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but I had a real problem with chocolate

1:01

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but Paul, I got over it, but

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it was a rocky road. They're

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going to rescind my job offer. All right.

1:13

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1:36

Welcome back to the Curbsiders. I'm Dr. Matthew Otto,

1:39

here with my great friend, Dr. Paul Nelson

1:41

Williams. Today we're gonna be talking about

1:44

HIV.

1:44

You know, what should we be, what

1:46

should we know about this as generalists

1:49

in primary care? And we have a great

1:51

guest, Dr. JJ Nunez. Paul,

1:53

before we introduce our wonderful guests, would

1:55

you tell people what is it that we do

1:56

on the curbsiders? Yeah, I often

1:59

ask myself, but thank you. Thank you, Matt. And also, by the way, thank

2:01

you, John, for that nice introduction. I have never

2:03

been introduced first in my entire life, by the way, so that was

2:05

a real thrill for me. That's nice that

2:07

I recorded for posterity. We are the

2:09

internal medicine podcast. We use expert interviews

2:12

to bring you clinical pearls and practice-changing knowledge. And

2:14

what an expert we have for you. I can say on a personal

2:17

note, I've known Dr. Nunez for

2:19

years, and he is one of those people who is, like,

2:21

annoyingly good. I don't

2:23

know if you know people like that, but, like, he's nice and then also

2:25

competent and takes good care of patients and is smart. And the type

2:28

of person who makes you feel bad about yourself if you're me at least.

2:30

So we're thrilled to have him, but I'll give a more formal bio now.

2:33

So Dr. Nunez received his medical degree from the University

2:35

of Connecticut School of Medicine, and what I want to

2:38

do is internal medicine residency at Yale New Haven Medical

2:40

Center and completed his fellowship in infectious disease

2:42

at the University of Pennsylvania with Penn Medicine.

2:44

Dr. Nunez is interested in health equity and medical

2:46

education. In addition, he has an interest

2:48

in improving access to medications for opioid use disorder,

2:53

medical and resident education, medical student and resident education,

2:55

that was probably as opposed to P, HIV primary

2:57

care and HIV-prevented medicine. So

2:59

without further ado, let's bring up Dr. Nunez. JJ. J.J.,

3:02

we're gonna tell you about Mr. Jones.

3:05

He is a 24-year-old gentleman, a self-identifying

3:07

male who presents to your

3:10

primary

3:10

care office for the establishment of care. He is transferring

3:12

care to your office after

3:14

moving to your city from out of state. Medical records are not available at

3:16

this time. So let's bring up Dr. Nunez.

3:18

JJ. All right, let's get right to a case,

3:20

right down to business. All right. JJ, we're

3:22

gonna tell you about Mr. Jones. He is a 24-year-old gentleman,

3:24

a self-identifying male, this visit. He's without

3:26

specific somatic concerns and

3:30

he reports a medical history significant for HIV

3:32

for which he takes Bictegrifir, Entercitabine,

3:35

and Tenofivir, otherwise known as Bictarvi. For

3:37

the purposes of this case, you're not an expert,

3:40

you are me, which means you are well-meaning

3:42

and you don't have a lot of experience in care of HIV, but you have

3:46

ready access to competent colleagues like yourself who are able

3:48

to do so. I feel like one

3:50

of the reasons I chose this case is this comes up in

3:52

my practice on Novacchiwado a lot where I have someone

3:54

who say their HIV is well managed by an

3:57

ID doc, but they still want somebody else for their primary care.

4:00

It's the lines get kind of blurred, and I feel like I need

4:02

a little bit of help. But for you, at a

4:04

first visit like this, where you're meeting this patient for the first time,

4:06

what are your goals, and what does this first conversation

4:08

look like for you? Yeah, so I think usually

4:11

when I'm first seeing any new patient, I

4:13

kind of always try to break the ice. I kind of introduce

4:16

myself. Mostly I try to tell them two things. I'm

4:18

slow, so I'm like molasses.

4:21

So I usually tell them probably don't

4:23

want to schedule an appointment after that, mostly

4:25

because it gives me time to really dive into a little

4:27

bit of the psychosocial stuff that's necessarily

4:30

going on. Second thing

4:32

I always tell them, I'm like Colombo. So I tend

4:34

to repeat myself a lot. And mostly I

4:36

feel like it's mostly just to pick up things that might not

4:38

have come up the first time, or maybe I

4:40

did not actually pick up when they were talking.

4:43

So I think from the first visit,

4:45

I really tried to get a sense of what brought them here

4:47

today. If they're transferring their care,

4:50

what was the reason that they're transferring care? Was

4:52

there barriers to the last practice that they're

4:54

necessarily at?

4:57

I think the other things, They're moving from a different

4:59

state. What brought them to the state?

5:01

Is it work? Is it employment?

5:04

I feel like starting off with some of those questions gives me

5:06

a little bit more about the social support as I

5:08

try to ask these questions overall.

5:12

Then during the actual visit, I think focusing

5:15

a little bit more on the HPI, mostly

5:17

of HIV, the big things I'm looking for mostly

5:20

is time of diagnosis. How

5:23

long have they been diagnosed? Are they actually

5:25

on medication? Are they taking their medication? Are they

5:27

struggling with adherence? Those are

5:29

the kind of the questions I'm necessarily asking

5:31

overall, mostly to kind of think about barriers

5:33

to care. I think we do an excellent

5:36

job of screening patients for HIV,

5:38

it's just retain patients in care, where

5:40

it's a little bit more difficult.

5:43

I noticed you mentioned Colombo. I'm 40

5:46

years old and I barely get that reference, so I'm sure

5:48

your patients really appreciate it. Yeah,

5:51

but

5:51

I wanted to ask about,

5:54

you mentioned psychosocial things is

5:56

like.

6:00

Like how, now I threw myself

6:02

off here, Paul. It's a solid joke though,

6:04

it's worth it. I just really

6:06

wanted to make the Colombo joke. No, but

6:09

at that first visit, how

6:12

much time are you getting and how much detail

6:14

are you getting into about like, you mentioned

6:16

the psychosocial stuff, so can you give an example of

6:18

like where you might spend the time on those, like

6:21

which specific issues? Sure, I think usually

6:23

I start off with just asking about the social history in the beginning,

6:26

really getting a chance to learn my patience. It makes

6:29

it easier for me to remember

6:30

who they are, especially when they're calling. So

6:32

I can really remember one or two special facts

6:34

necessarily about them. But I think the things I'm really

6:37

focusing on is in

6:39

a living situation,

6:41

things about how they interpret and

6:44

look at their disease, how do they feel

6:46

about their disease, how

6:48

do they feel about their medication management? These

6:51

are, are there things where they feel that they're empowered?

6:53

Are they feel like they're being listened to? Those

6:56

are some of the things I'm actually necessarily going through

6:58

as well. As I focus on that,

7:00

I'm also just trying to figure out if there's

7:02

issues with housing,

7:04

or if there's issues with changing

7:06

insurance, or making sure that there's coverage for the

7:08

medications. Are they having trouble

7:10

with side effects, or any reportable side effects

7:12

that I don't know about medications? So as

7:15

I go through with that, I also try to focus a little

7:17

bit more on mental health, just

7:19

to try to see where they're necessarily at. Have

7:22

they been treated before in the past for any mental

7:24

health? Are they having any barriers right now? So

7:27

a lot of times I think of it as more like a biopsychosocial

7:29

assessment than necessarily like a true

7:32

social history, actually. And then

7:34

that's where I kind of segue and make that

7:37

introduction to kind of the more

7:39

personal questions. I don't usually like to start off

7:41

with just the HIV questions, because sometimes they can

7:43

be a little bit more personable or intrusive.

