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. Chris Hoffmann:
Welcome to Viremic. I’m Chris Hoffmann coming to you from Johns Hopkins, and I’m joined today by Dr. Tony Urbina from New York City. Tony is a Professor of Medicine at the Icahn School of Medicine at Mount Sinai and the Medical Director of the Institute for Advanced Medicine, Mount Sinai’s HIV Prevention, Treatment, and Sexual Health Network, which spans 4 sites across New York City and cares for over 10,000 patients. He also directs the Clinical Education Initiative, funded by the New York State Department of Health AIDS Institute and serves on the AIDS Institute’s Medical Care Criteria Committee.

Before we start, if you like this podcast, please share 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.

Tony, it’s great to be with you today.

Dr. Tony Urbina:
It’s great to be here. Thank you for inviting me.

Chris:
Tony, before we begin, please share a bit about what led you to a career in HIV medicine.

Tony:
Yes. So, I trained here in New York City at St. Vincent’s Hospital, down in the West Village, and I came here for my internship and my residency. That was 1992 and it was the height of the epidemic, the AIDS epidemic, here in New York.

I think what I witnessed as an intern, really young men and women also just dying with HIV; I just felt compelled to really help this population and to get a grasp on what was happening. So, I think it was my initial exposure here in New York City and being at the height of the epidemic and seeing really sick patients that I think was what got me really involved with HIV medicine.

Chris:
Well, I know you continue to be inspired because you give such great summaries of new regimens and regimen selection during our Medical Care Criteria Committee meetings with the AIDS Institute. So, I’m excited today to be talking to you about a patient who may be the right candidate for one of the newer approved regimens. What I’m specifically thinking about are several approved or soon-to-be-approved fixed dose combinations, 2-drug regimens, specifically

Idvinso, which is doravirine [DOR] and islatravir [ISL], the recently approved Bixlenvo, which is bictegravir [BIC] and lenacapavir [LEN], and the not yet FDA labeled but likely soon to be lenacapavir and islatravir. None of these agents look to displace our current primary agents of Biktarvy [bictegravir/emtricitabine/tenofovir alafenamide] and Dovato [dolutegravir/lamivudine] as preferred agents for most patients. However, I wanted to hear your take on use-case scenarios for at least 1 of these new agents, and I’ve got a case that I think will allow for some discussion of some of the pros and cons of each of these regimens and specifically around this patient.

So, moving on into the case, it’s a case of a 43-year-old man with HIV who was diagnosed about 5 years ago. He’s also living with type 2 diabetes that is relatively well controlled but does have a history of nephropathy that’s been attributed to that diabetes, and he’s recently developed worsening kidney function, which has been attributed to a newly diagnosed IgA [immunoglobulin A] nephropathy. When he was first diagnosed with HIV, he had drug-resistance testing and had no HIV drug-resistance mutations identified by genotyping and was initiated on our tried-and-true first-line regimen of Biktarvy. He developed pretty bad headaches immediately after initiating Biktarvy or within 1 to 3 days, and they persisted even after about 2 weeks on therapy. These were thought to be a potential class-related INSTI [integrase strand transfer inhibitor] neuropsych manifestation or adverse event, and he was switched to Odefsey, rilpivirine/F/TAF [emtricitabine/tenofovir alafenamide], and had a resolution in the headaches.

He’s remained on Odefsey since that time and has maintained an undetectable viral load for the past 5 years. During much of this time he had an estimated eGFR [estimated glomerular filtration rate] of 50 to 60 mL/minute but has recently had a decline in kidney function, which led to the diagnosis of IgA nephropathy, and now his eGFR hovers around 30 mL/minute as estimated using cystatin C. The nephrologist managing his kidney disease wants to minimize all potential nephrotoxins and has recommended stopping TAF. Tony, before getting to any of the new alternative regimens to Odefsey, can you just provide some initial thoughts or how you would frame this patient and next steps?

