Dr. Stacey Rizza ’91: HIV Expert

HIV is no longer the headline-grabbing disease it was 30 years ago. But maybe it should be. In April 2016, the Centers for Disease Control announced that, despite decades of public health efforts, the U.S. rate of HIV infection has not decreased significantly. Every year, more than 50,000 new cases are reported. And there’s an even bigger infectious-disease threat: hepatitis C. As chair of the HIV clinic at the Mayo Clinic, director of its HIV transplant services, associate dean of the Mayo School of Health Sciences, and associate professor of medicine, Dr. Stacey Rizza is on the front lines of treating and understanding HIV and hepatitis C.

With everything that Americans know about HIV, why are there still 50,000 new cases of infection every year?

The biggest barrier is that not everyone is getting tested for HIV. Approximately 13 percent of people in the U.S. who have HIV don’t know that they are infected, so they continue to transmit it. That’s frustrating, because we now have very effective antiretroviral therapy that can help people live longer with HIV and decrease the chance that they will transmit it to others. If every person on the planet with HIV were diagnosed, linked to care, and on effective antiretroviral therapy, the virus would be eliminated from the human race within one generation.

Risk factors for HIV are fairly common knowledge. Why aren’t people in those risk groups getting tested?

It’s not just people with risk factors that should get tested. We find HIV in people who think they have zero risk factors. That’s why, in 2006, the CDC recommended universal HIV screening for all adults who come into health-care settings and have not been previously tested. But that’s not being done. Many physicians are either unfamiliar with the CDC recommendation or they feel uncomfortable discussing it with their patients.

That recommendation is 10 years old. What needs to change to make physicians compliant with it?

Our team at Mayo created electronic platforms to trigger those screenings. So an electronic flag will notify a doctor or health-care provider if the patient they are about to see has never been tested for HIV. Figuring out who is infected and getting them treatment is the top priority. The U.S. is getting better at it, but it’s something we still don’t do well.

Neither does India. International organizations report that India has the third largest number of HIV-infected people in the world. Less than half are on antiretroviral medications.

India has one of the largest and one of the most dangerous HIV epidemics in the world. The infection rate in India has increased at a rate that matches, and at some points exceeds, what the rates used to be in parts of Africa. There are countries in Africa—particularly South Africa—that are examples of what public health initiatives can do to dramatically decrease the rate of new HIV infections. South Africa has one of the world’s largest populations of HIV patients on antiretroviral medications paid for by the government. And, they have just instituted a policy to provide HIV pre-exposure prophylaxis [preventive medications] to all sex workers. That’s an example of a government focused on addressing the HIV epidemic. It has made a remarkable difference. Other countries should be mimicking those initiatives and donate to the global fund that supports them.

The official stance of many governments, especially Russia, is that HIV infections are due to the moral lapses of people who have it. That sounds like the American government’s response in the 1980s.

Countries with those epidemics have put their heads in the sand and turned HIV into a judgmental issue instead of a medical one. HIV needs to be addressed through public health initiatives, not through discussions of morality, especially those that are baseless. Worldwide, HIV is transmitted predominately by heterosexual sex. Studies done in large HIV clinics in southern India show that in some clinics with a majority of patients that are women, for 90 percent of those women, their only risk factor for HIV was having sex with their husband. It’s time for those governments to initiate public health strategies to get people tested and link them to care for therapy.

You say that HIV is not the most dangerous infectious disease in the world. What is?

Hepatitis C is an equally big, if not larger, epidemic than HIV. Numbers-wise, hepatitis C blows away HIV. There are 170 million people worldwide who have been infected with hepatitis C, and close to four million people in the U.S. are infected right now.

In May 2016, the CDC reported that deaths from hepatitis C were at an alltime high. How did hepatitis C become so widespread?

Once again, it’s a matter of testing people and getting them linked to care. We now have phenomenal treatments for hepatitis C. Many of the treatments are one pill a day for three months. In most studies, the cure rate is over 95 percent. If people respond to therapy, they are cured for life unless there is reinfection. That’s why we want to find people and connect them to care. If it is gone from their system, they can’t spread it. But the majority of people, unless they get tested, don’t know they have hepatitis C until they have the symptoms of liver failure.

Who should get tested for hepatitis C?

Hepatitis C is a blood-borne infection, so anyone who uses IV drugs, snorts cocaine, or has tattoos should be tested. It’s not easily transmitted sexually, but transmission is more likely to occur through rough sex, if a person is infected with HIV or another sexually transmitted disease, or has multiple sex partners. The CDC recommends universal [hepatitis C virus] screening for everyone born between 1945 and 1965. Epidemiologic studies show that most hepatitis C infections in the United States are in that population

Baby boomers are at the most risk for having hepatitis C?

Yes. That’s one of the messages that we are shouting from the mountaintops. A full 75 percent of hepatitis C infections in the U.S. are in that age group. During the baby-boomer era, it’s thought that there were lifestyle risk factors that made them more likely to be infected. As with HIV, if we could diagnose and treat everyone with hepatitis C, we could definitively prevent its spread.

One of your specialties is supervising transplants for people who are infected with HIV and hepatitis C, or both.

Twenty years ago, we wouldn’t have dreamed of doing transplantation in HIV patients. But now that many people living with HIV are taking combination antiretroviral medications and doing well, we are learning that complications of long-term HIV are not just from immune-system depletion. Long-term HIV can also cause direct organ damage. People with HIV are more likely to have heart attacks, strokes, and renal failure than people their age without HIV. Patients who are co-infected with hepatitis C and haven’t been treated are likely to develop liver failure over time. We now have many patients living with HIV who need kidney and liver transplants. And, HIV-infected patients who develop leukemia or lymphoma may need bone-marrow transplants. At Mayo, we are fortunate to have a large transplant center and a well-coordinated team, which allows us to be an HIV transplant center.

There have been such strides in antiretroviral therapy since you graduated from Haverford in 1991. Was it always your intention to go into medicine?

Definitely not. Towards the end of my time at Haverford, I fell in love with the idea of space travel. I learned from NASA that the highest number of people going on the space shuttle were M.D.s who became mission specialists. That’s when I decided to apply to medical school.

Did Haverford prepare you for medical school?

Yes, and not just academically. I was always stronger in math and science, and at Haverford those classes had a heavy male-to-female ratio. When I got to medical school, it was the same way. Also, being at Haverford is like living in a microcosm of the world, because there are people from all over the U.S. and the world. I loved being with so many people from so many places. In fact, I loved Haverford so much that my sister, Elizabeth [Rizza] Cimaroli, followed me there. She graduated in 1994.

How does a young woman who dreamed of being an astronaut become an HIV specialist?

I did an internal-medicine residency and a few aerospace projects and found it wasn’t to my liking. I preferred immunology and host-pathogen interactions. I did an infectious-disease fellowship at Mayo and worked in a research lab investigating HIV pathogenesis. I really enjoyed working with HIV.

That might sound strange to some folks.

You’re right. What I mean to say is that the HIV virus is very interesting. Is that better or worse? Well, the truth is that HIV is fascinating because of its host-virus interaction and the way it causes the immune system to die. The goal, in a nutshell, was to figure out how HIV makes the immune system vulnerable. In the last decade and a half, antiretroviral drugs have been developed and perfected to suppress the virus. Now the HIV community is working on research towards a complete cure.