Viremic – Cases in HIV

A 33-year-old man with HIV presents with a flu-like syndrome and a disseminated vesicular rash after sexual contact with a new partner. Differential diagnosis includes mpox, syphilis, other STIs, HSV and disseminated VZV. Listen as Eileen and her guest, Dr. Shauna Gunaratne work through the mpox diagnosis, and discuss the 2022 mpox outbreak, along with evidence-based recommendations for testing, treatment, and prevention.References Cited:Akter F, Hasan TB, Alam F, et al. Effect of prior immunisation with smallpox vaccine for protection against human Mpox: A systematic review. Rev Med Virol. 2023 Jul;33(4):e2444. Epub 2023 Mar 30. PMID: 36999223.CDC. Monkeypox. Tecovirimat (TPOXX) for Treatment of Monkeypox. Available at https://www.cdc.gov/monkeypox/hcp/clinical-care/tecovirimat.htmlDalton AF, Diallo AO, Chard AN, et al. Estimated Effectiveness of JYNNEOS Vaccine in Preventing Mpox: A Multijurisdictional Case-Control Study - United States, August 19, 2022-March 31, 2023. MMWR Morb Mortal Wkly Rep. 2023 May 19;72(20):553-558. PMID: 37200229.Mitjà O, Alemany A, Marks M, et al. Mpox in people with advanced HIV infection: a global case series. Lancet. 2023 Mar 18;401(10380):939-949. Epub 2023 Feb 21. Erratum in: Lancet. 2023 Apr 8;401(10383):1158. doi: 10.1016/S0140-6736(23)00584-6. PMID: 36828001.PALM007 Writing Group; Ali R, Alonga J, Biampata JL, et al. Tecovirimat for Clade I MPXV Infection in the Democratic Republic of Congo. N Engl J Med. 2025 Apr 17;392(15):1484-1496. PMID: 40239067.Titanji BK, Eick-Cost A, Partan ES, et al. Effectiveness of Smallpox Vaccination to Prevent Mpox in Military Personnel. N Engl J Med. 2023 Sep 21;389(12):1147-1148. PMID: 37733313.Related Guidelines and Guidance:New York State Department of Health AIDS Institute Clinical Guidelines Program:- Prevention and Treatment of Mpox- Immunizations for Adults With HIV > Mpox- Management of IRIS- Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections- Guidance: Adopting a Patient-Centered Approach to Sexual Health- GOALS Framework for Sexual History Taking in Primary CareResources:CDC Guidelines for Collecting and Handling Specimens for Mpox Testing NYSDOH Guidance on Testing at Commercial and Public Health Laboratories

Chris presents the case of a 42-yr-old gay man at high risk of anal cancer to guest Dr. Bruce Hirsch, and they work through the best course for screening and prevention of a disease with high rates of morbidity and mortality that disproportionately affects people with HIV. Listen as Chris and Bruce talk about who to vaccinate and when, who and when to screen, and what screening entails, while acknowledging the difficulties.References Cited:Palefsky JM, Lee JY, Jay N, et al. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med. 2022 Jun 16;386(24):2273-2282. PMID: 35704479.Barnell GM, Merchant M, Lam JO, Silverberg MJ. Early Outcomes of a High-Resolution Anoscopy-Based Anal Cancer Screening Program Among People With HIV Enrolled in an Integrated Health Care System. J Acquir Immune Defic Syndr. 2019 Jul 1;81(3):292-299. PMID: 30964759.Deshmukh AA, Lin YY, Damgacioglu H, et al. Recent and projected incidence trends and risk of anal cancer among people with HIV in North America. J Natl Cancer Inst. 2024 Sep 1;116(9):1450-1458. PMID: 38713084.Related NYSDOH AI Guidelines and Guidance:Screening for Anal Dysplasia and Cancer in Adults With HIVPrevention and Management of Human Papillomavirus Infection in Adults With HIVPrimary Care for Adults With HIVImmunizations for Adults With HIV > Human Papillomavirus (HPV)Guidance: Adopting a Patient-Centered Approach to Sexual Health