Tony:
Interesting case, and I think we’re increasingly seeing this in our patients aging with HIV, and in particular those with comorbidities—like this patient has diabetes—that are risk factors for declining renal function. So, I think that’s something that is really coming up a lot in our clinics (for) those of us that are treating patients living with HIV is this whole issue of aging with HIV and decreasing CKD [chronic kidney disease], and is it time to go tenofovir-free? That’s what a lot of us are being challenged with. Critically, at that eGFR at 30, we know TAF-based regimens, so tenofovir alafenamide-based regimens, you can dose them down to 30, but then, once you hit that critical eGFR, I think a lot of us are thinking, “Hey, what regimens can be fully suppressive and be tenofovir-free?” So that’s one of the thoughts that I have here, and I do want to restate, Chris, what I think you say that’s very important, that I don’t think any of these newer regimens are competing with first line, but I think they may be solving different problems.

What we’ll get into is that these newer single-tablet regimen combinations are really only indicated for patients that are switching. So, we kind of need a good reason—like what problem are we trying to solve? So, in this case, the thing that comes to mind is worsening renal function and the potential for it to get worse, and then I think the other one that you brought up was this headache. There’s huge differential for headache, but it could also be attributable to INSTIs, so it could be a spectrum that’s part of these neuropsych issues that have been described with the integrase class. And again, in this patient, it looked like the headache started after initiating the INSTI, so we have to believe that it may have been contributing. So we’re looking at tenofovir-free and INSTI-free are some of my initial thoughts here.

Chris:
Very good. I like your framing of that, Tony. There are certainly traditional meds that could potentially work, and we can discuss some of those, but I think this is an opportunity to talk about some of these new fixed-dose regimens. And although not all of them may be appropriate for this patient, I find I at least get confused when 3 similar-named regimens come out [at the] same time, so I thought it would be helpful if we just walk through all 3 of them and then can discuss the use cases a little bit around this patient.

Tony:
Sure. That sounds good.

Chris:
Yeah, can you describe the indication and dosing frequencies for doravirine/islatravir, lenacapavir/islatravir, and BIC/LEN, that would be great.

Tony:
I think these combinations are solving 3 different problems. For the doravirine/islatravir, so doravirine, a second-generation NNRTI [non-nucleoside reverse transcriptase inhibitor], can work, has a higher genetic barrier to resistance, and doesn’t have the baggage of the efavirenz with those central nervous system side effects. And then a kind of new-in-class antiretroviral, the islatravir, [a] non-nucleoside reverse transcriptase translocation inhibitor [NRTTI]. That’s a tough one to say.

So doravirine and islatravir—the brand name Idvynso—definitely tenofovir-free, INSTI-free. So to me, it kind of solves those cases where you don’t want to use tenofovir, and then also class avoidance—so avoiding the INSTI class altogether, and then obviously the protease inhibitor class. So that’s how I see that one.

Then bictegravir/lenacapavir. So bictegravir, we know it’s part of Biktarvy. It’s an INSTI [with] a high genetic barrier to resistance; I think we’re pretty familiar with it. Then with lenacapavir—that’s the capsid inhibitor—we’ve already seen it for treatment of HIV—so that’s Sunlenca—and then I think more recently with prevention—so subcutaneous LEN or Yeztugo. But the way that I see it with these single-tablet regimen combination(s), the BIC and the LEN, it kind of solves this resistance and, kind of, regimen complexity. I think it’s the smallest single-tablet regimen that hopefully we can switch patients that either have preexisting resistance [who] are taking multiple tablets or multiple times a day—so complex regimens that we can simplify. So that’s kind of how I see the niche of that one.

And then islatravir/ lenacapavir, so combining then this NRTTI with this capsid inhibitor that’s going to be dosed weekly. So, it’s kind of our first long-acting oral combination regimen. I think that one [islatravir/lenacapavir] can solve dosing burden and adherence preference and maybe [for] patients that don’t want to go on long-acting injectables.

As you kind of mention, I don’t think any of these are competing for first line. None of them showed really superiority, but that’s not really how the clinical trials were designed, you know. All of them were for switch.

