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

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]

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.