The case of a 28-year-old diagnosed with HIV when she became pregnant prompts Eileen and guest Dr. Jean Anderson to explore many of the challenges of HIV care in pregnancy: managing a new diagnosis, disclosure, stigma, partner involvement, antiretroviral therapy, perinatal transmission prevention, breastfeeding, harm reduction, and postpartum care. Their wide-ranging discussion opens with Jean’s perspective on care of women with HIV, which is informed by 40 years of ground-breaking work in the field. References Cited:Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med. 1994 Nov 3;331(18):1173-80. PMID: 7935654.Sibiude J, Le Chenadec J, Mandelbrot L, et al. Update of Perinatal Human Immunodeficiency Virus Type 1 Transmission in France: Zero Transmission for 5482 Mothers on Continuous Antiretroviral Therapy From Conception and With Undetectable Viral Load at Delivery. Clin Infect Dis. 2023 Feb 8;76(3):e590-e598. PMID: 36037040Related Guidelines and Guidance:American College of Obstetricians & Gynecologists (ACOG): Optimizing Postpartum Care. Committee Opinion Number 736. May 2018.U.S. Department of Health and Human Services (DHHS): Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States(June 2025)New York State Department of Health AIDS Institute Clinical Guidelines Program: - HIV Testing During Pregnancy, at Delivery, and Postpartum- NYS Good Practices to Prevent Perinatal HIV Transmission- Guidance: Questions, Answers, and Best Practices for Medical Management of Perinatal HIV Exposure in New York State- U=U Guidance for Implementation in Clinical Settings- PrEP to Prevent HIV and Promote Sexual HealthResources:Antiretroviral Pregnancy RegistryCDC HIV Hotlines and Warmlines > Perinatal HIV Hotline: Provides clinicians with around-the-clock advice on indications and interpretations of HIV testing in pregnancy, and consultation on antiretroviral use during pregnancy, labor and delivery, and the postpartum period. 1-888-448-8765 (24 hours, seven days a week)Edinburgh Postnatal Depression Scale

Like many in HIV, Chris is also a PrEP provider. In this episode, he presents a case to Dr. Rona Vail to work through the best approach to PrEP for a young, gay Black man. They work through the issues of oral vs injectable PrEP, dosing schedules for oral PrEP, the studies that support each approach, and this patient’s eligibility for each to determine the best recommendations. They end by discussing barriers to PrEP and the importance of choices now that there are so many PrEP options.References Cited: Bekker LG, Das M, Abdool Karim Q, et al. Twice-Yearly Lenacapavir or Daily F/TAF for HIV Prevention in Cisgender Women. N Engl J Med. 2024 Oct 3;391(13):1179-1192. PMID: 39046157.Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010 Dec 30;363(27):2587-99. PMID: 21091279. Kiweewa FM, Ahmed K, Nair G., et al. Adherence to F/TAF in cisgender women prevents HIV with low risk of resistance or diagnostic delay. Abstract 194. CROI; 2025 Mar 9-12; San Francisco, CA. https://www.croiconference.org/abstract/1937-2025/. Koss CA, Ayieko J, Kabami J, et al. Dynamic choice HIV prevention intervention at outpatient departments in rural Kenya and Uganda. AIDS. 2024 Mar 1;38(3):339-349. PMID: 37861683. Marrazzo J, Tao L, Becker M, et al. HIV Preexposure Prophylaxis With Emtricitabine and Tenofovir Disoproxil Fumarate Among Cisgender Women. JAMA. 2024 Mar 19;331(11):930-937. PMID: 38427359. Mayer KH, Molina JM, Thompson MA, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet. 2020 Jul 25;396(10246):239-254. PMID: 32711800.Molina JM, Ghosn J, Assoumou L, et al. Daily and on-demand HIV pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil (ANRS PREVENIR): a prospective observational cohort study. Lancet HIV. 2022 Aug;9(8):e554-e562. PMID: 35772417.Molina JM, Capitant C, Spire B, et al. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. N Engl J Med. 2015 Dec 3;373(23):2237-46. PMID: 26624850.Related NYSDOH AIDS Institute Clinical Guidelines and Guidance:PrEP to Prevent HIV and Promote Sexual HealthPEP to Prevent HIV InfectionGuidance: Adopting a Patient-Centered Approach to Sexual HealthGOALS Framework for Sexual History Taking in Primary CarePrevention and Management of Hepatitis B Virus Infection in Adults With HIV

Hello Viremic listeners. We are taking a break this week and encourage you to take a look back at our past episodes and catch up on any cases you may have missed. We'll be back on January 6, 2026 with a new case to discuss! From all of us at Viremic we hope you have a peaceful, healthy and joyous holiday season! 

