental disorder.

The beginning of change came in the 1960s, and many point to the Stonewall riots in New York City as the seminal turning point. In Greenwich Village, at 1:20 a.m. on Saturday, June 28, 1969, the Mob-owned Stonewall Inn bar was raided by police. This time, the 205 gay, lesbian, and transvestite patrons there did not go quietly into the night, or to the police station. One street queen, Sylvia Rivera, pronounced appropriately, “You’ve been treating us like shit all these years? Uh-uh. Now it’s our turn!”

A riot ensued, with cops chasing gay men around the streets of Greenwich Village, but given the winding nature of the streets, those same gay men then chased the cops. After a second night of rioting, political action stepped up in New York City and throughout the country, with the founding of new societies like the Gay Liberation Front and the newspaper Gay.

After many years of hard work and activism, today there are open gays in the military, and gay marriage is the law of the land. But make no mistake: Coming out of the closet is still a radical act. There’s discrimination, harassment, and violence. You can be fired from your job, disowned by your family, denied access to bathrooms; also shot, beaten, stabbed, or drowned because of your gender identity.

Here in twenty-first century America is Gwen Araujo, strangled at age seventeen by four male friends when they found out he was transgender. Over there is seventy-two-year-old Andrew Anthos, bludgeoned to death with a lead pipe while anti-gay slurs rained down on him. Bullets arced through an Orlando nightclub to find forty-nine people, all dead because of their sexual orientation.

There are many people who want to keep this population silent, and invisible. Those in power like to stay in power. They construct false ways of thinking, and they do it expertly by invoking slanted views of history, religion, God, universal laws, and biology. Any arguments you can think of they will twist to their ends. This is to say nothing of a tiny virus that came to America in the 1970s to wreak havoc on a community already afflicted with hate and prejudice.

***

One of the most extraordinary papers ever published in modern medicine was in a June 5, 1981, Centers for Disease Control Morbidity and Mortality Weekly Report (MMWR). Running a mere 522 words in length and with a paltry five references, it is a document that nobody recognized as anything remarkable at the time. Now, in retrospect, we know this one-page paper was the first official disclosure of a pandemic that was about to grip the country and the world.

The report out of UCLA in MMWR described five young men, all sexually active homosexuals, who got seriously ill with pneumonia. This may seem like nothing special, as having pneumonia, and dying of pneumonia, is nothing eye-catching, even today. Pneumonia kills thousands each year, young and old alike.

What was different about this pneumonia was the causative agent. It wasn’t a typical bacterium, like Streptococcus. All five young men were found to have a very strange fungus, Pneumocystis carinii. To date, this fungus was only known to infect patients with serious immune system dysfunction, such as those who are on drugs for an organ transplant, or patients with unusual genetic defects in their white cells. The five young men all also had documented infections with another fungus, Candida, as well as a strange virus, Cytomegalovirus. These infections were not known to occur in otherwise young and healthy people.

But the five gay men in Los Angeles weren’t healthy, and these patients were not a limited sample, but rather the tip of a huge iceberg that was about to be discovered beneath the surface of America. Within days of the June 5th report, other reports of gay men stricken with strange infections as well as strange cancers known to be caused by infections poured into the CDC. By June 8 of 1981 the CDC realized there was something very serious at hand, and established a task force to gather information on these unfamiliar, opportunistic infections happening in otherwise healthy men.

As the cases (and deaths) piled higher, and the press coverage with it, names like “gay plague” sprang up, along with “gay cancer.” A somewhat more scientific name, Gay-Related Immunodeficiency (GRID), was also coined. But soon this was found to be inaccurate, as the disease was discovered in populations including hemophiliacs, infants, and intravenous drug users.

But society found it easiest to associate the disease with gay people, perhaps in the hope of putting them back in the closet, locking it, and throwing away the key. President Ronald Reagan, on a trip to Philadelphia in 1987, espoused that in regard to HIV, “medicine and morality teach the same lessons.”

Back in 1982, the cause for this drop in immune function was not known. There was panic, both in the gay community and in hospitals. Scientists set to work to figure out what this unknown scourge was. Early hints that the disease was caused by an infection proved true, and in 1983 researchers brought us out of the darkness about the etiology of the disease. They announced discovery of the HIV virus, one that preferentially infects and kills our infection-fighting white blood cells.

Although the medical community was enlightened, there was still a ten-year gap before effective medications were available. This was known as the “reign of terror”, a time when hospital wards were filled with patients dying from these rare infections. The gay community was hit particularly hard. In 1987, there were 13,329 deaths from HIV. By 1995 the death rate had risen to 41,699, with the graph line going straight up.

