Viremic – Cases in HIV

Announcer:
Welcome to Viremic–Cases in HIV, hosted by Dr. Eileen Scully and Dr. Christopher Hoffmann, both HIV specialists at Johns Hopkins, who explore quandaries in adult HIV care. Each case discussion includes medical history and diagnoses, challenges in care and treatment, and key evidence and guidelines that inform clinical decision making.

Cases are presented as a composite from the hosts’ clinical practice, with all identifying details removed to protect the privacy of patients. Case discussions are for informational purposes only and 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 only, not an endorsement.

Dr. Christopher Hoffmann:
Welcome to Viremic. I’m Chris Hoffman, and I’m joined today by a special guest, Dr. Margie Urban, coming to us from Rochester, New York. Before we start, if you like this podcast, please share it with a colleague and follow us wherever you access podcasts. In addition, we love hearing from listeners. Please send questions or future topic suggestions to us at viremicpodcast@jh.edu.

Dr. Margie Urban is an infectious diseases clinician and a leader in training and guidance on managing sexually transmitted infections. She’s based at the University of Rochester School of Medicine, where she’s a professor in the Division of Infectious Diseases and medical director of the Center for Community Practice. She directs the New York State Department of Health Clinical Education Initiative, known as CEI, Sexual Health Center of Excellence, and is the medical director of the Monroe County Sexual Health Clinic. She’s also a longtime member of the Adult HIV Guidelines Committee of the New York State AIDS Institute Clinical Guidelines Program. Welcome Margie.

Dr. Marguerite (Margie) Urban:
Thanks so much, Chris. I’m happy to be here.

Chris:
Margie, we’re so happy to have you on the podcast and get more insights into managing sexually transmitted infections. Before we get to the case in hand, I just wanted to hear a little bit about what keeps you passionate about HIV and STI care and education?

Margie:
Well, it’s a big field. I might date myself a little here, but I did my medical school training and residency training and fellowship training as well at the height of the early days of HIV. And that was also a time with very, very large increases in syphilis cases in the U.S. That led to my fascination with STIs as a whole and HIV and the interaction between the two. I’ve been very fortunate in my career to see the evolution of the management of HIV and STIs to some extent.

One thing that has been really fortunate in my career has been my involvement with the Clinical Education Initiative. This has taken me outside of just medical school education to clinician education as a whole. I’ve been able to build rich relationships through this program with clinicians from around New York State who work with patients who might have some concerns with STIs and HIV.

So, it’s been a wonderful career of seeing scientific advances, seeing advances in how we handle things like social determinants of health that have such impact on health as a whole and certainly health involving these conditions, and also having the relationships built with education.

Chris:
Thanks so much, Margie, for talking about your career path and the important role that clinician education has for you and how meaningful it is.

Let’s move on to today’s case that starts out as a fairly straightforward STI case but may have a twist or two.

I saw a 32-year-old gay man for routine HIV care. He’s on Dovato; he is overweight and has metabolic-associated steatotic liver disease. He’s been treated for syphilis twice, along with several episodes of chlamydia and rectal gonorrhea over the past several years. He’s self-employed, lives alone, and has had several sexual partners in the past 6 months. He has bottom (or butt) sex, top, and oral sex.

He returned about 3 weeks ago from a cruise he went on with several friends. He drinks 4 to 6 drinks per week, mostly on weekends, occasionally smokes marijuana, and does not use chem sex. He reported no concerning symptoms when I asked for a brief review of symptoms.

If we move on to the exam, he was well-appearing. The only notable finding was that he had some mild pharyngeal erythema, and on further questioning, he noted a little bit of throat scratchiness.

In reviewing the labs that I had him complete 2 weeks before the clinic visit, his viral load was undetectable. He had mild chronic elevation in AST and ALT, as he has for several years, and a positive syphilis antibody with an RPR of 1:1, which has been stable over the past several years. The rest of his tests, including urine chlamydia and gonococcus NAAT, were negative.

From an STI perspective, what more information would you like about risks or symptoms and what additional testing should I be getting for him?