7:45

So then I kind of move into the history of

7:48

like when they were diagnosed, where they've been diagnosed.

7:50

Couple questions I might focus on for that

7:52

is, have they been on medications

7:54

that worked for them, Have they been on medications that

7:57

hadn't worked for them? Are there any side effects

7:59

for me to know about?

8:00

So, you know,

8:01

what do they look for in a

8:03

provider? Those are the things I kind of focus on during

8:06

the visit. Usually I

8:08

have about 40 to 60 minutes for new patients, which

8:10

is lovely. It also

8:12

runs slow, so it's going to be a little bit longer than that. In

8:15

my practice, you know, there's days I

8:18

have social worker and case managers, so I

8:20

think we're all working together as

8:22

they work with the patients. And I think at the

8:24

end, we try to debrief and see if there's

8:27

any issues that we might have missed. is

8:29

I'm just by myself, I

8:31

feel like the first visit is really a job interview.

8:34

That's really what it is for me. I

8:36

got to make sure that this patient feels comfortable to come back.

8:39

No one really wants to go to the doctor. I don't want to go to the doctor.

8:41

The only thing I'm more popular than, maybe

8:43

the dentist, okay. But I

8:45

feel like

8:46

how much I try to focus on that visit, you

8:48

know, I might have my expectations, but

8:50

it's really measuring what expectations my patient

8:53

have. If there's an ongoing issue or

8:55

medical concern that they have, I'm gonna push

8:57

some of that aside and really just focus on that

9:00

because I think one of the big things is trying to retain

9:02

them and cares making sure that we're taking care

9:04

of the issues that they have.

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well

10:21

Other than being your usual charming excellent doctor

10:24

Lee self Is there any sort of systemic

10:26

or sort of like clinic level stuff that you can do to encourage

10:28

retention and care? And I guess, what can we

10:30

do to keep these people engaged in treatment? Because I know that there's

10:32

going to be a challenge at times. I

10:34

feel like

10:36

jumping around a lot in the sense that

10:38

I mentioned what I do. I think the first thing I

10:41

also make sure is just making sure that we're using

10:43

right pronouns. So for some of my

10:45

patients, it might be fluid. So I might

10:47

ask during each particular visit. So

10:50

I think that might be one part where

10:52

I would start. I think one of the big things that

10:54

I try to make sure during the visit is ways I can

10:56

contact my patient. There was a study that

10:58

was done at one of the Ryan Wright conferences, I wanna

11:00

say like years ago, that was one

11:02

of the biggest predictors was change in full number in

11:05

a year. So I think for me, trying to focus

11:07

out where they're at, where I can contact them,

11:09

how I can contact them, recognizing especially

11:12

for my younger adolescent or

11:15

young adult patient population, cell

11:17

phone calling them is archaic. No

11:20

one calls them, right? So it's like usually through text. So

11:22

I try to find other ways in theirs as

11:25

well. I think the other thing systemically I try

11:27

to do just see them without medical

11:29

records. If I have it, lovely, awesome. If

11:31

it's not, that's fine too. I don't find

11:33

that they're overall super helpful. You get 200 pages

11:36

of stuff that you don't necessarily need. Right?

11:39

Yeah, it's more helpful if you have a specific

11:41

question when you get that 200 page document dump

11:44

of prior records. But

11:46

I wanted to point out to the audience, because I think about

11:48

this a lot. I'm a doctor,

11:50

but I try to read and listen to

11:53

stuff that's way outside of medicine and try to apply

11:55

it to medicine. But I think if you're in the audience

11:58

and you don't see anyone who has age. I

12:00

think a lot of what you talked about is just good doctoring,

12:02

where you're just like, I start off, I want to get

12:05

details about the person so I remember who they are.

12:07

I remember their story. You're building your memory

12:10

palace of who is this person. I

12:13

think that's great. So I think people

12:15

can apply that to whatever they're doing, even

12:18

if they're not seeing any HIV in their

12:20

clinic.

12:23

And you mentioned some of the things, but

12:25

I wonder if you could just sort of role model for us

12:27

what your specific HIV history looks like. once you

12:29

have the patient comfortable with you in terms of things

12:31

like date of diagnosis

12:34

and acquisition, are there any, and

12:36

I think you touched on most of those points, but you just sort of bullet

12:38

point out what you kind of ask about when you're asking about the HIV

12:40

history specifically.

12:42

Yeah, sure. So I try to figure out where

12:44

they're necessarily coming from, when they were diagnosed,

12:47

if they've ever been hospitalized or non-hospitalized,

12:49

this gives me an idea if there's been complications. Usually

12:52

I go back to see if they've been on history of

12:54

any opportunistic infections, so can kind of

12:56

give me an idea what stage of HIV or AIDS

12:59

or complications they might have had before

13:01

in the past.

13:02

You know, medications we talk about, I really

13:04

want to make sure that we're aware of resistance,

13:07

which most patients may not necessarily know.

13:10

They just may remember, hey, this medication I was told

13:12

does not work for me overall.

13:14

I want to get a sense if they have an understanding

13:17

of what the name of their medication is. Realistically,

13:19

they're probably going to know more about their medication than

13:21

some of the providers. We just don't see

13:23

it as often. And then what pharmacy that we've been

13:26

using it, how have they been getting it, have they

13:28

had any issues for the barriers for the pharmacy?

13:30

Because sometimes if it's smaller mom and pop

13:32

shops, the medication

13:35

can sometimes be delayed for getting it compared

13:37

to some of the bigger institutions. As

13:40

for additional HIV

13:42

history, you know, other things I try to get a sense

13:45

of as well as any other co-infections, mostly

13:48

thinking about hepatitis B and hepatitis C

13:50

because it's going to determine what I do for treatment. And

13:52

then want to make sure that we really treat hep C very

13:55

early on because with co-infection, progression

13:57

to liver disease is much higher.

14:00

I also want to make sure there's social support,

14:02

actually, so just making sure, like, as we're

14:04

working about things, you know, are

14:06

there people are aware of their diagnosis, are they not

14:09

aware of their diagnosis, are they secretive about

14:11

their diagnosis, stigma. The way I ask

14:13

that's mostly like, what's been barriers for you about, you

14:15

know, taking care of your medical condition, actually.

14:19

Paul

14:19

and I were talking about this on the

14:21

drive up, up here. I mean, it, I

14:24

feel like that it's, it's a chronic disease,

14:26

we have such good treatment for it, but the

14:28

stigma and people just remember the 80s

14:31

and the 90s when everyone was dying from it and

14:33

people are still just so secretive

14:35

about it or I've still had patients tell

14:37

me, please don't test me for HIV. I'm like, what are

14:39

you worried about getting tested? And they're like, I

14:42

just don't want to, I don't even want to go there. I'm like, well, it's

14:44

a chronic disease. Like you can get treated. And so

14:47

I think there's still a lot of like misinformed

14:49

patients. You know, you brought up an excellent point, Matt,

14:52

because like

14:52

how how I

14:54

always mention is it's a chronic disease that's

14:56

easy to treat, it is in diabetes. That

14:58

may be true for me as the provider, but

15:01

it may not be the truth for the patient. I

15:03

think a couple of times I always touch base with them is

15:05

just that they can tell you the exact date that

15:07

they were diagnosed. They can tell you the exact

15:09

situation that they were in when they were diagnosed.