After 3 years on injectable CAB/RPV, a patient develops viremia, with a viral load of ~1,300 copies/mL. Failure of injectable CAB/RPV occurs in 1% to 2%, despite adherence. What factors have been associated with CAB/RPV failure? Can regimen failure be predicted or prevented? Listen as Chris and Eileen discuss the data, their advice to patients considering a switch to injectable CAB/RPV, and their response when failure occurs.References Cited:Orkin C., Arasteh K., Gorgolas Hernandez-Mora M., et al. Long-acting cabotegravir and rilpivirine after oral induction for HIV-1 infection. N Engl J Med 2020;382(12):1124-35. PMID: 32130806.Overton E. T., Richmond G., Rizzardini G., et al. Long-acting cabotegravir and rilpivirine dosed every 2 months in adults with human immunodeficiency virus 1 type 1 infection: 152-week results from ATLAS-2M, a randomized, open-label, phase 3b, noninferiority study. Clin Infect Dis 2023;76(9):1646-54. PMID: 36660819.Swindells S., Andrade-Villanueva J. F., Richmond G. J., et al. Long-acting cabotegravir and rilpivirine for maintenance of HIV-1 suppression. N Engl J Med 2020;382(12):1112-23. PMID: 32130809.van Welzen BJ, Van Lelyveld SFL, Ter Beest G, et al. Virological Failure After Switch to Long-Acting Cabotegravir and Rilpivirine Injectable Therapy: An In-depth Analysis. Clin Infect Dis. 2024 Jul 19;79(1):189-195. PMID: 38207125.Related Guideline:NYSDOH AI: Use of Injectable CAB/RPV LA as Replacement ART in Virally Suppressed Adults

A 32-year-old man with well-controlled HIV, seen after a recent relationship split and sexual activity with new partners, is screened and diagnosed with syphilis. Eileen discusses this case with guest Dr. Matthew Hamill, who reviews his approach to STI screening and risk reduction, emphasizing an approach that normalizes screening. Matthew then reviews syphilis testing, diagnosis, and staging, including neurosyphilis assessment, and treatment.Related Guidelines and GuidanceCenters for Disease Control and Prevention:Sexually Transmitted Infections Treatment Guidelines, 2021. Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources.NYSDOH AI Clinical Guidelines Program: Guidance: Adopting a Patient-Centered Approach to Sexual HealthGOALS Framework for Sexual History Taking in Primary CareClinical ResourcesNational STD Curriculum: A free educational website from the University of Washington STD Prevention Training Center.STD Clinical Consultation Network: From the National Network of STD Clinical Prevention Training Centers For New York State Clinicians: CEI Clinician Consultation Phone Line: 866-637-2342: A toll-free service for New York State clinicians offering real-time clinical consultations with specialists on HIV, sexual health, hepatitis C, and drug user health.CEI Sexual Health Resources web page: https://ceitraining.org/resources/sexual-health

