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 FACULT Y

L E A D E D I TO R Benjamin Alfred, NP-​C

Family Health Center of Worcester
W. David Hardy, MD, AAHIVS Jonathan Appelbaum, MD, FACP, AAHIVS
Senior Director, Evidence-​Based Practices Florida State University College of Medicine
Whitman-​Walker Health
Lisa Armitige, MD, PhD
Adjunct Professor of Medicine
Heartland National TB Center
Johns Hopkins University School of Medicine
Washington, DC Renata Arrington-​Sanders, MD, MPH, ScM
Johns Hopkins School of Medicine
Jason V. Baker, MD, MS
C O -​E D I TO R S
University of Minnesota
Ben J. Barnett, MD
Jonathan S. Appelbaum, MD, FACP, AAHIVS
McGovern Medical School at University of Texas at Houston
Florida State University College of Medicine
Tamara Bininashvili, MD
Roberto C. Arduino, MD
University of California, San Francisco
Professor of Medicine
Department of Internal Medicine Jatandra Birney, PharmD
Division of Infectious Diseases Ascension Via Christi Hospital
McGovern Medical School, University of Texas Health
Emily Blumberg, MD
Sciences Center at Houston
Hospital of the University of Pennsylvania
Laurie L. Dozier Jr., MD
Philip Bolduc, MD, AAHIVS
Education Director and Professor of Internal Medicine
Family Health Center of Worcester
Interim Chair, Department of Clinical Sciences
Florida State University College of Medicine Christopher M. Bositis, MD, AAHIVS
Greater Lawrence Family Health Center
Jeffrey T. Kirchner, DO, FAAFP, AAHIVS
Medical Director, Penn Medicine/​LGHP Christian Brander, PhD
Comprehensive Care IrsiCalxa AIDS Research Institute
Lancaster General Hospital University of Vic-​Central Catalonia
Lancaster, PA Hospital Universitari Germans Trias i Pujol
William R. Short, MD, MPH Christopher Brendemuhl, DMD
Associate Professor of Medicine Maricopa Integrated Health System
Division of Infectious Diseases McDowell Dental Clinic
Perelman School of Medicine
John P. Casas, MD
University of Pennsylvania
Albany Stratton VA Medical Center
Elizabeth Chiao, MD, MPH
C O N T R I B U TO R S Michael E. DeBakey VA Medical Center
Carolyn Chu, MD, MSc, FAAFP, AAHIVS
Saira Ajmal, MD
University of California at San Francisco
Advocate Healthcare Illinois
Joseph A. Church, MD
Kevin Alby, MD
Children’s Hospital Los Angeles
University of North Carolina Hospitals
Keck School of Medicine of University of Southern
California

vii
Eva Clark, MD, PhD, DTM&H Margaret Hoffman-​Terry, MD, FACP, AAHIVS
Baylor College of Medicine Milton S. Hershey Medical Center
Pennsylvania State University College of Medicine
Jennifer Cocohoba, PharmD, BCPS, AAHIVP
Lehigh Valley Hospital
University of California, San Francisco, School of Pharmacy
University of California, San Francisco, Women’s HIV Jennifer Husson, MD, MPH
Program University of Maryland School of Medicine
Dagan Coppock, MD Nikyati Jakharia, MD
Drexel University College of Medicine University of Maryland
Vishal Dahya, MD Boris D. Juelg, MD, PhD
Florida State University College of Medicine Massachusetts General Hospital
Elizabeth David, MD Joseph S. Kass, MD, JD, FAAN
Baylor College of Medicine Baylor College of Medicine
Trew Deckard, PA-​C, MHS, AAHIVS Jeffrey T. Kirchner, DO, FAAFP, AAHIVS
Medical Practice of Dr. Steven M. Pounders Penn Medicine/​LGHP Comprehensive Care
Lancaster General Hospital
Alejandro Delgado, MD
Einstein Medical Center Philadelphia David E. Koren, PharmD
Temple University School of Pharmacy
Paul W. DenOuden, MD, AAHIVS
Temple University Hospital
Multnomah County Health Department
Carolyn Kramer, MD, MHS
Madeline B. Deutsch, MD, MPH
Sidney Kimmel Medical College at Thomas Jefferson
University of California, San Francisco
University
Quentin Doperalski, MD
Doris Kung, DO
University of California, San Francisco
Baylor College of Medicine
Richard Dunham, PhD
Eurides Lopes, MD
GlaxoSmithKline
Loma Linda University Healthcare
HIV Cure Center, University of North Carolina at
Chapel Hill Adrian Majid, MD
Weill Cornell Medicine
James P. Dunn, MD
New York-​Presbyterian Hospital
Wills Eye Hospital
Sidney Kimmel Medical College at Thomas Jefferson Poonam Mathur, DO, MPH
University University of Maryland Medical Center
Derek M. Fine, MD Jessica A. Meisner, MD, MS
Johns Hopkins Hospital University of Pennsylvania Health System
Anna Forbes, MSS Steven Menez, MD
American Academy of HIV Medicine Johns Hopkins School of Medicine
Rajesh Gandhi, MD Ana Monczor, MD
Massachusetts General Hospital McGovern Medical School at University of Texas at Houston
Harvard Medical School
Kudakwashe Mutyambizi, MD
Taylor K. Gill, PharmD, BCPS, AAHIVP MD Anderson Cancer Center
Ascension Via Christi Hospital The University of Texas Medical School at Houston
Michelle K. Haas, MD Puja H. Nambiar, MD
Denver Public Health Assistant Professor, Department of Medicine/​Infectious
University of Colorado, Anschutz Medical Campus Diseases
Louisiana State University Health
Dennis J. Hartigan-​O’Connor, MD, PhD
University of California, Davis Naiel Nassar, MD, FACP
University of California, San Francisco
Rodrigo Hasbun, MD, MPH
McGovern Medical School at University of Texas at Houston Karin Nielsen-​Saines, MD, MPH
David Geffen School of Medicine
Emily L. Heil, PharmD, BCIDP, BCPS, AAHIVP University of California, Los Angeles
University of Maryland School of Pharmacy

viii • FAC U LT Y
Karen Nunez-​Wallace, MD Baylor College of Medicine
Baylor College of Medicine
Kalpana D. Shere-​Wolfe, MD
Babafemi Onabanjo, MD, AAHIVS University of Maryland Medical System
Family Health Center of Worcester
Elizabeth M. Sherman, PharmD, AAHIVP
Edgar T. Overton, MD Nova Southeastern University
University of Alabama School of Medicine
William R. Short, MD, MPH, AAHIVS
Bruce J. Packett II University of Pennsylvania
American Academy of HIV Medicine
Daniel J. Skiest, MD, FACP, FIDSA
Neha Sheth Pandit, PharmD, AAHIVP, BCPS Baystate Health Professor of Medicine
University of Maryland School of Pharmacy University of Massachusetts Medical School-Baystate
Rachel A. Prosser, PhD, APRN, CNP, FAANP, AAHIVS Anthony C. Speights, MD, FACOG, AAHIVS
Hennepin County Medical Center Florida State University College of Medicine
University of Minnesota School of Nursing
Sally Spencer Long, ANP C
Metropolitan University School of Nursing
Bay State Medical Center
Centurion
RAAN Gary F. Spinner, PA, MPH, AAHIVS
Positive Healthcare LLC Southwest Community Health Center
Christian B. Ramers, MD, MPH, AAHIVS Rohit Talwani, MD
Family Health Centers of San Diego University of Maryland Medical Center
University of San Diego School of Medicine
San Diego State University School of Public Health Zelalem Temesgen, MD, FIDSA
Mayo Clinic
Brandon H. Samson, PharmD, MPW
Vaniam Group LLC Karen J. Vigil, MD
McGovern Medical School at University of Texas at Houston
Aroonsiri Sangarlangkarn, MD, MPH
HIV Netherlands Australia Thailand Research Sana Waheed, MD
Collaboration Clinic University of Wisconsin Hospitals and Clinics
Thai Red Cross Rakel Beall Wilkins, MD
Jason J. Schafer, PharmD, MPH, BCPS Magellan Health
AQ-​ID, BCIDP, AAHIVP Amanda L. Willig, PhD, RD
Jefferson College of Pharmacy The University of Alabama at Birmingham
Thomas Jefferson University
Daniel Wlodarczyk, MD
Hans P. Schlecht, MD, MMSc University of California, San Francisco
Baystate Health San Francisco General Hospital
Jeffrey T. Schouten, MD San Francisco Department of Public Health
Fred Hutchinson Cancer Research Center David A. Wohl, MD
James D. Scott, PharmD, Med, APh, University of North Carolina at Chapel Hill
FCCP, FASHP, AAHIVP NC AIDS Training and Education Center
Western University of Health Sciences College of Pharmacy Hojoon You, MD
Rajagopal V. Sekhar, MD Einstein Medical Center Philadelphia
Baylor College of Medicine Barry Zevin, MD
Lydia J. Sharp, MD San Francisco Department of Public Health

FAC U LT Y • ix
JOINT ACCREDITATION STATEMENT

In support of improving patient care, this activity has been planned and implemented by the
Postgraduate Institute for Medicine and American Academy of HIV Medicine. The Postgraduate
Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare
team.

