Viremic – Cases in HIV

Announcer:
Welcome to Viremic–Cases in HIV, a podcast that explores quandaries in adult HIV clinical care. In each episode, Drs. Eileen Scully and Christopher Hoffmann, HIV specialists at Johns Hopkins, discuss a case, review challenges in the plan of care, and highlight evidence and guidelines that inform clinical decision-making. Now, here is your host, Eileen Scully.

Dr. Eileen Scully:
Welcome to Viremic, a podcast where we talk about all things related to the care of people living with HIV. I’m Dr. Eileen Scully, coming to you from Johns Hopkins, and today, I have the immense pleasure of welcoming Dr. Jean Anderson.

Dr. Anderson is an obstetrician and gynecologist who has been a pioneer in caring for women living with HIV. She founded the HIV Women’s Health Program here at Johns Hopkins, a program that emerged out of the rising recognition of both cases of HIV among women in the late 1980s and early 1990s, but also from Dr. Anderson’s recognition and understanding of the challenges of providing care centered on the patient to women across the reproductive lifespan.

She’s been recognized by more organizations than we have time to go through for her work in truly establishing the standard of care for the prevention of vertical transmission of HIV through pregnancy, childbirth, and breastfeeding, and has continued to iterate and develop that standard with emerging therapeutics over the course of this pandemic. But in addition to this, she’s also someone who anyone who’s worked with will be just struck by how all of this science is always in direct service of the person in front of her. She’s the kind of doctor that we all want to be.

So, Dr. Anderson, welcome to the podcast. I was wondering if you could introduce yourself a little bit.

Dr. Jean Anderson:
Sure. Thank you so much, Dr. Scully, for inviting me and for those kind words of introduction.

I’ll start by giving a little bit of my background, which can put into perspective some of the work with women with HIV. I came to Johns Hopkins in 1986 after completing medical school, residency in OB/GYN, and 3 and a half years on the faculty at Vanderbilt in Nashville. That’s important to put it into that time perspective because I never learned about HIV in medical school or residency and never saw a case until I came to Hopkins.

The syndrome that came to be known as AIDS was not identified until 1981. At that time, of course, very little was known about it. So, when I came to Hopkins in 1986, there had been some advances—we knew at that time about the retrovirus, HIV, which caused the syndrome now known as AIDS. The modes of transmission had been determined, and a test for HIV was developed, but there was as yet no treatment. So again, I was a total neophyte in this area when I came. But the one person I knew in Baltimore who had been a co-resident at Vanderbilt was an infectious disease fellow at Hopkins. She called me one day and said, “We are beginning to see just a few women with HIV and wondered if you would be our OB/GYN?”

I had always been interested in infectious diseases. I had been drawn to care for women who were marginalized and poor, so that started me down a path that has given my career really great meaning for me.

It’s difficult for most folks today to understand what it was like then. I can say a little bit about what it was like and what led me to focus on developing a program for women with HIV. Again, there was no treatment at first. Our weekly patient conferences were a litany of the dead or dying. There was enormous stigma. Many patients were abandoned by their families, so in many ways, we the providers became their family.

As providers, we also dealt with stigma and ostracism by our colleagues because of fear of contagion and because of the patients we cared for who were some of the most marginalized people in society—gay men, injection drug users, poor minorities. At that time, women were still greatly outnumbered by men affected by HIV, but that was changing pretty fast. However, the face of HIV AIDS at that time was gay men, usually white men, who had more resources. They often were better educated and had higher status than women. So, one of the biggest gaps I saw was that women were simply overlooked or ignored. When they were considered, they were simply thought of as mothers or as whores, to be blunt.

Furthermore, the issues peripheral to HIV often took precedence for these women. They often were dependent on a partner for economic support. They often had little social support. If they had children, that was their priority. If they had an infected infant, and that’s how they were diagnosed, they had guilt. Or if they were pregnant, they feared passing HIV to their fetus in pregnancy. So, one of the early lessons learned was from one of my patients and this was when HIV was still essentially a death sentence. She told me one day, “Dr. Anderson, you don’t understand, AIDS is not my worst problem.”

A third gap I would highlight is that women were underrepresented in research around HIV AIDS. There were often stringent requirements in terms of contraception for non-pregnant women to be included in clinical trials. And in the early studies that did focus on women, specifically on prevention of mother-to-child transmission, there was a great deal of reluctance to expose women to antiretrovirals as they were developed for fear of harming the fetus.

