Viremic – Cases in HIV

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]

Case 21. If You’ve Seen One, You Haven’t Seen Them All: Elite Controllers

Eileen welcomes Dr. Joel Blankson [https://profiles.hopkinsmedicine.org/provider/joel-n-blankson/2709031] to review the case of 28-year-old man who is an elite controller. They discuss elite control characteristics, monitoring, and treatment, while also touching upon patient education and shared ART decision-making. References Cited: * Hatano H, Yukl SA, Ferre AL, et al. Prospective antiretroviral treatment of asymptomatic, HIV-1 infected controllers. PLoS Pathog. 2013;9(10):e1003691. Epub 2013 Oct 10. PMID: 24130489 [https://pubmed.ncbi.nlm.nih.gov/24130489/]. * Kwaa AK, Blankson JN. Immune Responses in Controllers of HIV Infection. Annu Rev Immunol. 2024 Jun;42(1):21-33. Epub 2024 Jun 14. PMID: 37827174 [https://pubmed.ncbi.nlm.nih.gov/37827174/]. * Li JZ, Blankson JN. How elite controllers and posttreatment controllers inform our search for an HIV-1 cure. J Clin Invest. 2021 Jun 1;131(11):e149414. PMID: 34060478 [https://pubmed.ncbi.nlm.nih.gov/34060478/]. * Li JZ, Segal FP, Bosch RJ, et al. Antiretroviral Therapy Reduces T-cell Activation and Immune Exhaustion Markers in Human Immunodeficiency Virus Controllers. Clin Infect Dis. 2020 Apr 10;70(8):1636-1642. doi: 10.1093/cid/ciz442. PMID: 31131858 [https://pubmed.ncbi.nlm.nih.gov/31131858/].

Case 20. New Options for Treating Pharyngeal Gonorrhea

How to treat pharyngeal gonorrhea in a 32-year-old gay man with HIV who has a documented cephalosporin allergy? Chris presents this case to guest Dr. Marguerite (Margie) Urban [https://www.urmc.rochester.edu/people/112358681-marguerite-a-urban], director of the NYSDOH CEI Sexual Health Center of Excellence and longtime member of the Adult HIV Guidelines Committee of Clinical Guidelines Program. They explore options for treatment and consider the role of gepotidacin and zoliflodacin, two new first-in-class drugs approved by the FDA in December 2025 for treatment of uncomplicated gonorrhea. References Cited:  * Barbee LA, Soge OO, Khosropour CM, et al. The Duration of Pharyngeal Gonorrhea: A Natural History Study. Clin Infect Dis. 2021 Aug 16;73(4):575-582. PMID: 33513222 [https://pubmed.ncbi.nlm.nih.gov/33513222/]. * Hutt DM, Judson FN. Epidemiology and treatment of oropharyngeal gonorrhea. Ann Intern Med. 1986 May;104(5):655-8. PMID: 2938529 [https://pubmed.ncbi.nlm.nih.gov/2938529/]. * Kirkcaldy RD, Workowski KA. Gentamicin as an alternative treatment for gonorrhoea. Lancet. 2019 Jun 22;393(10190):2474-2475. Epub 2019 May 2. Erratum in: Lancet. 2019 Jun 29;393(10191):2590. PMID: 31056292 [https://pubmed.ncbi.nlm.nih.gov/31056292/]. * Luckey A, Balasegaram M, Barbee LA, et al. Zoliflodacin versus ceftriaxone plus azithromycin for treatment of uncomplicated urogenital gonorrhoea: an international, randomised, controlled, open-label, phase 3, non-inferiority clinical trial. Lancet. 2026 Jan 10;407(10524):147-160. Epub 2025 Dec 11. PMID: 41391465 [https://pubmed.ncbi.nlm.nih.gov/41391465/]. * Luetkemeyer AF, Donnell D, Dombrowski JC, et al. Postexposure Doxycycline to Prevent Bacterial Sexually Transmitted Infections. N Engl J Med. 2023 Apr 6;388(14):1296-1306. PMID: 37018493 [https://pubmed.ncbi.nlm.nih.gov/37018493/].  * Ross JDC, Wilson J, Workowski KA, et al. Oral gepotidacin for the treatment of uncomplicated urogenital gonorrhoea (EAGLE-1): a phase 3 randomised, open-label, non-inferiority, multicentre study. Lancet. 2025 May 3;405(10489):1608-1620. Epub 2025 Apr 14. PMID: 40245902 [https://pubmed.ncbi.nlm.nih.gov/40245902/]. * St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020 Dec 18;69(50):1911-1916. PMID: 33332296 [https://pubmed.ncbi.nlm.nih.gov/33332296/]. Related Guidelines and Guidance: * Centers for Disease Control and Prevention (CDC): CDC Sexually Transmitted Infections Treatment Guidelines, 2021 [https://www.cdc.gov/std/treatment-guidelines/default.htm] * NYSDOH AI: * Questions, Answers, and Best Practices for Expedited Partner Treatment (EPT) [https://www.hivguidelines.org/guideline/sti-ept/?mycollection=sexual-health] * 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] * GOALS Framework for Sexual History Taking in Primary Care [https://www.hivguidelines.org/guideline/goals-framework/?mycollection=sexual-health] Resources for New York State Clinicians:  * Conversations With CEI Podcast: Two New Treatments for Gonorrhea; one is available now! [https://cei.podbean.com/e/two-new-treatments-for-gonorrhea-one-is-available-now/]  * CEI Sexual Health Center of Excellence: The Sexual Health Center of Excellence provides sexual health clinical education, trainings, preceptorships, and additional clinical tools for community providers in NYS. The Center educates clinicians on the latest NYS guidelines on the management of patients with STIs. Phone number: 585-274-3045. * CEI Clinical Consultation Line: 866-637-2342. This is a toll-free service for NYS clinicians offering real-time clinical consultations with specialists on HIV, sexual health, hepatitis C, and drug user health.