Margie:
Well, it seems like this is a pretty routine monitoring visit, and it sounds like your patient is feeling well. You’ve described a pretty thorough sexual history that includes a series of bacterial STIs in the past, along with recent sex with several different partners. With that background, I think it’s very possible that your patient might be concerned about some asymptomatic or maybe minimally symptomatic STIs right now. You don’t mention him expressing any concern, but one would wonder given the history of several in the past. You didn’t mention any use of STI prevention methods like condoms or possibly using doxy-PEP, so I might want to know about that. And you also didn’t mention any testing of extragenital sites, but I imagine that was probably done. So, I would want to know those results.

He has been on a cruise, so, there’s some travel in the recent past, and we know that STIs vary depending on where you are in the world. Sometimes even for common STIs, resistance patterns might vary depending on where you are or who you’re with or where they’ve been. I don’t know if that’s going to be the twist, but that might be something that you want to consider. Where was that cruise or where were the people on the cruise from?

Chris:
Let me give you some more information and try to answer some of those questions.

In terms of prevention or prophylaxis, he is not taking doxy-PEP, has not used that in the past. He uses condoms, but intermittently, and admits that he did not always use condoms with his regular partners as well as some new partners while he was on the cruise. The cruise was in the Mediterranean. I did not ask him where these partners originated from, but perhaps you can let me know the relevance of that.

I did extragenital testing with a rectal swab and a throat swab for chlamydia and gonococcal NAATs and got the results from those a few days later. The pharyngeal NAAT was positive for gonorrhea, negative for chlamydia, and the rectal NAATs were negative for both gonorrhea and chlamydia.

Perhaps you could comment on some of the symptoms to expect from pharyngeal gonorrhea—whether his scratchy throat could have been from gonorrheal pharyngitis, and what the timing after exposure to symptoms may be.

Margie:
This is a pretty common problem—pharyngeal gonorrhea. Perhaps of all sites where we could find gonorrhea, probably the least is known about the natural history of gonorrhea in the pharynx, but we do know some things.

Number one would be that most pharyngeal infections are asymptomatic. As with everything in medicine, there’s a bit of a bell curve. Certainly, there are cases where people have symptoms that are attributable to pharyngeal gonorrhea. Those symptoms typically are sore throat or scratchy throat, occasionally some lymphadenitis, some cervical adenopathy, but not usually dramatic symptoms.

There have been some very careful studies trying to get at the natural history of untreated pharyngeal gonorrhea. The most recent of those suggested that if you were going to develop pharyngeal gonorrhea, the average was about 1 to 2 weeks after the sexual exposure. That sexual exposure could be oral sex, oral-penile sex, oral-anal sex, or even sometimes kissing. I don’t know that we always think about that.

You said the cruise was 3 weeks ago. That’s a little outside of the 1 to 2 weeks, but probably well within the usual bell curve of medicine of not all things are exact. So, I think it’s certainly possible that he had acquired this gonococcal infection on that cruise.

The incubation here, as you know, seems like it might be a little bit longer than what we think of for urethral gonorrhea, which is typically much more symptomatic, and a pretty short incubation, usually 3 days. So, a little bit longer for pharyngeal gonorrhea.

There’s another wrinkle though, because in this most recent natural history study, it turns out if you just follow gonococcus in the pharynx without treatment, it can persist for quite a while, especially since it can be asymptomatic or minimally symptomatic. So, it’s sometimes difficult to decide when did it start. The persistence in that study was even up to about 4 months without treatment when you were looking for the infection by NAAT. Some earlier studies had shown that persistence was about 6 weeks when you were using the less sensitive culture technique. So, I don’t know; if we say the scratchy throat is due to the gonorrhea, which seems very possible, probably he got this within the last 2 to 3 weeks. But with that caveat that you could have persistent asymptomatic gonorrhea, maybe it was before that, and the scratchy throat is a red herring.

Chris:
Got it. What about your question about where the potential sexual partners were from?

Margie:
I’m sure anyone who’s interested in STIs is probably well aware of the concerns about antimicrobial resistance in gonorrhea. The organism is in the top 5 to worry about on all sorts of different resistance lists like the CDC or the World Health Organization or the World Bank, who are concerned about the development of polymicrobial resistance in different bacteria.

Depending on where you are, there’s different resistance patterns. For gonorrhea in particular, we know that there’s organisms that are resistant to some of the drugs that have been used in the past—doxycycline, quinolones, azithromycin—really worldwide, including the US.

