Viremic – Cases in HIV

A 43-year-old man with HIV is virally suppressed on Odefsey. He started Biktarvy 5 years ago but was switched because of headaches. He recently developed worsening kidney function. Listen as Chris Hoffmann of Johns Hopkins and guest Tony Urbina, from the Icahn School of Medicine at Mount Sinai, discuss switching this patient to a newly or soon-to-be approved antiretroviral medication.

References: 

• Colson AE, Kumar PN, Ruane PJ, et al. Switch to once-weekly, single-tablet islatravir-lenacapavir from daily standard of care for HIV-1 (ISLEND-2): a multicentre, randomised, open-label, active-controlled, phase 3 non-inferiority trial. Lancet 2026; Aug 29;408(10557):821-832. PMID: 42586113.
• Meissner EG, Ramgopal M, Ruane PJ, et al. Safety and efficacy of switching to bictegravir-lenacapavir versus continuing bictegravir-emtricitabine-tenofovir alafenamide in virologically suppressed people with HIV-1 (ARTISTRY-2): a double-blind, multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet HIV 2026; Aug;13(8):e538-e547. PMID: 42105781.
• Orkin C, Mngqibisa R, Velez JD, et al. Switch to fixed-dose doravirine (100 mg) and islatravir (0·25 mg) once daily in virologically suppressed adults with HIV-1 on oral antiretroviral therapy: 48-week results of a phase 3, multicentre, randomised, open-label, non-inferiority trial. Lancet 2026; Feb 7;407(10528):599-610. PMID: 41654374.
• Orkin C, Ruane PJ, Hedgcock M, et al. Switch to single-tablet bictegravir-lenacapavir from a complex HIV regimen (ARTISTRY-1): a randomised, open-label, phase 3 clinical trial. Lancet 2026; Mar 28;407(10535):1249-1258. PMID: 41763229.
• Rockstroh JK, Ramgopal MN, Curran Fàbregas A, et al. Phase 3 Trial of Weekly Oral Islatravir-Lenacapavir for HIV-1 Treatment. N Engl J Med 2026; Jul 29. PMID: 42525925.
• Rockstroh JK, Kassim S, Paredes R, et al. Fixed-dose daily doravirine (100 mg) with islatravir (0·25 mg) versus bictegravir, emtricitabine, and tenofovir alafenamide for initial HIV-1 therapy: 48-week results of a phase 3, randomised, controlled, double-blind, non-inferiority trial. Lancet HIV 2026; Jul;13(7):e440-e451. PMID: 41763226.

Related Resource:

• Viremic–Cases in HIV: Case 27. What’s New from AIDS 2026 in Brazil with Dr. Joel Gallant

A 48-year-old man with HIV that is well-controlled on dolutegravir/lamivudine has met someone and they are starting to date. His partner is HIV-seronegative, and they have not yet been sexually active. Listen as Eileen Scully and Chris Hoffmann of Johns Hopkins discuss the importance of normalizing sexuality in patients with HIV and strategies for counseling patients that “undetectable=untransmittable (U=U).”

References:

• Bavinton BR, Pinto AN, Phanuphak N, et al. Opposites Attract Study Group. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV 2018 Aug;5(8):e438-e447. [PMID: 30025681]
• Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016;375(9):830-39. [PMID: 27424812]
• Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000 Mar 30;342(13):921-9. [PMID: 10738050]
• Rodger AJ, Cambiano V, Bruun T, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019;393(10189):2428-38. [PMID: 31056293]
• Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016;316(2):171-81. [PMID: 27404185]
• Vernazza P, Hirschelb B, Bernasconic E, Fleppd M. HIV positive individuals not suffering from any other STD and adhering to an effective antiretroviral treatment do not transmit HIV sexually. (Les personnes séropositives ne souffrant d’aucune autre MST et suivant un traitment antirétroviral efficace ne transmettent pas le VIH par voie sexuelle). Bulletin des médecins suisses 2008; 89 (5). [Link to the English translation and original French publication] 

Related Guidelines and Resources:

• NYSDOH AI Clinical Guidelines Program: U=U Guidance for Implementation in Clinical Settings

A 53-yr-old woman has a long history of HIV and a fully suppressed viral load. She feels irritable, does not feel rested in the mornings, and wakes up with sweats at night. Listen as Eileen Scully of Johns Hopkins and guest Sara Looby, from Massachusetts General Hospital, assess her symptoms and history, diagnose her stage of menopause, and evaluate the risks and benefits of menopausal hormonal treatment.

