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Joel Gallant:Q&A Expert

Joel Gallant and his online creation.

Dear Dr. Gallant...Can I get HIV from being kissed on the neck, given that the skin on my neck is intact?
Dear Joel...Been on AZT/3TC/NVP for 18 months. Good response. 100% compliant. Is there any reason why I should not ask for my medication to be changed to AZT/3TC/EFV? Many thanks for this forum. Kind regards, Trevor.
Dr. Gallant...My sister is a barber at a barber in a very bad part of town. When I went in there the other day, she was washing out her mouth because she had gotten some hair in her mouth from some guy who she thinks is not in very good shape. Is hair infectious, especially in the mouth? P.S. If it is, how could she protect herself without quitting her job?

For more than six years, HIV/AIDS specialist Joel Gallant has been fielding questions like these as director of Expert Question & Answer, online forums that appear on the Johns Hopkins AIDS Service Web site. The Q&A forums attract several hundred questions each month on topics ranging from complex antiretroviral therapies to basic lifestyle issues. "They have helped to make the AIDS Service site one of the most distinctive and important HIV resources in the world," says Sharon McAvinue, director of point-of-care information technology for the Division of Infectious Diseases.

The entire site receives about 93,000 visits per month. Besides the Q&A forums, the site carries two publications that are a sort of bible for HIV practitioners: Medical Management of HIV Infection, a 300-page book published each year, and The Hopkins HIV Report, a 12-page, bimonthly newsletter. There are also excerpts from the patient newsletter Moore News Quarterly, case rounds, and information on conferences and events, clinical trials, HIV/AIDS epidemiology, prevention and more.

With it all, Expert Q&A is the most visited part of the site. A free service provided by faculty members who answer the questions, it's a two-part affair designed for HIV-treating physicians and HIV-positive patients. The patient forum receives about five times as many queries as the clinician forum. Gallant himself answers more than 100 questions a month, including more than half in the clinician forum and practically all those he deems suitable on the patient forum. Thanks to his clinical expertise, not to mention his advice-column know-how, he can dash off an answer-even a long, technical one-in just a minute or two. He does it at intervals here and there, in clinic when a patient misses an appointment, or in a hotel room late at night when he can't sleep.

Questions, some of them extremely complex, come in from all around the world. Over time, what's become clear is the tremendous disparity in the care patients are receiving. "Some ask questions that are very sophisticated; others know little," says Gallant, associate director of the Division of Infectious Diseases. Some are not even patients-a source of both exasperation and some of the humor on the site. "This site is designed for those who are HIV positive. But it also attracts the worried well, whose hypochondriasis, obsessive-compulsive disorder or sexual guilt lead them to become hysterical over inconsequential encounters and symptoms."

Q: I had sex with a woman!!! I used a condom and she doesn't seem to be sick! I had sex with her 7 months ago! Should I worry????

A: What you're asking me is whether you should worry about having had safe sex. If the answer were yes, then everyone would have to worry every time they had sex, which would mean either that people would stop having sex and the world's population would dwindle (unlikely), or that everyone would just go around in a perpetual state of anxiety. If you're going around in a perpetual state of anxiety, then maybe you're just not ready for sex.

The weighty world of academic medicine may seem an unusual setting for a Miss Manners-styled advice column, but it is precisely this unlikely combination that makes the forum so arresting. Gallant's scathing wit and breezy style percolates through the patient forum, and some of the most entertaining responses are collected in a "Favorites" archive.

With an archive of more than 6,000 questions dating back to 1997, the Q&A forums reveal a chronological portrait of the AIDS pandemic that is rich, real and constantly evolving. "People have forgotten what it was like [in '97] when effective therapies were just beginning to be used, and everyone was afraid they were going to die. Now, people take that effectiveness for granted; they're worried about side effects and long-term toxicity."

Q: I recently read an article that said it is very unlikely that scientists will EVER find a real "cure" for HIV. This is really upsetting news, to me. It seems to mean being condemned to a lifetime of taking multiple drugs whose long-term effects are unknown.
The Q&A forums got their start in the mid-1990s when Gallant began answering some of the HIV-related questions pouring into an AOL newsroom-and was promptly deluged with hundreds of personal e-mails. He turned pro when he began fielding questions for The Body, an online HIV/AIDS resource. Then he brought his creation to the Hopkins site.

At first, Gallant worried that the forum's "racy content" wouldn't pass muster, but he got the go-ahead, and so far, no one's objected. Well, almost no one. When Gallant queried the JHU Press about doing a Miss Manners-style book compiling questions and answers, he was asked to replace the forum's earthy language with proper medical terminology, a request he promptly rejected. "You can't talk about AIDS without talking about sex, and you have to use the language everyone understands."

Long a lover of literature and writing, Gallant says the forum is his "one opportunity to be creative, a way of helping out by giving information, and of expressing myself at the same time." It beats writing for dry, technical research journals, he insists, and it may reach a wider audience, too. "One of the great challenges in HIV is the speed with which data are generated and recommendations change." Books, and even journal articles, he says, are out of date by the time they're printed. But the Web, while it may not be "peer reviewed," is the ideal medium for disseminating information about HIV. "The journal AIDS costs $400 a year. They're not subscribing in Kinshasa," says Gallant, "but they are surfing the Web."

Gallant's ability to disperse expert information on HIV/AIDS has been the inspiration for a new consultation tool, the HIV Guide. Set to debut this fall, the HIV Guide will absorb the content of the current AIDS Service Web site (the didactic information, as well as Expert Q&A, will remain) and deliver concise, up-to-the-minute clinical assessments to handheld devices.

"And all of this," says McAvinue, "has blossomed out of Joel's Q&A forums and his ability to lend expert clinical assistance to people all over the world. Joel has made himself available in ways that no one ever has. He provides compassion in helping people deal with the awesome burden of HIV. He has been a lifeline to people everywhere."

- Ann Bennett Swingle

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