x
 PHYSICIAN CONTINUING MEDICAL EDUCATION

The Postgraduate Institute for Medicine designates these en- 1 Credit(s)™. Physicians should claim only the credit com-
during materials for a maximum of 43.75 AMA PRA Category mensurate with the extent of their participation in the activity.

xi
 CONTINUING PHAR MACY EDUCATION

The Postgraduate Institute for Medicine designates these con- Pharmacists should check their NABP account to ensure
tinuing education activities for 43.75 contact hour(s) (4.375 credit has been submitted; it must be submitted within
CEUs) of the Accreditation Council for Pharmacy Education. 60 days of completion of activity.

xii
 CONTINUING NUR SING EDUCATION

The maximum number of hours awarded for these Continuing for a total of 10 contact hours of pharmacotherapy credit for
Nursing Education activities is 40.7 contact hours; designated Advanced Practice Registered Nurses.

xiii
 CONTENTS

Disclosure of Conflicts of Interes xix Pharmacists –​0.75 contact hours (0.075 CEUs)
Method of Participation and Request for Credit xxii ACPE UAN: JA4008162-​9999-​19-​656-​H02-​P;
Knowledge
Disclosure of Unlabeled Use  xxiii
7. HIV Testing and Counseling 67
1. Epidemiology and the Spread of HIV 1 Physicians –​maximum of 0.75 AMA PRA Category 1
Physicians –​maximum of 0.1.0 AMA PRA Category 1 Credits™
Credits™ Nurses –​0.6 contact hours
Nurses –​1.0 contact hours Pharmacists –​0.75 contact hours (0.075 CEUs)
Pharmacists –​1.0 contact hours (0.10 CEUs) ACPE UAN: JA4008162-​9999-​19-​657-​H02-​P;
ACPE UAN: JA4008162-​9999-​651-​H02-P; Knowledge
Knowledge 8. Laboratory Testing Strategies Detection and Diagnosis 73
2. The Origin, Evolution, and Epidemiology of HIV-​1 Physicians –​maximum of 0.75 AMA PRA Category 1
and HIV-​2 15 Credits™
Physicians –​maximum of 0.75 AMA PRA Category 1 Nurses –​0.6 contact hours
Credits™ Pharmacists –​0.75 contact hours (0.075 CEUs)
Nurses –​0.6 contact hours ACPE UAN: JA4008162-​9999-​19-​658-​H02-​P;
Pharmacists –​0.75 contact hours (0.075 CEUs) Knowledge
ACPE UAN: JA4008162-​9999-​652-​H02-P; 9. The Medical History and Physical Examination of the
Knowledge Patient with HIV 83
3. Mechanisms of HIV Transmission 21 Physicians –​maximum of 0.5 AMA PRA Category 1
Physicians –​maximum of 0.75 AMA PRA Category 1 Credits™
Credits™ Nurses –​0.5 contact hours
Nurses –​0.6 contact hours Pharmacists –​0.5 contact hours (0.05 CEUs)
Pharmacists –​0.75 contact hours (0.075 CEUs) ACPE UAN: JA4008162-​9999-​19-​659-​H02-​P;
ACPE UAN: JA4008162-​9999-​653-​H02-P; Knowledge
Knowledge 10. Initial Laboratory Evaluation and Risk Stratification of
4. HIV Transmission Prevention 25 the Patient with HIV 87
Physicians –​maximum of 1.0 AMA PRA Category 1 Physicians –​maximum of 0.25 AMA PRA Category 1
Credits™ Credits™
Nurses –​1.0 contact hours, 0.1 pharmacotherapy for APRN Nurses –​0.2 contact hours
Pharmacists –​1.0 contact hours (0.10 CEUs) Pharmacists –​0.25 contact hours (0.025 CEUs)
ACPE UAN: JA4008162-​9999-​19-​654-​H02-​P; ACPE UAN: JA4008162-​9999-​19-​660-​H02-​P;
Knowledge Knowledge
5. Immunology 49 11. Recognition of Acute and Advanced HIV Infection 91
Physicians –​maximum of 0.75 AMA PRA Category 1 Physicians –​maximum of 0.75 AMA PRA Category 1
Credits™ Credits™
Nurses –​0.7 contact hours, 0.2 pharmacotherapy for APRN Nurses –​0.7 contact hours, 0.3 pharmacotherapy
Pharmacists –​0.75 contact hours (0.075 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​655-​H02-​P; Pharmacists –​0.75 contact hours (0.075 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​661-​H02-​P; Knowledge
6. HIV Cure Strategies 59 12. Health Maintenance 97
Physicians –​maximum of 0.75 AMA PRA Category 1 Physicians –​maximum of 1.25 AMA PRA Category 1
Credits™ Credits™
Nurses –​0.7 contact hours, 0.5 pharmacotherapy for Nurses –​1.2 contact hours, 0.1 pharmacotherapy
APRN for APRN

xv
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 Pharmacists –​1.25 contact hours (0.125 CEUs) Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​662-​H02-​P; ACPE UAN: JA4008162-​9999-​19-​669-​H02-​P;
Knowledge Knowledge
13. Issues in Specific Patient Populations 115 20. Principles of Applied Clinical Pharmacokinetics
Physicians –​maximum of 2.25 AMA PRA and Pharmacodynamics in Antiretroviral Therapy 219
Category 1 Credits™ Physicians –​maximum of 0.75 AMA PRA
Nurses –​2.1 contact hours, 0.4 pharmacotherapy for APRN Category 1 Credits™
Pharmacists –​2.25 contact hours (0.225 CEUs) Nurses –​0.7 contact hours, 0.3 pharmacotherapy
ACPE UAN: JA4008162-​9999-​19-​663-​H02-​P; for APRN
Knowledge Pharmacists –​0.75 contact hours (0.075 CEUs)
14. Complementary and Alternative Medicine/​Integrative ACPE UAN: JA4008162-​9999-​19-​670-​H02-​P;
Medicine Approaches 157 Knowledge
Physicians –​maximum of 1.0 AMA PRA Category 1 21. Classes of Antiretrovirals 225
Credits™ Physicians –​maximum of 0.75 AMA PRA Category 1
Nurses –​1.0 contact hours, 0.6 pharmacotherapy Credits™
for APRN Nurses –​0.6 contact hours, 0.6pharmacotherapy
Pharmacists –​1.0 contact hours (0.10 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​664-​H02-​P; Pharmacists –​0.75 contact hours (0.075 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​671-​H02-​P;
15. HIV Care Coordination 175 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 22. Initiation of Antiretroviral Therapy: What to Start With 239
Credits™ Physicians –​maximum of 0.5 AMA PRA Category 1
Nurses –​0.7 contact hours Credits™
Pharmacists –​0.75 contact hours (0.075 CEUs) Nurses –​0.5 contact hours, 0.1 pharmacotherapy
ACPE UAN: JA4008162-​9999-​19-​665-​H02-​P; for APRN
Knowledge Pharmacists –​0.5 contact hours (0.05 CEUs)
16. The Pharmacist’s Role in Caring for HIV-​Positive ACPE UAN: JA4008162-​9999-​19-​672-​H02-​P;
Individuals 183 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 23. HIV-​1 Resistance to Antiretroviral Drugs 245
Credits™ Physicians –​maximum of 0.5 AMA PRA Category 1
Nurses –​0.7 contact hours Credits™
Pharmacists –​0.75 contact hours (0.075 CEUs) Nurses –​0.5 contact hours
ACPE UAN: JA4008162-​9999-​19-​666-​H02-​P; Pharmacists –​0.5 contact hours (0.05 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​673-​H02-​P;
17. The Role of the Physician Assistant and the Nurse Knowledge
Practitioner in Caring for Persons Living with HIV 189 24. Managing the Patient with Multidrug-​Resistant HIV 257
Physicians –​maximum of 1.0 AMA PRA Category 1 Physicians –​maximum of 0.5 AMA PRA Category 1
Credits™ Credits™
Nurses –​1.0 contact hours Nurses –​0.5 contact hours, 0.4 pharmacotherapy
Pharmacists –​1.0 contact hours (0.10 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​667-​H02-​P; Pharmacists –​0.5 contact hours (0.05 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​674-​H02-​P;
18. Hospice and Palliative Care in Advanced HIV Disease 199 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 25. Future Antiretrovirals, Immune-​Based Strategies, and
Credits™ Therapeutic Vaccines 261
Nurses –​0.7 contact hours, 0.2 pharmacotherapy Physicians –​maximum of 0.5 AMA PRA Category 1
for APRN Credits™
Pharmacists –​0.75 contact hours (0.075 CEUs) Nurses –​0.5 contact hours, 0.2 pharmacotherapy
ACPE UAN: JA4008162-​9999-​19-​668-​H02-​P; for APRN
Knowledge Pharmacists –​0.5 contact hours (0.05 CEUs)
19. HIV Virology 205 ACPE UAN: JA4008162-​9999-​19-​675-​H02-​P;
Physicians –​maximum of 1.0 AMA PRA Category 1 Knowledge
Credits™ 26. Solid Organ Transplantation in Persons Living with HIV 275
Nurses –​1.0 contact hours, 0.4 pharmacotherapy Physicians –​maximum of 0.75 AMA PRA Category 1
for APRN Credits™