References:

• Santoro N. 2004. Expert view: Menopause misinformation is everywhere. Here’s how to detect it. ACOG.org.
• Women's Health Initiative: Changing the future of women’s health.
• Manson JE, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013;310(13):1353-68. 

Related Guidelines and Resources:

• DHHS: Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV → Considerations for Antiretroviral Use in Special Populations → Women With HIV → HIV and Menopause
• International Menopause Society (IMS): IMS Recommendations and Key Messages on Women’s Midlife Health and Menopause
• The Menopause Society
• Her & Now 

Dr. Joel Gallant joins host Chris Hoffmann of Johns Hopkins to review new data and developments from the 26th International AIDS Conference (AIDS 2026), which was held in Brazil in July. They focus on abstracts that have implications for HIV care.

Reference: 

• Perez Navarro A, Nutt CT, Siedner MJ, McCluskey SM, Hill A. Virologic Failure and Emergent Integrase Strand Transfer Inhibitor Drug Resistance With Long-Acting Cabotegravir for HIV Treatment: A Meta-analysis. Clin Infect Dis. 2025 Sep 16;81(2):274-285. PMID: 39724249.

Abstracts cited from AIDS 2026, the 26th International AIDS Conference:
Abstracts discussed by Chris and Joel are listed below in alphabetical order by first author’s last name. All abstracts are available online: JIAS. Volume 29, Issue S4 Supplement: Abstracts From AIDS 2026, the 26th International AIDS Conference, 26 – 31 July 2026 Rio de Janeiro, Brazil & virtual July 2026. JIAS makes abstracts available as an Epub and a PDF.

• Colson AE, Kumar PN, Ruane PJ, et al. OAX1106LB: Once-Weekly Oral Islatravir/Lenacapavir (ISL/LEN) Versus Daily Standard-of-Care Therapy in Virologically Suppressed Adults With HIV-1: Week 48 Results of the ISLEND-2 Phase 3 Trial
• Dangarembizi MB, Chappell E, Kekitiinwa AR, et al. OAX1105LB: Every-8-Weeks Injectable Cabotegravir and Rilpivirine is Superior to Daily Oral Tenofovir Disoproxil Fumarate/Lamivudine/Dolutegravir in Adolescents Living With HIV in Sub-Saharan Africa: LATA 96-Week Results
• Di Gregorio S, Brun LR, Mourelo S, et al. OAB3405: The Body Composition Signature of Switching to BIC/FTC/TAF or DTG/3TC Over 96 Weeks
• Dsouza G, Olshan S, Lahiri C, et al. TUPEB082: Risk of HPV-related cancers remain higher among people living with HIV in the ART era: evidence from a large U.S. cohort (MWCCS) 
• Ghosn J, Pulido F, Lopardo GD, et al. OAB0106LB In VOGUE: DTG/3TC 2-Drug Regimen is Non-Inferior to BIC/FTC/TAF 3-Drug Regimen in a Randomized Trial in Adults With HIV Naive to Treatment
• Jacobs J, Hoagland B, Coutinho C, et al. OAC2803: Challenges in Early HIV Detection During CAB-LA PrEP: Characterization of Inconclusive Serological Results in ImPrEP CAB Brasil
• Kiwanuka N, Malahleha M, Nair G, et al. OAC2802: Zero HIV Acquisitions With Twice-Yearly Subcutaneous Lenacapavir for PrEP During 52 Weeks of Open-Label Extension in PURPOSE 1
• Losso M, Santos B, Lama JR, et al. OAC2806LB: High Efficacy of Twice-Yearly Subcutaneous Lenacapavir for PrEP Through 52 Weeks of Open-Label Extension in PURPOSE 2
• Luetkemeyer AF, Bloch M, Scribner A, et al. OAB1405LB: Randomized, Active-Controlled, Phase 2b Study Evaluating Efficacy and Safety of Switch to Islatravir (ISL) 2 mg With Ulonivirine (ULO) 200 mg Once Weekly in Virologically Suppressed Adults Living With HIV-1.  
• McMahon J, Eron J, Gaur A, et al. OAB1403: Efficacy and Safety of Twice-Yearly Lenacapavir, Teropavimab and Zinlirvimab as an HIV-1 Treatment for up to 104 Weeks
• Niehaus ED, McKellar MS, Kenny A, Okeke NL. OAC4205: Real-World Effectiveness of Doxycycline Post-Exposure Prophylaxis for STI Prevention in a Southern U.S. HIV/PrEP Clinic
• Rockstroh JK, Ramgopal MN, Fabregas AC, et al. OAB1406LB: Once-Weekly Oral Islatravir/Lenacapavir (ISL/LEN) Versus Daily Bictegravir/Emtricitabine/Tenofovir Alafenamide (B/F/TAF) in Virologically Suppressed Adults With HIV-1: Week 48 Results of the ISLEND-1 Phase 3 Trial
• Saidi F, Squibb MA, Masano A, et al. OAC1306LB: Interim Analysis of Adverse Pregnancy Outcomes With Injectable CAB-LA Versus Oral PrEP: Findings From the PrIMO Safety Cohort
• Siegler A, Koh E, Corbin-Gutierrez E, et al. OAC1906LB: The First 6 Months of National Injectable Lenacapavir PrEP Prescribing and Equity, United States, June−December 2025
• Wang R, Chen W, Kumar A, et al. OAB2306LB: The Impact of Archived HIV-1 Drug Resistance on Maintenance of Virologic Suppression Through Week 48 in Children Aged 2 to <15 Years Receiving DTG/3TC: PENTA-21 Intensive Pharmacokinetic Sub-Study
• Woods J, Lebina L, Moller K, et al. OAB3406LB Opti-DOR: 48Week Data on DOR/3TC/TDF as an Alternative First-Line Antiretroviral Therapy (ART) Regimen to Integrase Inhibitors for People With HIV and BMI>25 kg/m2 in a Randomized Phase 3B Non-Inferiority Study