15:11

And for many, it was really, really traumatic, actually.

15:15

It was in a very awkward situation,

15:18

or the other thing was the involvement with the

15:20

healthcare system at that time, or

15:22

it was a complete shock. So

15:24

it's very easy for me to say, hey, it's easy to take

15:26

a pill every day. For some, it's really not.

15:29

So that's why I really try to get a sense of what

15:31

is their understanding of the disease and how do

15:33

they view themselves overall

15:35

during the visit.

15:37

And this is fairly granular. But

15:40

I wonder, how do you

15:42

document

15:44

in the record who knows about the diagnosis

15:46

and who it can be disclosed to? I feel like I don't know about

15:48

you all, but I've been involved in teams where

15:50

there's been catastrophic disclosure of diagnoses, the

15:52

family members who didn't know or that kind of thing. So is there a

15:54

way to sort of safely

15:57

sort of share that information so that you're protecting the patient the way

15:59

they need. we

16:00

were protected. Yeah, I try to keep it in

16:02

my note. I think I

16:04

try to forward with every part of my note, part

16:07

of the HIV initial history, so

16:09

that if anyone's pulling up the chart. I also try

16:11

to use stickies if we can. So

16:14

by previous medical records, you can actually put it. So

16:16

it comes up as a pop-up

16:18

that you can make sure that they're not aware of the diagnosis.

16:21

I know our medical

16:23

record here has that option too. I

16:26

just assume that no one knows, and you

16:28

shouldn't assume that anyone does. And I think

16:31

also when you're seeing patients in the hospitalized

16:33

setting, you just assume that someone in the room does not

16:35

know, actually. Because I've

16:37

had similar instances where they were accidentally

16:40

disclosed in front of people that didn't

16:42

know.

16:43

Thank you for not mentioning the medical record by

16:45

name. We bleeped that on the show. Actually,

16:47

a past guest complained to Paul and I because we

16:50

bleeped them because they said the medical record name

16:52

so many times that their colleagues

16:54

were like, why are you swearing so much on curbside?

16:57

And he's like, I wasn't swearing. I was saying the name of

16:59

a medical record. Yeah, listen, until they sponsor us. Anyway,

17:01

yeah. They're not getting free press from us. All right, Paul, should

17:03

we move on with the case? We should probably move on with the case.

17:08

All right, so Mr. Jones, in terms of getting

17:10

your excellent history, he tells you that he was diagnosed with HIV

17:12

three years ago. He states that his viral load is

17:15

undetectable. He believes his CD4 count was,

17:17

quote, pretty good at last check approximately

17:19

six months ago. He is without any other

17:21

medical issues other than occasional seasonal allergies.

17:23

He states that his parents are in good health. He reports

17:26

occasional alcohol use, smokes cannabis daily

17:28

and denies other substance use. He

17:30

is sexually active with two male partners and engages in

17:32

receptive and penetrative anal and oral sex, endorsing

17:35

routine barrier protection. He reports

17:37

a prior history of chlamydia infection about

17:39

nine months ago, and then again two years prior

17:41

to that, works as a graphic designer currently

17:44

and lives alone. We'll

17:46

get into some of the social history and some of the management

17:48

stuff, but I do want to give a space

17:50

to at least talk about your initial physical examination,

17:53

if this diagnosis changes anything that you would do, or

17:55

if it's just your routine bread and butter.

17:56

Sure. I think a lot of it's visualization actually

17:59

just like. looking at the patient if they seem anxious,

18:02

you know, overall that gives me some kind of things to kind

18:04

of look for. Also, the things I'm

18:06

looking for during my history, even though it's part

18:08

of the physical, you know, I always do

18:11

like a full review of symptoms because it might kind

18:13

of gears me if there's issues with adherence. Things

18:15

I'm looking for really is if

18:17

there's been any weight loss, any night sweats, any

18:20

fevers, you know, have they noticed any lymphadenopathy

18:24

overall because it might gear to me on what I'm going

18:26

to focus on on my necessarily exam

18:28

as well. And then thinking about the sexual history,

18:31

actually, which I'll talk about in a little bit, but

18:33

I think one of the big things is if they're having any active

18:35

symptoms, because again, you know, one of the big

18:37

things I try to do on the exam is make sure that,

18:40

you know, we're not missing anything on the diagnosis. And

18:42

then for the physical exam, you know,

18:44

really just like I tell the residents, it's

18:46

really just head to toe. But you know, a couple things for

18:48

me to kind of keep an eye on is if there's weight

18:51

loss, if the patient looks cactic.

18:54

I think other things, if there's visual field deficits,

18:56

you know, the rooms have a thaumascopes, We can use them

18:59

for reminding them that they're there, other than paper weights.

19:02

I do a good full skin exam, lymphadenopathy.

19:05

And then depending on patient preference and reading

19:07

the room, unless there's an active symptom that's

19:09

concerning for me for an STD, I also

19:12

make sure that I try to do a

19:15

sexual health exam as well. But that might

19:17

also be determined by patient comfort.

19:20

And you mentioned looking for a catexia

19:22

and everything. But one thing that I was, I guess,

19:25

not as aware of, like people

19:27

with screening for metabolic syndrome or just

19:29

like weight gain on medications, can you speak to that

19:31

a little bit? That wasn't really on my radar. Totally,

19:34

so like also part of my exam is looking

19:36

through the vitals and then also looking for like anything

19:38

that suggests of metabolic syndrome. So

19:41

why is that? Because I think, you know,

19:43

patients had mentioned that there has been weight

19:45

gain with certain HIV medications and I

19:48

think a lot of times back in my

19:50

day, as a trainee and as a

19:52

student and as a fellow, we used to always mention

19:54

that, you know, HIV is this catabolic state. You're

19:57

undetectable, you lose fat deposits.

20:00

You're on medications, that's why you're gaining

20:02

weight. Although, since

20:04

there's been newer treatment options,

20:06

which is awesome in the sense that they're

20:09

easier to take, has less reportable side

20:11

effects, they suppress the virus really well, we're

20:13

learning a lot about our patients on these new medications.

20:16

And I think there's been a lot of association with

20:18

weight gain as well. And when we

20:20

look at that, it's also not necessarily

20:23

equal actually. So I remember reading

20:25

something where about one in six patients within the next

20:27

two years will gain 10% of their body weight. actually

20:30

starting on antiretrovirals. And when you

20:32

split that even more, the weight gain's even

20:34

higher in African-Americans, and especially

20:36

African-American women, so nearly 20%

20:38

of patients. And some of these

20:40

studies, I think the one I remember is like the advanced

20:43

trial, noticed that there was a weight

20:45

gain about up to 6.4 kilos. So,

20:49

is it part of the medications? It could be. I

20:51

think some of the newer formulations, when

20:54

we used to use a lot of Tenofovir disaproxyl,

20:57

We kind of advanced to tenofovir alifinamide.

21:00

We're noticing that there is some weight gain, and there

21:02

might be even more concurrent weight gain with some of the integrase

21:04

inhibitors. So when we're thinking of dolatagravir

21:06

or bactagravir. So it's something to kind

21:09

of think of consul. So as exam wise,

21:11

it's important to note, to keep an eye on that,

21:13

because there is gonna be some weight

21:15

gain. And I think preparing patients for that, if you

21:18

wanna talk about adherence is important.