xvi • C ontents
 Nurses –​0.6 contact hours Nurses –​1.0 contact hours, 0.3 pharmacotherapy for APRN
Pharmacists –​0.75 contact hours (0.075 CEUs) Pharmacists –​1.0 contact hours (0.10 CEUs)
ACPE UAN: JA4008162-​9999-​19-​676-​H02-​P; Knowledge ACPE UAN: JA4008162-​9999-​19-​683-​H02-​P;
27. Antiretroviral Therapy in Pregnant Women 281 Knowledge
Physicians –​maximum of 0.5 AMA PRA 34. Malignancies in HIV 337
Category 1 Credits™ Physicians –​maximum of 1.5 AMA PRA Category 1
Nurses –​0.5 contact hours, 0.1 pharmacotherapy Credits™
for APRN Nurses –​1.5 contact hours, 0.3 pharmacotherapy
Pharmacists –​0.5 contact hours (0.05 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​677-​H02-​P; Pharmacists –​1.5 contact hours (0.15 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​684-​H02-​P;
28. Antiretroviral Therapy for Children and Newborns 287 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 35. Dermatologic Complications 379
Credits™ Physicians –​maximum of 1.0 AMA PRA Category 1
Nurses –​0.7 contact hours Credits™
Pharmacists –​0.75 contact hours (0.075 CEUs) Nurses –​1.0 contact hours, 0.4 pharmacotherapy
ACPE UAN: JA4008162-​9999-​19-​678-​H02-​P; for APRN
Knowledge Pharmacists –​1.0 contact hours (0.10 CEUs)
29. Immunosuppressants and Antiretroviral Therapy ACPE UAN: JA4008162-​9999-​19-​685-​H02-​P;
in HIV-​Positive Transplant Patients 297 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 36. Endocrine and Metabolic Disorders 391
Credits™ Physicians –​maximum of 0.75 AMA PRA Category 1
Nurses –​0.6 contact hours, 0.3 pharmacotherapy Credits™
for APRN Nurses –​0.7 contact hours, 0.1 pharmacotherapy
Pharmacists –​0.75 contact hours (0.075 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​679-​H02-​P; Pharmacists –​0.75 contact hours (0.075 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​686-​H02-​P;
30. Understanding and Managing Antineoplastic and Knowledge
Antiretroviral Therapy 301 37. Nonopportunistic Infections: Respiratory
Physicians –​maximum of 0.5 AMA PRA Category 1 Complications 399
Credits™ Physicians –​maximum of 0.75 AMA PRA Category 1
Nurses –​0.5 contact hours Credits™
Pharmacists –​0.5 contact hours (0.05 CEUs) Nurses –​0.7 contact hours, 0.1 pharmacotherapy
ACPE UAN: JA4008162-​9999-​19-​680-​H02-​P; for APRN
Knowledge Pharmacists –​0.75 contact hours (0.075 CEUs)
31. Substance Abuse in HIV Populations 309 ACPE UAN: JA4008162-​9999-​19-​687-​H02-​P;
Physicians –​maximum of 1.0 AMA PRA Category 1 Knowledge
Credits™ 38. Psychiatric Illness and Treatment in HIV Populations 403
Nurses –​1.0 contact hours, 0.6 pharmacotherapy Physicians –​maximum of 1.0 AMA PRA Category 1
for APRN Credits™
Pharmacists –​1.0 contact hours (0.10 CEUs) Nurses –​1.0 contact hours, 0.3 pharmacotherapy
ACPE UAN: JA4008162-​9999-​19-​681-​H02-​P; for APRN
Knowledge Pharmacists –​1.0 contact hours (0.10 CEUs)
32. Understanding the Use of Antiretrovirals in the Aging ACPE UAN: JA4008162-​9999-​19-​688-​H02-​P;
Patient 317 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 39. Neurological Effects of HIV Infection 413
Credits™ Physicians –​maximum of 1.25 AMA PRA Category 1
Nurses –​0.7 contact hours, 0.6 pharmacotherapy Credits™
for APRN Nurses –​1.2 contact hours, 0.3 pharmacotherapy
Pharmacists –​0.75 contact hours (0.075 CEUs) for APRN
ACPE UAN: JA4008162-​9999-​19-​682-​H02-​P; Pharmacists –​1.25 contact hours (0.125 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​689-​H02-​P;
33. Opportunistic Infections 323 Knowledge
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™

C ontents  • xvii
40. HIV and Hepatitis Coinfection 433 Pharmacists –​1.0 contact hours (0.10 CEUs)
Physicians –​maximum of 1.25 AMA PRA Category 1 ACPE UAN: JA4008162-​9999-​19-​696-​H02-​P;
Credits™ Application
Nurses –​1.2 contact hours, 0.6 pharmacotherapy for APRN 47. HIV-​Associated Lipodystrophy and Lipoatrophy 505
Pharmacists –​1.25 contact hours (0.125 CEUs) Physicians –​maximum of 0.75 AMA PRA
ACPE UAN: JA4008162-​9999-​19-​690-​H02-​P; Knowledge Category 1 Credits™
41. Ocular Complications 447 Nurses –​0.6 contact hours
Physicians –​maximum of 0.75 AMA PRA Pharmacists –​0.75 contact hours (0.075 CEUs)
Category 1 Credits™ ACPE UAN: JA4008162-​9999-​19-​697-​H02-​P;
Nurses –​0.7 contact hours, 0.1 pharmacotherapy Knowledge
for APRN 48. Immune Reconstitution Inflammatory Syndrome (IRIS) 513
Pharmacists –​0.75 contact hours (0.075 CEUs) Physicians –​maximum of 0.75 AMA PRA
ACPE UAN: JA4008162-​9999-​19-​691-​H02-​P; Category 1 Credits™
Knowledge Nurses –​0.6 contact hours
42. Cardiovascular Disease 453 Pharmacists –​0.75 contact hours (0.075 CEUs)
Physicians –​maximum of 1.0 AMA PRA Category 1 ACPE UAN: JA4008162-​9999-​19-​698-​H02-​P;
Credits™ Knowledge
Nurses –​1.0 contact hours, 0.4 pharmacotherapy 49. US Healthcare Systems, HIV Programs, and Coverage
for APRN Policy Issues 519
Pharmacists –​1.0 contact hours (0.10 CEUs) Physicians –​maximum of 0.75 AMA PRA Category 1
ACPE UAN: JA4008162-​9999-​19-​692-​H02-​P; Credits™
Knowledge Nurses –​0.6 contact hours
43. Renal Complications 469 Pharmacists –​0.75 contact hours (0.075 CEUs)
Physicians –​maximum of 1.0 AMA PRA Category 1 ACPE UAN: JA4008162-​9999-​19-​699-​H02-​P;
Credits™ Knowledge
Nurses –​1.0 contact hours, 0.5 pharmacotherapy 50. Legal Issues 525
for APRN Physicians –​maximum of 1.0 AMA PRA Category 1
Pharmacists –​1.0 contact hours (0.10 CEUs) Credits™
ACPE UAN: JA4008162-​9999-​19-​693-​H02-​P; Nurses –​0.8 contact hours
Knowledge Pharmacists –​1.0 contact hours (0.10 CEUs)
44. Body Composition Changes, Frailty, and ACPE UAN: JA4008162-​9999-​19-​700-​H02-​P;
Musculoskeletal Complications of HIV 481 Knowledge
Physicians –​maximum of 0.75 AMA PRA Category 1 51. Research Design and Analysis 541
Credits™ Physicians –​maximum of 0.75 AMA PRA
Nurses –​0.7 contact hours, 0.1 pharmacotherapy Category 1 Credits™
for APRN Nurses –​0.6 contact hours
Pharmacists –​0.75 contact hours (0.075 CEUs) Pharmacists –​0.75 contact hours (0.075 CEUs)
ACPE UAN: JA4008162-​9999-​19-​694-​H02-​P; ACPE UAN: JA4008162-​9999-​19-​701-​H02-​P;
Knowledge Knowledge
45. Sexually Transmitted Diseases 487 52. Ethical Conduct of Clinical Trials, Institutional
Physicians –​maximum of 0.75 AMA PRA Category 1 Review Boards, Informed Consent, and Financial
Credits™ Conflicts of Interest 545
Nurses –​0.7 contact hours, 0.1 pharmacotherapy Physicians –​maximum of 0.75 AMA PRA Category 1
for APRN Credits™
Pharmacists –​0.75 contact hours (0.075 CEUs) Nurses –​0.6 contact hours
ACPE UAN: JA4008162-​9999-​19-​695-​H02-​P; Pharmacists –​0.75 contact hours (0.075 CEUs)
Knowledge ACPE UAN: JA4008162-​9999-​19-​702-​H02-​P;
46. HIV and Bone Health 493 Knowledge
Physicians –​maximum of 1.0 AMA PRA Category 1
Credits™ Index 549
Nurses –​1.0 contact hours, 0.2 pharmacotherapy
for APRN

xviii • C ontents
 DISCLOSURE OF CONFLICTS OF INTEREST

The Postgraduate Institute for Medicine (PIM) requires activities and related materials that promote improvements or
instructors, planners, managers, and other individuals who are quality in healthcare and not a specific proprietary business
in a position to control the content of this activity to disclose interest of a commercial interest.
any real or apparent conflict of interest (COI) they may have The faculty reported the following financial relationships
as related to the content of this activity. All identified COIs are or relationships to products or devices they or their spouses/​
thoroughly vetted and resolved according to PIM policy. PIM life partners have with commercial interests related to the con-
is committed to providing its learners with high-​quality CME tent of this CME activity:

