Viremic – Cases in HIV

Schedule Update

Hello Viremic listeners. We are taking a break for the month of July. Please check out our past episodes and catch up on any cases you may have missed [https://viremic.org/episodes]. We love hearing from our listeners, so please send us comments or potential case topics to viremicpodcast@jh.edu [viremicpodcast@jh.edu]. Don’t forget to give us a like and follow us wherever you access podcasts. We’ll be back on Tuesday, August 4 with a new case to discuss. Thank you.

Case 25. A Few of Our Favorite Vaccines

A new-to-you patient—51-yr-old man with HIV since the early 2000s—has spotty vaccine records. How to educate, make recommendations, and avoid too many vaccinations at once? Listen as Chris and Eileen from Johns Hopkins make the case argue for their favorite vaccines among the many recommended for adults with HIV and describe their approaches to patient education, prioritizing based on specific patient needs, and strategizing vaccination schedules. Reference:  * Marks KM, Kang M, Umbleja T, et al. HepB-CpG vs HepB-Alum Vaccine in People With HIV and Prior Vaccine Nonresponse: The BEe-HIVe Randomized Clinical Trial. JAMA. 2025 Jan 28;333(4):295-306. PMID: 39616603 [https://pubmed.ncbi.nlm.nih.gov/39616603/]. Related Guidelines and Resources from the NYSDOH AI Clinical Guidelines Program: * Immunizations for Adults With HIV [https://www.hivguidelines.org/guideline/hiv-immunizations/?mycollection=hiv-care]; see especially: * Hepatitis B Virus (HBV) [https://www.hivguidelines.org/guideline/hiv-immunizations?mytab=tab_5&mycollection=hiv-care] * Human Papillomavirus (HPV) [https://www.hivguidelines.org/guideline/hiv-immunizations?mytab=tab_6&mycollection=hiv-care] * Measles, Mumps, Rubella (MMR) [https://www.hivguidelines.org/guideline/hiv-immunizations?mytab=tab_8&mycollection=hiv-care] * Pneumococcal [https://www.hivguidelines.org/guideline/hiv-immunizations?mytab=tab_12&mycollection=hiv-care] * Zoster [https://www.hivguidelines.org/guideline/hiv-immunizations?mytab=tab_15&mycollection=hiv-care] * Prevention and Management of Hepatitis B Virus Infection in Adults With HIV [https://www.hivguidelines.org/guideline/hiv-hbv/?mycollection=hepatitis-care] * Prevention and Management of Human Papillomavirus Infection in Adults With HIV [https://www.hivguidelines.org/guideline/hiv-hpv/?mycollection=hpv-care] * Viremic Case 15. A Pain in the Butt: Anal Cancer Screening and Prevention [https://viremic.org/episodes/case-15-a-pain-in-the-butt-anal-cancer-screening-and-prevention]

Case 24. A Violaceous Situation: Kaposi Sarcoma

A 42-yr-old man with AIDS presents feeling unwell, with white spots in his mouth, and scattered violaceous macules on his upper extremities; he has never taken ART. Listen as hosts Eileen Scully and Chris Hoffmann from Hopkins describe their initial work-up for a patient with a CD4 count of 10; discuss symptoms, diagnosis, and treatment of Kaposi sarcoma and other HHV8-related diseases; and remember the historical stigma of KS and the lingering effects of that stigma as they confirm the need to remain KS-aware even in 2026 in the U.S. References Cited: * Bettuzzi T, Lebbe C, Grolleau C. Modern Approach to Manage Patients With Kaposi Sarcoma. J Med Virol. 2025 Mar;97(3):e70294. PMID: 40119751 [https://pubmed.ncbi.nlm.nih.gov/40119751/]. * Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. National Institutes of Health, HIV Medicine Association, and Infectious Diseases Society of America. Human Herpesvirus-8 Disease. Updated April 23, 2025. Available online here [https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/human-herpesvirus]. Accessed 5/21/2026. Related Guidelines NYSDOH AI Clinical Guidelines Program: * Primary Care for Adults With HIV [https://www.hivguidelines.org/guideline/hiv-primary-care/?mycollection=hiv-care]; see especially Flowchart 3: Initial Visit: New Patient, HIV Confirmed, NOT Taking ART  * Management of IRIS [https://www.hivguidelines.org/guideline/hiv-iris/?mycollection=hiv-treatment] * Rapid ART Initiation [https://www.hivguidelines.org/guideline/hiv-art-rapid/?mycollection=hiv-treatment] Clinical Info HIV.gov:  * HIV Clinical Guidelines: Adult and Adolescent Opportunistic Infections [https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections] – Human Herpesvirus-8 Disease [https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/human-herpesvirus] Resource:  * DermNet – Kaposi sarcoma images [https://dermnetnz.org/topics/kaposi-sarcoma-images]