21:21

What do you do in terms of mitigation

21:23

strategies for that? I mean, I know this is not the episode

21:25

for initiation of therapy, I guess if you were at that point,

21:27

is it just an anticipatory guidance? Is there, how

21:30

do you talk to that with patients? I

21:32

think I've changed my focus on a couple

21:34

things. I think one, I really think

21:36

about talking about diet and nutrition very

21:39

early on. And then again, it's really not just that.

21:41

It's really checking if there's access

21:43

to healthy food. So I think if there's

21:45

an issue with that with patients, I might tie that in with my case

21:48

manager or local resources to kind of focus on that.

21:50

I think

21:51

three, try to really form and talk

21:53

about physical activity. When I talk

21:55

about physical activity, That's another kind of sneaky way

21:57

to kind of find out safety of the neighborhood because like there

21:59

are some neighborhoods where it's not super safe to go

22:02

exercise outside. It also has

22:04

made me rethink sometimes med switches. So

22:07

a lot of times, you know, the thought processes and your medication

22:09

comes out

22:11

super great,

22:12

less side effects, you know,

22:14

but if my patient haven't had issues to change

22:16

them, you know, sometimes it's conversations now that

22:18

I initiate, hey, there's this new option, but

22:21

let's sit down if this is the right option for you. So

22:23

I've been like rethinking some of the initiations

22:26

and switches overall. Or if

22:28

I do switch, mentioning that this

22:31

may be something that note that we will know,

22:35

actually. For the patients that

22:37

I've had some patients recently tell me that they

22:40

started doing like YouTube workouts, because you know,

22:42

like Peloton, all those things are expensive,

22:45

unattainable for a lot of patients. But like,

22:48

there's free workouts on YouTube and things. And

22:50

same thing, patients are like, my neighborhood's too dangerous.

22:52

So I don't, I don't walk around or during

22:55

the pandemic, people weren't comfortable going

22:57

outside so now they're doing that. I

23:00

did want to ask you, is it okay

23:02

to talk about labs now, Paul? Are we moving into

23:04

the initial labs or do we have something else? I can save

23:06

my question. Well, I guess while we're here in sort

23:09

of metabolic land, I guess there are any other considerations.

23:11

I know that I hear some rumblings about sort of screening

23:13

and diagnosing

23:14

diabetes and

23:16

sort of choosing labs for that and timing of the initiation

23:18

of ART and that kind of stuff. Is there anything that might

23:21

be a little bit more nuanced than we need here? But from a primary care

23:23

standpoint, is there anything that we should know about specifically between

23:25

HIV as treatments and diabetes? Yeah,

23:27

I think as part of the

23:30

one thing that's really interesting, and

23:32

I'm happy to have patients that are living longer

23:34

lives, I'm happy for the day they're cured, and I lose

23:36

my job. I tell them I'll cry tears of joy with

23:38

that. But there is a risk

23:42

for cardiovascular disease about two times

23:44

higher in patients living with HIV, even being

23:46

undetectable, and in higher

23:48

CD4 counts. So I think as we look back

23:50

at that, there's some kind of big focus

23:53

points for metabolic syndrome. You

23:55

know, I think one of the things is really being aggressive

23:57

to screen for diabetes. I

23:59

think all making sure that lipid profiles

24:01

that we're not just checking them, we're actually treating them

24:04

actually. So as we're thinking about things, you know, I have

24:06

many patients who are super well

24:08

controlled for

24:11

the HIV, their diabetes needs a

24:13

little bit of help actually. And I think

24:15

one of the big things as I focus on that is highlighting

24:17

that that's probably just as important or even

24:19

more important for mortality overall

24:22

than necessarily just treating your HIV. So

24:24

I think I tend to do a lot more

24:26

screening and then as I'm thinking about my antiretrovirals,

24:30

as we talk about switches, it's important to

24:32

think of what medication interactions there might be. I

24:35

think one of the big things is making sure that if a patient

24:37

needs to be on a statin medication to really

24:39

think about that. And you can't just go by the ACCVD

24:42

risk factor in our patients who are living with HIV

24:45

because we're not actually part of the calculation.

24:47

We know there's a risk. So as

24:50

I discuss with my patients why I'm doing

24:52

stuff. And I think one of the big things for my

24:54

patients is I feel a lot of times

24:56

overall, both non-HIV, more

24:58

meds, I'm always pushing meds, right? They want

25:00

less meds, but I try to really focus

25:02

that, hey, if you have a heart attack, there's gonna be about three

25:05

or four meds I'm gonna add onto your med list that probably won't

25:07

go off. And I think that's if

25:09

you have a minor heart attack

25:10

with no dysfunction after.

25:13

And then for, so for us, for

25:15

mostly taking off the patients for boosters for cholesterol

25:18

medications, if we can, some

25:20

of the protease inhibitors can cause dyslipidemia.

25:23

The newer ones, not as much, but compared

25:25

to the integrase inhibitors, they tend to be pretty

25:27

lipid neutral. But my dosing

25:30

for the statins can be contraindication.

25:32

I have to start with a lower dose and make sure that they're

25:34

not having any side effects. And the statins

25:37

we tend to use is Resuva statin or Torvastatin

25:39

overall. For diabetes

25:42

management, some of the longer-acting

25:44

integrase inhibitors actually do interact

25:46

with metformin. So the dosing should probably be a

25:48

little bit lower. So thinking about Della Tigrvir

25:51

and Bic Tigrvir. But

25:53

I think one of the big things is just making sure that as

25:56

a provider, we're doing just as updated

25:58

care for HIV for the... primary care. So like if

26:01

they really are indicated to get a GOP

26:03

one for diabetes really thinking about that if they

26:05

need the statin really thinking about that overall

26:08

so I tend to be pretty aggressive on that and same thing for blood

26:10

pressure control. Do you have any

26:12

preferred resources for the statin interactions or do

26:15

you just know these off the top of your head at this point? I

26:18

always double-check you know I think I

26:20

always double-check you know there's a couple great

26:22

resources I think University of Washington

26:24

has this like self-study module for HIV

26:27

and also HIV and primary care. It's

26:29

free, it's amazing. They also have one for Hep C.

26:32

UCSF also has one where I think they're

26:35

just revamping the website because it's been off for

26:37

about a year and it's called the Knowledge Link

26:39

and it's great because it's all topics necessarily

26:41

all towards there. Those are my kind of

26:45

go to ones and then I know I'm digressing

26:47

a little bit but I think as I talk about my patients

26:49

is really focused on smoking

26:52

because there's a much higher the prevalence of smoking

26:54

in patients living with HIV. And I describe

26:57

it as, you know, a couple years ago, our

26:59

journal, Clinical Infectious Disease, had a article

27:02

on smoking and smoking conversations

27:05

to have with patients, reviewing their treatments for patients,

27:07

you know, pretty much a primary care

27:10

article in a infectious disease journal.

27:12

And I think it just shows that the prevalence of smoking

27:14

is much, much higher. Yeah.

27:17

The quit line in

27:19

the state of Pennsylvania is great. They give five

27:21

free coaching sessions and they'll send patients

27:24

patches and then either gum or lozenges for

27:26

free. So it's a fantastic

27:28

resource. And I think it's a national resource. I

27:30

think if you call, you actually get a person

27:33

too. So I would recommend people

27:35

just even call it yourself just to see like what

27:37

experience the patient's got. I've done it and

27:39

it is very

27:42

helpful.