Case 19. Similar, but Not the Same: HIV-2 Diagnosis and Treatment

Eileen presents the case of a 32-yr-old woman newly diagnosed with HIV-2 and invites guest Dr. Sanjiv Shah [https://www.nychealthandhospitals.org/doctors-day-2022/sanjiv-shah/] to discuss HIV-2 epidemiology, diagnosis, treatment, and monitoring. Listen as they explore the difficulties in diagnosing HIV-2, the complexity of treatment, including in pregnant women, and resources available to clinicians. Reference Cited:  * Peruski AH, Wesolowski LG, Delaney KP, et al. Trends in HIV-2 diagnoses and use of the HIV-1/HIV-2 differentiation test - United States, 2010-2017. MMWR Morb Mortal Wkly Rep 2020;69(3):63-66. PMID: 31971928 [https://pubmed.ncbi.nlm.nih.gov/31971928].  Related NYSDOH AI Guidelines and Guidance: * Diagnosis and Management of HIV-2 in Adults [https://www.hivguidelines.org/guideline/hiv-2/?mycollection=hiv-testing-acute-infection] * HIV Testing [https://www.hivguidelines.org/guideline/hiv-testing/?mycollection=hiv-testing-acute-infection] * U=U Guidance for Implementation in Clinical Settings [https://www.hivguidelines.org/guideline/u-equals-u/?mycollection=hiv-treatment] * PrEP to Prevent HIV and Promote Sexual Health [https://www.hivguidelines.org/guideline/hiv-prep/?mycollection=pep-prep] * NYS Good Practices to Prevent Perinatal HIV Transmission [https://www.hivguidelines.org/guideline/hiv-perinatal-prevention/?mycollection=hiv-perinatal] Resources for New York State Clinicians:  * New York State Department of Health Wadsworth Center [https://wadsworth.org/]  |  HIV-1/HIV-2 Diagnostic Testing [https://www.wadsworth.org/programs/id/bloodborne-viruses/clinical-testing/hiv-2-nucleic-acid]  |  HIV-2 Nucleic Acid Testing [https://www.wadsworth.org/programs/id/bloodborne-viruses/clinical-testing/hiv-2-nucleic-acid] * CEI Clinical Consultation Line: 866-637-2342 [tel:+18666372342]  This is a toll-free service for NYS clinicians offering real-time clinical consultations with specialists on HIV, sexual health, hepatitis C, and drug user health. Resources for Clinicians Outside of New York State: * UW Medicine Laboratory Medicine & Pathology [https://dlmp.uw.edu/site/contact]