Name of Faculty or Presenter Reported Financial Relationship

Saira Ajmal Nothing to disclose

Kevin Alby Nothing to disclose
Benjamin Alfred Nothing to disclose
Jonathan Appelbaum Consulting fees: Merck, ViiV Healthcare
Lisa Armitage Nothing to disclose
Roberto C. Arduino Contracted Research Viiv Healthcare, Inc.
Renata Arrington-Sanders Nothing to disclose
Jason Baker Nothing to disclose
Ben J. Barnett, MD Consulting fees: Gilead, BMS
Fees for non-CME/CE services: Gilead, Merck
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Philip Bolduc Nothing to disclose
Christopher Bositis Nothing to disclose
Christian Brander Salary: Aelix Therapeutics
Consulting fees: Gritstone Inc, GLG
Contracted research: Aelix Therapeutics
Ownership interest: Aelix Therapeutics
Christopher Brendemuhl Nothing to disclose
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xix
Trew Deckard Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): Gilead Sciences, Janssen
Alejandro Delgado Nothing to disclose
Paul DenOuden Nothing to disclose
Madeline Deutsch Contracted research: Gilead
Quentin Doperalski Nothing to disclose
Richard Dunham Nothing to disclose
James Dunn Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): AbbVie
Derek Fine Nothing to disclose
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Rajesh Gandhi Consulting fees: Merck, Gilead
Research support: Gilead, Theratechnologies, ViiV, Janssen
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W. David Hardy Consulting fees: Gilead, Merck, ViiV/GSK
Contracted research: Amgen, Gilead, Janssen, Merck, ViiV/GSK
Rodrigo Hasbun Consulting fees: Gilead
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or their agents (e.g., speakers bureau): Gilead
Contracted research: ViiV
Jennifer Husson Contracted research: Merck, Sharpe, Dome Inc., Intercept Pharmaceuticals
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Joseph Kass Contracted research: Alzheimer’s Disease Clinical Trial supported by
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Contracted research: Gilead Sciences
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Jessica Meisner Nothing to disclose
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Ana Monczor Nothing to disclose
Kudakwashe Mutyambizi Maloney Nothing to disclose
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Edgar Overton Consulting fees: ViiV Healthcare, Merck, Thera Technologies
Bruce Packett Nothing to disclose
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Contracted research: Gilead, ViiV, GSK

xx • D isclosure of C onflicts of I nterest

 Christian Ramers Consulting fees: Gilead Sciences, AbbVie
Commercial interest or their agents (e.g., speakers bureau): Gilead Sciences,
AbbVie, ViiV, Merck
Contracted research: Gilead Sciences
Brandon Samson Nothing to disclose
Aroonsiri Sangarlangkarn Nothing to disclose
Jason Schafer Consulting fees: Theratechnologies Inc.
Contracted research: Merck Sharp and Dohme, Gilead Sciences
Hans Schlecht Nothing to disclose
Jeffrey Schouten Nothing to disclose
James Scott Nothing to disclose
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Lydia Sharp Nothing to disclose
Kalphana Shere-Wolfe Nothing to disclose
Elizabeth Sherman Nothing to disclose
Neha Sheth Pandit Nothing to disclose
William Short Consulting fees: ViiV, Gilead Sciences
Fees for non-CME/CE services received directly from a commercial interest
or their agents (e.g., speakers bureau): Janssen
Daniel Skiest Nothing to disclose
Anthony Speights Nothing to disclose
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Gary Spinner Consulting fees: Gilead Sciences
Ownership interest: Gilead Sciences
Rohit Talwani Nothing to disclose
Zelalem Temesgen Consulting fees: ViiV Healthcare
Karen Vigil Consulting fees: Viiv, Gilead, Napo Pharmaceuticals Consulting
research: Merck
Sana Waheed Nothing to disclose
Amanda Willig Nothing to disclose
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David Wohl Consulting fees: Gilead, ViiV, Janssen, Merck
Contracted research: Gilead, Merck, ViiV
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The planners and managers reported the following finan- The PIM planners and managers have nothing to disclose.
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The AAHIVM planners and managers have nothing to
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disclose.
related to the content of this CME activity:

D isclosure of C onflicts of I nterest  • xxi

 METHOD OF PARTICIPATION AND REQUEST
FOR CREDIT

There are no fees for participating and receiving CME/​ made available immediately. Processing credit requests online
CE credit for this activity. During the period May 1, 2019 will reduce the amount of paper used by nearly 100,000 sheets
through May 1, 2020, participants must read the learning per year.
objectives and faculty disclosures and study the educational
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xxii
 DISCLOSURE OF UNL ABELED USE

This educational activity may contain discussion of published DISCLAIMER

and/​or investigational uses of agents that are not indicated by
the US Food and Drug Administration (FDA). The planners Participants have an implied responsibility to use the newly
of this activity do not recommend the use of any agent outside acquired information to enhance patient outcomes and their
of labeled indications. own professional development. The information presented in
The opinions expressed in the educational activity are this activity is not meant to serve as a guideline for patient
those of the faculty and do not necessarily represent the views management. Any procedures, medications, or other courses
of the planners. Please refer to the official prescribing informa- of diagnosis or treatment discussed or suggested in this ac-
tion for each product for discussion of approved indications, tivity should not be used by clinicians without evaluation of
contraindications, and warnings. their patient’s conditions and possible contraindications and/​
or dangers in use, review of any applicable manufacturer’s
product information, and comparison with recommendations
of other authorities.

xxiii
 1.
EPIDEMIOLOGY AND THE SPREAD OF HIV
Philip Bolduc, Benjamin Alfred, and Babafemi Onabanjo

CHAPTER GOALS behind by the global AIDS response, including adolescent

Upon completion of this chapter, the reader should girls and young women, men who have sex with men
be able to (MSM), transgender people, people who inject drugs,
• Provide an overview of the global AIDS pandemic prisoners, and sex workers.
and the US epidemic
• HIV occurs as types 1 and 2, with several groups and
• Demonstrate and apply knowledge about the subtypes comprising HIV-​1. Subtype B predominates
evolving epidemiology of HIV to both individual in the Western Hemisphere and Western Europe,
and population-​wide aspects of clinical practice whereas other subtypes and recombinant forms are more
• Educate clinicians and patients about factors prevalent elsewhere. Introduction of other subtypes
driving HIV transmission so that they will and recombinant strains is occurring in the Western
understand who is at greatest risk of infection Hemisphere and Western Europe.

O VE RVI EW O F WO R L DW I D E PA N D E M I C O VE RVI EW O F G L O B A L PA N D E M I C

Data from the WHO and UNAIDS show global estimates

L E A R N I N G O B J E C T I VE
of HIV as a continuing pandemic, with increasing overall
Discuss the global prevalence and geographic distribution of prevalence (36.9 million) but fewer new infections each year
HIV-​1 and HIV-​2 infections. (1.8 million), more people on antiretroviral therapy (ART;
21.7 million), and fewer annual deaths (0.9 million) (Figures
1.1 and 1.2) (UNAIDS, 2018).
WH AT ’S N EW ?
Africa remains the continent most heavily affected by
The World Health Organization/​ Joint United Nations HIV/​AIDS, accounting for 70% of persons living with HIV
Programme on HIV and AIDS (WHO/​UNAIDS) estimates in 2017 (Figure 1.3). However, due to several global initiatives,
that, in 2017, nearly 40 million people worldwide were infected there has been a dramatic decline in the annual number of
with HIV (UNAIDS, 2018). Although the numbers of new new HIV infections (−24%) and deaths (−35%) in 2017
HIV infections and AIDS-​related deaths continue to decline compared to 2000 (UNAIDS, 2018). Annual infections and
in many regions of the world, including sub-​Saharan Africa, deaths have also declined over this period in the Americas
there are still certain regions where the incidence of HIV is (−5% and −20%, respectively) and Southeast Asia (−27%
rising, most notably in the eastern European and eastern and −40%), but trends in Europe (+20% and −5%) and the
Mediterranean areas. In his foreword to the UNAIDS Global Western Pacific areas (+7% and −45%) are mixed, and the
AIDS Update 2018, executive director Michel Sidibe writes Eastern Mediterranean area saw increases in both infections
“The global AIDS response is at a precarious point—​partial and deaths (+27% and +59%) (UNAIDS, 2018).
success in saving lives and stopping new HIV infections is Across all countries, several key demographic subgroups
giving way to complacency. At the halfway point to the 2020 continue to be most impacted by the HIV/​AIDS epidemic.
targets, the pace of progress is not matching the global ambi- UNAIDS has identified six populations at higher risk of HIV
tion” (Sidibe, 2018). infection that are in danger of being left behind by the global
AIDS response: adolescent girls and young women, MSM,
transgender people, people who inject drugs, prisoners, and
K EY P O I N TS
sex workers. The risk of acquiring HIV is 27 times higher
• UNAIDS identified several demographic subgroups at among MSM; 23 times higher among people who inject
high risk for HIV infection and in danger of being left drugs; 13 times higher for female sex workers; and 12 times

1
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 o to do,
In death he is worth a share of the clay which in life he
laboured through;
Wipe the spume from his pallid lips, and quietly cross his
hands,
And leave him alone with the Mother Earth and the Master
who understands."