Effective medicines did come, especially when used in combination. The 41,699 deaths per year turned into 16,685 just two years later. The medications didn’t cure, but suppressed and were effective when taken appropriately. Medicines today have no doubt changed the history of this disease dramatically. Today there is diver Greg Louganis, diagnosed in 1988 and now doing well. We also all know about Magic Johnson, living and thriving with HIV since 1991.

But the goal is not to get to one thousand cases, or one hundred cases, of HIV per year. The goal is to get to zero. To get there, we have to look not at the successes of our society, but the failures. Those people falling through the cracks. Today when an HIV patient comes into the hospital with a strange infection, it almost always indicates they are either not taking their medications or are taking them inappropriately. More often than not there’s a mix of contributing causes, like substance abuse, physical abuse, psychiatric illness, breakdown of family, paranoia, and homelessness.

These are the doomed people easily written off, a silent minority living among us who are ignored by those in power. When they come into the hospital, their diseases and problems are viewed as untouchable; there’s nothing we can do to help these people. They’re “crazy”, or they’re “drug addicts.”

In actuality, many of the people who come into the hospital today with HIV are beyond help, their diseases too far gone for current medications to help them, their organs too end-stage. Their bodies have passed the point of no return. But there is a window of opportunity for them before the damage and inflammation rage beyond control. Here at the edge people have made tremendous progress. Here there is a crack where doctors, advocates, politicians, and community members can make inroads.

***

There’s a concept of change in medicine called the edge effect. Some believe that to affect real change in society, the edge is where one needs to practice. Some doctor, or group of doctors, will have to go out to the edge, live and practice medicine there, and deal with withering criticism in hopes of affecting positive change.

The majority of doctors in America practice in the center of the field, where everything is risk free and comfortable. You do what’s always been done, and at the end of the day you go home to your family and pat yourself on the back that you’ve done a great job. Maybe you’ve handed out some inhalers to somebody with COPD. Maybe you’ve stitched up a wound in the emergency room. That’s practicing in the center.

Out at the edge, it’s more uncomfortable. People will tell you you’re wasting your time and money, dealing with the doomed and unsolvable. There’s fear, limited resources, disapproval, and denigration on your journey. An example is all the people who pushed for kidney transplants in patients who were HIV-positive. Most said it couldn’t be done, it was too risky, there were too many medications to handle. Until a few groups of doctors proved it could be done, and you could change these patient’s lives for the better.

In order to get anywhere out on the edge, you must combat the inevitable and relentless negativity with creativity, courage, collaboration, and persistence. Like Doctors Barry Marshall and Robin Warren, who were consistently ridiculed for their idea that a stomach ulcers were not caused by psychological or dietary factors, but were in fact caused by a bacteria. Until they proved it and then won the Nobel Prize in Medicine for their breakthrough in 2005.

Demetre knows about the edge of medicine because for most of his life that’s where he’s practiced. In 2014 a meningitis outbreak afflicting mostly HIV-positive gay men threatened New York City. This was a headline grabbing and life threatening emergency. HIV usually takes about ten years to become lethal. Meningitis can be lethal in ten hours.

To help combat the outbreak, Demetre went to the source: the city’s bathhouses and sex clubs. Here, peeling off a leather jacket to reveal a black muscle shirt and tattoos, he got people to trust him enough to inject them with the vaccine. That’s the kind of trust Demetre can engender. After speaking with him, they see his mission of pulling people back from the line that separates life and death. That’s when they let the sharp needle puncture their skin and some unknown, clear liquid seep in.

An unfamiliar man shows up in a leather jacket and covered in tattoos, and you let him stick a needle into you while you’re trying to relax or party. It sounds like something out of a demented late-night horror movie: a stranger in the darkness of Gotham coming to clean the streets of lowlifes. But Demetre has turned the twisted fable around — he is here to heal, not harm.

This image of Demetre in gay bathhouses and sex clubs is one of a doctor living and breathing “on the edge.”If recently his life has been there, he has the background to make sure he doesn’t slip over into the abyss. There is no creativity without a firm grounding, no successful spontaneity without a history of hard work.

As an undergraduate he studied biology at Columbia University, but also found time to do a co-major in religion. After medical school at New York University, he did his residency at Beth Israel Deaconess Medical Center in Boston, a major teaching hospital of Harvard Medical School.

Demetre was not the prototypical Harvard Medical School resident in his dress or his lifestyle. He wore an earring, and his ties and shirts often were brighter in color than the usual muted blue and beige of the rest of the medical residents. But he was typical for a Harvard Medical School resident in respect to his work ethic, quest for knowledge, and especially his ability to get patients to buy into his treatment plan. After residency he was chosen as a chief resident, then went on to an infectious disease fellowship at Mass General Hospital, and later took a degree in public health from Harvard.