I hope that gives a little bit of a historical perspective to bring us up to where we are today.

Eileen:
In the midst of this, how did you have the vision to see that this could be turned into a treatable condition? Was it a general optimism about clinical care? Was it a commitment to treatment even if you couldn’t improve the outcomes? Or what was the thread that brought you through that, which was obviously both professionally and personally a really challenging situation.

Jean:
I think it was a couple of things. I didn’t have a crystal ball, but certainly the science was moving very rapidly, and very quickly, we had our first antiretroviral, zidovudine or AZT. That gave great hope. So, there was that.

Also, there was recognition of the need to care for these women. Again, they were often abandoned or rejected by families, by friends. They were very isolated. We all bonded; we bonded not only to the patients, but the providers to each other. My closest friends come from those days. So, it was a combination of hope, but also just seeing a tremendous need.

Eileen:
I’ll also highlight that I think talking about specifically care for women, which often is structured around considerations around pregnancy, is it allows us to highlight that gap you mentioned, which is that women traditionally were excluded from early phase clinical trials because of concern for reproductive toxicities. In the end, that exclusion did not translate into the empowerment that comes with information and data about optimal therapies. The work that you and your colleagues have done in creating a pipeline for understanding antiretroviral therapy during pregnancy has been important in trying to address that gap across other situations where we also lack female-specific information about how therapeutics work. So, I guess that was just a long way to say thank you.

But with that, let’s turn to our hypothetical case for the day. For our amalgam patient, I’m going to give you a 28-year-old woman presenting in referral after taking a home pregnancy test. In the process of seeking initial care, she had some basic blood work done at a local community site, and that included an HIV screening test, which turned out to be positive. This is a new diagnosis for her, and she’s still adjusting to the results, and that is putting it in a mild way. She presents today in an urgent appointment, tearful about what to think about this new diagnosis.

I’d love to start off with your approach to counseling a woman today, which is obviously quite different than previously, who presents in these circumstances with a new diagnosis that’s frightening and stigmatizing. Where do you start in your history, and what kinds of reassurance do you offer right away?

Jean:
Well, certainly today I give reassurance right away that this is a treatable disease and that with appropriate care she can live a normal life and essentially normal lifespan and have a healthy baby. I think it’s important to get that right out there because when you are giving a diagnosis like this, that’s often the only thing they remember—what you first say. They may not hear much else. But after that, I ask her what she knows about HIV, really to assess her understanding or misunderstanding. To go on from there, I try to explain a little bit about HIV, what it is, how it’s transmitted, how we evaluate it, how it’s treated.

After these preliminaries, I began her history—a complete history, general medical history, other medical conditions, assessing any symptoms that might be HIV related. Social history is extremely important. Behaviors that might have put her at risk, but also critically her support systems. I do discuss stigma and disclosure—who needs to know and barriers or considerations around this and offer assistance.

This initial discussion requires time. It doesn’t fit into a 15 or 30-minute visit. It needs to include time for her to think up and ask questions. A follow-up should be scheduled in a short period of time because she will inevitably have additional questions. And as I said, she may not remember half of what you’ve said.

So that’s how I approach that initial visit.

Eileen:
I love that, and I love also that from a guidance for someone who’s caring for a woman in this situation, the idea of when the follow-up should occur has something to do with when you need your next labs, but more to do with how you can build a relationship and help to get through the current medical situation through [a] relationship with the patient, and that that’s just as important a part of the guideline recommendations as when you need your next labs.

But I’m also interested in hearing how you approach questions around the involvement of a partner in thinking about risk for violence or other concerns. While your care is centered on the patient, as you referenced even early on, there’s a lot of interdependence of women with other people and other relationships in their lives. So just curious about any thoughts you have about how you discuss the involvement or not of a partner in a pregnancy.

Jean:
Sure. I start out by trying to approach things non-judgmentally. I don’t make assumptions. I certainly ask about the partner. Is he involved? Is he happy about the pregnancy? How long have they been together? What he does for a living? Just try to get a sense for this person, but also their partnership. My questions generally go wherever she leads.