Resistance to cephalosporins is less common but is found more commonly in some areas of the world, like Southeast Asia in particular, where there’s been reports of relatively high rates of high MICs to ceftriaxone. So, you need more ceftriaxone to treat to effectively cure the infection in these particular organisms. Places like Cambodia and Vietnam have seen, in some surveillance reports, up to 30% of organisms having what is defined as a high MIC of >0.125 mics/mL. That might end up being important in this case if there was some concern that this organism ends up being not treatable by our usual methods.

Chris:
Well, I will add that question when I’m asking my patients who I diagnose with gonorrhea. Considering pharyngeal gonorrhea specifically, what are the treatment considerations that are different or may be different for pharyngeal gonorrhea compared to other sites (genital or rectal gonorrhea)?

Margie:
Even before the 2021 guidelines came out in late 2020, CDC issued a special MMWR talking about revised gonococcal treatment recommendations, specifically because of concerns about resistance spreading internationally. In that guideline, they increased the dose of ceftriaxone recommended for treatment of gonococcal infection. They implemented weight-based dosing. For those <100 kilos, it would be 500 milligrams IM, and for those >100 kilos, it would be 1 gram IM. That was true for pharyngeal gonorrhea as well.

They also implemented a universal test-of-cure for after the treatment of pharyngeal gonorrhea, even when that treatment was the recommended agent, ceftriaxone. That was a difference from the guidelines before late in 2020; then it was recommended to do a test-of-cure only if you used some sort of alternative regimen.

Right now, in the U.S., the recommended regimen for the treatment of gonococcal pharyngitis is only ceftriaxone, and you would use that weight-based dosing of 500 milligrams if <100 kilos or 1 gram if >100 kilos, followed by a test-of-cure.

CDC guidelines say 7 to 14 days; we tend to do longer than that because you can have lingering dead organism, if you will. If you test by NAAT, if you do it too soon, it can be hard to interpret that result, so, we tend to do 14 to 21 days in our clinical practice. That’s probably the biggest difference.

If you think a little bit deeper of why do we differentiate how we treat pharyngeal gonorrhea from rectal gonorrhea or urethral gonorrhea, it’s because the pharynx is kind of a funny place for bacterial infections. We know from other infections it’s kind of hard to eradicate bacteria that you don’t want in the pharynx. Think about how hard it is to eliminate group A strep carriage or meningococcal carriage. Why exactly that is, I don’t entirely understand. I think we do know that there are effectively lower drug levels in the pharyngeal tissue compared to some other body compartments, and that’s one reason why this higher dose of ceftriaxone might be important. For gonorrhea in particular, there are other organisms in the pharynx, commensal Neisseria species, so normal-flora Neisseria species in the throat, and they can persist there. So, they have some genetic material that allows them to persist in the throat without being cleared by the immune system. There have been considerations that maybe these Neisseria can share that genetic material with Neisseria gonorrhoeae and maybe allow that to evade the immune system somewhat as well.

Maybe you have some other theories of why the throat is kind of difficult to treat place for bacteria, but it does seem to be important.

Chris:
I’m learning from you, Margie. It’s certainly fascinating, and, as you said, with multiple bacterial infections, clearing it from the throat is a challenge. Somebody with more understanding of mucosal treatment and immunology maybe could help explain it to both of us.

I do have some more questions about treatment for my patient, and I’ll come back to that in a moment. I just wanted to ask you about partner testing or expedited partner therapy and what you recommend in situations like this and how it works in New York State.

Margie:
Chris, you’re asking about what we often abbreviate EPT. Sometimes that’s called expedited partner therapy. In New York State, they like to call it expedited partner treatment. That’s the situation where you as a clinician have an individual that you diagnose with gonorrhea (in this case). And ideally, you would like their partner to come in and be tested and see if that partner also has gonorrhea at the time.

The recommendation from CDC is if that partner were to come in and be tested and was testing negative but had been exposed to the person who was diagnosed with gonorrhea within the prior 60 days, then the partner who even has a negative test would be treated empirically for gonorrhea in case of incubating infection. Essentially, it’s a kind of post-exposure prophylaxis that’s given after exposure to STIs.