If the bulk of his formal training and education took place in John Winthrop’s “city upon the hill,” and enshrouded in the culture of Harvard’s Veritas, his heart and personal search for the truth have always firmly belonged in New York City. His pace and energy are more area code 212 than 617, his preferred lifestyle more New Amsterdam than old New England. He lives in the Williamsburg neighborhood of Brooklyn, where he rides the B62 bus to work, listens to music in Union Square with his husband, and every morning grabs a coffee and Danish at his local bodega.

Demetre loves living in New York City, and loves living and practicing on the edge. It is here, working at the New York City Department of Health and Mental Hygiene, that he has found his true home. It is here where he’s going to see if he can bring the edge into the mainstream. And get NYC to zero in the process.

***

When reports of Ebola circulated back to the United States in early 2014, it received a tremendous amount of press. Rightly so, because we were dealing with a lethal virus that had no treatment and no vaccine. The majority of people recognized it for what it was — an extreme emergency.

The argument could easily be made for this same approach to HIV. It’s a lethal virus that infects our white blood cells, killing them and leaving us defenseless against strange and unusual parasites, viruses, and bacteria, along with cancers caused by infections. It kills thousands every year. There are no medicines that will bring about a cure and no vaccine that will protect. Once you have it, you have it for life. So let’s go ahead and recognize HIV for the endogenous plague that it still is.

It was under this lens that the first part of the equation, Science+Community+Political Will=Zero, was first analyzed, starting back in 2014. Demetre and his people, like Herman Biggs over a century earlier working with Tammany Hall, looked to enlist the support of New York Governor Andrew Cuomo. The first part of the equation to solve is political will.

The meeting was a positive one, with the goal of keeping people negative for HIV. A task force was formed in October 2014, which met several times over the ensuing months. But time was recognized as short, this was an emergency, and by December 2014 a blueprint was published with the goal of eradicating HIV in New York City. The blueprint is an exhaustive outline of how things that haven’t been happening must now happen, with the imperative of the Mosaic tablets published on high. It contains a multitude of wide-ranging thoughts and ideas from all members of the community on how to tackle the HIV emergency.

The blueprint also discusses the second part of the equation, Science. The facts are arranged in Enlightenment style, cause-and-effect, thinking. If A, then B. Although there are no medicines to cure and no vaccine, we do have medicines that can indeed suppress the virus, keep it at bay, keep its replication slow enough that it can’t spill out into the blood. That is the “A” part of the equation.

We know further that people who have achieved viral suppression cannot transmit HIV. That is the “B” part, the powerful fact that can be acted upon, exploited like HIV exploits our cells. HIV can live incorporated in to the DNA of our white blood cells, but if it isn’t in a free-form swimming in our blood, it’s not going anywhere. So by achieving viral suppression in patients who currently have HIV, you will stop it in its tracks.

There are other powerful truths that have been identified, and need recognition. We know that condoms work against sexual transmission — simple barrier protection. We also know that post-exposure prophylaxis with medications not only works for those with a recent exposure, but the same medications have also recently been shown to be effective for pre-exposure prophylaxis disease prevention for those at high risk.

With the blueprint for New York State in hand, published on the Internet for all to see, the Mayor of New York City was next to chime in. At the famed Apollo Theater, on World AIDS Day on December 1, 2015, Bill de Blasio announced that the city would pledge $23 million that year and every year to fighting AIDS, so people wouldn’t have to choose between rent and medicine, or food and medicine.

So now, with the money (which is often shorthand for political will) and the science, Demetre saw it was time to go out and solve the final part of the equation, the Community. Which then begs the question of who is the community? Who are the patients that are HIV positive and aren’t on medications? Who would benefit from either pre-exposure prophylaxis or post-exposure prophylaxis but isn’t getting it?

These are the people who must be found. In looking at the information they had, Demetre and his colleagues at the public health department knew who to look for. Of the 2,493 new cases of HIV diagnosed in New York City in 2015, eighty-one percent were men, the majority of them men who have sex with men. Almost eighty percent of the total were also either Black or Hispanic. High poverty and very-high-poverty areas harbored the most cases.

The profile is not a white male injecting drugs in Staten Island. It is a Black or Hispanic male, whose preference is to have sex with men, and who lives in a very poor part of the city. These are the people we need to reach, to pull back from the edge. So where are we going to find these people?

Demetre thinks he knows where to start — the eight sexually transmitted disease clinics run by the city. There the potential to intervene with HIV is clearly evident. If you present to one of these clinics with syphilis, there’s a five percent chance you’ll have HIV after a year. If you present with anal gonococcus or Chlamydia, there’s a seven percent chance you’ll have HIV after a year. This is a clear opportunity, but one that will require a change in culture at the clinics. The old line at these eight clinics was, “Here’s treatment for your STD, see you in six months.” The new line, according to Demetre, is, “Here’s treatment for your STD, and would you like to start pre-exposure prophylaxis today?”