My mate seemed very much impressed by the poem, and remained

silent for a long while after I had finished reading it from the dirty
scrap of tea-paper on which it was written.
"Have you ever cared a lot for some one girl, Flynn?" he asked
suddenly.
"No," I answered, for I had never disclosed my little love affair to
any man.
"Have you ever cared a lot for one girl, Flynn?" repeated Joe.
"I have cared—once," I replied, and, obeying the impulse of the
moment, I told Joe the story. He looked grave when I had finished.
"They're all the same," he said; "all the same. I cared for a wench
myself one time and I intended to marry her."
I looked at my mate's unshaven face, his dirty clothes, and I laughed
outright.
"I'm nothin' great in the beauty line," went on Moleskin as if divining
my thoughts; "but when I washed myself years ago I was pretty
passable. She was a fine girl, mine, and I thought that she was
decent and aboveboard. It cost me money and time to find out what
she was, and in the end I found that she was the mother of two
kids, and the lawful wife of no man. It was a great slap in the face
for me, Flynn."
"It must have been," was all that I could say.
"By God! it was," Moleskin replied. "I tried to drink my regret away,
but I never could manage it. Have you ever wrote a love song?"
"I've written one," I said.
"Will you say it to me?" asked Joe.
I had written a love song long before, and knew it by heart, for it
was a song which I liked very much. I recited it to my mate,
speaking in half-whispers so that the gamblers at the far end of the
shack could not hear me.
"A LOVE SONG
 "Greater by far than all that men know, or all that men see is
this—
The lingering clasp of a maiden's hand and the warmth of her
virgin kiss,
The tresses that cover the pure white brow in many a
clustering curl,
And the deep look of honest love in the grey eyes of a girl.

"Because of that I am stronger than death and life is barren

no more,
For otherwise wrongs that I hardly feel would sink to the
heart's deep core,
For otherwise hope were utterly lost in the endless paths of
wrong—
But only to look in her soft grey eyes—I am strong, I am
strong!

"Does she love as I love? I do not know, but all that I know is
this—
'Tis enough to stay for an hour at her side and dream awhile
of her kiss,
'Tis enough to clasp the hands of her, and 'neath the shade of
her hair
To press my lips on her lily brow and leave my kisses there.

"In the dreary days on the vagrant ways whereon my feet

have trod
She came as a star to cheer my way, a guiding star from God,
She came from the dreamy choirs of heaven, lovely and
wondrous wise,
And I follow the path that is lighted up by her eyes, her
eyes."

"I don't like that song, because I don't know what it is about," said
Moleskin when I had finished. "The one about English Bill is far and
away better. When you talk about a man that drops like a spavined
mule in the knacker's yard, I know what you mean, but a girl that
comes from the dreamy choirs of heaven, wherever they are, is not
the kind of wench for a man like you and me, Flynn."
I felt a little disappointed, and made no reply to the criticism of my
mate.
"Do you ever think how nice it would be to have a home of your
own?" asked Moleskin after a long silence, and a vigorous puffing at
the pipe which he held between his teeth. "It would be fine to have
a room to sit in and a nice fire to warm your shins at of an evenin'. I
often think how roarin' it would be to sit in a parlour and drink tea
with a wife, and have a little child to kiss me as you talk about in the
song on the death of English Bill."
I did not like to hear my big-boned, reckless mate talk in such a way.
Such talk was too delicate and sentimental for a man like him.
"You're a fool, Joe," I said.
"I suppose I am," he answered. "But just you wait till you come near
the turn of life like me, and find a sort of stiffness grippin' on your
bones, then you'll maybe have thoughts kind of like these. A young
fellow, cully, mayn't care a damn if he is on the dead end, but by
God! it is a different story when you are as stiff as a frozen poker
with one foot in the grave and another in hell, Flynn."
"It was a different story the day you met the ploughman, on our
journey from Greenock," I said. "You must have changed your mind,
Moleskin?"
"I said things to that ploughman that I didn't exactly believe myself,"
said my mate. "I would do anything and say anything to get the best
of an argument."
Many a strange conversation have I had with Moleskin Joe. One
evening when I was seated by the hot-plate engaged in patching my
corduroy trousers Joe came up to me with a question which
suddenly occurred to him. I was held to be a sort of learned man,
and everybody in the place asked me my views upon this and that,
and no one took any heed of my opinions. Most of them
acknowledged that I was nearly as great a poet as Two-shift
Mullholland, now decently married, and gone from the ranks of the
navvies.
"Do you believe in God, Flynn?" was Joe's question.
"I believe in a God of a sort," I answered. "I believe in the God who
plays with a man, as a man plays with a dog, who allows suffering
and misery and pain. The 'Holy-Willy' look on a psalm-singing
parson's dial is of no more account to Him than a blister on a
beggar's foot."
"I only asked you the question, just as a start-off to tellin' you my
own opinion," said Joe. "Sometimes I think one thing about God,
and sometimes I think another thing. The song that you wrote about
English Bill talks of God takin' care of the soul, and it just came into
my head to ask your opinion and tell you my own. As for myself,
when I see a man droppin' down like a haltered gin-horse at his
work I don't hold much with what parsons say about the goodness
of Providence. At other times, when I am tramping about in the
lonely night, with the stars out above me and the world kind of
holding its breath as if it was afraid of something, I do be thinking
that there is a God after all. I'd rather that there is none; for He is
sure to have a heavy tally against me if He puts down all the things
I've done. But where is heaven if there is such a place?"
"I don't know," I replied.
"If you think of it, there is no end to anything," Moleskin went on. "If
you could go up above the stars, there is surely a place above them,
and another place in turn above that again. You cannot think of a
place where there is nothing, and as far as I can see there is no end
to anything. You can't think of the last day as they talk about, for
that would mean the end of time. It's funny to think of a man sayin'
that there'll be no time after such and such a time. How can time
stop?"
I tried to explain to Joe that time and space did not exist, that they
were illusions used for practical purposes.
"No man can understand these things," said Joe, as I fumbled
through my explanation of the non-existence of time and space. "I
have often looked at the little brooks by the roadside and saw the
water runnin', runnin', always lookin' the same, and the water
different always. When I looked at the little brooks I often felt
frightened, because I could not understand them. All these things
are the same, and no man can understand them. Why does a brook
keep runnin'? Why do the stars come out at night? Is there a God in
Heaven? Nobody knows, and a man may puzzle about these things
till he's black in the face and grey in the head, but he'll never get
any further."
"English Bill may know more about these things than we do," I said.
"How could a dead man know anything?" asked Joe, and when I
could not explain the riddle, he borrowed a shilling from me and lost
it at the gaming-table.
That was Joe all over. One moment he was looking for God in
Nature, and on the next instant he was looking for a shilling to stake
on the gaming-table. Once in an argument with me he called the
world "God's gamblin' table," and endeavoured to prove that God
threw down men, reptiles, nations, and elements like dice to the
earth, one full of hatred for the other and each filled with a desire
for supremacy, and that God and His angels watched the great
struggle down below, and betted on the result of its ultimate issue.
"Of course the angels will not back Kinlochleven very heavily," he
concluded.
 CHAPTER XXIX
I WRITE FOR THE PAPERS
 "'Awful Railway Disaster,'
The newspapers chronicle,
The men in the street are buying.
My! don't the papers sell.
And the editors say in their usual way,
'The story is going well.'"

—From Songs of the Dead End.