I do ask if she knows how she may have become infected and if her partner has a history or behaviors that may have put him at risk for HIV. I discuss disclosure and potential risks. It is very important to assess her safety. If there’s a history of intimate partner violence or if she expresses fear of her partner or fear of telling him, I, without hesitation, urge caution in disclosure. And I talk about the different options, offering direct assistance in disclosure, or sometimes that can be done anonymously through the health department.

[I] also assess other risks—abandonment, rejection. If she has other children, she may be absolutely dependent on him for not only social support but economic support, so that’s where it’s ideal to have a program or linkages to programs that can offer a lot of additional support—social services, peer supports can be especially helpful. Our program was one of the earliest to use peer support. That means other women from the community who were affected by HIV themselves either living with HIV or with close family members living with HIV. They’ve been extraordinarily effective in helping build trust and in problem solving.

One final point about the partner is if the partner is not known to be HIV infected, there is the opportunity to identify HIV in the partner to get them into treatment. But my primary priority at this time is the woman herself.

Eileen:
This woman also expressed in the early discussion that this is very much a wanted pregnancy. We’ll fill out the story a little bit. She does have a partner. She has not yet told him about her diagnosis but is not opposed to doing so. She does feel safe in the relationship. Not exactly clear on when she would have acquired it or whether or not her partner may also have HIV. But in general, some of those foundational things are not in their most risky scenario, and the focus shifts a bit towards whether or not she can have a healthy pregnancy and deliver a healthy child.

So, I was wondering if you could talk a little bit about vertical transmission—how it’s distributed across a pregnancy and delivery and how you think about a newly identified or potentially acute infection during pregnancy.

Jean:
This has been one of the most amazing, miraculous stories of HIV care, from the point of a baseline risk of transmission from mother to their fetus or infant, which was approximately 25%, to today where we’re talking about the possibility of eliminating perinatal transmission.

The story started with the use of zidovudine alone in a clinical trial known as the 076 study. In that clinical trial, zidovudine was begun in the second trimester of pregnancy. It was continued throughout pregnancy, given by IV infusion during labor and then to the neonate for 6 weeks. That, in and of itself, cut the risk of transmission by about two-thirds.

Fast forward to today with effective antiretroviral therapy, which results in maximal and sustained suppression of HIV viral load to undetectable levels—the risk is less than 1%. The majority of transmission occurs in late pregnancy around the time of delivery, though it can occur earlier in pregnancy. I think we’ll talk a little bit later about breastfeeding, but in untreated HIV, breastfeeding was also associated with considerable risk of transmission.

So, there are certainly variables that may modify or increase risk of transmission. Reducing the risk to the fetus as well as taking care of the mother requires, first of all, that she knows about HIV and that she be tested for HIV as early in pregnancy as possible and ideally, of course, prior to pregnancy. It’s currently recommended that all pregnant women have HIV testing on an opt-out basis in pregnancy.

And just to give you a sense of how far we’ve come, there was a study 2 or 3 years ago from France, the French perinatal cohort. In that study, almost 5,500 women who were on antiretroviral therapy prior to conception and had an undetectable viral load near delivery, and there were no transmissions. In another 4,600 women who were not started on ART until pregnancy but still achieved an undetectable viral load near delivery, transmission was 0.57%. Early diagnosis, early and effective treatment, and maximal and sustained viral load suppression are critical to reducing and eliminating perinatal transmission.

You mentioned acute or primary HIV infection. That’s important to note because it’s not talked about enough. Acute HIV infection in pregnancy is thought to be responsible for perhaps a major portion of residual perinatal infections today. Women who are pregnant may have tested negative early in pregnancy, but then they become infected later. There can be a number of reasons for that. They may be less likely to use safer sexual practices, such as condoms, during pregnancy because they think of condoms more in terms of contraception. There’s also evidence that there is an increased risk of acquiring HIV during pregnancy related to hormonal and immunologic changes. Furthermore, acute HIV is associated initially with a high viral load, which significantly increases risk of transmission. Therefore, it’s important both to counsel women about protection during pregnancy if they are negative and particularly if they are known to be in a high-risk relationship. It’s recommended to consider retesting later in pregnancy, somewhere around 28 to 32 weeks to potentially identify an infection that has occurred during pregnancy.

For women who are known to be at risk, for instance, with a partner who is known to be HIV infected, PrEP is a safe and appropriate option during pregnancy for those women.

