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: 36037040

Related 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 Health

Resources:

• Antiretroviral Pregnancy Registry
• CDC 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 Health
• PEP to Prevent HIV Infection
• Guidance: Adopting a Patient-Centered Approach to Sexual Health
• GOALS Framework for Sexual History Taking in Primary Care
• Prevention 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 Guidance

Centers 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 Health
• GOALS Framework for Sexual History Taking in Primary Care

Clinical Resources

• National 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 5962

Related 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 Checker
• Stanford HIV Drug Resistance Database

Related NYSDOH AIDS Institute Clinical Guidelines: 

• Second-Line ART After Treatment Failure or for Regimen Simplification
• HIV Resistance Assays
• Virologic and Immunologic Monitoring in HIV Care
• Primary 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 Checker
• FDA: Apixaban (Eliquis) Highlights of Prescribing Information
• FDA: Dabigatran etexilate (Pradaxa) Highlights of Prescribing Information  
• FDA: Edoxaban (Savaysa) Highlights of Prescribing Information

Related NYSDOH AIDS Institute Clinical Guidelines: 

• Second-Line ART After Treatment Failure or for Regimen Simplification
• Resource: ART Drug-Drug Interactions; specifically, see Drug-Drug Interactions by Common Medication Class Table 22: Anticoagulants
• Primary 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: 3010589
• Kozal 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: 32212519
• Segal-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: 35544387
• HIVAssist.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 Information
• FDA: Sunlenca (lenacapavir) Highlights of Prescribing Information
• FDA: Trogarzo (ibalizumab) Highlights of Prescribing Information

Related NYSDOH AIDS Institute Clinical Guidelines:

• Second-Line ART After Treatment Failure or for Regimen Simplification
• HIV Resistance Assays
• Primary 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 Supplements

Related NYSDOH AIDS Institute Clinical Guidelines: 

• Primary Care for Adults with HIV
• Second-Line ART After Treatment Failure or for Regimen Simplification
• Use of Injectable CAB/RPV LA as Replacement ART in Virally Suppressed Adults
• Prevention and Management of Hepatitis B Virus Infection in Adults With HIV