27:43

I wanted to ask a little

27:45

bit about,

27:47

or no, I'm sorry, I wanted to note the Liverpool calculator,

27:49

isn't that the one that like all the ID docs, I

27:52

think it's been mentioned on the show before. I think

27:54

they have one for hep C, for HIV, and for

27:57

the COVID medications, I think. Yeah, and thank you for bringing

27:59

that back.

28:00

because that one's also a very helpful source. I've

28:02

used it a lot during COVID, especially just

28:04

a magic check for the Pax Levitt interactions.

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29:18

All right Paul, where to next? Well

29:20

it's Valentine's Day. I mean we should probably why

29:23

she is Valentine's Day. Happy Valentine's

29:25

Day. Thanks to you too, buddy.

29:27

So actually, let's talk about, because I do want to

29:30

make space for this too, about the conversations

29:32

about transmissibility in relation

29:34

to, say, viral load in CD4 counts. Or what's

29:37

the current thinking, the current counseling? Can we, I just

29:39

want to make sure that we talk about the u equals u before we move

29:41

past it into the other screenings. Yeah,

29:43

so I think this was big when this

29:46

came out with CDC. I think there was many

29:48

studies that were already super suggestive

29:50

of this. there is a study which I

29:52

can't remember all. I think it was HPTN052.

29:56

You might quote me on that one. I should know that

29:57

one, but I think overall, I was looking at zero discord.

30:00

couples and what they noticed in serial-descorbent

30:02

couple one living with HIV, one without is that

30:05

the patient, as long as the patient was undetectable,

30:07

actually did not contract, was unable

30:10

to transmit HIV. And there's been several

30:12

iterations of it from different parts. There's the partner

30:14

studies and the partner two studies that looked at more

30:16

diversified patient populations

30:19

and same thing. So when we're looking at

30:22

patients that are MSM or gay, bisexual,

30:25

they were able to extrapolate that

30:27

as well, that U equals U. So really

30:30

thinking about treatment is not just treatment.

30:32

It's also preventive. So that's why I think

30:34

a lot of our Treatment options have

30:37

really focusing on starting medications very early

30:39

on. It's crazy like ten years ago I would

30:41

wait till they're a defining illness just talking about this.

30:43

Yeah, yeah, and I was a when I was a resident I

30:46

think the smart trial came out. So it was like CD4

30:49

come up 500. Yeah, and you

30:51

know really talking about the rapid initiation

30:53

and really bringing down that viral load as

30:55

quick as often And there's a lot of stuff from UCSF

30:58

also looking at bringing down that viral load

31:00

very quickly with same day initiation. You just got to

31:02

remember there's some patients that you may want

31:04

to do that too. There might be others that you want

31:06

to be careful on actually.

31:09

Yeah. And

31:10

I wanted to, you know, this is something I do

31:13

on the show from time to time. So I maybe

31:15

I'll tell me if I'm wrong. I might be wrong. Feel

31:17

free to shoot this down. He's going to be wrong, by the way. We

31:20

should just check the CD4 account. That's still most

31:22

important. and we should just check it like every

31:25

month or so for just the entire time

31:27

the person has HIV. What's the current

31:29

thinking on that? Am I up to date? So,

31:32

you know, we'll check a CD4 count initially

31:34

as a baseline when we're thinking of treatment

31:38

naive, mostly to give us an idea

31:40

of,

31:40

you know, if there's issues with us to think about

31:43

for opportunistic infections prophylaxis.

31:46

You know, the absolute number is what my patients are so

31:49

on and remember, but to me, just

31:51

as important as the CD4 count the percent because

31:53

the absolute number can change. Someone can be

31:56

ill, hospitalized with a pneumonia, come in with a colitis,

31:58

that absolute number can come down.

32:00

the percent tends to be less

32:02

variable. For how often we check it,

32:04

so I usually will check it within

32:07

three to six months, in the initial

32:09

part. As patients who've been undetectable

32:12

for greater than two years, I've sometimes just switched

32:14

to once yearly, actually. It

32:16

also is patient driven. There are some patients that

32:18

are really, that is super important for

32:21

them to know. So I think

32:23

that's

32:24

something that I keep in until my thought as well. It probably

32:26

depends on when they were diagnosed too, right? Yeah, I

32:28

mean we had talked years ago with Michael

32:32

Sagg and he was just like, yeah, viral load is what's

32:34

important now, suppressing that. Once someone's

32:36

viral load's suppressed and their CD4's greater

32:39

than 500 and stable for years, like

32:42

checking it has minimal value at that point

32:44

if they're staying

32:45

on their meds. I would agree with that. I

32:47

think some reporting that some funding comes

32:50

from different states for like our Ryan Wright program

32:52

still are on that. They still want that. I still want

32:54

that. But I think I agree with that. To me,

32:56

the bigger thing is making sure at the viral load. And

32:58

that's what I'm going to be checking more often, especially

33:00

I want to make sure that's dropping within a log, actually.

33:03

And with the introduction in integrase inhibitors, it does.

33:06

Where I get worried is if it's not. And that's

33:08

when you've got to start thinking about, hey, were

33:10

there barriers for adherence? Is

33:12

there some underlying resistance that I might

33:14

see? And that's where I might focus on. But

33:17

one thing I forgot to mention, even as I'm having

33:19

this discussion with this patient, too, is

33:23

taking a really good sexual history. Because

33:25

one of the big things I want to make sure is that

33:28

if their patient partners get offered PrEP

33:31

or discussions about HIV PrEP. And I know these

33:33

guys have done talks on HIV PrEP. I won't

33:35

focus so much on that. And then

33:38

also take a really good sexual history as

33:40

well. Yeah.

33:41

So before I actually, I would like to hear what

33:43

your sexual history sounds like before we get there and

33:45

before we leave this slide. Is there a recommended

33:48

duration of time for someone to be undetectable

33:50

before you can say with confidence, OK, equals you? Is

33:52

there guidance, recommendation for that? Is one lab sufficient?

33:55

How was the timing about that? So

33:59

back what I always.

34:00

remember when I'm talking about family planning, I would like

34:02

to make sure that they're undetectable for at least six months.

34:04

But I think honestly, the data suggests that if

34:06

they're been undetectable with viral loads

34:09

less than being

34:11

detectable, it reduces the chance.

34:13

Perfect. OK. And I know that you wanted to talk

34:15

about your sexual health history. This

34:18

feels like the right time. So I would say

34:20

that the greatest thing I've ever

34:22

had, honestly, was working with

34:24

a young patient population. Because they really

34:26

broke me down in the sense of like terms,

34:29

lingo, like everything. And I still learn so

34:31

much from them. I have a, it's a joy

34:33

taking care of them. I always think

34:35

of, there's actually an insert from like the CDC

34:38

and it's really thinking about like the five P's. Now

34:41

I don't always remember all the P's, but it's still good. So

34:44

I think one is like looking at practice. So

34:46

like, you know, what is their practice? So I usually

34:48

will go in, like, I always start off with like, I have no assumptions,

34:51

just tell me like, you know, what preference

34:53

of partners do you have? trans be female

34:55

by, you

34:57

know, overall how do you practice, top,

34:59

bottom, verse. Usually I preface

35:01

this by, this is important for me to think about for testing.