Day after day passed and the autumn was waning. The work went
on, shift after shift, and most of the money that I earned was spent
on the gambling table or in the whisky store. Now and again I wrote
home, and sent a few pounds to my people, but I never sent them
my address. I did not want to be upbraided for my negligence in
sending them so little. The answers to my letters would always be
the same: "Send more money; send more money. You'll never have
a day's luck if you do not help your parents!" I did not want answers
like that, so I never sent my address.
One night towards the end of October I had lost all my money at the
gambling school, although Moleskin had twice given me a stake to
retrieve my fallen fortunes. I left the shack, went out into the
darkness, a fire in my head and emptiness in my heart. Around me
the stark mountain peaks rose raggedly against the pale horns of the
anæmic moon. Outside the whisky store a crowd of men stood, dark
looks on their faces, and the wild blood of mischief behind. Inside
each shack a dozen or more gamblers sat cross-legged in circles on
the ground, playing banker or brag, and the clink of money could be
heard as it passed from hand to hand. Above them the naphtha
lamps hissed and spluttered and smelt, the dim, sickly light showed
the unwashed and unshaven faces beneath, and the eager eyes that
sparkled brightly, seeing nothing but the movements of the game.
Down in the cuttings men were labouring on the night-shift, gutting
out the bowels of the mountain places, and forcing their way
through the fastness steadily, slowly and surely. I could hear the
dynamite exploding and shattering to pieces the rock in which it was
lodged. The panting of weary hammermen was loud in the darkness,
and the rude songs which enlivened the long hours of the night
floated up to me from the trough of the hills.
I took my way over the slope of the mountain, over the pigmies who
wrought beneath, fighting the great fight which man has to wage
eternally against nature. Down in the cuttings I could see my mates
toiling amidst the broken earth, the sharp ledges of hewn rock, and
the network of gang-planks and straining derricks that rose all
around them. The red glare of a hundred evil-smelling torches flared
dismally, and over the sweltering men the dark smoke faded away
into the rays of the pallid moon. With the rising smoke was mingled
the steam of the men's bent shoulders and steaming loins.
Above and over all, the mystery of the night and the desert places
hovered inscrutable and implacable. All around the ancient
mountains sat like brooding witches, dreaming on their own story of
which they knew neither the beginning nor the end. Naked to the
four winds of heaven and all the rains of the world, they had stood
there for countless ages in all their sinister strength, undefied and
unconquered, until man, with puny hands and little tools of labour,
came to break the spirit of their ancient mightiness.
And we, the men who braved this task, were outcasts of the world.
A blind fate, a vast merciless mechanism, cut and shaped the fabric
of our existence. We were men flogged to the work which we had to
do, and hounded from the work which we had accomplished. We
were men despised when we were most useful, rejected when we
were not needed, and forgotten when our troubles weighed upon us
heavily. We were the men sent out to fight the spirit of the wastes,
rob it of all its primeval horrors, and batter down the barriers of its
world-old defences. Where we were working a new town would
spring up some day; it was already springing up, and then, if one of
us walked there, "a man with no fixed address," he would be taken
up and tried as a loiterer and vagrant.
Even as I thought of these things a shoulder of jagged rock fell into
a cutting far below. There was the sound of a scream in the
distance, and a song died away in the throat of some rude singer.
Then out of the pit I saw men, red with the muck of the deep earth
and redder still with the blood of a stricken mate, come forth,
bearing between them a silent figure. Another of the pioneers of
civilisation had given up his life for the sake of society.
I returned to the shack, and, full of the horror of the tragedy, I
wrote an account of it on a scrap of tea-paper. I had no design, no
purpose in writing, but I felt compelled to scribble down the
thoughts which entered my mind. I wrote rapidly, but soon wearied
of my work. I was proceeding to tear up the manuscript when my
eye fell on a newspaper which had just come into the shack
wrapped around a chunk of mouldy beef. A thought came to me
there and then. I would send my account of the tragedy to the
editor of that paper. It was the Dawn, a London halfpenny daily. I
had never heard of it before.
I had no envelope in my possession. I searched through the shack
and found one, dirty, torn, and disreputable in appearance. Amongst
all those men there was not another to be found. I did not rewrite
my story. Scrawled with pencil on dirty paper, and enclosed in a
dirtier envelope, I sent it off to Fleet Street and forgot all about it.
But, strange to say, in four days' time I received an answer from the
editor of the Dawn, asking me to send some more stories of the
same kind, and saying that he was prepared to pay me two guineas
for each contribution accepted.
The acceptance of my story gave me no great delight; I often went
into greater enthusiasm over a fight in the Kinlochleven ring. But
outside a fight or a stiff game of cards, there are few things which
cause me to become excited. My success as a writer discomfited me
a little even. I at first felt that I was committing some sin against my
mates. I was working on a shift which they did not understand; and
men look with suspicion on things beyond their comprehension. A
man may make money at a fight, a gaming table or at a shift, but
the man who made money with a dirty pencil and a piece of dirty
paper was an individual who had no place in my mates' scheme of
things.
For all that, the editor's letter created great stir amongst my mates.
It passed round the shack and was so dirty on coming back that I
couldn't read a word of it. Red Billy said that he could not
understand it, and that I must have copied what I had written from
some other paper. Moleskin Joe said that I was the smartest man he
had ever met, by cripes! I was. He took great pleasure in calling me
"that mate of mine" ever afterwards. Old Sandy MacDonald, who
had come from the Isle of Skye, and who was wasting slowly away,
said that he knew a young lad like me who went from the Highlands
to London and made his fortune by writing for the papers.
"He had no other wark but writin', and he made his fortune," Sandy
asserted, and everyone except myself laughed at this. It was such a
funny thing to hear old Sandy make his first joke, my mates thought.
A man to earn his living by writing for the papers! Whoever heard of
such a thing?
In all I wrote five articles for the Dawn, then found that I could write
no more. I had told five truthful and exciting incidents of my
navvying life, and I was not clever enough to tell lies about it. Ten
guineas came to me from Fleet Street. Six of these I sent home to
my own people, and for the remainder I purchased many an hour's
joy in the whisky store and many a night's life-giving excitement at
the gaming table.
I sent my address home with the letter, and when my mother replied
she was so full of her grievances that she had no time to enquire if I
had any of my own. Another child had been born, and the family in
all now consisted of thirteen.
 CHAPTER XXX
WINTER

"Do you mind the nights we laboured, boys, together,

Spreadeagled at our travail on the joists,
With the pulley-wheels a-turning and the naphtha lamps a-
burning,
And the mortar crawling upwards on the hoists,
When our hammers clanked like blazes on the facing,
When the trestles shook and staggered as we struck,
When the derricks on their pivots strained and broke the
crank-wheel rivets
As the shattered jib sank heavy in the muck?"

—From Songs of the Dead End.