Chris:
I just wanted to highlight a few of those points, briefly describing the registrational trials for each of those regimens starting with Idvynso or doravirine/islatravir. There are 2 registrational trials, as is standard with the FDA, and 1 of them, authored by Chloe Orkin and colleagues, (which) was a switch trial, as you highlighted, is key for all of these. And that was a switch to doravirine/islatravir or to remain on whatever first-line regimen the patient was on, so no placebo was involved. And there were about 500 participants randomized 2:1 to DOR/ISL or their current first-line regimen. Sixty percent were male with a median age of 51, 45% were black, and as you said, the DOR/ISL was noninferior to the first-line regimen at 48 weeks. I believe [sic] a little over 1% of the DOR/ISL participants had a viral load >50, compared to close to 5% of those on their baseline ART regimen. The 1 notable side effect that was somewhat increased in the DOR/ISL was diarrhea, I think. It is important to note that in switch studies, when somebody’s switched to a new regimen, they’ll almost always report more side effects, even if there are not truly more side effects with the new regimen compared to continuing what somebody was on.

The other DOR/ISL registrational trial was authored by Jorgen Rockstroh and colleagues, and this was a double-blind, placebo-controlled trial with treatment-naive individuals without any notable NRTI [nucleoside/nucleotide reverse transcriptase inhibitor] or NNRTI mutations, importantly including no M184V or M184I mutation. About 500 participants were randomized 2:1 to either DOR/ISL or BIC/F/TAF. The median age was 32; 29% were female. And also this showed noninferiority, DOR/ISL or BIC/F/TAF at 48 weeks, with 92% versus 91% having a viral load <50 in DOR/ISL versus BIC/F/TAF, respectively. In this study, side effects were relatively similar between the groups, and again a placebo-controlled trial.

One of the comments I wanted to make, not so much for these trials but just overall, are some of the considerations with prescribing ISL—and one was included in these trials—that the M184V or M184I reduces susceptibility by about 5-fold to ISL, and the other is that 3TC [lamivudine] and FTC [emtricitabine] have a competitive inhibition of ISL because of co-competition for the deoxycytidine kinase, which leads to decreased levels of the active islatravir triphosphate. Anything else to add, Tony?

Tony:
I think those are really important points to bring up. In terms of the M184V and other mutations, I think this is an emerging field. There’s some evidence that the M184V can lead to this fold resistance to islatravir, but we don’t have the clinical cutoffs yet. So, I think it’s something that we do need to be concerned about when we switch patients and we look at any preexisting mutations, any previous resistance test, maybe even possibly an archive, just to see if these mutations may impact on the success of islatravir-containing regimens. An isolated M184V is probably tolerable, but I don’t think we know that. In addition, I think if the patient has TAMS [thymidine analogue mutations] in addition to M184V, that that might be a different proposition. And we cannot really say where activity is lost because we don’t really have those clinical cutoffs. They just don’t exist. So, that’s a very interesting point to bring up.

I think for the competing mechanisms of the emtricitabine and the lamivudine you couldn’t concomitantly give those agents with other islatravir-containing compounds because they’re going to compete for that same enzyme activation site. That would be a contraindication.

And maybe the last point, Chris, that I would like to make with these is that really none of these combinations has activity against hepatitis B. We really need to screen our patients prior to switch, make sure that they are immune to hepatitis B, [and] if they’re not, we vaccinate them even prior to switch. One of the outcomes from the study, which was a little different from the arms that did contain tenofovir-containing regimens, is that cases of new Hep B or hepatitis B reactivation. So, I think it’s going to be important for us to really consider hepatitis B and all of these regimens.

Chris:
Such an important point, definitely, in terms of the Hep B, and I think that’s going to be something that, as we move away from TAF-containing regimens, as much as that happens and is what’s certainly happening as we use more dolutegravir/3TC, is a greater mindfulness to both hepatitis B vaccination and prevention of acute hepatitis B through vaccination and repeat testing of hepatitis B antibody levels to make sure that there’s still protection, as well as assessing whether or not a patient has chronic hepatitis B that was controlled with their TAF-containing regimen and now no longer will be controlled when they’re no longer on either TAF or FTC or 3TC.

Tony:
Yeah, you’re absolutely right, and at Sinai here, we’ve been implementing that. I think Cabenuva [cabotegravir/rilpivirine] was our first big foray into these tenofovir-free regimens, and just really keeping an eye out on that hepatitis B. But also, just the previous regimens, like you mentioned, Dovato that may not have tenofovir, but also Juluca [dolutegravir/rilpivirine]. I think that’s going to be a very important educational concept in the field of HIV as these newer treatments come up, because they do seem to be increasingly tenofovir-free. So, I think you bring up a really good point there, Chris.

