Viremic – Cases in HIV

A 30-year-old bisexual man is hospitalized and diagnosed with advanced HIV disease and presumptive Pneumocystis pneumonia (PCP). He has an initial CD4 cell count of 34 cells/cubic-mm and viral load of 160,000 copies/mL, and he is treated with bictegravir/emtricitabine/tenofovir alafenamide, broad-spectrum antibiotics, and trimethoprim sulfamethoxazole. After discharge, the patient reports headaches and fever. Listen as Chris Hoffmann and Eileen Scully from Johns Hopkins discuss the patient’s laboratory results, the differential for these symptoms, the biology of immune reconstitution inflammatory syndrome (IRIS), and symptom management.

References:

• Boulware DR, Meya DB, Muzoora C, et al. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med 2014 Jun 26;370(26):2487-98. PMID: 24963568
• Török ME, Yen NT, Chau TT, et al. Timing of initiation of antiretroviral therapy in human immunodeficiency virus (HIV)--associated tuberculous meningitis. Clin Infect Dis 2011 Jun;52(11):1374-83. PMID:21596680

Related Guidelines:

• NYSDOH AI: Management of IRIS
• DHHS:
  Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV
  Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV

A 45-year-old male patient with HIV and a history of sustained viral suppression suddenly has detectable viremia that persists for more than 12 months (range 80 to 250 copies/mL). The patient has been taking bictegravir/emtricitabine/tenofovir alafenamide for more than 6 years, and assessment indicates high adherence and no drug-drug interactions. Listen as Eileen Scully and guest Francesco Simonetti of Johns Hopkins discuss nonsuppressible viremia (NSV), including the mechanisms underlying it, the potential clinical impact, and how to address it with patients.

References:

• Box JR, Camilo-Contreras A, Dragoni F, et al. 5' leader defects drive persistent HIV-1 viremia on long-term ART. Nat Commun 2026 Jun 8;17(1):4725. PMID: 42259781 
• Halvas EK, Joseph KW, Brandt LD, et al. HIV-1 viremia not suppressible by antiretroviral therapy can originate from large T cell clones producing infectious virus. J Clin Invest 2020 Nov 2;130(11):5847-5857. PMID: 33016926 
• Mohammadi A, Etemad B, Zhang X, et al. Viral and host mediators of non-suppressible HIV-1 viremia. Nat Med 2023 Dec;29(12):3212-3223. PMID: 37957382 
• White 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 Mar 15;133(6):e165245. PMID: 36602866 

Resource:

• Clemente T, Stam A, Elvstam O, et al. Guidance on the clinical management of HIV-1 persistent low-level viraemia on antiretroviral treatment: a scoping review and an international Delphi consensus. The Lancet HIV 2026;13: e502-e514. PMID: 42276093 

A patient asks, “Can I get the every-six-month treatment?” Listen as Eileen Scully and Chris Hoffmann of Johns Hopkins review recent study results on HIV treatment with lenacapavir and two broadly neutralizing antibodies (bNAbs), the status of bNAbs for HIV treatment, cure, and prevention, and what to discuss with patients considering a bNAb clinical trial.

References:

• Balazs, A., Chen, J., Hong, C, et al. Antibody-based protection against HIV infection by vectored immunoprophylaxis. Nature 2012:481, 81–84. PMID: 22139420
• Corey L, Gilbert PB, Juraska M, et al. Two randomized trials of neutralizing antibodies to prevent HIV-1 acquisition. N Engl J Med. 2021 Mar 18;384(11):1003-1014. doi: 10.1056/NEJMoa2031738. PMID: 33730454
• Lee M, Cherrill L, Zacharopoulou P, et al. Time to HIV rebound after infusion of long-acting broadly neutralising antibodies 3BNC117-LS and 10-1074-LS and analytical treatment interruption (the RIO trial): a double-blind, randomised, placebo-controlled trial. Lancet HIV 2026; 13: e527-e537. PMID: 42202839
• McMahon J, Eron J, Gaur A, et al. Efficacy and safety of twice-yearly lenacapavir, teropavimab and zinlirvimab as an HIV-1 Treatment for up to 104 Weeks. JIAS. Volume 29, Issue S4 Supplement: Abstracts from AIDS 2026, the 26th International AIDS Conference, 26–31 July 2026 Rio de Janeiro, Brazil and virtual July 2026. OAB1403
• Ndung'u T, Dong KL, Colby DJ, et al. Recommendations from the 2nd Consensus Workshop on Analytical Treatment Interruption in HIV Research trials. Lancet HIV 2026 Apr;13(4):e271-e281. PMID: 41747748

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