The winter was at hand. When the night drew near, a great
weariness came over the face of the sun as it sank down behind the
hills which had seen a million sunsets. The autumn had been mild
and gentle, its breezes soft, its showers light and cool. But now,
slowly and surely, the great change was taking place; a strange
stillness settled softly on the lonely places. Nature waited breathless
on the threshold of some great event, holding her hundred winds
suspended in a fragile leash. The heather bells hung motionless on
their stems, the torrents dropped silently as smoke from the scarred
edges of the desolate ravines, but in this silence there lay a menace;
in its supreme poise was the threat of coming danger. The crash of
our hammers was an outrage, and the exploding dynamite a
sacrilege against tired nature.
A great weariness settled over us; our life lacked colour, we were
afraid of the silence, the dulness of the surrounding mountains
weighed heavily on our souls. The sound of labour was a comfort,
the thunder of our hammers went up as a threat against the vague
implacable portent of the wild.
Life to me had now become dull, expressionless, stupid. Only in
drink was there contentment, only in a fight was there excitement. I
hated the brown earth, the slushy muck and gritty rock, but in the
end hatred died out and I was almost left without passion or
longing. My life now had no happiness and no great sadness. My
soul was proof against sorrow as it was against joy. Happiness and
woe were of no account; life was a spread of brown muck, without
any relieving splash of lighter or darker colours. For all that, I had no
great desire (desire was almost dead even) to go down to the
Lowlands and look for a newer job. So I stayed amidst the brown
muck and existed.
When I had come up my thoughts for a long while were eternally
straying to Norah Ryan, but in the end she became to me little more
than a memory, a frail and delightful phantom of a fleeting dream.
The coming of winter was welcome. The first nipping frost was a call
to battle, and, though half afraid, most of the men were willing to
accept the challenge. A few, it is true, went off to Glasgow, men old
and feeble who were afraid of the coming winter.
In the fight to come the chances were against us. Rugged cabins
with unplanked floors, leaking roofs, flimsy walls, through the chinks
of which the winds cut like knives, meagre blankets, mouldy food,
well-worn clothes, and battered bluchers were all that we possessed
to aid us in the struggle. On the other hand, the winter marshalled
all her forces, the wind, the hail, frost, snow, and rain, and it was
against these that we had to fight, and for the coming of the
opposing legions we waited tensely and almost eagerly.
But the north played a wearing game, and strove to harry us out
with suspense before thundering down upon us with her cold and
her storm. The change took place slowly. In a day we could hardly
feel it, in a week something intangible and subtle, something which
could not be defined, had crept into our lives. We felt the change,
but could not localise it. Our spirits sank under the uncertainty of the
waiting days, but still the wild held her hand. The bells of the
heather hung from their stems languidly and motionless, stripped of
all their summer charm, but lacking little of the hue of summer. Even
yet the foam-flecked waters dropped over the cliffs silently as figures
that move in a dream. When we gathered together and ate our
midday meal, we wrapped our coats around our shoulders, whereas
before we had sat down without them. When night came on we
drew nearer to the hot-plate, and when we turned naked into bed
we found that the blankets were colder than usual. Only thus did the
change affect us for a while. Then the cold snap came suddenly and
wildly.
The plaintive sunset waned into a sickly haze one evening, and when
the night slipped upwards to the mountain peaks never a star came
out into the vastness of the high heavens. Next morning we had to
thaw the door of our shack out of the muck into which it was frozen
during the night. Outside the snow had fallen heavily on the ground,
and the virgin granaries of winter had been emptied on the face of
the world.
Unkempt, ragged, and dispirited, we slunk to our toil, the snow
falling on our shoulders and forcing its way insistently through our
worn and battered bluchers. The cuttings were full of slush to the
brim, and we had to grope through them with our hands until we
found the jumpers and hammers at the bottom. These we held
under our coats until the heat of our bodies warmed them, then we
went on with our toil.
At intervals during the day the winds of the mountain put their
heads together and swept a whirlstorm of snow down upon us,
wetting each man to the pelt. Our tools froze until the hands that
gripped them were scarred as if by red-hot spits. We shook
uncertain over our toil, our sodden clothes scalding and itching the
skin with every movement of the swinging hammers. Near at hand
the lean derrick jibs whirled on their pivots like spectres of some
ghoulish carnival, and the muck-barrows crunched backwards and
forwards, all their dirt and rust hidden in woolly mantles of snow.
Hither and thither the little black figures of the workers moved
across the waste of whiteness like shadows on a lime-washed wall.
Their breath steamed out on the air and disappeared in space like
the evanescent and fragile vapour of frying mushrooms.
"On a day like this a man could hardly keep warm on the red-hot
hearth of hell!" Moleskin remarked at one time, when the snow
whirled around the cutting, causing us to gasp with every fiercely-
taken breath.
"Ye'll have a heat on the same hearthstone some day," answered
Red Billy, who held a broken lath in one mittened hand, while he
whittled away with his eternal clasp-knife.
When night came on we crouched around the hot-plate and told
stories of bygone winters, when men dropped frozen stiff in the
trenches where they laboured. A few tried to gamble near the door,
but the wind that cut through the chinks of the walls chased them to
the fire. Moleskin told the story of his first meeting with me on the
Paisley toll-road, and suddenly I realised that I was growing old. It
was now some years since that meeting took place, and even then I
was a man, unaided and alone, fighting the great struggle of
existence. I capped Moleskin's story with the account of Mick
Deehan's death on the six-foot way. Afterwards the men talked
loudly of many adventures. Long lonely shifts were spoken of, nights
and days when the sweat turned to ice on the eyelashes, when the
cold nipped to the bone and chilled the workers at their labours. One
man slipped off the snow-covered gang-plank and fell like a rock
forty feet through space.
"Flattened out like a jelly-fish on the groun' he was," said Clancy,
who told the story.
Red Billy, who worked on the railway line in his younger days, gave
an account of Mick Cassidy's death. Mick was sent out to free the
ice-locked facing points, and when they were closed by the
signalman, Cassidy's hand got wedged between the blades and the
rail.
"Held like a louse was Cassidy, until the train threw him clear,"
concluded Billy, adding reflectively that "he might have been saved if
he had had somethin' in one hand to hack the other hand off with."
Joe told how one Ned Farley got his legs wedged between the
planks of a mason's scaffold and hung there head downwards for
three hours. When Farley got relieved he was a raving madman, and
died two hours afterwards. We all agreed that death was the only
way out in a case like that.
Gahey told of a night's doss at the bottom of a coal slip in a railway
siding. He slept there with three other people, two men and a
woman. As the woman was a bad one it did not matter very much to
anyone where she slept. During the night a waggon of coal was
suddenly shot down the slip. Gahey got clear, leaving his thumb with
the three corpses which remained behind.
"It was a bad endin', even for a woman like that," someone said.
Outside the winds of the night scampered madly, whistling through
every crevice of the shack and threatening to smash all its timbers to
pieces. We bent closer over the hot-plate, and the many who could
not draw near to the heat scrambled into bed and sought warmth
under the meagre blankets. Suddenly the lamp went out, and a
darkness crept into the corners of the dwelling, causing the figures
of my mates to assume fantastic shapes in the gloom. The circle
around the hot-plate drew closer, and long lean arms were stretched
out towards the flames and the redness. Seldom may a man have
the chance to look on hands like those of my mates. Fingers were
missing from many, scraggy scars seaming along the wrists or across
the palms of others told of accidents which had taken place on many
precarious shifts. The faces near me were those of ghouls worn out
in some unholy midnight revel. Sunken eyes glared balefully in the
dim unearthly light of the fire, and as I looked at them a moment's
terror settled on my soul. For a second I lived in an early age, and
my mates were the cave-dwellers of an older world than mine. In
the darkness, near the door, a pipe glowed brightly for a moment,
then the light went suddenly out and the gloom settled again. The
reaction came when Two-shift Mullholland's song, The Bold Navvy
Man, was sung by Clancy of the Cross. We joined lustily in the
chorus, and the roof shook with the thunder of our voices.
"THE BOLD NAVVY MAN.
"I've navvied here in Scotland, I've navvied in the south,
Without a drink to cheer me or a crust to cross me mouth,
I fed when I was workin' and starved when out on tramp,
And the stone has been me pillow and the moon above me
lamp.
I have drunk me share and over when I was flush with tin,
For the drouth without was nothin' to the drouth that burned
within!
And where'er I've filled me billy and where'er I've drained me
can,
I've done it like a navvy, a bold navvy man.
A bold navvy man,
An old navvy man,
And I've done me graft and stuck it like a bold navvy man.

"I've met a lot of women and I liked them all a spell—

They drive some men to drinkin' and also some to hell,
But I have never met her yet, the woman cute who can
Learn a trick to Old Nick or the bold navvy man.
Oh! the sly navvy man,
And the fly navvy man,
Sure a woman's always runnin' to the bold navvy man.

"I do not care for ladies grand who are of high degree,
A winsome wench and willin', she is just the one for me,
Drink and love are classed as sins, as mortal sins by some,
I'll drink and drink whene'er I can, the drouth is sure to come
—
And I will love till lusty life runs out its mortal span,
The end of which is in the ditch for many a navvy man.
The bold navvy man,
The old navvy man,
Safe in a ditch with heels cocked up, so dies the navvy man.

"I've splashed a thousand models red and raised up fiery Cain

From Glasgow down to Dover Pier and back that road again;
 From Glasgow down to Dover Pier and back that road again;
I've fought me man for hours on end, stark naked to the buff
And me and him, we never knew when we had got enough.
'Twas skin and hair all flyin' round and red blood up and out,
And me or him could hardly tell what brought the fight about.
—
'Tis wenches, work and fight and fun and drink whene'er I
can
That makes the life of stress and strife as suits the navvy
man!

"Let her go, boys; let her go now!" roared Clancy, rising to his feet,
kicking a stray frying-pan and causing it to clatter across the shack.
"All together, boys; damn you, all together!

"Then hurrah! ev'ry one

For the bold navvy man,
For fun and fight are damned all right for any navvy man!"