Chris:
Why don’t we talk a little bit about the BIC/LEN trials for registration of Bixlenvo? Those are the ARTISTRY-1 and ARTISTRY-2 trials authored by Chloe Orkin and colleagues, and ARTISTRY-2 by Eric Meissner and colleagues.

For ARTISTRY-1, there were close to 400 participants in the BIC/LEN arm receiving daily BIC/LEN and close to 200 in the continued complex regimen arm. The median age was 60. These participants had a whopping 28 years of prior antiretroviral treatment duration, so they were highly treatment-experienced. This regimen was noninferior at 48 weeks to continuation of the complex regimen. In the publication, it nicely describes and shows what the complex regimens were, and there was a wide range. Many participants were on dolutegravir plus boosted darunavir, but there were a host of other various combinations as well. This switch allowed going from multiple pills; I think the median was around 4 tablets to a single tablet daily.

[sic] ARTISTRY-2—this was a double-blind trial of BIC/LEN versus continuation of BIC/F/TAF for individuals with viral suppression on BIC/F/TAF—[had] similar numbers in the 2 arms as in ARTISTRY-1. And similarly, there was noninferiority. In this trial, like some of these others, diarrhea was a little higher in the experimental arm: 8% versus 5% in the BIC/ F/TAF continuation arm.

One of the comments I wanted to make about this, and I think really the implications are still to play out, but the half-life of lenacapavir is much longer than bictegravir, which is what allows ISL/LEN weekly dosing. But that could lead to an unbalanced treatment tail when combined with bictegravir, which has a half-life of <1 day compared to the 5 to 9 for the lenacapavir. That may or may not be an issue in the future with increased risk for lenacapavir resistance in patients with intermittent or discontinued dosing of that regimen.

Anything else to add, Tony?

Tony:
Yeah, just on that one. I think that mismatch on half-lives—and I’ll call it the tail problem—you bring up a really good point that really hasn’t been brought to the forefront [for] these regimens compared to what we’re kind of used to with our first-line regimens, because we have the data to know genetic barrier to resistance and just a lot of trial data. But because of [this] mismatch of half-life—so for the BIC/LEN, just like you pointed out, bictegravir has a half-life of about 17 hours, and oral LEN is about 10 to 12 days. So, when you stop it [BIC/LEN], those bictegravir levels are going to clear within days and then the lenacapavir [levels] are going to persist for weeks, maybe longer, so you’re going to have functional lenacapavir levels.

So, I think we’re also going to have to prescreen patients because, the ARTISTRY study, you know, they were complex patients, many years taking their regimens. But for other patients, maybe where they didn’t have 15 years of perfect prescription refills, I think we are going to have to talk about, “Hey, if you should decide to interrupt therapy, there’s a risk here that you may more likely develop resistance to this regimen.” So, adherence is a bigger issue here in terms of durability of these regimens, and I think [it is] something that we’re going to need to discuss more and also screen patients and say, “Hey, we really need to make sure that with these 2 drugs, that are combined to a tablet, that you really adhere to therapy.” So, I think that’s a really important point that you brought up.

Chris:
I thought it would be useful to just very briefly touch on the trial of islatravir/lenacapavir. And again, that can be dosed once weekly, although is not yet FDA-approved. And there were 2 trials that are both published but also both presented at AIDS 2026, and you can hear more of an in-depth discussion with Joel Gallant on our podcast on AIDS 2026.

In ISLEND-1, it was ISL/LEN [once per] week versus a continuation of BIC/F/TAF, and that was placebo-controlled. There were about 300 participants in both arms: 21% were female, 31% were black. In the ISL/LEN arm, no patients had a viral load >50 at 48 weeks; 1 patient had a viral load >50 at 48 weeks in the BIC/F/TAF arm. Side effects were overall similar between the arms.

And in ISLEND-2, which was a switch from a current regimen to ISL/LEN or to stay on that current regimen—about 300 participants in both arms; 34% were female, 31% were black, and very similar noninferiority results—very few participants had a viral load >50 at 48 weeks in either arm.