Related NYSDOH AI Guidelines:

• Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections
• Immunizations for Adults With HIV
• PEP to Prevent HIV Infection
• PrEP to Prevent HIV and Promote Sexual Health
• Prevention and Management of Hepatitis B Virus Infection in Adults With HIV
• Prevention and Management of Human Papillomavirus Infection in Adults With HIV
• Primary Care for Adults With HIV
• Rapid ART Initiation
• Selecting an Initial ART Regimen
• Screening for Anal Dysplasia and Cancer in Adults With HIV
• Screening for Cervical Dysplasia and Cancer in Adults With HIV
• Use of Injectable CAB/RPV LA as Replacement ART

A 41-yr-old man with HIV for 15 years, suppressed on ART, has had elevated liver enzymes for several years. Listen as Chris Hoffmann and Juhi Moon from Hopkins review the differential diagnosis and diagnostic and management approaches with a focus on metabolic dysfunction associated steatotic liver disease.

References:

• Bril F. Metabolic liver disease: A summary of major guidelines and identifying opportunities to improve future guidelines. Diabetes Obes Metab. 2026;28 Suppl 2(Suppl 2):63-80. PMID: 41821514.
• Cinque F, Saeed S, Farina F, et al. FIB-4 fails to identify significant liver fibrosis in people with HIV: A large multinational screening study. Hepatology. Published online May 1, 2026. PMID: 42065895.
• Eckard AR, Wu Q, Sattar A, et al. Once-weekly semaglutide in people with HIV-associated lipohypertrophy: a randomised, double-blind, placebo-controlled phase 2b single-centre clinical trial. Lancet Diabetes Endocrinol. 2024;12(8):523-534. PMID: 38964353.
• European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines on the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Obes Facts. 2024;17(4):374-444. PMID: 38852583.
• Harrison SA, Taub R, Neff GW, et al. Resmetirom for nonalcoholic fatty liver disease: a randomized, double-blind, placebo-controlled phase 3 trial. Nat Med. 2023;29(11):2919-2928. PMID: 37845512.
• Horberg M, Thompson M, Agwu A, et al. Primary Care Guidance for Providers of Care for Persons With Human Immunodeficiency Virus: 2024 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. Published online October 12, 2024. PMID: 39393187.
• Lake JE, Kitch DW, Kantor A, et al. The Effect of Open-Label Semaglutide on Metabolic Dysfunction-Associated Steatotic Liver Disease in People With HIV. Ann Intern Med. 2024;177(6):835-838. PMID: 38684100.
• Medeiros DG, Ferreira LF, Lamp JDS, Telles da Rosa LH. The impact of resistance training in patients diagnosed with metabolic dysfunction-associated steatotic liver disease: a systematic review. Eur J Gastroenterol Hepatol. 2025;37(2):129-136. PMID: 39589803.
• Roen AO, Peters L, Wandeler G, et al. Chronic Liver Enzyme Elevation and Use of Contemporary ARVs Among People With HIV. Open Forum Infect Dis. 2024;11(6):ofae308. Published 2024 Jun 8. PMID: 38919512.
• Sanyal AJ, Newsome PN, Kliers I, et al. Phase 3 Trial of Semaglutide in Metabolic Dysfunction-Associated Steatohepatitis. N Engl J Med. 2025;392(21):2089-2099. PMID: 40305708.
• Sterling RK, Duarte-Rojo A, Patel K, et al. AASLD Practice Guideline on imaging-based noninvasive liver disease assessment of hepatic fibrosis and steatosis. Hepatology. 2025;81(2):672-724. PMID: 38489518
• Wohl DA, Koethe JR, Sax PE, et al. Antiretrovirals and Weight Change: Weighing the Evidence. Clin Infect Dis. 2024;79(4):999-1005. PMID: 38606799.
• Wood S, Won SH, Hsieh HC, et al. Risk Factors Associated With Chronic Liver Enzyme Elevation in Persons With HIV Without Hepatitis B or C Coinfection in the Combination Antiretroviral Therapy Era. Open Forum Infect Dis. 2021 Feb 24;8(3):ofab076. PMID: 33738323.

