Debbie Winter's dedication to HIV prevention starts at home: She has tirelessly educated her two teenagers about the importance of safety and the risk factors associated with sex. From there, she branched out to educate her children's peers at community centers. She uses her experiences with HIV nursing in Ethiopia to convey to young Americans the gravity of poverty in Africa and how this affects the ability of people there to function with the disease. Winter seldom fails to mention how lucky Americans are to live in a place where medications and proper medical supervision are widely available.
Debbie has been a nurse working with HIV patients since joining a private practice in 1991. Before that, she worked on AZT (also known as Retrovir, this was the first drug approved to treat HIV) trials in the late 1980s. Since her move into HIV education and care, she has focused on establishing an environment where her patients feel safe and open to living a healthy lifestyle.
Tell us a bit about yourself.
I've always lived in New Jersey. I grew up in Maplewood and now I live in Flemington. I have two children, Alex, 15, a sophomore in high school, and Tori, 14, an eighth grader. My husband is a professor at Fairleigh Dickinson University, who teaches a lot of philosophy logic and moral contemporary issue courses. He actually ends up teaching a lot of nurses.
How do you teach your children?
I try to educate my children to the best of my ability so they are ready to amply protect themselves when they enter into the real world and are faced with decisions that they may not have a lot of time to think about right then. I believe abstinence is the best option, but I'm realistic about the way kids are today. I have a jar full of condoms on the shelf to make sure they know I'm serious about their safety. After working in this field for all these years, I'm still amazed at how many new cases we are still getting. I wonder how this can be possible. With all the education that is supposedly being taught in our schools, I know that I need to reinforce the importance of safety at home.
I understand you have been working in Ethiopia.
I just spent a month there. I'm an ITECH Nurse Advisor. [International Training and Education Center for HIV/AIDS (ITECH) is under the auspices of the U.S. Department of Health and Human Services.] I identify nurse leaders and then train them to train others. Antiviral medications were supposed to become available at the end of January 2005, which is why I was over there. I help the nurses in coaching patients for the new life they will face -- taking these pills for the rest of their lives. When I left, the medicines had still not arrived, but I was busy the entire time anyway. There is a lot of preparation for the nurses, managing the patient load and teaching patients how to take the drugs. In the whole month I spent there, I only had one day off.
Is it an impossible workload?
The ratio of physicians to patients in Ethiopia is overwhelming. There are only 1,000 physicians and 7,000 nurses in the whole country. A lot of what I do is teach the nurses and doctors about the expanded role these educated nurses are going to need to take in fighting this disease. We try to teach the nurses to use what they have, and that they are an underused resource. The doctors don't have to do everything anymore. The nurses are trained and capable and there are just too many patients to be relying on the physicians for all the medical care. But that is how they were taught to do it in medical school, so it is actually teaching a shift in how they think about their roles.
Is the workload for American nurses the same?
We have had the same struggles here in the U.S. With the discovery of HIV, nurses became partners with physicians. HIV changed the face of nursing entirely because physicians learned early on that they just couldn't do it all anymore. Nursing came up to the plate to help manage the disease. That's how I started in HIV care. The doctor that hired me into private practice has been more than a boss for this process, more a mentor, and now I am turning it around to bring the Ethiopian nurses up to the advanced practice level we have in the U.S.
Where do you live when you are in Ethiopia?
This time I was in the mountains. It's very rural, very poor, not what you or I would think of as a hotel, but they have running water. I just walk through the town to the hospital. The hospitals are lacking the basics, the manpower, etc. I have shifted my focus from seeing the experience of patients being able to live with the disease in the U.S. with the help of medication and support, to the chaotic problems of the Ethiopian medical system where there is such a shortage of manpower. They bury 800 people a day from HIV in Ethiopia.
What level of care do your HIV education programs in Ethiopia affect?
All levels. Because of all the mistakes we've made in the U.S. with the medicines, what to take, how much, we can now share our education with the Ethiopian medical community. I want to share with them the knowledge I have so that their infected population doesn't encounter the same mistakes.
What kind of mistakes?
Drug resistance is happening because people don't take their drugs every day. I know that if they don't enforce the guidelines for taking the medicines as prescribed, there can be even greater negative effects, meaning an infected person who doesn't take the medication and whose virus mutates can then pass that mutated virus onto someone else ... I always tell patients that adherence will be the hardest thing they will ever do. We've had people starting and stopping, skipping doses, splitting doses with a family member. All of these behaviors make it so the virus has a chance to mutate. HIV is a smart virus; if a few doses are skipped, it will mutate.
How do you keep from burning out?
I like to have a healthy lifestyle. I run every morning at 5 a.m. There is a group of women I run with -- sometimes I'm amazed at how fast these women run. I use it as therapy, it keeps me from getting burned out at work. I've done a dozen marathons and various triathlons. Last summer I ran up Mt. Washington in New Hampshire. The run happens on Father's Day weekend in June and a whole bunch of crazy people, including me, run a vertical 7.6 miles. I'm going to do it again this year.
Does your emphasis on healthy living carry over into your professional/patient relationships?
Very much so. I'm always encouraging healthy living. I'm very much into alternative medicine. I try to emphasize a positive lifestyle with all my patients. Keeping a person as healthy as possible in the mind is just as important as the body.
What do you do when you find a patient who has problems with substance abuse?
When substance abuse becomes an aspect of the patient's lifestyle, the HIV becomes almost secondary; the substance abuse needs to be addressed first. The nurses and physicians that work with these people want to make sure they are going to take these medicines every day. If they are focused on something else as a priority, they will put their medication schedule on the back burner, and then bigger problems arise.
Who do you have the most challenging relationships with?
I find my relationship with my female patients is always the most challenging. Women always take care of themselves last.
How do you see your future?
I would like to move to Africa, as my experiences there have been so rewarding. I want to go somewhere I'll be needed, where my expertise is being used and I'm doing a lot of good. I feel I don't have the same impact in the U.S. as in Ethiopia. Here HIV has become a disease that, with a healthy lifestyle and proper medication, a person is capable of living with for a long time. Over there, when I say the exact same information, even though nothing I'm saying is profound or new, it is new, and everything that comes out of my mouth is gold. The other half to that future is continuing domestic education, working with nurses and patients. I'm trying to pass on as much knowledge as I can to educate everyone from eighth graders at local schools to substance abusers that come into the clinic.