Well, we know that even though the recommendation is for the partner to come in and seek testing, many times this doesn’t happen. There had been some research done in the last decades looking to see if there would be another way to intervene, and that was what we now term expedited partner treatment. That is to have the clinician who has the patient diagnosed with the bacterial STI gonorrhea, in this case, actually say, “I have 2 partners who were exposed in the last 60 days. I don’t think they’ll come in to get tested and treated” and the clinician is then free by law to provide that patient with the medicine or the prescription for medicine to give to their partner. So, the part you’re skipping here is the testing of the partner, but they are still getting that post-exposure prophylaxis.

In New York, this is legal to be offered to those who are diagnosed with gonorrhea, chlamydia, or trichomonas infections, but cannot be used for those diagnosed with syphilis infection, even though that is also a bacterial, curable STI. New York also specifies that it can be done with the clinical diagnosis or a laboratory diagnosis of those conditions. So, you don’t actually have to have the lab test back at the time that you offer that EPT.

It’s interesting that New York State actually changed their terminology from expedited partner “therapy” to expedited partner “treatment.” They did that because they had some focus groups and interaction with patients and clients who could attend a sexual health clinic, and they found that in the consumer world, that idea of expedited partner “therapy” could be interpreted to be counseling about safer sex, whereas if they used the word “treatment,” it was more clear that they were talking about medication to prevent this bacterial STI.

Chris:
That’s so helpful, Margie. I sometimes am overly focused on my patient or the patient in front of me. But certainly, when it comes to STDs or STIs, I need to remind myself sometimes to think about the partners and expedited partner treatment. I’ll use that terminology talking to patients moving forward.

Margie:
I’ll just add one more thing. If you are listening to this and you’re not a clinician, you might not realize that the ceftriaxone that we’re talking about is given as an IM dose. So, it’s an intramuscular dose. It’s a shot. But if you’re giving this expedited partner therapy to treat gonorrhea, obviously you can’t give a medication that has to be an injection to the patient to deliver to their partner. So, we have to use not the drug of choice to treat the partner. We end up using cefixime, which is another oral cephalosporin, at a higher than previous dosing at 800 milligrams as a single dose. In this instance, you’re receiving medication as EPT as opposed to receiving medication as therapy, the treatment is different because the primary therapy for gonorrhea is injectable ceftriaxone.

Chris:
I’ll keep cefixime in mind. Thanks also for that Margie.

I do have a twist now in the case: My patient has a documented cephalosporin allergy. Before I was part of the care team, he had outpatient surgery for which he received preoperative cefazolin and subsequently developed angioedema, wheezing, and hypotension. Subsequently, he was seen by an allergist who diagnosed an IgE-mediated cephalosporin allergy. Obviously, I’d like to avoid the risk of anaphylaxis treating him with the standard regimen of ceftriaxone. What options do we have for cephalosporin allergies, especially when considering pharyngeal gonorrhea.

Margie:
That’s a bit of a tricky question. As we said earlier, ceftriaxone is really the single recommended agent. So, if this were a question on a test, I don’t know exactly how I would answer. I think the answer might be to desensitize and give ceftriaxone as the drug of choice. But I think in the world, for a largely asymptomatic infection that is not causing long-term complications, that would be very unlikely to happen. I think that’s probably not going to happen unless you have treatment failure. You could consider giving ertapenem, which is a drug that is not listed in the CDC guidelines, but has been studied as an alternative for gonorrhea as we try to build up our list of meds that might be active against gonorrhea as resistance spreads. But again, I think in the real world, ertapenem is kind of a big gun antibiotic, if you will, and probably unlikely to be used at least as first line for pharyngeal gonorrhea.

So probably, I would go to the alternate that’s listed in the CDC STI treatment guidelines for gonococcal infection at other mucosal sites, and that would be gentamicin plus azithromycin as a combination treatment. This is another IM dose of medication plus an oral medication. It’s recommended for urogenital gonorrhea, but not necessarily for pharyngeal gonorrhea, so whether it would work 100%, we’re not exactly sure. So you’d have to be certain that you pursue that test of cure after doing that.

I’ve gotten this call sometimes from providers who are in this situation where they can’t use ceftriaxone for some reason. And I say, “Well, you could use gentamicin plus azithromycin,” and they say, “But I don’t have gentamicin,” another drug that’s not commonly carried in outpatient settings.