Eileen:
Those are excellent points. One of the challenges with PrEP is making sure that the people who can provide it, or who are most likely to think of it, actually interface with the patients who are at highest risk of acquisition. Hopefully putting that into people’s minds as ART is not only a consideration for people who have acquired HIV, but also those at risk, and in particular, if you’re trying to conceive in a discordant partnership, that is a key time to be considering this type of question. So, thank you for highlighting that.

I think some of the points that you touched on feed back into how far we’ve come in terms of HIV regimens, where we have guidelines that give us preferred options, and preferred status is based on both the efficacy and durability of the treatment itself for suppression of HIV, but also the acceptability of use and toxicity and the pregnancy-specific pharmacokinetic data when that’s available, and then also the risk-benefit ratio and thinking about maternal and fetal risks.

I was wondering if you could speak a little bit about the therapies of choice currently, and if there are any specific things that you think people should be aware of.

I’ll just briefly mention that for anyone who’s listening, you don’t have to write everything down. There are excellent guidelines that we will provide links to. And also, there’s a warm hotline that you can call for specific questions around perinatal concerns. Just give us an overview of the general principles of the preferred options for therapy during pregnancy.

Jean:
Sure. The basic principle of ART treatment in pregnancy is that pregnancy, or lactation, or pregnancy potential should not preclude the use of drug regimens that would be chosen for those who aren’t pregnant unless there are known adverse effects that outweigh potential benefits or there’s concern about adequate drug levels being attained in pregnancy. Most of the time, there are no specific concerns.

In general, women who present in pregnancy already on antiretroviral therapy that is effective, and assuming it’s safe and well tolerated, they should continue that regimen. It shouldn’t be stopped or interrupted, with the exception if they’re on an old regimen that’s no longer recommended due to toxicity.

Selection of drugs should be individualized for HIV during pregnancy, and you’ve already mentioned some of the considerations. Their effectiveness, their durability, how tolerable they are, how simple they are, easy to take, are very important for ensuring adherence and preserving future treatment options.

You already mentioned the preferred drugs. If you go to the antiretroviral guidelines from DHHS, the categories are preferred, alternative, insufficient data to recommend, not recommended except in special circumstances, and not recommended.

The preferred drugs are clearly the ones we have the most information on regarding their efficacy and the other characteristics, as well as those that have pregnancy-specific pharmacokinetic data available to guide dosing. They are also drugs that have a favorable risk-benefit balance versus other options and acceptable safety outcomes.

Alternative drugs are those that have shown efficacy but in clinical trial data in adults, but we just have more limited data in pregnancy.

Insufficient data is fairly self-explanatory.

And not recommended except in special circumstances are drugs or regimens that may have more limited data on safety or efficacy, but may need to be continued or initiated, particularly in women who may have more ART experience and problematic resistance profiles.

Not recommended, of course, those where there is inferior efficacy or potentially concerning maternal safety or fetal safety concerns or pharmacokinetic problems in general.

That’s why there’s the links that you’re going to provide to the DHHS guidelines are so critical because these things change. Drugs tend to migrate from insufficient data to alternative to preferred as we get more experience. This tends to be parallel to the adult guidelines but a little bit behind. In some cases, they may move in the other direction from preferred to alternative as better drugs become available, and zidovudine is a good example of this. Currently, particularly for women who are newly diagnosed and antiretroviral naïve, the recommended initial agent is bictegravir plus tenofovir alafenamide plus emtricitabine in the fixed dose once-a-day regimen. That is preferred, again, because of its effectiveness, because of its tolerability and its simplicity. So, I would definitely follow those guidelines. They are updated regularly. They have some great tables that summarize different scenarios for all the different drugs or combinations and where, in particular, you might consider changing, but in many if not most cases continuing regimens.

Eileen:
That point about the movement between categories is critical and also recognizing that there is a living document which people can access to get the most up-to-date information.

Another link we’ll provide is the antiretroviral pregnancy registry. That’s one of the ways that drugs can move between those categories, where if you have an individual who has advanced resistance and is on an atypical regimen and becomes pregnant, it’s a reporting system where the individual treating the patient can report the experience of a pregnancy on an agent for which we have inadequate data. I would encourage people that when they’re caring for challenging cases to consider that potential to add to the body of data and help move the novel medications between these insufficient categories so that we have more information.

Jean:
I would totally second that and would encourage any provider for pregnant women who are on antiretroviral regimens to report to the registry. And in particular, report real time, which is of course going to be less biased than retrospective reporting.