Related Guidelines and Resources:

• AASLD: AASLD Practice Guideline on imaging-based noninvasive liver disease assessments of hepatic fibrosis and steatosis
• EASL: EASL–EASD–EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD)
• NYSDOH AI Clinical Guidelines Program: Primary Care for Adults With HIV
• Viremic—Cases in HIV: Case 10. A Growing Problem: ART-Associated Weight Gain

Hello Viremic listeners. We are taking a break for the month of July. Please check out our past episodes and catch up on any cases you may have missed.

We love hearing from our listeners, so please send us comments or potential case topics to [email protected]. Don’t forget to give us a like and follow us wherever you access podcasts. We’ll be back on Tuesday, August 4 with a new case to discuss.

Thank you.

A new-to-you patient—51-yr-old man with HIV since the early 2000s—has spotty vaccine records. How to educate, make recommendations, and avoid too many vaccinations at once? Listen as Chris and Eileen from Johns Hopkins make the case argue for their favorite vaccines among the many recommended for adults with HIV and describe their approaches to patient education, prioritizing based on specific patient needs, and strategizing vaccination schedules.

Reference: 

• Marks KM, Kang M, Umbleja T, et al. HepB-CpG vs HepB-Alum Vaccine in People With HIV and Prior Vaccine Nonresponse: The BEe-HIVe Randomized Clinical Trial. JAMA. 2025 Jan 28;333(4):295-306. PMID: 39616603.

Related Guidelines and Resources from the NYSDOH AI Clinical Guidelines Program:

• Immunizations for Adults With HIV; see especially:
  • Hepatitis B Virus (HBV)
  • Human Papillomavirus (HPV)
  • Measles, Mumps, Rubella (MMR)
  • Pneumococcal
  • Zoster
• Prevention and Management of Hepatitis B Virus Infection in Adults With HIV
• Prevention and Management of Human Papillomavirus Infection in Adults With HIV
• Viremic Case 15. A Pain in the Butt: Anal Cancer Screening and Prevention

A 42-yr-old man with AIDS presents feeling unwell, with white spots in his mouth, and scattered violaceous macules on his upper extremities; he has never taken ART. Listen as hosts Eileen Scully and Chris Hoffmann from Hopkins describe their initial work-up for a patient with a CD4 count of 10; discuss symptoms, diagnosis, and treatment of Kaposi sarcoma and other HHV8-related diseases; and remember the historical stigma of KS and the lingering effects of that stigma as they confirm the need to remain KS-aware even in 2026 in the U.S.

References Cited:

• Bettuzzi T, Lebbe C, Grolleau C. Modern Approach to Manage Patients With Kaposi Sarcoma. J Med Virol. 2025 Mar;97(3):e70294. PMID: 40119751.
• Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. National Institutes of Health, HIV Medicine Association, and Infectious Diseases Society of America. Human Herpesvirus-8 Disease. Updated April 23, 2025. Available online here. Accessed 5/21/2026.

