‘We have battles to fight, but if I don’t speak for people, who will?’
Michael Kolber, M.D., Ph.D., professor of medicine, came to the University of Miami as a young immunologist who was keen on researching T-cells. In the face of Miami-Dade County’s rapidly growing HIV epidemic in the early 1990s, however, Kolber was enlisted to head UM’s first HIV Division. He would soon become a prominent leader in the region’s fight against the disease and would help devise a sustainable plan to give infected residents comprehensive care and support.
Kolber, who also serves as Clinical Director of HIV for Infectious Diseases, and Director of the Comprehensive AIDS Program, has built UM’s solid relationships with local community partners to reach high-risk people for testing and linkage to care. He has long championed pre-exposure prophylaxis (PrEP) and recently conducted a clinical study showing that individuals at behavioral risk for infection will take, and are interested in taking, the medication when offered a “real-world” setting.
Here the passionate clinician and researcher chats with Medical Communications about his inspirations, UM’s remarkable legacy as a regional powerhouse for HIV research and his hopes of eradicating the virus.
What led you to a career in medicine?
I was born in Mount Vernon, N.Y., but I grew up in Westchester County. I was always more adept at math and science in school, and I was a physicist before I became a doctor. I received my Ph.D. in physics from the University of Illinois, and then did a post-doc in Pharmacology at UM so that I could do biophysics. My efforts were more directed toward clinical science during this period, so I became interested in the medical side. This interest led me to complete my M.D. at UM and then onto my residency at George Washington University Hospital in Washington, D.C. Afterwards I spent two years doing bench research as a medical staff fellow at the National Institutes of Health Experimental Immunology Branch. I came to the University of Miami in 1988 as an assistant professor of medicine. I had a strong focus in researching T-cell immunology at that time. As my career progressed, I became involved in immunologic aspects of HIV research. Not surprisingly, I approach HIV as an immunologist, but I am not boarded in infectious diseases.
How did you get involved in HIV at UM?
That took place in the early ’90s. As happenstance would have it, Dr. Laurence Gardner gave me an opportunity to run UM’s first designated HIV section. It was a pivotal time for HIV and AIDS. The ’80s were really challenging during the Reagan era, but federal resources became available toward the early ’90s where different federal HIV efforts came together to form the Ryan White CARE Act. It was a time when the Public Trust team at Jackson Memorial Hospital and the services at UM were combined in my section. My goal was to learn as much as I could about HIV care and to give faculty the opportunity to learn and do HIV research.
Can you describe UM’s early HIV clinical program, and how it became a model for success?
The Ryan White CARE Act was, and continues to be, one of the biggest players in our ability to provide adequate care for patients, especially those of low socioeconomic status. We’re funded through several aspects of the program. Jackson, where we provide the bulk of care, has always had a large clinic and has provided space and staff support, which really allowed us to practice quality care. The county, overall, has been a major resource and great to work with. We consider Jackson to be a partner of UM in the HIV effort, and our work together has allowed us to be a center of HIV care excellence.
As my work in HIV increased, I started getting more involved in community outreach, which was crucial for building awareness, testing and linkage to care. We then started developing our services into a comprehensive care program. We partnered with the UM School of Law to start a medical legal clinic at Jackson. It’s a unique model, and it has been an extraordinarily successful venture in training lawyers in health care law and helping thousands of patients with various levels of assistance. We also work closely with various federally qualified health centers to provide expert HIV care to their populations.
What inspired you to make a career in HIV care?
The faculty in the HIV section really led the way for me. They are quality individuals who practiced HIV-related care not for the money but for the cause. They were interested in forwarding the research and care. Then the Center for AIDS Research came about with the help of Dr. Eckhard Podack, who was always a scientific champion. He brought in Dr. Savita Pahwa. Then Dr. Mario Stevenson came, the current Division Head of Infectious Diseases. Dr. Stevenson has recently created the AIDS Institute as an umbrella organization under which the CFAR and Comprehensive AIDS Program reside. So the bricks kept building and enriched the foundation that was already here. We now have world-renowned researchers in HIV and some of the strongest nationally recognized clinicians. Our team makes it hard not to be inspired. They effectively go to work every day to improve the lives of people living with HIV.