But not only pre-exposure prophylaxis. Let’s offer same-day medication starts for HIV infection if needed, or post-exposure prophylaxis, and throw in teaching and samples of effective barrier contraception. Let’s also get you to a social worker and get you health insurance, and make sure you follow up with an appropriate physician who can take care of you for the long term.

So like disco clubs of the 1970s, the STD clinics are part of the past. There are officially no more STD clinics in New York City. The eight sites are now sexual health clinics, tasked with the front-line mission of getting New York City’s HIV infection rate down.

The efforts are paying off already. Between implementation in mid-2016 through October of 2017, more than four thousand patients were seen for pre-exposure prophylaxis, and over a thousand for post-exposure prophylaxis. About sixty-five percent of these visits have been with black or Hispanic patients. A lot of pills are getting out there as well. In 2019, 39,921 individuals filled prescriptions for pre-exposure prophylaxis, while 3,300 filled prescriptions for post-exposure prophylaxis. The program’s success is seen in the bottom line metric of total HIV infections. In 2008, there were 3,693 people diagnosed with HIV in NYC. This has come down to 1,771 in 2019, less than half.

The eight sexual health clinics are a great place to start. But the plan extends way beyond these sites. Both pre- and post-exposure prophylaxis needs to be readily available to providers throughout the city, as well as people throughout the city. For post-exposure prophylaxis, a twenty-four-hour hotline has been set up so an at-risk person can stop the clock by getting a pill in their mouth as soon as possible, at any hour of the day or night.

Demetre not only wants to get a lot of pills out there, but also he wants to remove any stigma, any judgment, from the culture. The person who has HIV and the person who is at risk for HIV are the same person, just at different points along the line. They both need diligent care.

Fear is another thing Demetre wants to take away. Let’s not live our lives in anxiety and shame, he says. Let’s recognize that pleasure is a part of our life’s experience and what we seek. Let’s embrace the concept of harm reduction, not denial. One idea to help align pleasure and HIV care came to him from a twenty-two-year old black man from Harlem.

Demetre was seeing the young man in his office, and noticed a neat square kit he was carrying with him. The man opened it up to reveal condoms, lube, and his medications. Demetre recognized this as a great idea, and within a few years over a hundred thousand of these kits have been distributed throughout New York City. Called the #PlaySure kit, it helps people get beyond fear and loathing.

What Demetre is saying is let’s get people medication, and protection — but also housing. If an HIV individual is homeless, is that person going to spend time and money on their HIV, or are they going to ignore their HIV and spend their energy on stop-gap fixes to get a roof over their head? The answer is easy. In response, the HIV/AIDS Services Administration got rid of the stipulation that an HIV patient must have advanced stage HIV in order to get housing. The program has qualified an additional three thousand people for housing and counting. This is a recognition that servicing their needs is the priority. HIV is merely a symptom, while the disease is lack of housing. Treat the disease.

His list of action-ideas goes on, from supporting LGBTQ communities with a new Bill of Rights, to helping fledgling transgender organizations develop infrastructure. There are also efforts to educate drug users on safe methods of injection, and making sure harm reduction is in place for the developing methamphetamine and opioid addiction scene in the city.

He’s also saying let’s get the word out in new and unique ways. Almost half of new infections occur in people under thirty. For them, there’s the website liveundetectable.org, where comic books chronicle HIV-positive superheroes’ efforts to get those in the shadows on medication. In bold letters, the website confirms the powerful medical fact that UNDETECTABLE=UNTRANSMITTABLE.

The Undetectables website lists resources for medical support and peer support, along with a system for people to receive text message reminders to take their medicine. There’s also financial incentive for staying undetectable. Yes, financial support. Let’s take the stigma, the morality, out of treating HIV. Let’s treat the disease (poverty), not the symptom (HIV).

In the most recent edition of the Undetectables, a new character emerges at the end of the story to join characters like the Gender Warrior and The Relentless Advocate to fight Phear, Denial, and Apatha, along with the always-powerful Stigma. His name is the Wisdom Spreader, and he looks a lot like Demetre. Wisdom Spreader’s plan is to gather up all the slogans, all the political will, all the science, and lead us down the path. All the way to zero.

***

Dr. Michael J Stephen is a lung doctor in Philadelphia. His book, Breath Taking, will come out January 19th, 2021. It covers every element of the lungs and breath, from why and how we breath, to diseases like asthma, tuberculosis, and COVID-19. It can be preordered now at https://www.amazon.com/Breath-Taking-Fragility-Future-Extraordinary/dp/0802149316/ref=sr_1_1?crid=3RVU5SJWK3WFS&dchild=1&keywords=breath+taking+stephen&qid=1607866883&sprefix=breath+taking+%2Caps%2C170&sr=8-1 Full website is drmichaelstephen.com.