Any comments on those trials, Tony?

Tony:
Yeah, I think that’s amazing. No emergent islatravir or lenacapavir resistance, high rates of virologic suppression, and adherence was also just amazing with the weekly as well. I guess what’s, to me, really interesting about these—and again, really 2 kinds of these newer antiretrovirals, so it’s unlikely that patients will have preexisting resistance to them. I think with the islatravir, like we mentioned earlier, concerns about that M184V or M184V with TAMS. I think we’re going to need to get a little bit more clarity about that one as we move forward. But I think what’s the real important story here is these patient-reported outcomes with the weekly (dosing). Nearly two-thirds said that their prior daily regimen was more burdensome and only 1% said that about the weekly pill. Participants were greater than 75% more satisfied with the weekly regimen. So, I think that’s really important and interesting that moving away from the burden of having to take a pill every day, I think is evidenced by this patient outcome, [is] just destigmatizing for patients. Again, just to keep mentioning, neither of these has activity against Hep B—I think there was 1 case of acute hepatitis B in these trials—the importance about screening and then vaccinating.

And then, Chris, I think as opposed to the other, the DOR/ISL and the BIC/LEN, I think the ISL/LEN, they have more, like, matched half-lives; so I think that’s a little bit more reassuring in that when patients discontinue, that maybe the drugs will clear at the same rate. That might be less concern for emerging resistance, but I still think we’re going to have to keep an eye on that. But those are my additional thoughts about that. Even when I ask patients now in the clinic, “How do you feel about a once-weekly regimen for HIV?” they seem to really like the idea of that option. I don’t know if you’ve experienced the same.

Chris:
So, many of my patients ask about an every-6-months regimen, and certainly I do have quite a few patients on CAB [cabotegravir]/rilpivirine every 2 months. I’ve only asked a few patients about weekly. What I’d have to say is my first thought is that somebody who might have a hard time remembering things, remembering it every week, and certainly missing a dose is much worse presumably than missing a dose when you’re taking it every day. But, from the trial it seemed like people did very well taking it weekly in the open-label arm, so that gives me some reassurance.

Tony:
You’re right. I think the PK [pharmacokinetic data] shows maybe a 2-week forgiveness, but you’re absolutely right. How many patients forget their Fosamax [alendronate], right? So again, I think prescreening, letting them know about that window.

One other issue with the lenacapavir—any lenacapavir-containing regimen, but with the BIC/LEN and the ISL/LEN—is that they’re going to need oral loading doses, so they just don’t really start off weekly, but they’re going to have to orally load with the additional tablets of lenacapavir on day 1 and day 2. And, similarly, for the Bixlenvo—so that(s) BIC/LEN—I think on day 1, it’s that 1 Bixlenvo, plus they’ve got to take 2 of the 300 milligram tablets of lenacapavir, then day 2 they have to repeat that. So, there is going to be some loading with the lenacapavir combinations. That’ll be important, because if patients fall outside of their window, they’re going to have to reload.

Chris:
Very important points, and adds a little complexity beyond what we’ve become familiar with [with] Biktarvy and Dovato, where complexity has almost been removed from the HIV ART prescribing equation.

Tony:
You are right about that. So, I think we have to be solving a problem when we start looking at these newer agents. One of the things with the complexity, too, I think that you’re bringing up, is that initially when they start, it’s going to be 2 prescriptions, so making sure that patients take 2 and that they kind of do their loading correctly. So, are we going to bring them into clinic for those first couple of days to make sure they do it correctly? Or are we going to give them instructions to do it at home, which I’m assuming, but it’s going to be 2 different prescriptions for those lenacapavir ones [regimens] and just a little bit of patient education to go along with that to make sure that things are done correctly and safely.

Chris:
If we circle now back to our patient, I’ll provide you with just a little bit of additional relevant info. So, he was vaccinated for Hep B and developed Hep B antibodies about 4 years ago but has not had any subsequent hepatitis B surface antibody testing. He is very concerned about his declining kidney function and wants to follow his nephrologist’s advice to get off of the TAF-containing regimen but is concerned about any INSTI-containing regimen, given his prior experience with a headache that’s been attributed to the bictegravir. How would you approach regimen selection for him?