35:04

So like I usually will preface that from that. Sometimes

35:06

I'll even ask them, you know, have they been tested in that

35:09

modality before overall. I

35:12

think the next thing I kind of get to is number of partners

35:14

within the last three to six months. So again,

35:16

it gives me an idea of how often to do STD screening, making

35:19

sure that that's offered. thinking about

35:22

HIV prep if there's like also partners that

35:24

they're necessarily having that might be interested in

35:26

that as

35:27

well. You know, I think

35:30

also prior history,

35:32

so again, knowing if they had previous histories

35:34

of STDs, mostly to make sure that they get tested

35:37

more frequently, and then also to make sure that

35:39

they're getting tested correctly. A lot of times I see

35:41

the primary care providers, amazing, they'll do a good job

35:43

of screening. They forget the check syphilis. So

35:45

like a lot of times I'll see like the urine and the

35:48

swab, but I won't see the RPR

35:50

actually. So just there's higher rates of syphilis

35:54

as expected. And then one other thing that might be

35:56

a little bit different in my patient population is hep C. So

35:59

there's.

36:00

There's been some

36:01

data looking at sexual

36:03

transmission, mostly in MSM. So

36:06

there's been thoughts that screen hep C might

36:08

want to have a discussion with patients to screen yearly,

36:11

actually. So that might be something else in my practice. And

36:13

making sure they're immune for hep B is also

36:15

a part of my practice. So like looking through all

36:18

these is making sure that if we do have the

36:20

swabs to do recto-infringial testing,

36:22

that should be included as well,

36:24

because we'll catch more cases that way. Yeah. We

36:28

did a STI episode years

36:30

ago and I

36:31

again was embarrassed to not know that. I

36:34

was just like, oh,

36:34

do the urine nucleic acid amplification

36:37

test

36:37

and I'm good to go. And our guest is like, no, you

36:39

miss a ton if you do that. Like you have to ask them

36:41

like, how are you having sex? You know, if and

36:44

then you have to do rectal swabs or pharyngeal

36:46

swabs, as you just said, as well if

36:49

that's happening. So I think that's,

36:51

we can't say that enough so that people remember to

36:54

do that. What

36:55

else, Paul? I wanted

36:57

to ask about, well,

36:59

actually, I guess, let's get into the labs first. So

37:02

we have some of these up here. Hopefully, they're

37:04

reasonably accurate. But I guess, let

37:08

me go back to my original question. I heard

37:11

rumblings about doxycycline for

37:13

STI prep. Can you talk me where are we

37:15

at with that? How should we be thinking about that? Is that something that

37:17

is commonly used? Sure. When I was in

37:19

Philadelphia, there was an arm of the hypergase

37:22

study that looked at doxycycline to

37:24

look at reducing the cases

37:26

of syphilis and chlamydia.

37:29

As the advent of HIV prep, great

37:32

in preventing HIV expectations

37:34

that there's been higher cases of STD, especially

37:36

in certain patient populations where there's just

37:38

much, much higher cases overall. The

37:41

thought process is that it's really thinking

37:45

about post-exposure prophylaxis, because

37:47

what they're looking at is providing doxycycline,

37:49

which is 200 milligrams within. You want to do

37:52

it within 24 hours, but up to 72 hours after

37:54

condomless sexual activity. And

37:56

what they noticed is that it actually decreased syphilis

37:59

case. and chlamydia cases, UCSF

38:02

and their state health department, I thought, had just

38:04

come out with a study, because it was kind of mentioned

38:07

in the International AIDS Conference from last summer,

38:10

actually looking at doxycycline, and they were

38:12

only looking at it for MSM. So it's only really,

38:14

MSM, it's cis

38:17

men or trans females, to think about when we're

38:19

talking about doxy prep, actually, and

38:21

what their, although there's ongoing studies looking

38:24

at it for cis females as well. But

38:27

what they noticed was that reduced STDs, but

38:29

up to 66%. And as

38:32

a former, before ID

38:34

fellowship, I was an epidemiologist, and

38:36

I can tell you, I've never done syphilis contact tracing,

38:38

but I've done other contact tracing. Takes up

38:40

a lot of time and resources to really

38:42

find patient zero. So when you're trying to find

38:45

and track cases of syphilis, how

38:48

much resources are spent, thinking

38:50

about conversations about doxypep might

38:53

be something to actually talk about. And

38:55

this is a daily doxy dose

38:57

to prevent? It's two different ways. So

39:00

most ways I've used it is mostly as

39:02

post-exposure prophylaxis. So 200 milligrams

39:04

within the 72 hours, really

39:06

try to put it 24 hours. There's other studies that are

39:08

coming from Canada and Australia that are

39:11

both looking at both PEP and Doxy

39:13

Prep as well. So there might

39:15

be stuff coming about because next week is our

39:17

big retrovirus and opportunistic

39:19

conference, which is a mouthful. So we just call it CROI.

39:22

So CROI. So there might be some updates. By the time

39:24

this airs, we might have to update the show. You'll let

39:27

us know if you need to update the show notes by the time

39:29

this airs. But the question comes

39:31

on who to think about it. So when I was

39:33

in Philadelphia, I remember the health department meeting

39:35

with us and just talking about

39:37

how much resources they use for syphilis testing.

39:40

And there had been discussions and reflections on should

39:43

we be thinking about doxypeps. So it's a conversation

39:45

that I've had for my patients. I think of any

39:47

patients that had more than one or two STDs actually

39:50

within a year, especially if it

39:52

was syphilis, actually. So it's like one

39:54

of the big things have had discussions with

39:57

the controversy or the part did not know in that

39:59

study. the most recent one was there was more

40:01

resistance to gonorrhea. Like it reduced it,

40:03

I think by 50%. Yeah, we don't want super gonorrhea

40:06

to get any more prevalent than it. But the

40:08

caveat is that we don't really use tetracycline

40:11

for gonorrhea treatment. But

40:13

the question is, well, will it change the biome

40:15

or resistance for other stuff that we use doxycycline

40:18

for, right? So when we think about staph infections

40:20

and stuff like that. So I think there's still a lot of data. So

40:22

like CDC's inputs like,

40:24

hey, it can be used off-label,

40:27

but there's still need a lot of data. Well,

40:30

I wanted to ask, because

40:32

we do want to leave time

40:33

for audience questions. I know we have

40:36

a lot of other stuff to test for. I did want

40:39

to ask about anal cancer screening,

40:41

because that's, I think probably most primary care

40:43

docs are less familiar with that. And

40:45

talking about doing digital rectal exams and

40:48

anal PAPs, are you doing those in the

40:50

off? Like who's doing those? Should primary

40:52

carers be doing those? if their patient's

40:54

not seeing an HIV specialist, really?

40:56

Sure, yeah, I've been doing

40:59

anal pap screening.

41:02

I did a lot of it before coming

41:03

to Penn State Hershey. The

41:06

issue sometimes I worry is that the costs of

41:08

the testing for patients prior, but I

41:11

think a lot of things have swayed in the last couple

41:13

years. Last year at CROI, the anchor study

41:15

kind of gave out some preliminary results looking

41:17

at anal cancer screening. So I'm

41:20

trying to remember what the anchor study stands for, things like

41:22

anal cancer, high-grade

41:25

squamous intraepithelial lesions.

41:28

Oh, that's great. Yeah, it's probably a cardiology

41:30

trial. That's not bad. Yeah, yeah. But

41:33

what they were looking at was they were screening patients over the

41:35

age of 35. They had both men and women, trans-female, trans-males

41:38

as well. And they were looking through and

41:41

seeing if a patient tested

41:43

positive for a high-grade lesion, should

41:45

they just take it out or should they just monitor

41:48

it? And the study actually had closed early. It

41:50

was between 15 different sites overall

41:52

in the U.S. and just because

41:54

there was clear benefit necessarily from it.