The patient population also inspires me. It’s ethnically diverse, yet the communities in Miami-Dade County are very distinct. Their lives are not easy, because in some quarters there is a lot of stigma attached to HIV, and every day is a challenge when you don’t have food, housing or transportation.
I am very proud of our efforts to move into the 21st century of care by leading the way in providing patient-centered care. The goal of our patient-centered medical home practice model is to provide patients with access to coordination of care and improve their health outcomes. We have mental health specialists, social workers, dermatology and gynecology services, a pharmacy, a dentist and case managers when they need to see them. The list goes on and on. We try to make it a one-stop clinic. It is hard not to be inspired when the team you work with is of such a high quality.
Who are UM’s greatest partners and allies in the regional war on HIV?
Jackson Memorial Hospital is very much a part of us. We work with strong and effective agencies such as Care Resources and Borinquen Health Clinic. We work very closely with our community partners and assist them as much as possible. Community partners are especially important because HIV is a disease best tackled as a team and recognizing that working together will allow better resource utilization and outcomes.
I work very closely with the local and state departments of health and have participated on White House panels focused on the national HIV/AIDS strategy. UM is often brought to the table when federal and state entities convene on HIV. Our expertise is widely respected. We work closely with the Centers for Disease Control and Prevention, and I was an expert reviewer for the recent CDC guidelines for PrEP.
Our relationships are some of the strongest in the state. Miami-Dade County continues to be where the greatest HIV incidence occurs. We are the national epicenter for new infections. Our clinic is predominantly indigent and we have one of the most demographically diverse patient populations in the country. This provides challenges but also gives us a lot of information and expertise in areas of greatest need. People respect our institution as being the leaders in HIV care in South Florida as well as nationally.
You have been fighting HIV and AIDS for a long time.
I’ve morphed into an advocate for people with HIV and AIDS. I believe very strongly in treatment as prevention, and I believe that people have a right to care. I do understand some of the challenges we face here, but once people have care it keeps people out of the hospital and costs down. Does it wear on me sometimes? Yes. We have battles to fight, but if I don’t speak for people, who will?
What are your goals for the UM’s HIV program in the next 5 to 10 years?
We talk about a cure being closer than it has ever been. There is the Berlin patient who had a functional cure. There was also the Mississippi baby who was treated early on, came off of medication and was free of the virus for a number of years until it came back. We know that there are reservoirs in the body where the virus hides out until it resurfaces. Dr. Stevenson has received state funding to effectively advance the cure agenda, and the progress being made here by our basic science researchers is astounding. But treatment as prevention is effective, as well. We just completed a large pre-exposure prophylaxis study with our partners in Washington, D.C., and San Francisco. What we found is that people will take PReP more often than not when offered. There is a lot of science that has shown if you treat at-risk people with PrEP before they get HIV, then they won’t get it. It’s expensive and that has concerned many groups in terms of how best to allocate resources. As usual, there needs to be more research, but our group is participating in numerous efforts in this area.
I think that effective HIV vaccines are well on their way, and hopefully in the near future we will begin to see human vaccine trials. I expect UM to be a leader in this effort, as well. Injectable antiretrovirals are also being studied, and they will be a big leap forward since they can be long acting. I try to be optimistic that new doctors and researchers will bring even more effective ideas to the fight. If we can get needle exchange, reduce transmission and get everyone tested, then the virus can’t go anywhere and just dies out. That has historically been the case with infections and epidemics.
However, if you get a 10 percent change in the infection rate by vaccines or treatment as prevention annually, this may be a success as well, because if we continue to reduce infection rates by 10 percent, we might just eradicate it. The solution is easy to talk about but difficult to achieve. You have to test everyone and effectively treat those that are infected. We can use PrEP if we are not able to do the first two perfectly.
What are your outside interests?
I don’t have much leisure time because I wear several hats, but I do bike and read, and I love cooking.