Tony:
I think with the INSTIs, again, that one of the potential side effects that I think is maybe not talked [about] enough [with] patients are these potential neuropsych issues. There may be a possible mechanistic reason for it in that it may inhibit acetylcholinesterase, so almost act like the drug Aricept [donepezil] does, and maybe that cholinergic surge may drive these symptoms of headache and insomnia being the most common. It could be specific to the bictegravir, but it could also just be a class effect.

If we wanted to think about going INSTI-free here, which I think may be important to the patient and maybe minimize these side effects, I may think about doravirine/islatravir in the situation. It doesn’t look like he has any preexisting mutations that I would be concerned about, has maintained viral logic suppression. BIC/LEN or Bixlenvo has the integrase, but lenacapavir has drug-drug interactions. It’s not a strong inhibitor like ritonavir or cobicistat, but it’s a moderate inhibitor of cytochrome 3A4. You said he had nephropathy, right?

Chris:
Right.

Tony:
So, if they wanted to give him targeted steroids, budesonide or something that may be metabolized via CYP3A4, then bringing LEN into a switch, I would be concerned about maybe some newer drug-drug interactions. I think those can mainly be managed as we do with Sunlenca and Yeztugo, but LEN is a moderate inhibitor of CYP3A4. I think given those and his prior history, I might go for DOR/ISL.

Chris:
If there’s a good use case for DOR/ISL, it seems like it would be a patient like this one who could really benefit both in terms of avoiding a potential INSTI side effect as well as a very renal-sparing regimen. And certainly, we could come up with other regimens using other agents such as proteases inhibitors, which there’s a general movement away [from] given potential increased cardiovascular and other side effects. But I think DOR/ISL, assuming his insurance would cover it, would be a very appealing regimen for this gentleman.

Tony:
I think so too. And I think with all of these regimens, too, these newer ones, Chris, that we’ve been talking about, less concerns about renal dosing or use in patients with CKD, so I think that’s very attractive for HIV practitioners managing their patients that are now getting older. Tenofovir- and INSTI-free kind of regimen. So, these, class-sparing—I do agree with you, I think a lot of us are moving away from PIs just because of the boosting effect and the metabolic effects and the lipid effects that, you know, may come along with these. I just think it’s great that we still have options in the field to really tailor our regimens and adapt to our patients’ comorbidity. I don’t think any of them so far have been, metabolically superior in any of the trials, except for maybe when they’ve come off of a protease inhibitor and lipids have improved. I think they’ve shown that in the ISLEND trials. But, again, just a little bit more renally friendly. TAF is definitely something that can be dosed down to a creatine clearance of 30, but I think a lot of our nephrologists at Sinai as well are saying, “When I see renal function deteriorating, is there an option to take tenofovir off?” And I think we’re finally starting to get those options.

Chris:
It’s exciting and keeps making HIV medicine exciting that we have new regimens and continue to have new regimens that both are challenging for the clinician, but most importantly, options for improved quality of life for our patients. That’s certainly one of the things that keeps me excited in this field.

Tony:
I agree with that, and I think if you just look at the remarkable trajectory of these antiretroviral therapies, where we started—and Chris, I know you’ve also been around as long as I have—it’s just really been remarkable, and just to see it to continue to evolve and not just for long-acting injectables but also for long-acting orals, as we’re seeing with the once-weekly oral. I agree, really exciting, especially for younger clinicians that are interested in HIV medicine.

Chris:
Tony, thanks so much for this conversation. It’s been really fun discussing this case and how new agents do or don’t fit into our treatment landscape. I must say once ISL/LEN is available and approved, we may have to come up with a use case for that and discuss that regimen in more depth. Thanks so much.

Tony:
Thank you so much, Chris, for inviting me.

Chris:
To our listeners, thanks for joining another episode of Viremic. Please send any comments or questions to viremicpodcast@jh.edu. We’ll be back in 2 weeks with a case about clinical trials of broadly neutralizing antibodies and discussing these with patients, so please join us then.

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 Jen Ham and Brian Hatcher with assistance from Jesse Ciekot and Laura LeBrun Hatcher.