Related Guidelines
NYSDOH AI Clinical Guidelines Program:

• Primary Care for Adults With HIV; see especially Flowchart 3: Initial Visit: New Patient, HIV Confirmed, NOT Taking ART 
• Management of IRIS
• Rapid ART Initiation

Clinical Info HIV.gov: 

• HIV Clinical Guidelines: Adult and Adolescent Opportunistic Infections – Human Herpesvirus-8 Disease

Resource: 

• DermNet – Kaposi sarcoma images 

Chris presents a 62-yr-old man with HIV for >30 yrs, with viral suppression and many drug resistance mutations, whose ART must be changed due to a drug-drug interaction, but also for simplification. As part of their discussion, Chris and Eileen review reasons to change ART regimens, and work through the evidence-based options for this patient based on his history and resistance mutations profile.

References Cited:

• Ciaffi L, Koulla-Shiro S, Sawadogo AB, et al. Boosted protease inhibitor monotherapy versus boosted protease inhibitor plus lamivudine dual therapy as second-line maintenance treatment for HIV-1-infected patients in sub-Saharan Africa (ANRS12 286/MOBIDIP): a multicentre, randomised, parallel, open-label, superiority trial. Lancet HIV. 2017 Sep;4(9):e384-e392. Epub 2017 May 28. PMID: 28566227.
• Hocqueloux L, Raffi F, Prazuck T, et al. Dolutegravir Monotherapy Versus Dolutegravir/Abacavir/Lamivudine for Virologically Suppressed People Living With Chronic Human Immunodeficiency Virus Infection: The Randomized Noninferiority MONotherapy of TiviCAY Trial. Clin Infect Dis. 2019 Oct 15;69(9):1498-1505. PMID: 30601976.
• 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.
• Raffi F, Babiker AG, Richert L, et al. Ritonavir-boosted darunavir combined with raltegravir or tenofovir-emtricitabine in antiretroviral-naive adults infected with HIV-1: 96 week results from the NEAT001/ANRS143 randomised non-inferiority trial. Lancet. 2014 Nov 29;384(9958):1942-51. Epub 2014 Aug 4. PMID: 25103176.
• Severe P, Pierre S, Homeus F, et al. Bictegravir, emtricitabine, and tenofovir alafenamide versus ritonavir-boosted protease inhibitor-based antiretroviral therapy in people with HIV and viral suppression on second-line therapy in Haiti: an open-label, randomised, non-inferiority trial. Lancet HIV. 2025 Sep;12(9):e616-e626. Erratum in: Lancet HIV. 2026 Feb;13(2):e84. Erratum in: Lancet HIV. 2026 Feb 24:S2352-3018(26)00037-8. PMID: 40883049.

Related NYSDOH AI Guidelines:

• Second-Line ART After Treatment Failure or for Regimen Simplification
• HIV Resistance Assays
• Drug-Drug Interaction Guide: From HIV Prevention to Treatment
• Virologic and Immunologic Monitoring in HIV Care

With guest Dr. Jeremy Kidd, Chris reviews the case of a 27-yr-old man with HIV who reports using methamphetamine to enhance sex and has unsuppressed HIV. Is this chemsex? Is the unsuppressed viral load related? How should Chris discuss this with his patient, and what should he recommend? How should he approach the topic of harm reduction if the patient is not going to stop using chemsex?

References Cited:

• Kidd JD, Smiley SL, Coffin PO, et al. Sexual orientation differences among men in a randomized clinical trial of extended-release naltrexone and bupropion for methamphetamine use disorder. Drug Alcohol Depend. 2023 Sep 1;250:110899. Epub 2023 Jul 17. PMID: 37478502.
• Reback CJ. The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles. 1997. Available online here. Accessed February 24, 2026.
• Trivedi MH, Walker R, Ling W, et al. Bupropion and Naltrexone in Methamphetamine Use Disorder. N Engl J Med. 2021 Jan 14;384(2):140-153. PMID: 33497547.

Documentaries Mentioned:

• parTy boi, black diamonds in ice castles
• Crystal City

Related NYSDOH AI Guidelines and Guidance:

• Chemsex: Questions and Answers
• Substance Use Screening and Risk Assessment
• Substance Use Harm Reduction
• PrEP to Prevent HIV and Promote Sexual Health
• PEP to Prevent HIV Infection
• Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections
• Guidance: Adopting a Patient-Centered Approach to Sexual Health