Case 18. What’s New from CROI 2026 with Dr. Paul Sax

Dr. Paul Sax [https://physiciandirectory.brighamandwomens.org/details/1354/paul-sax-infectious_disease-internal_medicine-boston], author of an annual “Really Rapid Review of the Conference on Retroviruses and Opportunistic Infections (CROI) [https://voices.nejm.org/],” joins host Eileen Scully to review CROI 2026 [https://www.croiconference.org/] abstracts of particular interest to clinicians taking care of patients with HIV. CROI 2026 abstracts: Abstracts are cited within the transcript text and those cited are listed below in numerical order, with the abstract number, authors, and title for each. If you attended CROI 2026, you have access to the abstracts online now through the CROI website; if you were not an attendee, check the CROI website late April/early May for access to the abstracts through the CROI searchable abstract database [https://www.croiconference.org/search-abstracts/]. * Abstract 126. Kapoor, Y. MK-8527 Phase III Dose Selection for Monthly Oral HIV-1 Preexposure Prophylaxis.  * Abstract 128. Ndlovu, N et al, Twice-Yearly Subcutaneous Lenacapavir for PrEP: Updated HIV-1 Incidence and Safety Data in PURPOSE 1. * Abstract 129. Cantos Lucio, VD. Lenacapavir for PrEP: HIV-1 Incidence and Safety From PURPOSE 2 at End of Randomized Blinded Phase. * Abstract 134. Edgar, J. Altered Viral Kinetics at ATI After Dual LS-bNAbs Plus ART: A Preliminary Analysis of RIO Arm B. * Abstract 140. Pires Dos Santos, AG., Immune-Mediated Viral Control With Budigalimab ± Trosunilimab: First Results of Phase II Global RCT. * Abstract 142. Haser, G et al., Hepatitis B Reactivation/Infection in People With HIV on Tenofovir-Sparing Antiretroviral Therapy. * Abstract 177. Rockstroh, JK et al., DOR/ISL (100/0.25 mg) vs BIC/FTC/TAF for Initial HIV-1 Therapy: Week 48 Results of a Phase III Study. * Abstract 181. Cantos Lucio, VD. Lenacapavir for PrEP: HIV-1 Incidence and Safety From PURPOSE 2 at End of Randomized Blinded Phase. * Abstract 529. Spinelli, M. et al, Virologic Outcomes After LA ART Initiation With and Without Viremia in 2 Large US Clinic Cohorts. * Abstract 530. Chan, NY, et al. Week-24 Outcomes of Long-Acting Injectable ART in People With HIV and Suboptimal Viral Suppression. * Abstract 593. Dieterich, DT et al., HIV-HBV Coinfection and Long-Acting Cabotegravir + Rilpivirine in the US: HBV and HIV Outcomes. * 513: Meissner, E. et al. Phase III Efficacy and Safety of Switch From B/F/TAF to Single-Tablet BIC/LEN in ARTISTRY-2. * 197: Seib, KL, Meningococcal B (4CMenB) Vaccination for the Prevention of Gonorrhea in Men Who Have Sex With Men. References Cited: * Bekker LG, Das M, Abdool Karim Q, et al; PURPOSE 1 Study Team. Twice-Yearly Lenacapavir or Daily F/TAF for HIV Prevention in Cisgender Women. N Engl J Med. 2024 Oct 3;391(13):1179-1192. Epub 2024 Jul 24. PMID: 39046157 [https://pubmed.ncbi.nlm.nih.gov/39046157/]. * Kelley CF, Acevedo-Quiñones M, Agwu AL, et al; PURPOSE 2 Study Team. Twice-Yearly Lenacapavir for HIV Prevention in Men and Gender-Diverse Persons. N Engl J Med. 2025 Apr 3;392(13):1261-1276. Epub 2024 Nov 27. PMID: 39602624 [https://pubmed.ncbi.nlm.nih.gov/39602624/]. * Ombajo LA, Penner J, Nkuranga J, et al. Second-Line Switch to Dolutegravir for Treatment of HIV Infection. N Engl J Med. 2023 Jun 22;388(25):2349-2359. PMID: 37342923 [https://pubmed.ncbi.nlm.nih.gov/37342923/]. * Paton NI, Musaazi J, Kityo C, et al; NADIA Trial Team. Dolutegravir or Darunavir in Combination with Zidovudine or Tenofovir to Treat HIV. N Engl J Med. 2021 Jul 22;385(4):330-341. PMID: 34289276 [https://pubmed.ncbi.nlm.nih.gov/34289276/]. * Rockstroh JK, Kassim S, Paredes Ret al. Fixed-dose daily doravirine (100 mg) with islatravir (0·25 mg) versus bictegravir, emtricitabine, and tenofovir alafenamide for initial HIV-1 therapy: 48-week results of a phase 3, randomised, controlled, double-blind, non-inferiority trial. Lancet HIV. 2026 Feb 25:S2352-3018(26)00033-0. Epub ahead of print. PMID: 41763226 [https://pubmed.ncbi.nlm.nih.gov/41763226/]. * 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/]. Resources from Paul E. Sax, MD: * NEJM Voices: Really Rapid Review: Conference on Retroviruses and Opportunistic Infections 2026 [https://voices.nejm.org/doi/full/10.1056/VOICESpost2600002] * PaulSaxMD Substack [https://paulsaxmd.substack.com/] Related NYSDOH AIDS Institute Clinical Guidelines: * Use of Injectable CAB/RPV LA as Replacement ART [https://www.hivguidelines.org/guideline/hiv-art-injectable/?mycollection=hiv-treatment] * PrEP to Prevent HIV and Promote Sexual Health [https://www.hivguidelines.org/guideline/hiv-prep/?mycollection=pep-prep] * Prevention and Management of Hepatitis B Virus Infection in Adults With HIV [https://www.hivguidelines.org/guideline/hiv-hbv/?mycollection=hepatitis-care] * Immunizations for Adults With HIV [https://www.hivguidelines.org/guideline/hiv-immunizations/?mycollection=hiv-care]