41:57

So it's something that I've been doing a lot

41:59

more in my patients. and practice and having that discussion

42:02

overall. And

42:04

I've caught a lot of high grade lesions. And then

42:07

after that, really tying them for the anoscopy

42:09

or colorectal to take a look to make sure if there's any

42:11

suspicious lesions. And then after that, follow

42:13

up with colorectal. And any resources

42:16

for people? I mean, I don't

42:18

think I did not learn how to do that. I know I

42:20

did not learn how to do that in training. So what resources

42:22

are there for people if they have to learn

42:24

how to do anal path? Yeah, so there's what

42:27

we call, there's a wonderful iteration

42:29

and stuff from some of the health departments overall.

42:33

It sounds more difficult than it is. It's

42:36

just a brush, actually, overall. And

42:38

you're trying to get around the z-line and putting pressure

42:40

as you go in, put pressure as you go in, and then

42:42

just spin as you go out. It's

42:45

been, you can Google it. There's many

42:47

different things in PDF. And patients can't

42:49

self-swab for that. That's one where we don't

42:51

recommend necessarily self-swabbing. And then

42:53

sometimes also thinking recto

42:55

exam, digital exam, just making sure you're not missing the

42:57

lesion from the brush. So those are things

43:00

I've had discussions with my patients

43:02

and recognized that overall,

43:04

they may not want to do that at the moment. Or

43:06

I don't save it for the first visit. It might be stuff as

43:08

we develop rapport. OK, great.

43:11

And along those lines for cervical cancer screening,

43:14

I know things are a little bit different for patients living with HIV.

43:17

You don't have to go too, too granular, but

43:19

any big differences between anything

43:22

that you would do differently for someone who is living with HIV

43:24

than someone who is not? Yeah, so I think

43:27

if I remember correctly from the primary

43:29

care guidelines, usually age 65, you

43:31

would necessarily stop for cervical cancer

43:34

screening in patients not living with HIV. In

43:36

persons living with HIV, actually

43:38

it goes on past that. So overall,

43:42

also depends, we try

43:44

to do it within the first time of diagnosis,

43:46

but still go by the guidelines, so nothing

43:48

earlier than necessarily 21. And

43:50

then I always have to look at the flowchart

43:52

overall to make sure that I remember, but

43:55

excellent chart up there that you're

43:57

showing.

43:59

So Paul, I

44:01

think we should leave a

44:03

few minutes for audience questions. We have some time left. But

44:05

what else do you definitely want to get to? I know we've got

44:07

into a lot of the stuff on here already. I think the

44:09

things I want to hit for sure, any differences in vaccines.

44:12

And then I think

44:13

we should probably finish up with the future is the injectable

44:15

stuff, because I feel like that's an important conversation to have. So why don't

44:17

we, any difference

44:19

in terms of vaccine considerations for someone with a diagnosis

44:22

of HIV? Yeah, I think as I think

44:24

about

44:26

necessarily vaccines, making

44:28

sure that they're definitely screened for

44:31

hep A and hep B. So making sure that

44:33

they're hep A and hep B immune.

44:35

Actually, again, for prevention

44:38

as an STD, but also co-infection, there's

44:40

worse liver with co-infection. Strep

44:43

the caucus pneumonia. So really thinking

44:45

about strep pneumo vaccinations actually

44:47

indicated there's higher rates. Which ones? Right.

44:50

I always, yeah, same thing. So usually I start

44:52

off with the PCV 15 and then 23. No.

44:58

I got to look at it again. It's changed so much

45:00

recently. It's what it's a day before. It's usually 23.

45:02

Yeah. Yeah. And then the other things to think about meningococcal

45:05

will vaccinate every five years for

45:08

meningococcal. And then even when I was

45:10

looking at the ACIP guidelines,

45:12

thinking about recombinant zoster

45:14

as well.

45:16

Yeah, I know they're trying to simplify. They tried to simplify

45:18

the pneumococcal guidelines, but I still think

45:21

it's still, because there's been so many

45:23

changes in quick succession and there's two new

45:25

vaccines, the two new PREVNARS, I feel

45:27

it's still confused and people are still confused.

45:30

Patients are like, didn't I already have two pneumonia vaccines?

45:32

So anyway, I'm on your side about, I'm on team JJ

45:35

for this one. I'm genuinely angry

45:37

about the pneumococcal vaccinations, which is not great for my patients.

45:39

Well, you know, I think like there's still some tables that

45:41

I have where I usually sit in my pod in clinic

45:43

and I'm like, yes, I'm still up to date on that one. Yeah,

45:46

all right. Well, let's talk about, I

45:48

was excited, I think the first I heard about

45:50

this

45:50

was last year at probably

45:52

ACP talking about the injectable

45:55

medicine, both for prep and for just like

45:57

once, once every eight weeks injectable.

46:00

and they don't have to take a daily pill. Can

46:02

you talk about this? Is this, are

46:05

there any barriers to this? Any downsides to

46:07

this?

46:08

So I think this has been really exciting. A

46:10

lot of patients had been hearing rumblings

46:12

for quite a while. As I mentioned

46:15

to you, it's very easy for me to come in and go, hey, take your

46:17

medication every day. Easy, but

46:19

I have patients that, it's a constant reminder

46:22

of their diagnosis necessarily. I have patients

46:24

that hide their pills or their transitional

46:27

housing in between, So like not making sure

46:29

that they don't want anyone to know that they necessarily

46:31

have HIV. And then I have other patients

46:33

that have just trouble taking pills. So when

46:35

this came out, it was really awesome to kind

46:37

of really talk about different treatment

46:39

options overall. One of the big

46:41

things is it can't be used with Hep B. So they have

46:43

to be hepatitis B, can't

46:47

have chronic hepatitis B, as we tend to

46:49

use tenofovir a lot for heptie

46:53

infections. But I think it's been really

46:55

revolutionary and really giving some of the

46:57

autonomy back to the patient that they don't

46:59

have to take a daily pill. When they were looking at the studies,

47:02

there's two, actually one that we're looking at it monthly,

47:04

the other looked at higher dosing and providing the

47:06

first shot, then the second shot, and then after that, every

47:08

two months. And patients did well.

47:10

There was not

47:12

as many breakthroughs overall from becoming

47:15

detectable. So I think it's a really effective

47:17

tool in our toolbox. Couple of caveats

47:20

to it is that it has to be done in a medical

47:22

visit. So because it's a gluteal

47:25

injection, actually it has to be

47:27

done. And I always tell it is that commercial is awesome.

47:30

I love the commercials. Commercial doesn't tell you that's

47:32

actually two shots. So like

47:34

actually as you're selling it with

47:37

the patients overall. So like the- Wait,

47:39

two shots on the same day? Yeah, so one

47:41

per

47:43

gluteal cheek. So

47:45

like as I just- I think you started with gluteal and then someone with

47:47

cheek at the end. Like you started out medical and then just

47:49

kind of- Sorry. You know, that's how I talk about it with my

47:51

patients. But I think one of the big things to really

47:53

highlight overall from it is from

47:56

the patients that have had transition,

47:58

they've absolutely loved it. I mean. And I think one

48:00

of the big things that I really

48:02

want to try to make sure is I need to

48:04

have a way to find our patient. And

48:06

I think that's the hard part sometimes is like, you

48:08

know, you have to remember to come

48:11

back to get that second shot.

48:13

You know, we have a little bit of a window or wiggle room,

48:16

but the always concerning part is if you pass

48:18

that window and the levels are starting to come down and

48:20

we're promoting resistance actually. So

48:23

you know, I've been having my patients do it.