So, you’re down to third line. Sometimes what I’ve done is recommend that you use ciprofloxacin plus azithromycin. These are both drugs where we know there’s some resistance, maybe even quite a bit of resistance, like 1/3 of organisms might be resistant to cipro, but that means 2/3 thirds are not. Then again, pursue a test of cure after doing that.

I think probably you’re going to jump in and ask me about all the press right now about 2 new agents, if I’m guessing right.

Chris:
Yeah, indeed. In December of 2025, 2 new agents were FDA approved for uncomplicated gonorrhea—gepotidacin and zoliflodacin (apologies to whoever came up with those names for my pronunciation). Perhaps you can situate where you place those agents in gonorrhea treatment and especially in a situation with a patient that has a cephalosporin allergy.

Margie:
Yeah, these might end up being pretty important drugs, particularly for a patient like this, who it seems like is not going to be able to take a cephalosporin now or in the future.

These, as you said, were both FDA approved in December of 2025. They are both first-in-class drugs—different but slightly related classes—the first in their respective classes. They do have activity against DNA gyrase, so it’s somewhat similar to quinolones, but the beauty of these drugs and the reason they were developed and pursued for the treatment of is that they seem to have activity against many resistant organisms, including potentially cephalosporin-resistant organisms.

They both are oral drugs, so that’s definitely a benefit, but they both also have some nuances that I think we’re going to need to see how that all settles out.

The first one is gepotidacin. That was already FDA-approved for use in uncomplicated urinary tract infection. That is commercially available as we speak, which is early winter of 2026. So, you can get that. It did have some significant drug interaction concerns, like prolonged QTc and acetylcholinesterase inhibition; can’t use it in pregnancy.

The dose ends up being a twice a day dose, so it’s not as ideal as a single dose that could be directly observed therapy. The second dose has to be taken 10 to 12 hours after the first dose, so the patient would already be home. It turned out that, at least in the early days, it seems like that dose interval is pretty important. So, you really do have to take it within 10 to 12 hours and not forget and take it 2 days later.

The cure rates for urogenital gonorrhea, though, were non-inferior to ceftriaxone. So, in the major study, it was a 93% cure rate. Like other drugs, the cure rate for pharyngeal infection was lower—about 80%—similar to gentamicin alone in a different study. So, I think it’s going to be important. It has activity against cephalosporin-resistant organisms. But whether it’s ready for prime time, I’m not sure yet.

The second drug, zoliflodacin, is similar. It’s an oral drug. It’s a single dose. It comes as a granule, so you have to dissolve it in water, and it was quite a bit of water, like 60 mLs of water that needed to be to be taken in as the dose. It had to be given with food to the point that they actually gave people a meal in the study if they had not eaten, which is well beyond what is usually done in a clinical setting. So how important that is going to end up being as we get more data, I’m not sure.

It also had non-inferiority for urethra gonorrhea, so a high cure rate, similar to ceftriaxone, but was a little bit less active in the pharynx, about 80% also. This one has also a warning on it. Well, warning’s too strong a word, but in the dosing guidelines, it says that males with partners who can become pregnant should use barrier precautions for 3 months after having even this single dose of med because of some animal studies and some concerns about toxicity that could impact a future pregnancy. So again, in a sexual health clinic, that might be a difficulty.

So how these 2 will end up unfolding, I’m not exactly sure yet. I do think it’s critical that we increase the number of drugs that we have that we can use to treat gonorrhea. There’s been a lot of excitement in both the lay press and in the medical press about having 2 new drugs that are new classes of drugs that could be active. So, I think they will be important, but I think they’re not going to be run-of-the-mill kind of drugs any time soon.

One final thing is, at least presently, they’re pretty expensive, and presently, zoliflodacin is not even commercially available in the U.S. at least.

Chris:
That’s so helpful to learn more about those 2 drugs. Although gepotidacin is theoretically available, a lot of caution with using it. Do you have any comments about the issue that you’ve already raised and drug-resistant gonorrhea? Is that in the clinical trials or other studies of these 2 drugs? Is that likely to be a big issue or we just don’t have enough information yet?