A 54-year-old woman with longstanding HIV and obesity is stable on ART, but concerned that it is causing weight gain. How best to address this growing concern? Listen as Chris and Eileen decipher the evidence related to weight gain and ART and weigh the best strategies for addressing this increasingly common and social media inflected concern for patients with HIV and their care providers?References Cited:Abelman RA, Ma Y, Mehta CC, et al. Switch to Integrase Strand Transfer Inhibitors During the Menopausal Transition Is Associated With Accelerated Body Composition Change in Women With HIV. Clin Infect Dis. 2025 Jun 4;80(5):1125-1132. PMID: 39495675.Caniglia EC, Shapiro R, Diseko M, et al. Weight gain during pregnancy among women initiating dolutegravir in Botswana. EClinicalMedicine. 2020 Nov 5;29-30:100615. PMID: 33437946.Elion J, Gruber J, Radtchenko M, et al. Predictors of weight gain among people with HIV (PWH) over 3-year period. Abstract Supplement Abstracts from IAS 2025, the 13th IAS Conference on HIV Science, 13 - 17 July, Kigali, Rwanda & Virtual. J Int AIDS Soc. 2025 Jul;28 Suppl 4(Suppl 4):e26518. PMID: 40657994. Glidden DV, Mulligan K, McMahan V, et al. Metabolic Effects of Preexposure Prophylaxis With Coformulated Tenofovir Disoproxil Fumarate and Emtricitabine. Clin Infect Dis. 2018 Jul 18;67(3):411-419. PMID: 29415175.Griesel R, Maartens G, Chirehwa M, et al. CYP2B6 Genotype and Weight Gain Differences Between Dolutegravir and Efavirenz. Clin Infect Dis. 2021 Dec 6;73(11):e3902-e3909. Erratum in: Clin Infect Dis. 2022 Mar 1;74(4):755. PMID: 32960272.Koethe J. ACTG A5391: A Randomized Multicenter 3-arm Controlled Trial for People with Obesity on Integrase Inhibitors and Tenofovir Alafenamide switching to Doravirine, with or without Tenofovir Disoproxil Fumarate (The DO-IT Trial). Abstract. Supplement Abstracts from IAS 2025, the 13th IAS Conference on HIV Science, 13 - 17 July, Kigali, Rwanda & Virtual. J Int AIDS Soc. 2025 Jul;28 Suppl 4(Suppl 4):e26518. PMID: 40657994.Lake JE, Wu K, Bares SH, et al. Risk Factors for Weight Gain Following Switch to Integrase Inhibitor-Based Antiretroviral Therapy. Clin Infect Dis. 2020 Dec 3;71(9):e471-e477. PMID: 32099991.Landovitz RJ, Zangeneh SZ, Chau G, et al. Cabotegravir Is Not Associated With Weight Gain in Human Immunodeficiency Virus-uninfected Individuals in HPTN 077. Clin Infect Dis. 2020 Jan 2;70(2):319-322. PMID: 31125395.Norwood J, Turner M, Bofill C, et al. Brief Report: Weight Gain in Persons With HIV Switched From Efavirenz-Based to Integrase Strand Transfer Inhibitor-Based Regimens. J Acquir Immune Defic Syndr. 2017 Dec 15;76(5):527-531. PMID: 28825943. Ogbuagu O, Ruane PJ, Podzamczer D, et al. Long-term safety and efficacy of emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV-1 pre-exposure prophylaxis: week 96 results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet HIV. 2021 Jul;8(7):e397-e407. Erratum in: Lancet HIV. 2021 Dec;8(12):e734. PMID: 34197772.Sax PE, Erlandson KM, Lake JE, et al. Weight Gain Following Initiation of Antiretroviral Therapy: Risk Factors in Randomized Comparative Clinical Trials. Clin Infect Dis. 2020 Sep 12;71(6):1379-1389. PMID: 31606734.Venter WDF, Moorhouse M, Sokhela S, et al. Dolutegravir plus Two Different Prodrugs of Tenofovir to Treat HIV. N Engl J Med. 2019 Aug 29;381(9):803-815. Epub 2019 Jul 24. PMID: 31339677. [ADVANCE Trial]Short WR, Ramgopal M, Hagins DP, Lee J, Simonson J, Hsu T-H, Xu P, Anderson D. DEFINE Study A prospective, randomized trial to assess a protease inhibitor–based regimen switch strategy to manage integrase inhibitor–related weight gain 12th IAS Conference on HIV Science, 23 - 26 July,  Brisbane, Australia & Virtual Abstract 5962Related Guideline:Clinical Info HIV.gov: Weight Gain in People With Treated HIV. Cardiovascular and Metabolic Complications in People With HIV. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV, September 2025.