Eileen:
For the case of our patient, she elects to start dolutegravir plus emtricitabine/tenofovir alafenamide— 2 pills instead of one. The reason why she chooses this is that she prefers the smallest pills possible. That’s her number one priority. And that’s also a preferred option. She suppresses rapidly, and she maintains her viral suppression through pregnancy. She has an overall happy course. She discloses to her partner who does also test positive, and they are supportive of each other, both invested in the pregnancy, and comes in late in the second trimester and has some questions about breastfeeding.

Can you talk to us about how you discuss the decision around breastfeeding, which has been a major shift in clinical practice over the last several years?

Jean:
Sure. This is an area where the recommendations have changed significantly. The tension has always been the risk of transmission through breast milk versus the well-known benefits of breastfeeding in terms of infant health with reductions in asthma, gastroenteritis, otitis media, improvement in maternal-infant bonding, and benefits in maternal health reductions in hypertension, type 2 diabetes, breast and ovarian cancer.

We’ve known for years about these benefits, but until a few years ago, breastfeeding was not recommended in the setting of HIV because of concern about transmission. So, what has changed is that there are good data to show that, with effective antiretroviral therapy and again maintenance of an undetectable viral load, the risk of breastfeeding is quite low and therefore the benefits come more strongly to the fore.

It’s also important to recognize that even in the United States, sometimes accessing clean water or an adequate supply of formula may be difficult due to cost or other barriers.

We start talking about infant feeding early in pregnancy and revisit it throughout pregnancy. Usually, I begin by asking what her thoughts are and desires. Some of the key messages we give her is that replacement feeding with either formula or donor human milk from a milk bank, which is by the way quite expensive, are the ways to totally eliminate risk of postnatal HIV transmission through breastfeeding. That if she chooses to breastfeed, it’s critical to achieve and maintain viral suppression; that decreases the risk to less than 1%, but it’s not zero.

This is a situation to take a harm reduction approach, to be non-judgmental, to approach it using shared decision making. We assess potential barriers to adherence and to her breastfeeding safely because there are a lot of things to consider. Besides the environmental, there may be social, or familial, or personal pressures to consider breastfeeding. Many factors affect her decision to breastfeed. In some cases, there are cultural imperatives that she feels to breastfeed or religious factors. She may have concerns about stigma or inadvertent disclosure if she doesn’t breastfeed. So, our goal is to help her think through all of this with her partner if he is involved and she is willing and to really think about what the challenges are. If she does choose to breastfeed, we want to support her in every way possible.

Other things we talk about is exclusive breastfeeding (meaning no formula or other foods for the first six months is recommended, and then begin introducing complementary foods), and breast health—identifying and treating mastitis or thrush or cracked or bleeding nipples. These conditions may increase the risk of HIV transmission through breastfeeding, although we don’t have a lot of data in the era of effective ART.

And we talk about, along with breastfeeding or any infant feeding, appropriate antiretroviral prophylaxis for the newborn. The specific regimen is determined by maternal and infant factors.

That’s the way we think about counseling about breastfeeding in the setting of HIV, and trying to troubleshoot with her challenges that she may have. We follow viral load fairly carefully in someone who’s breastfeeding. If she develops a detectable viral load during breastfeeding, we generally recommend that breastfeeding be stopped, at least temporarily, or discontinued and formula feeding initiated while the viral load is rechecked; we assess causes for viremia and adherence.

That’s a general overview of how we think about and counsel about breastfeeding today.

Eileen:
Well, that dovetails into another question. I’ll put the end of our case here, which is also the beginning for this new little family.

Our patient comes in, in labor at 38 weeks, and her most recent viral load was 2 weeks prior and was fully suppressed. So, I’m going to ask you to comment on how you would manage her delivery. And then also, as you’ve spoken about breastfeeding and maintaining viral suppression, she did opt to breastfeed. So, again, all of this support becomes critical for many reasons. But are there specific considerations around monitoring for postpartum mental health challenges and supporting adherence during the new life that involves an infant? So, again, what is the management when someone presents in labor for delivery? And are there specific considerations that you have for postpartum monitoring?

Jean:
Absolutely. It is recommended that viral load be repeated in late pregnancy, at about 36 weeks, or within what you think is about a month before she would be liable to go into labor. If that repeat viral load is undetectable, delivery can be managed as for a woman without HIV, planning for vaginal delivery with standard obstetrical indications as needed for cesarean delivery.

