In addition to currently treating 130 patients, Dr. Farthing is Medical Director of the AIDS Healthcare Foundation in Los Angeles, a community-based HIV/AIDS medical provider with 6,000 HIV-positive patients in 10 Los Angeles clinics and another 1,000 across the country. Under his leadership, the Foundation has opened clinics in Honduras, Uganda and South Africa.
"And we're expanding further to reach our goal of 'Three by Five,' that's three million HIV/AIDS patients under treatment by the end of 2005," Dr. Farthing says.
That's an ambitious objective for a man who started out as a dermatologist in New Zealand years before HIV/AIDS was ever heard of. But while practicing in England in the 1980s, Dr. Farthing began treating patients with the disease. He later organized one of the first AIDS clinics in the U.K, lectured throughout the country and became a government advisor on HIV/AIDS, even chairing a parliamentary committee on HIV/AIDS.
After earning a fellowship to study HIV at Bellevue Hospital in New York in 1988, Dr. Farthing later became Director of the hospital's AIDS Program. In 1994, he moved to Los Angeles to engage in research, and in 2001 joined the AIDS Healthcare Foundation.
Today, Dr. Farthing, who at one time volunteered to undergo human testing of new HIV drugs (a request denied because it was considered too dangerous), remains outspoken about the state of attention to HIV/AIDS, particularly about the lack of focus on prevention.
"Prevention efforts in this country are pathetic. They have been far more effective in Uganda," says Dr. Farthing. "No politician in Uganda is allowed to make a speech anywhere without mentioning the need for HIV prevention. Would that were the case here. We need much greater exposure of the population to messages about the need for prevention."
As for treatment, Dr. Farthing longs for the day of the once-daily pill, but in the interim encourages education to help people with HIV understand and cope with the disease. For his own patients, Dr. Farthing offers a program of four talks on HIV/AIDS with dinner and a $40 grocery voucher -- if the patients stay for all four talks: HIV 101, Antiretrovirals 101, Adherence 101 and Living With HIV.
For relaxation, Dr. Farthing likes to listen to classical music. Perhaps not surprising for a would-be priest turned HIV advocate, his favorite piece is Handel's "Messiah."
How long have you been practicing?
In HIV for 22 years. Practicing medicine since graduation 29 years ago.
Can you describe how your work has changed since you first started?
Regarding HIV, it is immeasurably easier than it was, but the challenges are different. In the past, the big challenges were differential diagnosis and treatment of opportunistic infections and supporting patients when intermittently extremely sick or dying. Now it is all about designing the right antiretroviral regimen and trying to persuade patients to take their medication.
What's the best thing about your job?
What's the worst thing about your job?
The administration -- what doctor would say otherwise?
What have been your greatest successes in your work? Greatest failures?
Greatest successes: Excellent rapport with patients, hopefully most of the time. Greatest failures: When patient rapport breaks down.
What is the biggest challenge you face as a clinician? Would other clinicians give a similar answer?
Patient adherence to antiretrovirals and safe sex -- I think others would say the same.
What do you think is the biggest problem people with HIV face today?
Accepting their disease -- if they do, these days, most patients (at least new diagnoses) face few of the problems (such as high pill burden, toxicity and health issues), which plagued patients a decade ago.
For the most part, what do you think is the biggest risk factor for HIV?
Crystal methamphetamine -- at least in Los Angeles.
Do you think that the prevention efforts are sufficient? Anything you would change?
Prevention efforts in this country are pathetic. They have been far more effective in Uganda. And, at the recent CROI conference it was surmised that the reason for this is not because of the nature of any particular message used in Uganda, but the constant reference to the need for prevention. No politician in Uganda is allowed to make a speech anywhere without mentioning the need for HIV prevention -- would that were the case here. We need much greater exposure of the population to messages about the need for prevention.
What single change would you like to see in HIV care? What would it accomplish?
One pill, once-a-day treatment, and it is coming. It would accomplish better adherence and thus better control of the disease in many people.
What do you provide in terms of education or counsel for a patient who is just diagnosed?
My own counseling, a social worker's intake evaluation, and a program of four lectures on HIV/AIDS with dinner and a $40 grocery voucher if the patients stay for all four talks. The four talks are: HIV 101, Antiretrovirals 101, Adherence 101 and Living with HIV.
What T-cell count do you recommend that your patients begin treatment?
Generally 350/mm3, but possibly higher if the patient has an HIV-related problem that might occur at a higher CD4 (such as thrombocytopenia, Kaposi's sarcoma, psoriasis or vasculitis), or if they have a very high viral load.
If you were infected with HIV today, at what T-cell count would you begin treatment?
If I was infected today I would start treatment today and stay on it.
What treatment regimen would you choose if you had to begin treatment today? Explain.
Most likely (and there are many variables including the patient's opinion) Truvada (tenofovir + FTC) and Reyataz (atazanavir) plus minidose Norvir (ritonavir). The reason I would choose these meds is because I want a non toxic nucleoside backbone and I believe boosted protease inhibitor regimens are more forgiving and less vulnerable to the development of resistance than NNRTIs. Having said that, I often begin with Truvada plus either Viramune (nevirapine), Sustiva (efavirenz) or Kaletra (lopinavir/ritonavir).