A 62-year-old patient with HIV for ~40 yrs presents on the life-saving TRIO regimen after a beloved care provider retires. Will a switch improve his quality of life? Eileen and Chris suspect that a change to a once-a-day regimen with fewer pills will maintain his viral suppression and make life easier, but the TRIO regimen inspires dedication in many long-term patients. Would he be open to a switch? Would it confer other benefits? Listen as Eileen and Chris consider the necessity of switch and plot a treatment course.References and Resources Cited:Paton NI, Musaazi J, Kityo C, et al. Efficacy and safety of dolutegravir or darunavir in combination with lamivudine plus either zidovudine or tenofovir for second-line treatment of HIV infection (NADIA): week 96 results from a prospective, multicentre, open-label, factorial, randomised, non-inferiority trial. Lancet HIV. 2022 Jun;9(6):e381-e393. Epub 2022 Apr 20. PMID: 35460601.University of Liverpool HIV Drug Interactions: Interaction CheckerStanford HIV Drug Resistance DatabaseRelated NYSDOH AIDS Institute Clinical Guidelines: Second-Line ART After Treatment Failure or for Regimen SimplificationHIV Resistance AssaysVirologic and Immunologic Monitoring in HIV CarePrimary Care for Adults With HIV and Guidance: Addressing the Needs of Older Patients in HIV Care

Subspecialists request simplified ART for a 56-year-old woman with a long ART history, who is taking a DOAC, has evolving renal function, and some drug resistance. Which factors to prioritize? Eileen and Chris have some, but not a complete medical history. Listen as they work through the information they do have, consider 7 questions key in making an ART switch, and evaluate the available options. References and Resources Cited:Paton NI, Musaazi J, Kityo C, et al. Efficacy and safety of dolutegravir or darunavir in combination with lamivudine plus either zidovudine or tenofovir for second-line treatment of HIV infection (NADIA): week 96 results from a prospective, multicentre, open-label, factorial, randomised, non-inferiority trial. Lancet HIV. 2022 Jun;9(6):e381-e393. Epub 2022 Apr 20. PMID: 35460601.University of Liverpool HIV Drug Interactions: Interaction CheckerFDA: Apixaban (Eliquis) Highlights of Prescribing InformationFDA: Dabigatran etexilate (Pradaxa) Highlights of Prescribing Information  FDA: Edoxaban (Savaysa) Highlights of Prescribing InformationRelated NYSDOH AIDS Institute Clinical Guidelines: Second-Line ART After Treatment Failure or for Regimen SimplificationResource: ART Drug-Drug Interactions; specifically, see Drug-Drug Interactions by Common Medication Class Table 22: AnticoagulantsPrimary Care for Adults With HIV

How to formulate an effective ART regimen acceptable to 56-year-old man, with unsuppressed HIV, 20+ yr. ART history, extensive drug resistance, and adherence challenges? Listen as Eileen and Chris interpret resistance testing results, discuss barriers to treatment and adherence for this patient, and evaluate the possibility of using one of the novel agents—fostemsavir, ibalizumab, and lenacapavir. What would you do?References and Resources Cited:Emu B, Fessel J, Schrader S, et al. Phase 3 Study of Ibalizumab for Multidrug-Resistant HIV-1. N Engl J Med. 2018;379(7):645-654. PMID: 3010589Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in Adults with Multidrug-Resistant HIV-1 Infection. N Engl J Med. 2020;382(13):1232-1243. PMID: 32212519Segal-Maurer S, DeJesus E, Stellbrink HJ, et al. Capsid Inhibition with Lenacapavir in Multidrug-Resistant HIV-1 Infection. N Engl J Med. 2022;386(19):1793-1803. PMID: 35544387HIVAssist.org: A free, interactive, educational tool to inform clinical decision making for ARV selection.Stanford University HIV Drug Resistance Database: A curated public database to represent, store and analyze HIV drug resistance data. FDA: Rukobia (fostemsavir) Highlights of Prescribing InformationFDA: Sunlenca (lenacapavir) Highlights of Prescribing InformationFDA: Trogarzo (ibalizumab) Highlights of Prescribing InformationRelated NYSDOH AIDS Institute Clinical Guidelines:Second-Line ART After Treatment Failure or for Regimen SimplificationHIV Resistance AssaysPrimary Care for Adults With HIV