Case 23. Managing Directly (Inter)Acting Medications

Chris presents a 62-yr-old man with HIV for >30 yrs, with viral suppression and many drug resistance mutations, whose ART must be changed due to a drug-drug interaction, but also for simplification. As part of their discussion, Chris and Eileen review reasons to change ART regimens, and work through the evidence-based options for this patient based on his history and resistance mutations profile. References Cited: * Ciaffi L, Koulla-Shiro S, Sawadogo AB, et al. Boosted protease inhibitor monotherapy versus boosted protease inhibitor plus lamivudine dual therapy as second-line maintenance treatment for HIV-1-infected patients in sub-Saharan Africa (ANRS12 286/MOBIDIP): a multicentre, randomised, parallel, open-label, superiority trial. Lancet HIV. 2017 Sep;4(9):e384-e392. Epub 2017 May 28. PMID: 28566227 [https://pubmed.ncbi.nlm.nih.gov/28566227/]. * Hocqueloux L, Raffi F, Prazuck T, et al. Dolutegravir Monotherapy Versus Dolutegravir/Abacavir/Lamivudine for Virologically Suppressed People Living With Chronic Human Immunodeficiency Virus Infection: The Randomized Noninferiority MONotherapy of TiviCAY Trial. Clin Infect Dis. 2019 Oct 15;69(9):1498-1505. PMID: 30601976 [https://pubmed.ncbi.nlm.nih.gov/30601976/]. * Paton NI, Musaazi J, Kityo C, et al. Efficacy and safety of dolutegravir or darunavir in combination with lamivudine plus either zidovudine or tenofovir for second-line treatment of HIV infection (NADIA): week 96 results from a prospective, multicentre, open-label, factorial, randomised, non-inferiority trial. Lancet HIV. 2022 Jun;9(6):e381-e393. Epub 2022 Apr 20. PMID: 35460601 [https://pubmed.ncbi.nlm.nih.gov/35460601/]. * Raffi F, Babiker AG, Richert L, et al. Ritonavir-boosted darunavir combined with raltegravir or tenofovir-emtricitabine in antiretroviral-naive adults infected with HIV-1: 96 week results from the NEAT001/ANRS143 randomised non-inferiority trial. Lancet. 2014 Nov 29;384(9958):1942-51. Epub 2014 Aug 4. PMID: 25103176 [https://pubmed.ncbi.nlm.nih.gov/25103176/]. * Severe P, Pierre S, Homeus F, et al. Bictegravir, emtricitabine, and tenofovir alafenamide versus ritonavir-boosted protease inhibitor-based antiretroviral therapy in people with HIV and viral suppression on second-line therapy in Haiti: an open-label, randomised, non-inferiority trial. Lancet HIV. 2025 Sep;12(9):e616-e626. Erratum in: Lancet HIV. 2026 Feb;13(2):e84. Erratum in: Lancet HIV. 2026 Feb 24:S2352-3018(26)00037-8. PMID: 40883049 [https://pubmed.ncbi.nlm.nih.gov/40883049/]. Related NYSDOH AI Guidelines: * Second-Line ART After Treatment Failure or for Regimen Simplification [https://www.hivguidelines.org/guideline/hiv-2nd-line-art/?mycollection=hiv-treatment] * HIV Resistance Assays [https://www.hivguidelines.org/guideline/hiv-resistance-assays/?mycollection=hiv-treatment] * Drug-Drug Interaction Guide: From HIV Prevention to Treatment [https://www.hivguidelines.org/guideline/hiv-art-drug-interactions/?mycollection=hiv-treatment] * Virologic and Immunologic Monitoring in HIV Care [https://www.hivguidelines.org/guideline/hiv-monitoring/?mycollection=hiv-treatment]

Case 22. Sex with Drugs: Talking About Chemsex and Harm Reduction

With guest Dr. Jeremy Kidd [https://www.jeremykiddmd.com/], Chris reviews the case of a 27-yr-old man with HIV who reports using methamphetamine to enhance sex and has unsuppressed HIV. Is this chemsex? Is the unsuppressed viral load related? How should Chris discuss this with his patient, and what should he recommend? How should he approach the topic of harm reduction if the patient is not going to stop using chemsex? References Cited: * Kidd JD, Smiley SL, Coffin PO, et al. Sexual orientation differences among men in a randomized clinical trial of extended-release naltrexone and bupropion for methamphetamine use disorder. Drug Alcohol Depend. 2023 Sep 1;250:110899. Epub 2023 Jul 17. PMID: 37478502 [https://pubmed.ncbi.nlm.nih.gov/37478502/]. * Reback CJ. The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles. 1997. Available online here [https://static1.squarespace.com/static/5a1dda626957daf4c4f9a3bb/t/5acfa4f72b6a28b299792da0/1523557626159/SocialConstruction_Reback.pdf]. Accessed February 24, 2026. * Trivedi MH, Walker R, Ling W, et al. Bupropion and Naltrexone in Methamphetamine Use Disorder. N Engl J Med. 2021 Jan 14;384(2):140-153. PMID: 33497547 [https://pubmed.ncbi.nlm.nih.gov/33497547/]. Documentaries Mentioned: * parTy boi, black diamonds in ice castles [https://www.imdb.com/title/tt7685942/] * Crystal City [https://www.imdb.com/title/tt9001652/] Related NYSDOH AI Guidelines and Guidance: * Chemsex: Questions and Answers [https://www.suguidelinesnys.org/guideline/chemsex] * Substance Use Screening and Risk Assessment [https://www.suguidelinesnys.org/guideline/substance-use-screening] * Substance Use Harm Reduction [https://www.suguidelinesnys.org/guideline/substance-use-harm-reduction] * PrEP to Prevent HIV and Promote Sexual Health [https://www.hivguidelines.org/guideline/hiv-prep/?mycollection=pep-prep] * PEP to Prevent HIV Infection [https://www.hivguidelines.org/guideline/hiv-pep/?mycollection=pep-prep] * Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections [https://www.hivguidelines.org/guideline/sti-doxy-pep/?mycollection=sexual-health] * Guidance: Adopting a Patient-Centered Approach to Sexual Health [https://www.hivguidelines.org/guideline/sexual-health-framework/?mycollection=sexual-health]