What's the key to a great healthcare provider/patient relationship?
Listening to the patient and explaining things well to the patient.
How do you feel about patients who take a proactive role in their own treatment?
I prefer patients to take a proactive role and take an interest in their disease. It is after all their disease. Doctors look after hundreds of diseases and have to know a lot about all of them -- that is hard -- but it is not that hard to know a lot about one disease -- the one you have. Having said that, and I do believe it is important, it is not good if a patient obsesses about his or her disease too much. They should learn a lot about it and keep up to date, but, in between times, they should forget about it and lead a normal life.
Who was your all-time favorite patient and why?
You ask in the past tense expecting to talk about someone who has passed. Well, that is probably the case. I was very fond of a man I cared for in the U.K. who was a principal dancer in The Royal Ballet. We really loved each other, but he respected every boundary. On his deathbed, when I was present, he said, "had we met in different circumstances, Charles, we both know that things would have been very different between us." That was so nice of him.
What is the most important, memorable or useful thing you have learned from your patients?
That saying sorry when you have goofed up in some way works!
How do you maintain a positive outlook and avoid burning out?
By having a balanced life and a good relationship. Burn out is not nearly the threat now that it was to HIV physicians in the 1980s. Then we were way overworked, as so few were in the field (only a few physicians showed interest initially and there was no extra funding at the beginning) -- and the emotional toll was worse as so many patients were sick and dying. Now most patients are well or getting better -- a doctor shouldn't burn out now, unless he or she works too hard and we must guard against that.
If you weren't a clinician what would you be? Why?
Perhaps an actor or a teacher because I enjoy those activities.
Who would you dedicate this award to if you could?
My partner, Dougie Lui.
Where did you grow up?
Christchurch, New Zealand.
What did you want to be when you were a kid?
A priest when I was a little boy, probably because of my Catholic school education.
What kind of work did your parents do?
Father: an accountant. Mother: music (piano) teacher.
When did you decide on medical school? (What was your major in college?)
High school. I enjoyed first aid classes and loved biology.
What made you decide to go into HIV care?
Sympathy/empathy for the patients; the fact that I was knowledgeable in internal medicine, dermatology, venereology and immunosupression; and scientific interest in a horrific fascinating disease mysteries.
Personally, it's a rather long story. I had been practicing medicine in Christchurch for five years. One day I was walking down the hospital hall and heard the bell ring for the start of rounds. A few steps further, I heard the bells ringing from my primary school. I realized I hadn't traveled more than three-quarters of a mile from where I'd grown up. I said to myself: "Charles, you've got to do something!" Further down the hall, I ran into a colleague who said he was going to Saudi Arabia to do some work, and asked if I wanted to go. I said yes on the spot.
I later practiced in England for five years as a dermatologist intending to earn a lot of money. But I began seeing the first rashes of infections that signaled HIV/AIDS. I started reading literature from the United States on the subject. I organized one of the first AIDS clinics in the U.K., and designed the first purpose-built AIDS clinic and ambulatory day care clinic in the country. I lectured throughout the U.K. on AIDS and was advisor to the government health department's public education on AIDS. I also chaired an all-party parliamentary committee on AIDS to inform parliament and peers on AIDS and to discuss government policy on AIDS. Eventually, I earned a Winston Churchill fellowship to the USA to study AIDS at Bellevue Hospital in New York (1988) and later became director of the hospital's AIDS program. In 1994, I moved to L.A. to engage in AIDS research as principal investigator for AIDS Healthcare Foundation research, where I remain today. But in 2001 I joined the AIDS Healthcare Foundation, where I am now medical director.
Who were the most influential people in your life, both professionally and personally? Why?
My mother and father -- bequeathed me their moral code and taught me about loving relationships.
Father Timothy Raphael and Father Bill Kirkpatrick -- priests who shared a lot of wisdom and common sense.
Marcus Conant, David Ho and Alvin Freidman Kein -- all AIDS physicians and researchers who have taught me enormous amounts, acted as great role models, and helped me enormously.
What do you do in your spare time?
Swim, gym, movies, travel, attend performing arts (opera, ballet, choir, orchestra, drama) and watch old British comedy on TV.
Do you have a partner? What is your partner's job? Kids? Pets?
Yes, he is an accountant/restaurateur. No kids. I have had two cats for 15 years.
Where do you live? What kind of community is it?
Los Angeles. Historic housing neighborhood.
If you had anyplace to live besides where you live now, where would you live?
The seaside. Actually, I just said that because I live so close to the ocean but not on the beach. Truly, I think I'd like to live in mainland Europe and immerse myself in the old world culture.
What's the best vacation you ever had?
Alaska -- the inner passage.
What's the biggest adventure you ever had?
Driving from Riyadh, Saudi Arabia to London in 1982 -- including driving through the Sinai desert just two weeks after Israel returned it to Egypt.
What's currently on your bedside table for reading?
Me Talk Pretty One Day by David Sedaris. Nicholas Nickelby by Charles Dickens.
What kind of music do you like to listen to? What album do you listen to the most?
Classical music. Handel's "Messiah."
Is there anything else you think it would be important that people reading this interview know about you?
I doubt there is much left! Cheers!