Healthy 48-year-old man with HIV for 15 years, stable viral suppression, looking to optimize health—diet, exercise, immune-boosting supplements, safest HIV and HTN meds. Listen as Chris and Eileen discuss their approach to giving patients the good news about their health, health maintenance, supplement use, and whether to stay the course or switch ART regimens in patients who are doing well.Resources:NIH Office of Dietary Supplements: Dietary Supplement Fact Sheets  FDA: Information for Consumers on Using Dietary SupplementsRelated NYSDOH AIDS Institute Clinical Guidelines: Primary Care for Adults with HIVSecond-Line ART After Treatment Failure or for Regimen SimplificationUse of Injectable CAB/RPV LA as Replacement ART in Virally Suppressed AdultsPrevention and Management of Hepatitis B Virus Infection in Adults With HIV

New COVID-19 vaccine policy, proviral DNA testing, then the case of a woman with 10+ years viral suppression, CKD, and CVD, identified as a statin candidate after a significant cardiac event. With no family history of CVD, her risks included exposure to older ARVs and smoking 1 to 3 cigarettes/day. Listen as Drs. Scully and Hoffmann delve into non-infectious comorbidities associated with HIV, risk factors, and adjusted CVD risk calculation for women and African Americans.References CitedBeavers C, Pau AK, Glidden D, et al. Statin Therapy as Primary Prevention for Persons With HIV: A Synopsis of Recommendations From the U.S. Department of Health and Human Services Antiretroviral Treatment Guidelines Panel. Ann Intern Med. Published online May 27, 2025. PMID: 40418812D:A:D Study Group, Sabin CA, Worm SW, et al. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study: a multi-cohort collaboration [published correction appears in Lancet. 2008 Jul 26;372(9635):292]. Lancet. 2008;371(9622):1417-1426. PMID: 18387667Elion RA, Althoff KN, Zhang J, et al. Recent Abacavir Use Increases Risk of Type 1 and Type 2 Myocardial Infarctions Among Adults With HIV. J Acquir Immune Defic Syndr. 2018;78(1):62-72. PMID: 29419568Fichtenbaum CJ, et al “Abacavir is associated with elevated risk for cardiovascular events in the REPRIEVE trial” IAC 2024; Abstract OAB3406LB.Grinspoon SK, Zanni MV, Triant VA, et al. Performance of the pooled cohort equations and D:A:D risk scores among individuals with HIV in a global cardiovascular disease prevention trial: a cohort study leveraging data from REPRIEVE. Lancet HIV. 2025;12(2):e118-e129. PMID: 39832519SMART Study Group, El-Sadr WM, Lundgren J, et al. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006;355(22):2283-2296. PMID: 171355583 Prasad V, Makary MA. An Evidence-Based Approach to Covid-19 Vaccination. N Engl J Med. Published online May 20, 2025. PMID: 40392534Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008;359(21):2195-2207. PMID: 18997196Selinger S. In adults with HIV and low-to-moderate CV risk, pitavastatin reduced MACE over a median 5.1 y. Ann Intern Med. 2023;176(11):JC130. PMID: 37931263Wensing AM, Charpentier C, Calvez V, et al. Utilizing HIV Proviral DNA to Assess for the Presence of HIV Drug Resistance. Clin Infect Dis. Published online April 3, 2025. doi:10.1093/cid/ciaf161. PMID: 40176204.Related Guidelines from the NYSDOH AI Clinical Guidelines ProgramPrimary Care for Adults With HIV Immunizations for Adults With HIV: COVID-19