Margie:
I think we don’t have enough information. As I said, they were developed with an eye toward resistant gonorrhea, so that it’s very intentional. I’ve read in the commercial press that [with] zoliflodacin in particular, the intent was to limit this to only the treatment of gonorrhea. So hopefully, by limiting its use, we would preserve the length of time when it continues to have activity against gonorrhea because we’re not using it to treat other things and then potentially breeding resistance by having a lot of drug exposure for other reasons. So, I think we just don’t know yet.

Chris, let me just mention that if people want to learn more about the new agents that are FDA-approved for the treatment of gonorrhea—zoliflodacin and gepotidacin—CEI, our clinical education initiative, just released a podcast that was done by Dr. Stephen Fine, who’s one of my colleagues at the University of Rochester, discussing these 2 drugs in more depth. That podcast is called Conversations with CEI and can be found on any platform that hosts podcasts, but also could be found on the CEI website, is ceitraining.org.

Chris:
Margie, that’s a great resource and we’ll have a link in our show notes to CEI.

We can keep our hope out that we will continue to have some antibiotics that are effective against gonorrhea and perhaps keep the specter of completely drug-resistant gonorrhea at bay for a little while at least.

I want to move on to post-treatment care. You already mentioned the test-of-cure that you do in your practice, usually 2 to 3 weeks following treatment. Can you mention some of the counseling you give to a patient who’s had multiple STIs and also has varied and multiple sexual partners?

Margie:
Post-treatment, test of cure, but also the recommendation is for repeat testing in 3 months, given such high rates of reinfection with both gonorrhea and chlamydia. So, someone who is diagnosed, that is the recommendation— that 3 months later they would have a repeat test to look for reinfection.

For counseling for this patient, I think with everyone, it’s general counseling. We attempt to be stigma free in our language and in our thoughts, really, to be sure that we’re communicating with a patient in a way that is open and invites communication back from the patient. I encourage patients to talk with their partners.

This patient has had several STIs, all of which seem curable. All have been bacterial. Maybe there’s others that you didn’t tell me about. We do know there are some that are not curable, like herpes, or one could say HIV, which in another setting might come up. And we know that new STIs come along periodically, like Mpox. So, I would counsel the patient to view their sexual partnerships with an eye toward these potential risks.

There are ways, if one chooses, to mitigate some of those risks, like condoms, which certainly are not acceptable to a lot of people. It sounds like this patient does use that as a mitigation strategy because he uses condoms some of the times. So, he’s making an assessment of what he feels is acceptable risk and not acceptable risk.

I think doxy-PEP is the big new development over the last few years. That’s the use of doxycycline taken after sex to attempt to prevent chlamydia, syphilis, and gonorrhea. It’s a little bit more effective at preventing chlamydia and syphilis than gonorrhea because of this potential for gonococcal resistance that we’ve mentioned. In the clinical trials at least it did work in the U.S. at reducing all 3 of those infections. This patient, by what you’ve described, exactly fits the entry criteria of the big studies that looked at doxy-PEP that that were so effective that they actually stopped the study because it was so effective the regimen was offered to everyone. That would be something I would want to talk to this patient about.

Chris:
It sounds like he should have a prescription for doxycycline to be able to take 200 milligrams or 2 tabs of doxycycline within 72 hours of potential exposure.

Margie:
That’s right. Maybe he doesn’t want that; maybe he already has that. But I think that’s a real option for this patient as a way to prevent future STIs.

Chris:
Margie, I’ve really enjoyed our conversation. I’ve learned a lot about gonorrhea, especially considering new agents and drug resistance in gonorrhea. Thank you so much for joining Viremic today and for this great discussion.

Margie:
Well, thanks so much, Chris. It’s been good to talk about this subject. It’s really nice to have new developments in the field of STIs that are actually advances in the field [instead] of just the changing epidemiology of STIs of where our rate’s higher or lower. It seems like for a number of years, that’s all we had. But we have some real advances in the last several years that are very exciting.

Chris:
To our listeners, thanks for joining in to another episode of Viremic. Please send any comments or questions to viremicpodcast@jh.edu. We’ll be back in two weeks with a case involving HIV management for an elite HIV controller.

Announcer:
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.

Viremic’s case discussions are for informational purposes only and 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 only, not an endorsement

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