48:25

We try to track it as best as we can, but I

48:27

think sometimes it's just that might be a

48:29

barrier to think about as implementing is really

48:31

the patient follow-up and retention.

48:34

And then the other thing I mentioned is that injectable

48:37

repivirin, so I also do a lot of methadone,

48:39

so like injectable repivirin can actually prolong

48:41

QTC. So like one thing to remember

48:43

is that if there's other QTC prolonging agents

48:46

to make sure there's a baseline EKG, and

48:48

cabbatagravir can actually interact with methadone. So

48:51

it can actually lower the dose. So it's something to think about

48:53

when you're discussing if they're getting methadone

48:56

with their site to make sure that they're

48:58

mentoring for any withdrawal symptoms overall.

49:01

And logistically with these, do you do an oral

49:03

run-in period for tolerance? Like are the

49:05

oral medications first and then transition to the injections?

49:08

So what does this look like? I know probably more than I need

49:10

to know specifically. No, no. So it's a great question.

49:12

For some patients, you know, if I

49:15

haven't done an oral lead-in, you don't necessarily

49:17

have to do the oral lead-in. And if you're doing

49:19

a switch, actually, and they're undetectable, they

49:21

tolerate it well. For patients where I've had

49:23

a lot of issue with medication side effects, I'll still

49:26

do an oral lead in just to make sure that

49:28

they're not having any side effects. So I've had patients

49:30

where we cycled through many different

49:31

antiretrovirals overall,

49:34

and that might be the time that I'll talk about it. The

49:36

other thing is just remembering that they can't

49:38

have NNRTI resistance. So if

49:40

they have resistance to ripivirine,

49:42

it's not an option. If there's a lot of integrase-inhabitore

49:45

resistance, it's not an option. But

49:47

I think it's a good discussion to have with

49:49

our patients overall. overall. And then the exciting

49:51

part of Cabotagravir as well is thinking at

49:54

it as an option for prep.

49:56

All right, well, should we take, I think we should

49:58

probably take questions from. the audience. We

50:01

might probably only have time for maybe like one or so,

50:03

but we'll just call on you and

50:05

we'll repeat it for the people in the audience.

50:08

So does anybody have any questions?

50:11

If not, that's okay. We're happy to just

50:13

get some take home points and get you all out of here. So

50:16

the question was, is there a PAP equivalent for

50:19

HPV related cancer screening?

50:21

I believe so.

50:23

I think... Yeah,

50:27

it's okay. If the answer is we're not sure... I

50:29

would say I'm not as sure for that, so I wouldn't feel comfortable mentioning

50:31

it. But that is a great question. Yeah, I know

50:33

people, I have had patients ask me that question.

50:35

They're worried about it. I think some celebrity has,

50:38

you know, head and neck cancer from HPV

50:40

and people are now aware that

50:42

that could be a thing. Any other questions

50:45

from the audience?

50:49

Okay. It feels like a question.

50:51

Just the furious avoidance of eye contact is my favorite thing

50:53

about medical education. All right. But we could, we could end

50:55

on time. Let's get some take home points. Like people,

50:57

we've talked about a

50:58

lot today. I mean, we've done hero's work as

51:01

always. As always. But

51:02

if there was like maybe a couple of things,

51:05

one, two, three things you wanted the audience to remember,

51:07

what would those be? You

51:09

know, I think just making sure that

51:12

we're

51:12

balancing patient expectations

51:14

and what they're looking for in primary

51:16

care, recognizing that barriers that they may have experienced,

51:19

I think that's something to kind of really think about

51:22

as we work with our patient populations. The second

51:24

thing that drives me crazy is the expectation

51:26

that if patients are late, we just reschedule.

51:29

We have no clue how our

51:31

patient's journey to come to our clinic or

51:34

practice that day. And you don't know the competing factors

51:36

that they're necessarily having. So I think one

51:38

of the big things is just being slightly flexible. And

51:41

I think one of the big things is recognizing that when

51:43

a patient has questions that if you don't know the answer,

51:46

just making sure that you can either refer or touch base

51:48

with much smarter colleagues overall

51:51

and not ignoring that. And I bring that up because a lot of

51:53

times, we've always talked about patients mentioning, hey,

51:55

I'm gaining weight, I'm gaining weight, I'm gaining weight, and

51:57

then now there's like a lot data suggesting that hey it's

51:59

true.

52:00

you gained weight on your medication. So I think listening to

52:02

the patients overall. And

52:05

we will be back with our lightning round.

52:09

All right, so before JJ, these

52:11

people know you, but maybe they don't have a

52:13

time to talk to you about like, some

52:15

of the more fun stuff. So maybe

52:18

give them a pick of the week. What are you

52:20

enjoying these days? And that you would recommend

52:22

to them and to the audience at home listening to

52:24

this after the fact. So if I

52:27

kind of want to seem like I'm sophisticated, So

52:29

I probably might start off with an actual book. I

52:31

do love to read. I wish I could say something

52:34

like, memoirs or biographies

52:36

or like stuff, but it's usually sci-fi. So

52:38

I think right now I'm reading The Wandering Earth, which is

52:40

really good. It's about moving this planet

52:42

as our sun is dying. It's very depressing,

52:44

but very good. Sounds right up my alley. Depression

52:47

sci-fi is like my specific niche, so I'll have to check it out.

52:49

And then realistically, probably playing

52:51

video games is my, you know, my stress

52:54

reliever and mass effect. I'm really

52:56

enjoying that. Okay, is

52:58

that available on Switch? Not,

53:00

not the moment. Yeah, I probably won't check

53:02

that out then because, yeah,

53:05

PS5's still hard to come by, maybe, I don't

53:07

know. It's fine.

53:10

This has been another episode of The Curbsiders,

53:12

bringing you a little knowledge food for your brain hole. Yummy?

53:15

I mean, it could have been your chance to shine. Do you want to say, do you want to

53:18

yummy? I'm okay. In front of your colleagues? I mean,

53:20

you can, right here. I'm okay. Great.

53:23

All right, missed opportunity buddy. All right, get your shout outs to thecurbsiders.com

53:25

and while you're there signing for a mailing list to get our weekly show notes in your inbox.

53:28

Plus, twice each month, you'll get our curbsiders digest, recapping

53:31

the latest practice changing articles, guidelines, and news

53:33

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53:35

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53:37

And we'd also like your feedback. Please subscribe,

53:39

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53:41

on YouTube, Spotify, or Apple Podcasts.

53:44

You can also email us at askcurbsiders at

53:46

gmail.com.

53:47

And I wanted to give a special thanks to the great Dr.

53:50

Paul Nelson Williams, America's primary care

53:52

doctor, and to

53:55

Dr. Beth Garbz-Garbatelli for helping

53:57

to write this episode. the curbsiders tech

54:00

is done by the team at Podpaste, Elizabeth Proto, and

54:03

Jen Watto run our social media, and Stuart Brigham composed

54:05

our theme music. And with

54:07

all that, until next time, I've been Dr. Matthew

54:09

Frank Watto. I do want to throw in a quick thanks

54:11

for Dr. Ellen Todaldi, who actually is one of my

54:14

legit heroes, who's at Temple right now, who actually looked

54:16

over the script and gave me some ideas. So I just

54:18

wanted to say thank you to her. And then also just ask for

54:20

another round of applause to the great Dr. Níngez

54:22

before they say hi. I'm Paul Williams. Thanks,

54:25

guys. Thanks guys.