Even old Sandy MacDonald joined in the chorus with his weak and
querulous voice. The winter was touching him sharply, and he was
worse off than any of us. Along with the cold he had his wasting
disease to battle against, and God alone knew how he managed to
work along with his strong and lusty mates on the hammer squad at
Kinlochleven. Sandy was not an old man, but what with the dry
cough that was in his throat and the shivers of cold that came over
him after a long sweaty shift, it was easily seen that he had not
many months to live in this world. He looked like a parcel of bones
covered with brown withered parchment and set in the form of a
man. How life could remain fretting within such a frame as his was a
mystery which I could not solve. Almost beyond the effects of heat
or cold, the cold sweat came out of his skin on the sweltering warm
days, and when the winter came along, the chilly weather hardly
made him colder than he was by nature. His cough never kept silent;
sometimes it was like the bark of a dog, at other times it seemed as
if it would carry the very entrails out of the man. In the summer he
spat blood with it, but usually it was drier than the east wind.
At one period of his life Sandy had had a home and a wife away
down in Greenock; but in those days he was a strong lusty fellow, fit
to pull through a ten-hour shift without turning a hair. One winter's
morning he came out from the sugar refinery, in which he worked,
steaming hot from the long night's labour, and then the cold settled
on him. Being a sober, steady-going man, he tried to work as long as
he could lift his arms, but in the end he had to give up the job which
meant life and home to him. One by one his little bits of things went
to the pawnshop; but all the time he struggled along bravely, trying
to keep the roof-tree over his head and his door shut against the
lean spectre of hunger. Between the four bare walls of the house
Sandy's wife died one day; and this caused the man to break up his
home.
He came to Kinlochleven at the heel of the summer, and because he
mastered his cough for a moment when asking for a job, Red Billy
Davis started him on the jumper squad. The old ganger, despite his
swearing habits and bluntness of discourse, was at heart a very
good-natured fellow. Sandy stopped with us for a long while and it
was pitiful to see him labouring there, his old bones creaking with
every move of his emaciated body, and the cold sweat running off
him all day. He ate very little; the tame robin which flitted round our
shack nearly picked as much from off the floor. He had a bunk to
himself at the corner of the shack, and there he coughed out the
long sleepless hours of the night, bereft of all hope, lacking
sympathy from any soul sib to himself, and praying for the grave
which would end all his troubles. For days at a stretch he lay supine
in his bed, unable to move hand or foot, then, when a moment's
relief came to him, he rose and started on his shift again, crawling
out with his mates like a wounded animal.
Winter came along and Sandy got no better; he could hardly grow
worse and remain alive. Life burned in him like a dying candle in a
ruined house, and he waited for the end of the great martyrdom
patiently. Still, when he could, he kept working day in and day out,
through cold and wet and storm. Heaven knows that it was not work
which he needed, but care, rest, and sympathy. All of us expressed
pity for the man, and helped him in little ways, trying to make life
easier for him. Moleskin usually made gruel for him, while I read the
Oban Times to the old fellow whenever that paper came into the
shack. One evening as I read something concerning the Isle of Skye
Sandy burst into tears, like a homesick child.
"Man! I would like tae dee there awa' in the Isle of Skye," he said to
me in a yearning voice.
"Die, you damned old fool, you?" exclaimed Joe, who happened to
come around with a pot of gruel just at that moment and overheard
Sandy's remark. "You'll not die for years yet. I never saw you lookin'
so well in all your life."
"It's all over with me, Moleskin," said poor Sandy. "It's a great
wonder that I've stood it so long, but just now the thocht came to
me that I'd like tae dee awa' back in my own place in the Isle of
Skye. If I could just save as muckle siller as would take me there, I'd
be content enough."
"Some people are content with hellish little!" said Joe angrily.
"You've got to buck up, man, for there's a good time comin', though
you'll never—I mean that ev'rything will come right in the end. We'll
see that you get home all right, you fool, you!"
Joe was ashamed to find himself guilty of any kind impulse, and he
endeavoured to hide his good intentions behind rough words. When
he called Sandy an old fool Sandy's eyes sparkled, and he got into
such good humour that he joined in the chorus of the Bold Navvy
Man when Clancy, who is now known as Clancy of the Cross, gave
bellow to Mullholland's magnum opus.
Early on the morning of the next day, which was pay-day, Moleskin
was busy at work sounding the feelings of the party towards a great
scheme which he had in mind; and while waiting at the pay-office
when the day's work was completed, Joe made the following speech
to Red Billy's gang, all of whom, with the exception of Sandy
MacDonald, were present.
"Boys, Sandy MacDonald wants to go home and die in his own
place," said Joe, weltering into his subject at once. "He'll kick the
bucket soon, for he has the look of the grave in his eyes. He only
wants as much tin as will take him home, and that is not much for
any man to ask, is it? So what do you say, boys, to a collection for
him, a shillin' a man, or whatever you can spare? Maybe some day,
when you turn respectable, one of you can say to yourself, 'I once
kept myself from gettin' drunk, by givin' some of my money to a
man who needed it more than myself.' Now, just look at him comin'
across there."
We looked in the direction of Joe's outstretched finger and saw
Sandy coming towards us, his rags fluttering around him like the
duds of a Michaelmas scarecrow.
"Isn't he a pitiful sight!" Moleskin went on. "He looks like the Angel
of Death out on the prowl! It's a God's charity to help a man like
Sandy and make him happy as we are ourselves. We are at home
here; he is not. So it is up to us to help him out of the place. Boys,
listen to me!" Moleskin's voice sank into an intense whisper. "If every
damned man of you don't pay a shillin' into this collection I'll look for
the man that doesn't, and I'll knuckle his ribs until he pays for booze
for ev'ry man in Billy's shack, by God! I will."
Everyone paid up decently, and on behalf of the gang I was asked to
present the sum of three pounds fifteen shillings to Sandy
MacDonald. Sandy began to cry like a baby when he got the money
into his hands, and every man in the job called out involuntarily:
"Oh! you old fool, you!"
Pay-day was on Saturday. On Monday morning Sandy intended
starting out on his journey home. All Saturday night he coughed out
the long hours of the darkness, but in the morning he looked fit and
well.
"You'll come through it, you fool!" said Moleskin. "I'll be dead myself
afore you."
On the next night he went to bed early, and as we sat around the
gaming table we did not hear the racking cough which had torn at
the man's chest for months.
"He's getting better," we all said.
"Feeling all right, Sandy?" I asked, as I turned into bed.
"Mon! I'm feelin' fine now," he answered. "I'm goin' to sleep well to-
night, and I'll be fit for the journey in the morn."
That night Sandy left us for good. When the morning came we found
the poor wasted fellow lying dead in his bunk, his eyes wide open,
his hands closed tightly, and the long finger-nails cutting into the
flesh of the palm. The money which we gave to the man was bound
up in a little leathern purse tied round his neck with a piece of
string.
The man was very light and it was an easy job to carry him in the
little black box and place him in his home below the red earth of
Kinlochleven. The question as to what should be done with the
money arose later. I suggested that it should be used in buying a
little cross for Sandy's grave.
"If the dead man wants a cross he can have one," said Moleskin Joe.
And because of what he said and because it was more to our liking,
we put the money up as a stake on the gaming table. Clancy won
the pile, because his luck was good on the night of the game.
That is our reason for calling him Clancy of the Cross ever since.
The winter rioted on its way. Snow, rain, and wind whirled around us
in the cutting, and wet us to the bone. It was a difficult feat to close
our hands tightly over the hammers with which we took uncertain
aim at the drill heads and jumper ends. The drill holder cowered on
his seat and feared for the moment when an erring hammer might
fly clear and finish his labours for ever. Hourly our tempers grew
worse, each movement of the body caused annoyance and
discomfort, and we quarrelled over the most trivial matters. Red Billy
cursed every man in turn and all in general, until big Jim Maloney
lost his temper completely and struck the ganger on the jaw with his
fist, knocking him senseless into a snowdrift.
That night Maloney was handed his lying time and told to slide. He
padded from Kinlochleven in the darkness, and I have never seen
him since then. He must have died on the journey. No man could
cross those mountains in the darkness of mid-winter and in the teeth
of a snowstorm.
Some time afterwards the copy of a Glasgow newspaper, either the
Evening Times or News (I now forget which), came into our shack
wrapped around some provisions, and in the paper I read a
paragraph concerning the discovery of a dead body on the
mountains of Argyllshire. While looking after sheep a shepherd came
on the corpse of a man that lay rotting in a thawing snowdrift.
Around the remains a large number of half-burnt matches were
picked up, and it was supposed that the poor fellow had tried to
keep himself warm by their feeble flames in the last dreadful hours.
Nobody identified him, but the paper stated that he was presumably
a navvy who lost his way on a journey to or from the big waterworks
of Kinlochleven.
As for myself, I am quite certain that it was that of big Jim Maloney.
No man could survive a blizzard on the houseless hills, and big Jim
Maloney never appeared in model or shack afterwards.
 CHAPTER XXXI
THE GREAT EXODUS

"We'll lift our time and go, lads,

The long road lies before,
The places that we know, lads,
Will know our like no more.
Foot forth! the last bob's paid out,
Some see their last shift through.
But the men who are not played out
Have other jobs to do."

—From Tramp Navvies.

'Twas towards the close of a fine day on the following summer that
we were at work in the dead end of a cutting, Moleskin and I, when
I, who had been musing on the quickly passing years, turned to
Moleskin and quoted a line from the Bible.
"Our years pass like a tale that is told," I said.
"Like a tale that is told damned bad," answered my mate, picking
stray crumbs of tobacco from his waistcoat pocket and stuffing them
into the heel of his pipe. "It's a strange world, Flynn. Here to-day,
gone to-morrow; always waitin' for a good time comin' and knowin'
that it will never come. We work with one mate this evenin', we beg
for crumbs with another on the mornin' after. It's a bad life ours, and
a poor one, when I come to think of it, Flynn."
"It is all that," I assented heartily.
"Look at me!" said Joe, clenching his fists and squaring his
shoulders. "I must be close on forty years, maybe on the graveyard
side of it, for all I know. I've horsed it since ever I can mind; I've
worked like a mule for years, and what have I to show for it all to-
day, matey? Not the price of an ounce of tobacco! A midsummer
scarecrow wouldn't wear the duds that I've to wrap around my hide!
A cockle-picker that has no property only when the tide is out is as
rich as I am. Not the price of an ounce of tobacco! There is
something wrong with men like us, surely, when we're treated like
swine in a sty for all the years of our life. It's not so bad here, but
it's in the big towns that a man can feel it most. No person cares for
the likes of us, Flynn. I've worked nearly ev'rywhere; I've helped to
build bridges, dams, houses, ay, and towns! When they were
finished, what happened? Was it for us—the men who did the
buildin'—to live in the homes that we built, or walk through the
streets that we laid down? No earthly chance of that! It was always,
'Slide! we don't need you any more,' and then a man like me, as
helped to build a thousand houses big as castles, was hellish glad to
get the shelter of a ten-acre field and a shut gate between me and
the winds of night. I've spent all my money, have I? It's bloomin'
easy to spend all that fellows like us can earn. When I was in
London I saw a lady spend as much on fur to decorate her carcase
with as would keep me in beer and tobacco for all the rest of my life.
And that same lady would decorate a dog in ribbons and fol-the-
dols, and she wouldn't give me the smell of a crust when I asked her
for a mouthful of bread. What could you expect from a woman who
wears the furry hide of some animal round her neck, anyhow? We
are not thought as much of as dogs, Flynn. By God! them rich
buckos do eat an awful lot. Many a time I crept up to a window just
to see them gorgin' themselves."
"I have often done the same kind of thing," I said.
"Most men do," answered Joe. "You've heard of old Moses goin' up
the hill to have a bit peep at the Promist Land. He was just like me
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