Viremic – Cases in HIV

After 3 years on injectable CAB/RPV, a patient develops viremia, with a viral load of ~1,300 copies/mL. Failure of injectable CAB/RPV occurs in 1% to 2%, despite adherence. What factors have been associated with CAB/RPV failure? Can regimen failure be predicted or prevented? Listen as Chris and Eileen discuss the data, their advice to patients considering a switch to injectable CAB/RPV, and their response when failure occu...

A 32-year-old man with well-controlled HIV, seen after a recent relationship split and sexual activity with new partners, is screened and diagnosed with syphilis. Eileen discusses this case with guest Dr. Matthew Hamill, who reviews his approach to STI screening and risk reduction, emphasizing an approach that normalizes screening. Matthew then reviews syphilis testing, diagnosis, and staging, including neurosyphilis asses...

A 54-year-old woman with longstanding HIV and obesity is stable on ART, but concerned that it is causing weight gain. How best to address this growing concern? Listen as Chris and Eileen decipher the evidence related to weight gain and ART and weigh the best strategies for addressing this increasingly common and social media inflected concern for patients with HIV and their care providers?

References Cited:

• Abelm...

A 62-year-old patient with HIV for ~40 yrs presents on the life-saving TRIO regimen after a beloved care provider retires. Will a switch improve his quality of life? Eileen and Chris suspect that a change to a once-a-day regimen with fewer pills will maintain his viral suppression and make life easier, but the TRIO regimen inspires dedication in many long-term patients. Would he be open to a switch? Would it confer other b...

Subspecialists request simplified ART for a 56-year-old woman with a long ART history, who is taking a DOAC, has evolving renal function, and some drug resistance. Which factors to prioritize? Eileen and Chris have some, but not a complete medical history. Listen as they work through the information they do have, consider 7 questions key in making an ART switch, and evaluate the available options.

References and Resources ...

How to formulate an effective ART regimen acceptable to 56-year-old man, with unsuppressed HIV, 20+ yr. ART history, extensive drug resistance, and adherence challenges? Listen as Eileen and Chris interpret resistance testing results, discuss barriers to treatment and adherence for this patient, and evaluate the possibility of using one of the novel agents—fostemsavir, ibalizumab, and lenacapavir. What would you do?

Referen...

Healthy 48-year-old man with HIV for 15 years, stable viral suppression, looking to optimize health—diet, exercise, immune-boosting supplements, safest HIV and HTN meds. Listen as Chris and Eileen discuss their approach to giving patients the good news about their health, health maintenance, supplement use, and whether to stay the course or switch ART regimens in patients who are doing well.

Resources:

• NIH Office...

New COVID-19 vaccine policy, proviral DNA testing, then the case of a woman with 10+ years viral suppression, CKD, and CVD, identified as a statin candidate after a significant cardiac event. With no family history of CVD, her risks included exposure to older ARVs and smoking 1 to 3 cigarettes/day. Listen as Drs. Scully and Hoffmann delve into non-infectious comorbidities associated with HIV, risk factors, and adjusted CVD...

After brief mention of an HIV vaccine, the hosts turn to the challenges of treating cryptococcal meningitis in a 46-year-old woman with profound immune suppression after being off ART for 6-12 months. Emphasizing the high potential for morbidity and mortality, Chris and Eileen focus on the complexities of cryptococcal meningitis medical management, including the role of immune constitution, timing of ART initiation, and th...

After presenting with fatigue, malaise, and muscle cramps, a 28-yr-old man with history of STIs is diagnosed with new renal failure (Cr >9 mg/dL) and HIV (VL ~3 mil. copies/mL). Drs. Scully and Hoffmann note the missed opportunities for HIV prevention, then review HIV-associated kidney disease and evaluate regimens safe for rapid ART initiation.

References Cited

• Bahr NC, Yarlagadda SG. Fanconi Syndrome and Ten...

Mid-50s-yr-old man with HIV since the early 1990s presented for evaluation of persistent low-level viremia, despite consistent engagement in care and ART. Genotypic testing found only a variety of minor mutations. The patient and his care provider were concerned about the health consequences, including the risk of inflammatory diseases in the future, and about implications for U=U. After a brief discussion of the good news...

48-yr-old man with HIV for 12 years presented 1 year after his last visit with a history of methamphetamine use, inconsistent engagement in care, and a new diabetes diagnosis. He reported no recent ART and no meth use for about 8 months. On returning to care, his viral load was 250,000 copies/mL, the CD4 count was 230 cells/mm3, creatinine levels were elevated, and genotype testing found a K103N mutation. He was motivated ...