If her viral load is over 1,000 copies/mL or is unknown during the time of birth and particularly if there have been concerns about adherence, then a scheduled cesarean birth at 38 weeks gestation is recommended to further minimize perinatal HIV transmission.

We also continue antiretroviral therapy in labor, the regimen she’s on, although if she is on a once-a-day pill, then she may deliver before she needs her next dose. We make decisions about whether or not to include intrapartum IV zidovudine based on laboratory and clinical information near the time of birth. Certainly, intrapartum IV zidovudine is recommended if the viral load is increased, is not suppressed, or if it’s unknown, if there is known or suspected lack of adherence, or if a woman is newly diagnosed in labor, which is certainly not the case here, but expedited HIV testing is recommended in labor for women who haven’t been tested.

It sounds like she’s in good shape to proceed with hopefully a vaginal delivery.

To think about the postpartum challenges, again, this is something we start preparing for well before the baby’s born—the challenges she sees and the challenges she might not yet see. I would emphasize the importance of continuing her antiretroviral therapy after delivery and maintaining viral load suppression because that’s critical to reduce the risk of transmission since she will be breastfeeding, but it’s also critical for her own health. Generally, we would continue the same regimen, but in some cases, antiretroviral therapy regimens could even be simplified. But there’s no question that there are challenges to adherence as well as retention and care in the postpartum period.

Studies have shown that women are at higher risk for nonadherence and lost to follow-up in the postpartum period. This is probably due to a number of reasons—the stress of taking care of a new baby, including giving them medication; concerns about disclosure if other family members don’t know her diagnosis; postpartum depression. Certainly, symptoms of depression have been associated with lower adherence and lower viral suppression during pregnancy and in the postpartum period. Furthermore, postpartum depression is common, as common in the context of HIV. So, we screen for postpartum depression routinely, in pregnancy but also in the postpartum period. The test we use is the Edinburgh Postnatal Depression Scale, which is a pretty simple 10-item questionnaire.

We also again inquire about intimate partner violence, about food or housing insecurity, about substance use, because those are also factors that have been associated with lack of adherence but also worsening depression.

We emphasize that the postpartum physical and psychological changes as well as the stresses and demands of caring for a new baby will make adherence more difficult and try to assess what additional support they have or may need. Postpartum care used to be ended arbitrarily at 6 weeks. We now talk about, and the American College of Obstetricians and Gynecologists endorse, extending postpartum follow-up for all women. This is especially true for women who have HIV or those who are newly diagnosed with HIV in pregnancy. So, we talk about the fourth trimester of pregnancy, which is the postpartum period.

ACOG recommends contact with an OB/GYN within 3 weeks postpartum, but then to have ongoing postpartum care based on what the individual needs rather than as one-size-fits-all. In general, a follow-up appointment in 2 to 4 weeks of discharge after delivery is recommended when a woman is living with HIV. From there, it depends on the particular challenges. In this case, checking in via telemedicine when that’s possible can be considered.

At the same time, it’s important to provide linkage to ongoing HIV care, particularly for women who’ve never been in HIV care before. This is where case managers and peer support can be instrumental in helping make this transition as smooth as possible.

Eileen:
Well, thank you for that. As we draw to a close here, to summarize what I think anyone listening to this can take away, is that this discussion has provided the rubric for how to care for a person that is so much more valuable than just the list of preferred medications.

And I’m just so grateful, Dr. Anderson, for your time, for your expertise, and for all of your contributions to making care so much better for women living with HIV. And I’d like to thank you for joining us.

Jean:
Thank you so much.

Eileen:
And to all of our listeners here at Viremic, please join us again next time.

Announcer:
Thanks for listening to Viremic. If you enjoyed the show, please subscribe wherever you listen to podcasts. We’ll be back in a couple of weeks with a new case to discuss.

Viremic is sponsored by the Clinical Guidelines Program, a collaborative effort of the New York State Department of Health AIDS Institute and the Johns Hopkins University Division of Infectious Diseases.

Visit the program’s website at HIVguidelines.org.

The podcast is produced and edited by Mary Beth Hansen and Brian Hatcher with appreciated assistance from Jesse Ciekot and Laura LeBrun Hatcher.

Viremic’s case discussions are presented for informational purposes only and are not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use, not an endorsement.