CHEYENNE - When Dr. Carol Fischer saw her first HIV-infected patient in 1989, she told him the stark truth: There was no treatment for the disease, and she was not an AIDS expert.

But Fischer vowed to care for him anyway.

Over time, more HIV-positive Wyomingites found their way to Fischer, who treated them - even when some doctors were reluctant to tackle the then-mysterious disease - in part because of her own close ties to someone with HIV.

"I had someone that I loved who had the disease, so to honor that person I needed to make sure I stood up and cared for some of these patients," said Fischer, a Green River native.

Twenty years later, Fischer continues to treat HIV-infected patients as a small but important part of her family medical practice in Cheyenne. Despite no formal certification in HIV/AIDS treatment, she is the de facto AIDS doctor for southeastern Wyoming.

Only one other Wyoming physician treats large numbers of HIV/AIDS patients, and he comes from a much different background.

Dr. Mark E. Dowell was a young doctor training in Galveston, Texas, when men in their 20s and 30s began showing signs of a "weird pneumonia" that turned out to be AIDS, a disease that weakens the immune system, gradually destroying the body's ability to fight infections and certain cancers.

Dowell eventually became an expert in infectious diseases and moved to Wyoming in 1992 to become the state's first full-time infectious disease specialist.

Soon after reaching Wyoming, he noticed a lack of understanding about the disease and set out to fill in the knowledge gap.

"I found that there was a great interest in learning about the disease, but also a lack of education about it," said Dowell, who worked to raise awareness about HIV by speaking to school children and adults across the state.

He also launched HIV/AIDS outreach clinics, extending care to patients living in Laramie, Rock Springs, Riverton, Lander and Gillette.

"I see HIV-positive patients in every one of those communities," said Dowell, who today serves as chief of staff at Wyoming Medical Center in Casper.

"About the only group of HIV patients I do not see regularly are maybe in the Cody area and some in Sheridan and Cheyenne," Dowell said. "But other than that I have had patients from western Nebraska to Jackson to South Dakota."

Keeping the faith

According to the state Department of Health, there are more than 170 HIV-positive people living in Wyoming. Dowell and Fischer treat most of them.

Dr. Ghazi Ghanem of Casper, who partners with Dowell, also shares the load.

Fischer said she came to treat HIV/AIDS patients largely because she was willing to provide the treatment at a time when some doctors were wary.

"There was as much fear in the medical community as there was in the general population, for sure," said Fischer, who now treats 30 to 50 infected patients at any given time.

Another big factor in Fischer's decision to handle HIV cases was her children. She wanted to set a good example.

"I think it's important in my family to be a good role model," Fischer said. "I wanted my children to know they need to be able to contribute in any way they can to help other people."

Initially, AIDS was considered a death sentence, and many of Fischer's patients succumbed to the disease. A big part of her job in those early years was tending to her patients' emotional needs.

"The hardest thing was maintaining hope, and telling them there would be something better coming along so just hang in there," Fischer said.

Early losses

Fischer learned how to treat HIV by seeing patients, researching on her own and by calling doctors in San Francisco and other places where the disease was more prevalent.

"I think that early on particularly there were just so few doctors giving care that you wanted someone else who took care of more patients than you did to bounce things off," Fischer said.

Over time, treatments improved and grassroots organizations began to spring up in Wyoming offering support to HIV patients. Patients also began to live longer.

"I have some patients I know have had the disease for 20 to 25 years and are doing well," Fischer said. "It's unbelievable the advancements that have been made in the last 15 to 20 years."

From her position on the front lines of HIV treatment in Wyoming, Fischer has seen her share of HIV-related tragedies, many of them created by stigma and misunderstandings about the disease.

For example, she watched as one of her patients, a young woman, was fired from her job after contracting HIV, and then died before the wrongful-termination lawsuit moved through the courts, Fischer said.

Many years ago, she nearly lost a patient because she said first responders were unwilling to administer emergency life-saving techniques when they found out the man was HIV positive.

"I don't know if that situation would happen now or not," Fischer said. "In the early days people were so afraid of it."

Myths persist

Dowell remembers those early days as a time when knowledge about HIV, even among doctors, was limited.

"People were very uncomfortable taking care of it because they had no real training in it," Dowell said.

Even now, Dowell said, AIDS and its treatment remain a highly complicated and ever-changing area of medicine.

Patients become sick in mysterious ways. The medications themselves can make patients ill. Treatments and medications evolve quickly.

"It really is best suited for people who do it all the time," Dowell said.

That makes it difficult for doctors in Wyoming to treat the disease, as they may see just a few cases over their careers.

"You can imagine if you are a rural doctor in Rock Springs with only one HIV-positive patient in their practice," Dowell said.

Dowell said rural HIV patients face hardships that their more urban counterparts do not.

Persistent myths about the disease, long travel distances to see doctors and the lack of HIV/AIDS support groups make life difficult for Wyoming HIV patients.

Stigma also continues to be a problem. Despite some improvements, both doctors said a considerable number of their patients choose to keep their illness secret for fear of losing jobs, alienating friends and family and losing status in their communities.

Improving care

In spite of those hurdles, Dowell said he pushes his patients to remain engaged with the world around them.

Especially now that HIV patients are living much longer, Dowell said, it's important that they return to the work force and get involved in their communities.

Dowell said he encourages his patients to get jobs or go back to school rather than "sit around and live on disability."

"I believe we need to look at getting people back to work," he said.

Fischer is also working to improve care for HIV-infected patients in Wyoming, by helping other doctors learn skills to care for the patients. She has offered to consult with rural doctors who treat their own patients.

"You can run into someone who is HIV positive anywhere, whether it's in Wamsutter or Rawlins, and they deserve to have local care," Fischer said. "They cannot be traveling 200 or 300 miles to see a doctor.

"Doctors need to feel more comfortable in their ability to do the primary care," she added.

Both Fischer and Dowell said they are disturbed at some recent HIV/AIDS trends in Wyoming.

Fischer said she's seeing more female patients, and patients in their early 20s.

"I have several patients in their early 20s, college-age, so that's a scary trend," said Fischer, who attributes the uptick in cases to carelessness in sexual practices and recreational drug use.

Dowell, who has noticed similarly concerning trends, said people need to stay vigilant about AIDS prevention.

"Yes, HIV is a long-term disease, but that doesn't mean you can have unprotected sex and use dirty needles," Dowell said.

A difficult situation

Both doctors also said that funding shortages are a key problem in the current fight against HIV in Wyoming.

Dowell said the loss of a federal grant in April has seriously hurt HIV treatment in the state.

The state Department of Health confirmed that in April it capped the number of patients who qualify for some kinds of AIDS treatment funds.

"I'm doing the best I can with a very difficult situation," Dowell said.

Fischer said AIDS patients routinely require medications that cost $2,000 to $3,000 per month, which are expensive even for those who work.

"Even the best insurance, the deductible might be a couple of hundred dollars a month, and it's hard for a family to come up with $300 or $400 or $500 a month," she said.

Despite the challenges, Fischer and Dowell said treating HIV patients in Wyoming is important. Fischer called the work a privilege.

"It's amazing how much more they've given me than I've given them," she said. "I've met some wonderful, wonderful people through all this work."

Contact capital bureau reporter Jared Miller at 307-632-1244 or jared.miller@trib.com. Read his blog at tribtown.trib.com/JaredMiller/blog.

BY THE NUMBERS

HIV/AIDS cases in Wyoming by age:

Under 13: 3

13-24: 23

25-44: 119

45-64: 30

Over 65: 1

Total: 176

Source: Wyoming Department of Health, December 2008 figures