After brief mention of an HIV vaccine, the hosts turn to the challenges of treating cryptococcal meningitis in a 46-year-old woman with profound immune suppression after being off ART for 6-12 months. Emphasizing the high potential for morbidity and mortality, Chris and Eileen focus on the complexities of cryptococcal meningitis medical management, including the role of immune constitution, timing of ART initiation, and the risk of IRIS. Listen as they work through the treatment requirements and clinical decisions involved in this complicated case.    References CitedBoulware DR, Meya DB, Muzoora C, et al. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med. 2014;370(26):2487-2498. PMID: 24963568Chang CC, Dorasamy AA, Gosnell BI, et al. Clinical and mycological predictors of cryptococcosis-associated immune reconstitution inflammatory syndrome. AIDS. 2013;27(13):2089-2099. PMID: 23525034Gandhi RT, Landovitz RJ, Sax PE, et al. Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations of the International Antiviral Society-USA Panel. JAMA. 2025;333(7):609-628. PMID: 39616604Ingle SM, Miro JM, May MT, et al. Early Antiretroviral Therapy Not Associated With Higher Cryptococcal Meningitis Mortality in People With Human Immunodeficiency Virus in High-Income Countries: An International Collaborative Cohort Study. Clin Infect Dis. 2023;77(1):64-73. PMID: 36883578Kwizera R, Kiiza TK, Akampurira A, Kimuda S, Mugabi T, Meya DB. Evolution of Laboratory Diagnostics for Cryptococcosis and Missing Links to Optimize Diagnosis and Outcomes in Resource-Constrained Settings. Open Forum Infect Dis. 2024;11(9):ofae487. Published 2024 Aug 27. PMID: 3928635Makadzange AT, Ndhlovu CE, Takarinda K, Reid M, Kurangwa M, Gona P, Hakim JG. Early versus delayed initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa. Clin Infect Dis. 2010 Jun 1;50(11):1532-8. PMID: 20415574.Srichatrapimuk S, Sungkanuparph S. Integrated therapy for HIV and cryptococcosis. AIDS Res Ther. 2016;13(1):42. Published 2016 Nov 29. PMID: 27906037Related GuidelinesClinical info HIV.gov: Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV: CryptococcosisIAS-USA: Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations of the International Antiviral Society-USA Panel  NYSDOH AI Clinical Guidelines Program: Management of IRIS

After presenting with fatigue, malaise, and muscle cramps, a 28-yr-old man with history of STIs is diagnosed with new renal failure (Cr >9 mg/dL) and HIV (VL ~3 mil. copies/mL). Drs. Scully and Hoffmann note the missed opportunities for HIV prevention, then review HIV-associated kidney disease and evaluate regimens safe for rapid ART initiation.References CitedBahr NC, Yarlagadda SG. Fanconi Syndrome and Tenofovir Alafenamide: A Case Report. Ann Intern Med. 2019;170(11):814-815. PMID: 30690644 Diana NE, Naicker S. The changing landscape of HIV-associated kidney disease. Nat Rev Nephrol. 2024;20(5):330-346. PMID: 38273026Gallant JE, Parish MA, Keruly JC, Moore RD. Changes in renal function associated with tenofovir disoproxil fumarate treatment, compared with nucleoside reverse-transcriptase inhibitor treatment. Clin Infect Dis. 2005;40(8):1194-1198. PMID: 15791522 Jiang SX, Duncan J, Ko HH. Acquired Fanconi Syndrome from Tenofovir Treatment in a Patient with Hepatitis B. Case Reports Hepatol. 2023;2023:6158407. Published 2023 Jun 17. PMID: 37362623Karris MY. Short Communication: Resolution of Tenofovir Disoproxil Fumarate Induced Fanconi Syndrome with Switch to Tenofovir Alafenamide Fumarate in a HIV-1 and Hepatitis B Coinfected Patient. AIDS Res Hum Retroviruses. 2017;33(7):718-722. PMID: 28403627 Related Guidelines from the NYSDOH AI Clinical Guidelines ProgramPrEP to Prevent HIV and Promote Sexual HealthDoxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted InfectionsSelecting an Initial ART Regimen

Mid-50s-yr-old man with HIV since the early 1990s presented for evaluation of persistent low-level viremia, despite consistent engagement in care and ART. Genotypic testing found only a variety of minor mutations. The patient and his care provider were concerned about the health consequences, including the risk of inflammatory diseases in the future, and about implications for U=U. After a brief discussion of the good news on lenacapavir for HIV prevention and a reminder about mpox vaccination, Drs. Scully and Hoffmann delve into the patient’s history to uncover the source of his LLV and treatment options. References CitedBroyles LN, Luo R, Boeras D, Vojnov L. The risk of sexual transmission of HIV in individuals with low-level HIV viraemia: a systematic review. Lancet. 2023;402(10400):464-471. PMID: 37490935.Esber A, Polyak C, Kiweewa F, et al. Persistent Low-level Viremia Predicts Subsequent Virologic Failure: Is It Time to Change the Third 90? Clin Infect Dis. 2019;69(5):805-812. PMID: 30462188Fleming J, Mathews WC, Rutstein RM, et al. Low-level viremia and virologic failure in persons with HIV infection treated with antiretroviral therapy. AIDS. 2019 Nov 1;33(13):2005-2012. PMID: 31306175Hillus D, Le NH, Tober-Lau P, et al. Safety and effectiveness of MVA-BN vaccination against mpox in at-risk individuals in Germany (SEMVAc and TEMVAc): a combined prospective and retrospective cohort study. Lancet Infect Dis. Published online March 18, 2025. PMID: 40118087Jatt LP, Mgodi NM, Buchbinder SP, Gray GE, Kublin JG. An HIV Vaccine in the Era of Twice-Yearly Lenacapavir for PrEP - Essential or Irrelevant? N Engl J Med. 2025;392(16):1561-1563. PMID: 40260855White JA, Wu F, Yasin S, et al. Clonally expanded HIV-1 proviruses with 5'-leader defects can give rise to nonsuppressible residual viremia. J Clin Invest. 2023;133(6):e165245. Published 2023 Mar 15. PMID: 36602866.Related Guidelines NYSDOH AI Clinical Guidelines Program: Second-Line ART After Treatment Failure or for Regimen SimplificationClinical Info HIV.gov: Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV. Management of People With HIV and Antiretroviral Therapy Experience: Virologic Failure

48-yr-old man with HIV for 12 years presented 1 year after his last visit with a history of methamphetamine use, inconsistent engagement in care, and a new diabetes diagnosis. He reported no recent ART and no meth use for about 8 months. On returning to care, his viral load was 250,000 copies/mL, the CD4 count was 230 cells/mm3, creatinine levels were elevated, and genotype testing found a K103N mutation. He was motivated to resume ART. Drs. Scully and Hoffmann evaluate the patient’s new ART options in light of his clinical viremia and comorbidities.  References CitedAndreatta K, D’Antoni ML, Chang S, et al. High efficacy of bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) in Black adults in the United States, including those with pre-existing HIV resistance and suboptimal adherence. J Med Virol. 2024;96(10):e29899. PMID: 39370775.Denyer R, Zemskova J, Benator DA. HIV treatment with dolutegravir and doravirine: rationale for selection and clinical outcomes in a highly treatment experienced population. Int J STD AIDS. 2022;33(12):1073-1077. PMID: 36113042Figueroa MI, Sued O, Cecchini D, et al. Dual therapy based on co-formulated darunavir/ritonavir plus lamivudine for initial therapy of HIV infection: The ANDES randomized controlled trial. Int J Antimicrob Agents. 2024;64(4):107301. PMID: 39151647Kabra M, Barber TJ, Allavena C, et al. Virologic Response to Dolutegravir Plus Lamivudine in People With Suppressed Human Immunodeficiency Virus Type 1 and Historical M184V/I: A Systematic Literature Review and Meta-analysis. Open Forum Infect Dis. 2023;10(11):ofad526. Published 2023 Oct 27. PMID: 38033982Paton NI, Musaazi J, Kityo C, et al. Dolutegravir or Darunavir in Combination with Zidovudine or Tenofovir to Treat HIV. N Engl J Med. 2021 Jul 22;385(4):330-341. PMID: 34289276.Rolle CP, Berhe M, Singh T, et al. Dolutegravir/lamivudine as a first-line regimen in a test-and-treat setting for newly diagnosed people living with HIV. AIDS. 2021;35(12):1957-1965. PMID: 34115650Rossotti R, D'Amico F, Bana NB, et al. Durability of doravirine with dolutegravir dual regimen compared with other dolutegravir-based dual combinations. HIV Med. 2024;25(6):675-683. PMID: 38263787Sax PE, Rockstroh JK, Luetkemeyer AF, et al. Switching to Bictegravir, Emtricitabine, and Tenofovir Alafenamide in Virologically Suppressed Adults With Human Immunodeficiency Virus. Clin Infect Dis. 2021;73(2):e485-e493. PMID: 32668455Related Guidance and GuidelinesNYSDOH AI Clinical Guidelines Program:ChemSex: Questions and AnswersHIV Resistance AssaysResource: ART Drug-Drug InteractionsStimulant Use Clinical GuidanceSubstance Use Harm Reduction in Medical CareUse of Injectable CAB/RPV LA as Replacement ART in Virally Suppressed AdultsClinical Info HIV.gov:Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIVGuidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV