POZ July/August 2021 by Smart + Strong

A SMART+STRONG PUBLICATION JULY/AUGUST 2021 POZ.COM $3.99

H E A L T H ,

L I F E

H I V

Beyond COVID-19 Adapting to life with the coronavirus and HIV SARS-CoV-2 (virus with red spikes) causes COVID-19, while HIV can lead to AIDS.

IMPORTANT FACTS FOR BIKTARVY®

This is only a brief summary of important information about BIKTARVY and does not replace talking to your healthcare provider about your condition and your treatment.

(bik-TAR-vee)

MOST IMPORTANT INFORMATION ABOUT BIKTARVY

POSSIBLE SIDE EFFECTS OF BIKTARVY

BIKTARVY may cause serious side effects, including:

BIKTARVY may cause serious side effects, including:  Those in the “Most Important Information About BIKTARVY” section.  Changes in your immune system. Your immune system may get stronger and begin to ﬁght infections that may have been hidden in your body. Tell your healthcare provider if you have any new symptoms after you start taking BIKTARVY.  Kidney problems, including kidney failure. Your healthcare provider should do blood and urine tests to check your kidneys. If you develop new or worse kidney problems, they may tell you to stop taking BIKTARVY.  Too much lactic acid in your blood (lactic acidosis), which is a serious but rare medical emergency that can lead to death. Tell your healthcare provider right away if you get these symptoms: weakness or being more tired than usual, unusual muscle pain, being short of breath or fast breathing, stomach pain with nausea and vomiting, cold or blue hands and feet, feel dizzy or lightheaded, or a fast or abnormal heartbeat.  Severe liver problems, which in rare cases can lead to death. Tell your healthcare provider right away if you get these symptoms: skin or the white part of your eyes turns yellow, dark “tea-colored” urine, light-colored stools, loss of appetite for several days or longer, nausea, or stomach-area pain.  The most common side effects of BIKTARVY in clinical studies were diarrhea (6%), nausea (6%), and headache (5%).

 Worsening of hepatitis B (HBV) infection. Your

healthcare provider will test you for HBV. If you have both HIV-1 and HBV, your HBV may suddenly get worse if you stop taking BIKTARVY. Do not stop taking BIKTARVY without ﬁrst talking to your healthcare provider, as they will need to check your health regularly for several months, and may give you HBV medicine.

ABOUT BIKTARVY BIKTARVY is a complete, 1-pill, once-a-day prescription medicine used to treat HIV-1 in adults and children who weigh at least 55 pounds. It can either be used in people who have never taken HIV-1 medicines before, or people who are replacing their current HIV-1 medicines and whose healthcare provider determines they meet certain requirements. BIKTARVY does not cure HIV-1 or AIDS. HIV-1 is the virus that causes AIDS. Do NOT take BIKTARVY if you also take a medicine that contains:  dofetilide  rifampin  any other medicines to treat HIV-1

BEFORE TAKING BIKTARVY Tell your healthcare provider if you:  Have or have had any kidney or liver problems,

including hepatitis infection.  Have any other health problems.  Are pregnant or plan to become pregnant. It is not known if BIKTARVY can harm your unborn baby. Tell your healthcare provider if you become pregnant while taking BIKTARVY.  Are breastfeeding (nursing) or plan to breastfeed. Do not breastfeed. HIV-1 can be passed to the baby in breast milk.

Tell your healthcare provider about all the medicines you take:  Keep a list that includes all prescription and over-the-

counter medicines, antacids, laxatives, vitamins, and herbal supplements, and show it to your healthcare provider and pharmacist.

 BIKTARVY and other medicines may affect each other.

Ask your healthcare provider and pharmacist about medicines that interact with BIKTARVY, and ask if it is safe to take BIKTARVY with all your other medicines.

These are not all the possible side effects of BIKTARVY. Tell your healthcare provider right away if you have any new symptoms while taking BIKTARVY. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088.

Your healthcare provider will need to do tests to monitor your health before and during treatment with BIKTARVY.

HOW TO TAKE BIKTARVY Take BIKTARVY 1 time each day with or without food.

GET MORE INFORMATION  This is only a brief summary of important information

about BIKTARVY. Talk to your healthcare provider or pharmacist to learn more.

 Go to BIKTARVY.com or call 1-800-GILEAD-5  If you need help paying for your medicine,

visit BIKTARVY.com for program information.

BIKTARVY, the BIKTARVY Logo, GILEAD, the GILEAD Logo, and LOVE WHAT’S INSIDE are trademarks of Gilead Sciences, Inc., or its related companies. Version date: February 2021 © 2021 Gilead Sciences, Inc. All rights reserved. BVYC0370 04/21

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HUGO LIVING WITH HIV SINCE 1995 REAL BIKTARVY PATIENT

KEEP CONNECTING. Because HIV doesn’t change who you are.

BIKTARVY® is a complete, 1-pill, once-a-day prescription medicine used to treat HIV-1 in certain adults. BIKTARVY does not cure HIV-1 or AIDS.

Ask your healthcare provider if BIKTARVY is right for you. See Hugo’s story at BIKTARVY.com. Featured patient compensated by Gilead.

Please see Important Facts about BIKTARVY, including important warnings, on the previous page and visit BIKTARVY.com.

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CONTENTS

EXCLUSIVELY ON

POZ.COM

Dafina Ward advocates for people living with HIV in the South.

POZ BLOGS Our roster of bloggers spans the diversity of the HIV epidemic. Go to poz.com/ blogs to read varying points of view from people living with the virus as well as from HIV-negative advocates. Join the conversation in the comments section. Visit the blogs to find hope and inspiration from others.

POZ OPINIONS

#UNDETECTABLE The science is clear: People who have an undetectable viral load don’t transmit HIV sexually. In addition to keeping people healthy, effective HIV treatment also means HIV prevention. Go to poz.com/undetectable for more.

POZ DIGITAL Scan the QR code (left) with your smartphone camera or go to poz.com/digital to view the current issue and read past issues online.

22 HIV AND COVID-19: GETTING HIV CARE BACK ON TRACK Lessons learned from HIV have informed the response to COVID-19, but has the new focus derailed HIV services? BY LIZ HIGHLEYMAN 28 CAN HIV MEDS PREVENT ALL TRANSMISSION OF THE VIRUS? After learning that HIV treatment prevents sexual transmission, researchers address questions about breastfeeding and injection drug use. BY HEATHER BOERNER 3 FROM THE EDITOR Brand New Day

treatment • therapeutic vaccines for a cure • HIV rates among Native Americans

4 POZ Q+A

16 ASK POZ

Andrew Spieldenner, PhD, shares his vision for the future of MPact Global Action for Gay Men’s Health and Rights.

Do I need to take meds daily?

6 POZ PLANET Artist Frederick Weston and writer Samuel R. Delany in conversation • R.I.P. a Visual AIDS visionary • 25 years of Dining Out For Life • Everyday AIDS milestones

12 VOICES JD Davids urges the HIV movement to come through for people with long COVID and provides a list of related resources.

14 RESEARCH NOTES

A messenger RNA vaccine for HIV? • four-day

18 BASICS Keeping your weight under control lowers the risk of many health problems.

20 CARE AND TREATMENT

Tivicay and Biktarvy are tops for tots • if you have sleepless nights, you’re not alone • cholesterol drugs boost survival • pick your poison: smoking or heavy drinking

32 HEROES Dafina Ward is the executive director of the Southern AIDS Coalition, which she views as a megaphone and bridge for people with HIV in the South, especially in rural areas.

POZ (ISSN 1075-5705) is published monthly except for the January/February, April/May, July/August and October/November issues ($19.97 for an 8-issue subscription) by Smart + Strong, 1001 Avenue of the Americas, FL 12, New York, NY 10018-5460. Periodicals postage paid at New York, NY, and additional mailing offices. Issue No. 253. POSTMASTER: Send address changes to POZ/Smart + Strong, 1001 Avenue of the Americas, FL 12, New York, NY 10018-5460. Copyright © 2021 CDM Publishing, LLC. All rights reserved. No part of this publication may be reproduced, stored in any retrieval system or transmitted, in any form by any means, electronic, mechanical, photocopying, recording or otherwise without the written permission of the publisher. Smart + Strong® and POZ® are registered trademarks of CDM Publishing, LLC.

COVER: (SARS-C O V-2 AND HIV) ISTOCK; THIS PAGE: (WARD) ANGELA HOPPER; (MEGAPHONE AND SPEECH BUBBLES) THINKSTOCK; (MAGNIFIER) ISTOCK

Advocates, researchers, politicians, thought leaders and folks just like you all have ideas worth sharing. Go to poz.com/ opinions to read about topics such as living with HIV, improving care and treatment, increasing prevention efforts and fighting for social justice.

FROM THE EDITOR

Brand New Day

EDITOR-IN-CHIEF

ORIOL R. GUTIERREZ JR. MANAGING EDITOR

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AM FINDING IT DIFFICULT TO adjust to the new reality we are all living through—COVID-19 rates are quickly decreasing in the United States. Although the coronavirus pandemic is far from over, the U.S. outlook is truly improving. That’s not just my wishful thinking. The statistics from the Centers for Disease Control and Prevention and other such sources continue to show that new coronavirus cases are way down, as are hospitalizations and deaths. Mask and social distancing mandates are rapidly disappearing. And yet a nagging feeling persists in my gut. Perhaps yours too. As an over-50 person living with HIV and other health conditions, I am cautiously optimistic about COVID-19. I want to believe, but my experience with HIV has often made me think twice about getting ahead of the science emotionally. To that end, our cover story in this special treatment issue addresses questions about COVID-19 many of us living with HIV still have, including its impact on our lives. Specifically, we dive deep into how COVID-19 has affected HIV services. Go to page 22 to read how HIV care is getting back on track. An interesting aspect of the fight against COVID-19 is just how crucial HIV advocates have been in the response. Indeed, comparisons between AIDS and COVID-19 have been made since the beginning of the new pandemic. Go to page 27 to read more about the parallels and the lessons learned. A big part of getting HIV care back on track after COVID-19 is refocusing on the many unanswered questions remaining when it comes to fighting the retrovirus. Case in point: Can HIV treatment prevent all transmission of the virus? A decade after learning that antiretrovirals (ARVs) prevent sexual transmission of HIV— a concept now known as Undetectable Equals Untransmittable (U=U)—researchers are addressing whether ARVs can prevent transmission via breastfeeding and injection drug use. Go to page 28 for more.

As mentioned in this issue’s U=U feature story, July 2021 marks 10 years since the idea was first announced at an HIV research conference. This year also marks five years since the launch of the U=U movement by the Prevention Access Campaign. Seems like only yesterday, but also like a lifetime ago. The COVID-19 pandemic had the same time-warping effect the HIV/AIDS pandemic had before it. It’s mind-boggling that June 5, 2021, marked 40 years that the retrovirus has been a part of our collective consciousness. So much has happened in these four decades, which means a lot is at risk of being forgotten. Thankfully, we still have many HIV advocates among us ensuring that we remember. Andrew Spieldenner is one of them. He is the new executive director of MPact Global Action for Gay Men’s Health and Rights. Go to page 4 to read a Q&A with him. Dafina Ward is another. She is the new executive director of the Southern AIDS Coalition. Go to page 32 for more on her advocacy. And go to page 12 to read about JD Davids advocating for people living with long COVID.

ORIOL R. GUTIERREZ JR. EDITOR-IN-CHIEF editor-in-chief@poz.com

Want to read more from Oriol? Follow him on Twitter @oriolgutierrez and check out blogs.poz.com/oriol.

poz.com JULY/AUGUST 2021 POZ 3

POZ Q+A

BY GREGORY TARTAGLIONE

HEALTH AND HUMAN RIGHTS

NDREW SPIELDENNER, PhD, BECAME THE NEW EXECUTIVE director of MPact Global Action for Gay Men’s Health and Rights on March 1, 2021. Gregory Tartaglione, senior communications officer at MPact, interviewed Spieldenner to learn more about him and to pick his brain about his vision for the future of MPact. Below is an edited version.

Hi, Andy, how’s it going? How’s quarantine been treating you this last year?

Is that even a question? Obviously, this last year has been incredibly hard. Like everyone else, it’s given me a lot of time to think about what’s really important to me, and that’s a big part of what led me to MPact. I think that one of the lessons we’ve learned during COVID is how vulnerable LGBT people still are around the world. Government leaders and policymakers have been quick to turn on us during this pandemic, and gay men globally need a voice that can speak on behalf of our health needs and our human rights. Absolutely! Can you tell us a little bit about your upbringing and how you first got interested in advocacy work?

Sure. I grew up all over the United States. My mom’s family were all refugees of the Vietnam War, and I remember at one point we had as many as 25 people living in our house. I’ve witnessed a huge shift in the sentiment about refugee communities since that time. Once, at a gay bar in Berlin, I saw this sign that said, “Nobody ever leaves without a reason,” and that really resonated with me, both as a child of immigrants and as a queer person. Many of us queer people have migrated in search

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of finding a safe place to come out and to be ourselves, and I think MPact has a big role to play in advocating for those people who don’t have access to legislators, to resources and to protection around the world. What was your introduction to MPact?

George [Ayala, MPact’s founding executive director] and I have been friends for close to 30 years, so I remember when he started this organization, and I’ve gotten to meet other MPact staff over the years at various conferences. Back in 2012, I was asked to be part of a panel at MPact’s pre-meeting at the International AIDS Conference in DC. I remember one of the panelists didn’t show up, and we found out it was because he had been murdered in his country the week before. It was an incredibly sobering experience. Here we were, gathered to talk about HIV, but that news was a terrible reminder of all the many ways in which our communities are still not protected.

ISTOCK

The new executive director of MPact shares his vision for the future of the global organization.

HIV is a huge issue, of course, but in many parts of the world, including the United States, we can still be killed just for being ourselves.

work, or gay trans men and nonbinary people. We need more spaces where we can articulate the needs of these parts of our community.

What’s the biggest issue facing gay and bisexual men these days?

What are some of the organizations doing this kind of work right now?

Sexual health. I think COVID especially has disrupted our ability to talk about sex. There is already a lot of shame in the gay community when people are open and honest about their sex life, and now you add COVID on top of that. It’s the same stigma that prevents people from being comfortable talking to their doctors and getting the health care we need. COVID has also isolated us from our communities. Even with all these virtual gatherings, if you’re not out to the people you live with, how are you supposed to participate? I think there’s going to be a lot of work to repair the damage from this year of isolation, and we’re going to have to come up with new, healthier ways to support gay and bisexual men to connect.

I really respect organizations like the Positive Women’s Network–USA, the Black AIDS Institute and The Counter Narrative Project that are shifting the narratives about HIV and racial justice. They are extraordinary leaders in bringing resources to the communities who need them most. Also one of the reasons I was really excited to join MPact was to get to work with the global key population networks—INPUD, NSWP, ICW, GNP+, GATE—that are doing amazing advo-

For sure! What’s one thing you would change about the gay community?

I wish we still embraced sex as a revolutionary act. Queerness to me has always been about pushing the norms and being disruptive. A lot of the big cis gay institutions focus only on helping queer people try to fit in, proving that they’re not so different from straight people. But what about the rest of us who don’t fit in? The fact of the matter is that our sexuality and our identities are not the norm in much of the world. That’s why there are still policies and people that are firmly against us. I want to dream of what kind of society and community we can build beyond that.

CAITLYN GAURANO

Same question but about the field of sexual health: What do you wish were different?

As somebody living with HIV, I find it sad when HIV is removed from the conversation. We can’t talk about gay men without talking about gay men who are living with HIV, or gay men who use drugs, or gay men who engage in sex

Andrew Spieldenner

should know who MPact is and be able to find our resources easily to make their dreams for their community a reality. What can we expect from MPact in the next year?

One of the lessons we’ve learned is how much can be done remotely and online. I’m interested in exploring how we can continue to push our work into the digital space, whether that be refining the way we use our social media platforms or hosting digital trainings for service providers and people in our community. Even with our advocacy—now that all of these high-level meetings are happening online—we have to come up with new strategies to reclaim our space at these virtual tables. It gives us

“The people who need us most are the ones who probably don’t know we exist.”

cacy to advance the human rights focus of the global HIV response. Who do you think are the people who need MPact most, and what can we do for them?

The people who need us most are the ones who probably don’t know we exist. I remember I was in Haiti with my best friend, and we were going to visit his family, and our bus broke down in the middle of nowhere. Within the hour, a small group of people came to sell us food and keep us entertained, and the person running the whole show and telling everyone what to do was this amazing young gender-nonconforming queer person. That’s the kind of community leader who needs our support. That person

a unique opportunity to rethink the way we collaborate with other global net works and all of our partners around the world as well, which I think is really exciting. What’s something people probably don’t know about you?

I’m a total comics geek. I go to San Diego Comic-Con every year. Comic books were how I first learned how to read, and as a young queer kid, I was obviously drawn to the tightly clad superhero men and the fierce superhero divas. Comics were a place where a queer kid could escape and be safe and where being different was something to be celebrated and not hidden. Except behind a mask, I guess. But we’ve all gotten used to wearing masks this last year. ■

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POZ PLANET BY TRENT STRAUBE

ART, SEX AND TIMES SQUARE Locations can inspire art. For writer Samuel R. Delany, famous for his science fiction, and artist Frederick Weston, best known for his collages, you could say their muse is Times Square—but not today’s sleek, Disneyfied version. Instead, as the two men reveal in the latest installment of Duets, Visual AIDS’s series of publications featuring conversations between artists, their beloved Times Square existed in the last decades of the 20th century and was a seedy hub of porn theaters and hustler bars where folks not only explored sexual desires but also found community and friendship. For Weston, Times Square also offered employment. Among other places, he worked in the coat check at Stella’s, on West 47th Street, where he snapped Polaroids of the bar’s denizens and at one point transformed the headshots into an art installation that covered the walls. “I was always doing collages, taking pictures and photocopying them,” the HIV-positive artist tells Delany. “I think I’m really kind of a painter, but I don’t paint with paint, I paint with pieces of paper.” The first work he sold was Water/Bed (1999), a collage from an exhibit at Village Care, his HIV day-treatment program. Over the years, his work grew in scope and scale, allowing him to delve into personal issues such as race and depression— though he notes it took a while after his HIV diagnosis before the subject appeared in his work, including his poetry and performance pieces. Delany is HIV negative, which he tells Weston is likely a result of the fact that he didn’t like penetrative sex and preferred to perform oral sex in porn theaters. (Their frank and unapologetic conversation will surely be a shock to some readers.) Sadly, Weston died of cancer in 2020 before this Duets was completed but not before making his mark. As The New York Times noted in his obituary, “for decades he made his art in dingy Manhattan hotel rooms living hand-to-mouth, hoping for his big break. It finally arrived just a few years before his death.” He was 73. In a blog post about Weston’s passing, Visual AIDS, which uses art to fight HIV and support HIV-positive artists, wrote, “We are grateful for the many ways he brought his visionary talent and personal warmth to our lives and to our programs. He spoke and performed original poetry at our public events, led education workshops, contributed to exhibitions and was a valued member of our archive and our community. Fred lived near our office and would often stop by for visits that were the highlight of our week. We will feel a keen sense of loss without Fred’s creativity, his warm and welcoming personality, his sartorial style, his iconic double hugs and his signature sign-off, ‘Bye for now!’”

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Clockwise from top left: Samuel R. Delany and Frederick Weston; samples of Weston’s art included in Duets: a collage from his series Blue Bathroom Blues, 1999; Body Map (Arms), 2017; Divorce from My Cowardice, 2009; Body Map 1, 2015; and the cover of Duets, which features Weston’s Self-Portrait, 1979, created with dot matrix print and tape

(ALL DUETS IMAGES) COURTESY OF VISUAL AIDS; (O’CONNELL) BUCK ENNIS; (RED RIBBON) ISTOCK

Two queer Black artists discuss it all in the latest Duets book from Visual AIDS.

AIDS Art Visionary

poz.com JUNE 2015 POZ 7

Founded in 1988, Visual AIDS produces exhibitions and publications, supports HIVpositive artists, catalogs their artwork (via galleries on VisualAIDS.org) and uses art to remind the world that AIDS is not over. The group’s first director, Patrick O’Connell, who served from Patrick 1989 to 1995, died of AIDSO’Connell in related illness in March 2021. a 1994 POZ He was 67 and had lived with profile. He was HIV for nearly 40 years. the founding “Patrick was instrumendirector of tal in coordinating and Visual AIDS. distributing our early AIDS activist projects, such as Day Without Art, Night Without Light, and the Red Ribbon,” wrote Visual AIDS in an Instagram post noting his passing. Yes, those red ribbons. A collection of Visual AIDS artists created the ribbons in 1991 as a simple way for anyone to show support for people living with HIV. The concept caught on across the globe. In 1989, Visual AIDS spearheaded the first Day Without Art, for which over 1,100 art organizations, including museums, obscured a selection of artworks as a way to draw attention to the many artists dying in the epidemic. That event lives on today, reimagined as Day With(out) Art, for which Visual AIDS invites artists and filmmakers to submit proposals for short films that are produced and then premiered on Day With(out) Art events around the world to coincide with World AIDS Day, December 1. According to Visual AIDS, this year’s eight commissioned videos will “center stories of collective care, mutual aid and solidarity that recast community work as a form of medicine.” 2022 is already in the works.

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POZ PLANET BY TRENT STRAUBE

A Toast to 25 Years of Dining Out to Fight HIV Sometimes the simplest recipe is the best. For the past 25 years, HIV fundraiser Dining Out For Life (DOFL) has served up opportunities to support local restaurants and AIDS service organizations. The way it works is easy: On a designated day, you dine out at a participating eatery, and a portion of the proceeds goes to a local HIV group. Cities, municipalities and states organize their events on different days, so visit DiningOutForLife.com to see when your community participates—or how to launch an event; you can also search #DOFL and #DineOutEndHIV on social media. DOFL has raised more than $4.5 million in the United States and Canada, supporting more than 50 HIV organizations and including over 2,400 restaurants and 4,100 volunteers. What’s the secret sauce that makes this such an enduring hit? Brett Klein, a

The musical comedy web series MERCE, starring Charles Sanchez as a gay man living with HIV in New York City, debuts online. (2015)

Prevention Access Campaign, a coalition of activists, community members and scientists, launches the UNDETECTABLE EQUALS UNTRANSMITTABLE (U=U) movement. (2016)

The U.S. Food and Drug Administration announces that SMALL QUANTITIES OF UNAPPROVED DRUGS can be imported for people with life-threatening illnesses, including HIV/AIDS. (1988)

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at decreased capacity. But participants got creative in their efforts—for example, by allowing takeout orders and direct donations to the HIV groups. “Dining Out For Life gives everybody the opportunity to make a meaningful contribution to the fight against HIV/ AIDS just by doing something you would do anyway,” Allen tells POZ. “And all the money raised goes to your community. You’re helping your very own friends and neighbors. Maybe you feel a little less guilty about ordering dessert or a second bottle of champagne.” Bon appétit!

These dates represent milestones in the HIV epidemic. Visit poz.com/aidsiseveryday to learn more about the history of HIV/AIDS. BY JENNIFER MORTON

July

Above: designer Mondo Guerra; left: two participating DOFL eateries in Tacoma, Washington

August

DAVID HO publishes “Time to Hit HIV, Early and Hard” in The New England Journal of Medicine. (1995)

JEFFREY, a romantic comedy about a gay actor who decides to become celibate because of the risk of AIDS, opens in theaters. (1995)

20 29

SOUTHERN HIV/AIDS AWARENESS DAY

NATIONAL FAITH HIV/AIDS AWARENESS DAY (Last Sunday in August)

(DOFL RESTAURANTS INDOCHINE ASIAN DINING LOUNGE AND HELLO, CUPCAKE) COURTESY OF DOFL/MOLLY WALSH; (MONDO GUERRA) COURTESY OF DOFL; (MERCE) MERCE) COURTESY OF CHARLES SANCHEZ; (U=U) PREVENTIONACCESS.ORG;(HO)WIKIMEDIA/CC BY-SA 4.0

EVERYDAY

DOFL board member, attributes the success to “our ambassador community, consisting of thousands of dedicated volunteers who not only help raise unrestricted funds but also bring people together to share a meal and give back. And that is the second part of our success: Everyone needs to eat, and there is no better way to create a community than sharing a meal with friends new and old.” Celebrity spokespeople actress Pam Grier, designer Mondo Guerra and Chopped host Ted Allen also champion the event, which is sponsored by Subaru. This past year, Guerra even designed face masks for all DOFL licensed groups. And yes, COVID-19 did affect fundraising efforts, Klein says, because many eateries have been closed or operating

If you are living with HIV, ask yourself the following questions: Have I lost weight? Have I lost weight without trying? Does the change in my weight impact how I feel about myself or my health? Is my clothing looser than before because I have lost weight without trying? Have those I know mentioned that my appearance has changed?

Do I have less energy? Are any of my usual activities more difficult to perform? Am I exercising less than in the past? Do I need to take a break more often? Do I tire more easily after certain activities?

If you answered “yes” to any of these questions, take this questionnaire to your next appointment with your healthcare provider to start a conversation about HIV-associated wasting and to inquire about treatment. Together you can discuss next steps. To learn more about HIV-associated wasting, visit: AmIWasting.com

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VOICES

THE HIV MOVEMENT MUST COME THROUGH The following opinion piece by HIV activist JD Davids is an edited version of a post from his Substack site, The Cranky Queer. This version is accompanied by a list of additional resources for long COVID.

’VE BEEN AN HIV-FOCUSED ACTIVIST FOR MOST OF MY LIFE. AND ALTHOUGH I am not living with HIV, I’ve spent a lot of that time dealing with illness and chronic pain. Now, many children, adults and elders who have gone through COVID-19— even with an asymptomatic infection—are experiencing some of the health challenges that have changed my life. For months, over a year or perhaps permanently, they are living with long COVID. People with long COVID, also known as COVID long-haulers, continue to experience symptoms long after the days or weeks that make up a typical course of the disease. They need our understanding and our help.

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Moreover, we need to fight together for the comprehensive care and resources we all need. We’re already seeing new threats to HIV funding, as health departments struggle to pay for the costs of the COVID pandemic, alongside the ongoing, drastic lack of research and care for complex chronic illnesses that now include long COVID. As a person living with myalgic encephalomyelitis—known as ME or ME/CFS and often called/minimized as chronic fatigue syndrome—as well as other chronic conditions, I constantly have the three most common symptoms of long COVID: fatigue, cognitive dysfunction (trouble with thinking) and post-exertional malaise (known as PEM, in which symptoms emerge or relapse up to 48 hours after mental or physical effort). Unlike many, I’ve been able to get diagnoses and some care for my chronic conditions. But that’s largely because I am white, urban and “professional.” I have, and have often needed to use, my skills and connections as a research and treatment advocate, and I have private health insurance—although I have to pay out of pocket for my ME specialist and several of my treatments. My experience can help show why there’s a decades-long misunderstanding that ME somehow occurs only in white people. Now, many of the faces appearing in media stories about long COVID are white, even though it likely has a disproportionate impact among the Black and brown people who were most affected by the COVID pandemic itself. Sound familiar? Here’s another dynamic similar to the early days of HIV: If people don’t have a history of a positive COVID test—which many don’t have, especially those who already had barriers or faced bias in health care—they aren’t eligible for many of the few long COVID care programs or emerging clinical trials, even if they clearly had COVID and are suffering now. It’s like when women living with HIV were locked out of care, benefits and research when the definition of AIDS itself excluded some of the opportunistic infections most common in women, and we said, “Women don’t get AIDS; they just die from it.” Long COVID was predicted by disabled people and people with chronic illnesses. But we were talked about, not listened to, as the pandemic approached and began to spiral out of control. That’s because while

ISTOCK

BLOGS AND OPINIONS FROM POZ.COM

COVID-19 is indeed a new disease, it’s been known for over 100 years that people can become chronically ill after a viral infection. But when we have post-viral conditions, like ME or long COVID, we still struggle to be believed. We scramble to find care providers who can help. We suffer the consequences of systems that split us up by medical specialties rather than our actual needs as humans. And unless there’s an expensive treatment for us, we don’t see the kind of in-depth consumer health information or support underwritten by drug company advertising. Today, I’m able to use my experience as an HIV activist as we face these challenges. I hope you’ll join me. For example, when I had the honor of collaborating with a group of scientists living with long COVID, I encouraged them to emphasize that they were patient-led as they published their findings. The Patient-Led Research Collaborative for Long COVID (led by women, by the way) is now a central force in long COVID science and advocacy; its very name emphasizes that the expertise of the collective’s members

JD Davids

comes from living with long COVID. Research and care for complex chronic conditions has never been a focus of our public health or medical care systems. It’s why we desperately needed, and still need, the Ryan White AIDS Program. It provides funds to coordinate the care of people living with HIV, links and trains medical providers, ensures access to medication and more. And as people living with HIV age, we see that some are very much back in complex care territory, dealing with comorbidities

(DAVIDS) LOUIE ORTIZ-FONSECA

RESOURCES FOR LONG COVID Research shows that 10% to 30% of people who get COVID-19 will experience some form of long COVID. While people who were hospitalized or in intensive care due to COVID may experience distinct forms of organ damage and ongoing health challenges, many people with long COVID had mild or even asymptomatic illness. The condition can include a range of symptoms from mild to severe. However, an international patient-led survey of 3,762 participants found that most people with long COVID hadn’t returned to previous levels of work in six months. So what can people with long COVID do? How can their friends and families support them? If you read nothing else in this list, read and share this: #StopRestPace. Here’s why: Many people with long COVID are encouraged to build back stamina and strength through exercise. But we know that some people with myalgic encephalomyelitis (ME), a similar chronic condition, who were able to deeply rest during the first months of illness were more likely to recover. In addition, it is common for people with postexertion malaise to have setbacks after exercise. “Pacing is a self-management strategy for activity,” explains #MEAction (MEAction.net), a group for people with ME, many symptoms of which mirror those of long COVID. “Patients who pace well are active when able and rest when tired. They may plan extra rest ahead of strenuous activities.” As in the early years of the HIV pandemic, people with long COVID have often been the best source of information for one another. Body Politic, a queer feminist wellness collective in New York City whose founders got long COVID early in the pandemic, hosts dozens of topical discussions

like heart disease and diabetes or conditions like frailty. But truly, all people need and deserve care and support as we face health challenges, rather than being put in competition for what still amounts to crumbs. May the intensely unjust horrors of the COVID pandemic bring us together to finally achieve what we’ve had the right to all along— comprehensive universal health care and services for all. ■

JD Davids (@TheCrankyQueer), is living with ME, fibromyalgia and other chronic conditions and is a board member of #MEAction. Raised by ACT UP Philadelphia, he has organized on many issues, including access to syringes and other HIV prevention methods, health care for people in jails and prison, trans research and health and global access to HIV treatment. He has served as an external adviser to the Centers for Disease Control and Prevention and the National Institutes of Health. He now primarily works with national networks of U.S. people living with HIV and as a strategist and storyteller for The Cranky Queer Guide to Chronic Illness.

in its online support group, which uses the Slack platform. The collective’s resource page is updated frequently, and its members have created a list of recommended medical providers. #MEAction (for which I serve on the board of directors) is tapping the wisdom of the global community of people living with ME to provide information and support to people with long COVID. The COVID-19 Longhauler Advocacy Project maintains a comprehensive guide for both people with long COVID and doctors. Organizations and individuals can also join the Long COVID Alliance, a growing network of advocates with long COVID, scientists and others who are demanding research on and resources for post-viral illness. Want to be a good ally to people with long COVID? • Believe the people in your life who are still sick months after they had COVID—even if they didn’t know they had it. Help them find support (such as online support groups like Body Politic) and help them #StopPaceRest. • Bring long COVID into the conversation about COVID-19, which still is reduced to focusing on acute COVID and viewing vaccines as the solution. • Fight for equity-based public health and medical care for all people with long COVID, HIV, ME and all other chronic conditions (learn more at bit.ly/chronicinjustice). • Speak out or stand up for long COVID and ME care for all, regardless of proof of a positive COVID test (bit.ly/covidtestjustice). • Bridge the gap between HIV advocacy and disability justice to combat the stigma against all of us (start with watching Crip Camp https://cripcamp.com and learn from http://disabilityvisibilityproject.com). —JD

poz.com JULY/AUGUST 2021 POZ 13

RESEARCH NOTES BY LIZ HIGHLEYMAN

PREVENTION

TREATMENT

CURE

CONCERNS

The same messenger RNA (mRNA) technology used for the Moderna and PfizerBioNTech COVID-19 vaccines also shows promise for HIV. Researchers with the National Institute of Allergy and Infectious Diseases designed a vaccine regimen that delivers mRNA for envelope proteins from three different subtypes of HIV. Fourteen male macaque monkeys received one of two vaccine combinations or placebo injections; some got a final booster containing stabilized HIV spike proteins that are more easily recognized by broadly neutralizing antibodies. All the vaccinated monkeys produced antibodies against the viral proteins in the vaccine. When rectally exposed to an engineered HIV-like virus, all seven monkeys in the placebo group became infected within several weeks. But the vaccinated monkeys remained uninfected longer, and a few were still protected after 13 virus exposures—up to an 88% risk reduction. Phase I human trials of two mRNA HIV vaccine candidates from Moderna are expected to start this year.

Taking antiretrovirals for four consecutive days each week followed by a threeday break may maintain viral suppression as well as daily pills. The French QUATOR trial enrolled more than 600 adults with a viral load below 50 for at least a year. For the first 48 weeks, they were randomly assigned to either stay on their existing daily regimens, most of which included an integrase inhibitor or a non-nucleoside reverse transcriptase inhibitor (NNRTI), or to take their meds Monday through Thursday followed by three days off. After that, both groups followed the four-day schedule for another 48 weeks. Among participants who were on the four-day schedule for two years, 93% maintained viral suppression, 4% developed virological failure (more common among NNRTI recipients) and several developed drug-resistance mutations. Both treatment strategies were safe and well tolerated, but people in the four-day group saw a small improvement in kidney function. What’s more, the four-day regimen reduced the cost of treatment by about 40%.

Therapeutic HIV vaccines could one day be part of a combination strategy for achieving a functional cure for HIV. Spanish scientists tested a series of HTI (HIVACAT T-cell immunogen) vaccines designed to help T cells recognize parts of the virus that trigger immune responses in people who naturally control HIV. One delivers HIV DNA directly, one uses a modified vaccinia Ankara viral vector and one uses a chimpanzee adenovirus vector similar to the one used for the AstraZenecaOxford COVID-19 vaccine. In this early study, 45 people who started antiretroviral therapy soon after infection and had an undetectable viral load received up to eight vaccine or placebo injections; they could then opt for a treatment interruption. Viral load rebounded in all cases, but the new viral setpoint was lower in the vaccine group. In a subset of 32 participants, eight vaccine recipients (40%) and one placebo recipient (8%) were able to remain off antiretrovirals for nearly six months. Five vaccine recipients and one placebo recipient maintained a viral load below 2,000.

HIV diagnoses rose among Native Americans and Alaska Natives between 2014 and 2018, but death rates decreased, according to a study from the Centers for Disease Control and Prevention and the Indian Health Service, which is the primary source of health care for 1.6 million American Indians and Alaska Natives. Overall, the diagnosis rate was about the same in 2014 and 2018 (7.7 per 1,000 people), but this masked annual changes that varied by age. Adults ages 25 to 34 and 35 to 44 saw a steep climb from 2015 to 2016 followed by a decline, while those ages 13 to 24 saw a decrease followed by a rise from 2017 to 2018. Gay and bisexual men and two-spirit people accounted for nearly two thirds of new diagnoses, and the Navajo Nation had the highest burden (13.7 per 100,000). The proportion of Native Americans and Alaska Natives living with diagnosed HIV rose by 20.7% during the study period. The overall death rate among people living with HIV declined by 30.4%, but those ages 25 to 34 saw an increase from 2017 to 2018.

4-Day Treatment

14 POZ JULY/AUGUST 2021 poz.com

Vax for a Cure?

Native Americans

ALL IMAGES: ISTOCK

mRNA Vaccine

LOWER YOUR VIRAL LOAD. AND MAKE UNDETECTABLE * A POSSIBILITY AGAIN. * Undetectable viral load is defined as fewer than 50 copies of HIV per mL of blood.

Ask your healthcare provider about TROGARZO® – A fully active HIV-1 treatment designed specifically for those with treatment failures

For more information, visit TROGARZO.com WHAT IS TROGARZO®? TROGARZO® (ibalizumab-uiyk) is a prescription medicine that is used with other antiretroviral medicines to treat Human Immunodeficiency Virus-1 (HIV-1) infection in adults who: • have received anti-HIV-1 regimens in the past, and • have HIV-1 virus that is resistant to antiretroviral medicines, and • who are failing their current antiretroviral therapy It is not known if TROGARZO® is safe and effective in children. IMPORTANT SAFETY INFORMATION Do not receive TROGARZO® if you have had an allergic reaction to TROGARZO® or any of the ingredients in TROGARZO®. TROGARZO® can cause serious side effects, including: • Allergic reactions. TROGARZO® can cause allergic reactions, including serious reactions, during and after infusion. Tell

your healthcare provider or nurse, or get medical help right away if you get any of the following symptoms of an allergic reaction: trouble breathing, swelling in your throat, wheezing, chest pain, chest tightness, cough, hot flush, nausea or vomiting. • Changes in your immune system (Immune Reconstitution Inflammatory Syndrome) can happen when you start taking HIV-1 medicines. Your immune system might get stronger and begin to fight infections that have been hidden in your body for a long time. Tell your health care provider right away if you start having new symptoms after receiving TROGARZO®. The most common side effects of TROGARZO® include diarrhea, dizziness, nausea, and rash. These are not all the possible side effects of TROGARZO®. Before you receive TROGARZO® (ibalizumab-uiyk), tell your healthcare provider about all of your medical conditions, including if you are:

• Pregnant or plan to become pregnant. It is not known if TROGARZO® may harm your unborn baby. Tell your healthcare provider if you become pregnant during treatment with TROGARZO®. • Breastfeeding or plan to breastfeed. You should not breastfeed if you have HIV-1 because of the risk of passing HIV-1 to your baby. Do not breastfeed if you are receiving TROGARZO® as it is not known if TROGARZO® passes into breast milk. Talk with your healthcare provider about the best way to feed your baby during treatment with TROGARZO®. Also tell your healthcare provider about all the medicines you take, including all prescription and over-the-counter medicines, vitamins, and herbal supplements. For more information or medical advice about side effects, ask your healthcare provider. You may report side effects to the FDA at 1-800-FDA-1088 or the THERA patient support® program at 1-833-238-4372.

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ESA

ASK POZ WELLNESS TIPS FROM POZ.COM

DO I NEED TO TAKE MEDS DAILY? HIV treatment usually requires daily pills, but longer-acting regimens are gaining ground.

16 POZ JULY/AUGUST 2021 poz.com

THE 2021 HIV DRUG CHART: A QUICK REFERENCE GUIDE

H E A L T H ,

L I F E

H I V

This quick-reference chart compares antiretroviral (ARV) options for the treatment of HIV, including adult dosing and dietary restrictions. Visit poz.com/drugchart for more info.

tenofovir disoproxil fumarate + lamivudine

efavirenz + tenofovir disoproxil fumarate + emtricitabine

One tablet once a day. Each tablet contains 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take with or without food.

COMBIVIR * zidovudine + lamivudine One tablet twice a day. Each tablet contains 300 mg zidovudine + 150 mg lamivudine. Take with or without food.

BIKTARVY bictegravir + tenofovir alafenamide + emtricitabine

DESCOVY

One tablet once a day. Each tablet contains 50 mg bictegravir + 25 mg tenofovir alafenamide + 200 mg emtricitabine. Take with or without food.

tenofovir alafenamide + emtricitabine One tablet once a day. Each tablet contains 25 mg tenofovir alafenamide + 200 mg emtricitabine. Take with or without food.

cabotegravir + rilpivirine

COMPLERA rilpivirine + tenofovir disoproxil fumarate + emtricitabine One tablet once a day. Each tablet contains 25 mg rilpivirine + 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take with a meal.

DELSTRIGO doravirine + tenofovir disoproxil fumarate + lamivudine One tablet once a day. Each tablet contains 100 mg doravirine + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take with or without food.

DOVATO

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs, or nukes)

EMTRIVA * CABENUVA A long-acting injectable regimen administered as two intramuscular injections every four weeks (or eight weeks pending FDA approval) after a one-month lead-in period with oral Vocabria (cabotegravir) + Edurant (rilpivirine). Take with food.

dolutegravir + lamivudine One tablet once a day. Each tablet contains 50 mg dolutegravir + 300 mg lamivudine. Take with or without food.

emtricitabine (also known as FTC) One 200 mg capsule once a day. Take with or without food.

EPIVIR * lamivudine (also known as 3TC)

One 25 mg tablet once a day. Take with food.

INTELENCE etravirine One 200 mg tablet twice a day. Take with food.

PIFELTRO doravirine One 100 mg tablet once a day. Take with or without food.

SUSTIVA * efavirenz One 600 mg tablet once a day, or three 200 mg capsules once a day. Take on an empty stomach or with a low-fat snack. Dose should be taken at bedtime to minimize dizziness, drowsiness and impaired concentration.

atazanavir + cobicistat One tablet once a day. Each tablet contains 300 mg atazanavir + 150 mg cobicistat. Take with food.

One tablet once a day. Each tablet contains 600 mg abacavir + 300 mg lamivudine. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

KALETRA * lopinavir + ritonavir

RETROVIR * zidovudine (also known as AZT) One 300 mg tablet twice a day. Take with or without food.

TEMIXYS tenofovir disoproxil fumarate + lamivudine One tablet once a day. Each tablet contains 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take with or without food.

Two tablets twice a day, or four tablets once a day, depending on HIV drug resistance. Each tablet contains 200 mg lopinavir + 50 mg ritonavir. Take with or without food.

PREZCOBIX darunavir + cobicistat One tablet once a day. Each tablet contains 800 mg darunavir + 150 mg cobicistat. Take with food.

PREZISTA

TRUVADA *

darunavir

tenofovir disoproxil fumarate + emtricitabine

elvitegravir + cobicistat + tenofovir alafenamide + emtricitabine

rilpivirine

EVOTAZ EPZICOM * abacavir + lamivudine

One 800 mg tablet (or two 400 mg tablets) plus one 100 mg Norvir tablet once a day, or one 600 mg tablet plus one 100 mg Norvir tablet twice a day, depending on drug resistance. Take with food.

One tablet once a day. Each tablet contains 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take with or without food.

GENVOYA

(Pills not shown actual size)

EDURANT

One 300 mg tablet once a day, or one 150 mg tablet twice a day. Take with or without food. Also approved for the treatment of hepatitis B virus but at a lower dose. People living with both viruses should use the HIV dose.

Protease Inhibitors (PIs)

One tablet once a day. Each tablet contains 600 mg efavirenz + 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take on an empty stomach. Dose should be taken at bedtime to minimize dizziness, drowsiness and impaired concentration.

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs, or non-nukes)

*Generic version available in the U.S.

CIMDUO ATRIPLA *

One tablet once a day. Each tablet contains 150 mg elvitegravir + 150 mg cobicistat + 10 mg tenofovir alafenamide + 200 mg emtricitabine. Take with food.

REYATAZ *

VIREAD *

atazanavir

tenofovir disoproxil fumarate

Two 200 mg capsules once a day, or one 300 mg capsule plus one 100 mg Norvir tablet once a day. Take with food.

One 300 mg tablet once a day. Take with or without food.

JULUCA dolutegravir + rilpivirine

ZIAGEN *

One tablet once a day. Each tablet contains 50 mg dolutegravir + 25 mg rilpivirine. Take with a meal.

abacavir

ISENTRESS

One 300 mg tablet twice a day, or two 300 mg tablets once a day. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

One tablet once a day. Each tablet contains 25 mg rilpivirine + 25 mg tenofovir alafenamide + 200 mg emtricitabine. Take with a meal.

RUKOBIA fostemsavir One 600 mg tablet twice a day for people with HIV treatment experience. Take with or without food.

raltegravir

Integrase Inhibitors

ODEFSEY rilpivirine + tenofovir alafenamide + emtricitabine

Two 600 mg Isentress HD tablets (above) once a day for those who are treatment naive or whose virus has been suppressed on an initial regimen of Isentress. One 400 mg Isentress tablet twice daily for people with HIV treatment experience. Take with or without food.

TIVICAY dolutegravir One 50 mg tablet once a day for those ﬁrst starting ARV therapy or for those who have not used an integrase inhibitor in the past. One 50 mg tablet twice a day for treatment-experienced individuals who have HIV that is resistant to other integrase inhibitors and when taken with certain ARVs. Take with or without food.

STRIBILD elvitegravir + cobicistat + tenofovir disoproxil fumarate + emtricitabine One tablet once a day. Each tablet contains 150 mg elvitegravir + 150 mg cobicistat + 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take with food.

Entry Inhibitors

VOCABRIA cabotegravir

SELZENTRY maraviroc One 150 mg, 300 mg or 600 mg tablet twice a day, depending on other meds used, for people with HIV treatment experience. Take with or without food.

One 30 mg tablet taken once a day with once-daily Edurant for a month as a lead-in regimen before switching to Cabenuva injections or for short-term treatment. Take with food.

These antiretroviral medications are rarely prescribed and no longer recommended:

SYMFI AND SYMFI LO efavirenz + tenofovir disoproxil fumarate + lamivudine

APTIVUS

One tablet of either Symfi or Symfi Lo once a day. Each tablet of Symfi contains 600 mg efavirenz + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Each tablet of Symfi Lo (above) contains 400 mg efavirenz + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take on an empty stomach. Dose should be taken at bedtime to minimize dizziness, drowsiness and impaired concentration.

tipranavir

TROGARZO

CRIXIVAN

ibalizumab

indinavir

A long-acting injectable administered intravenously as a single loading dose of 2,000 mg followed by a maintenance dose of 800 mg every two weeks for people with HIV treatment experience.

FUZEON enfuvirtide

INVIRASE saquinavir

SYMTUZA

LEXIVA

darunavir + cobicistat + tenofovir alafenamide + emtricitabine One tablet once a day. Each tablet contains 800 mg darunavir + 150 mg cobicistat + 10 mg tenofovir alafenamide + 200 mg emtricitabine. Take with food.

fosamprenavir

NORVIR * ritonavir Six 100 mg tablets twice a day. The full dose of Norvir is rarely used. It is most often used at lower doses to boost the levels of other ARVs in the blood. Take with food.

TRIZIVIR abacavir + zidovudine + lamivudine

VIRACEPT nelﬁnavir

TRIUMEQ dolutegravir + abacavir + lamivudine One tablet once a day. Each tablet contains 50 mg dolutegravir + 600 mg abacavir + 300 mg lamivudine. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

VIRAMUNE TYBOST cobicistat One 150 mg tablet once a day in combination with ARVs that require boosting. Used only to boost other drugs. Take with food.

Ask POZ is an ongoing section on POZ.com dedicated to answering general wellness questions. Go to poz.com/ask to read more answers, and email ask@poz.com to submit your questions!

nevirapine

ZERIT stavudine

ISTOCK

Antiretroviral (ARV) options abound for both those who are new to HIV treatment and those who are experienced. The new chart in the back of this issue provides an overview of the latest ARVs for the treatment of HIV, including adult dosing and dietary restrictions.

PK Boosters

is under evaluation). Trogarzo involves IV infusions every two weeks, but it is indicated only for people with highly resistant HIV, and it must be used in addition to daily pills. Further back in the pipeline, the long-acting islatravir pill has the potential for once-weekly dosing; it is being studied in combination with another long-acting drug dubbed MK-8507. Lenacapavir, the first HIV capsid inhibitor, remains at high enough levels in the body to be given by injection once every six months. Studies of oral and injectable combinations of islatravir and lenacapavir are expected to start soon. Broadly neutralizing antibodies against HIV may also have the potential to be used in long-acting combination regimens for HIV treatment and prevention. —Liz Highleyman

Complete Regimens

TANDARD ANTIRETROVIRAL treatment requires taking pills each day. Good adherence to this schedule keeps drug levels in the body high enough to maintain an undetectable viral load, which prevents disease progression and transmission of the virus. Fortunately, many people— especially those who are newly diagnosed with HIV—can take a single combination pill once daily, making modern treatment much easier and more convenient than it was in the past. Nonetheless, treatment that can be taken less often is an active area of research. Some studies have found that taking meds just four or five days a week can maintain viral suppression as well as daily pills. But this is not a recommended approach, and you shouldn’t take treatment breaks without consulting your doctor. Some people who have trouble taking daily pills may be able to switch to Cabenuva, a long-acting injectable regimen. This involves visiting a health care provider to get two injections each month (an every-other-month schedule

WHEN IT’S HARD BELLY (EXCESS VISCERAL ABDOMINAL FAT)

IT MAY BE TIME FOR EGRIFTA SV

IF YOU ARE LIVING WITH HIV AND LIPODYSTROPHY ASK YOUR HEALTHCARE PROVIDER ABOUT EGRIFTA SV TM.

FIND A SPECIALIST AT EGRIFTASV.COM

Actual patient living with HIV.

IMPORTANT INFORMATION FOR PATIENTS ABOUT EGRIFTA SV (TESAMORELIN FOR INJECTION) TM

What is EGRIFTA SV (tesamorelin for injection)? • EGRIFTA SV is an injectable prescription medicine used to reduce excess abdominal fat in adult patients living with HIV and lipodystrophy. EGRIFTA SV is a growth hormone-releasing factor (GHRF) analog. • EGRIFTA SV is not for weight loss management. • The long-term safety of EGRIFTA SV on the heart and blood vessels (cardiovascular) is not known. • It is not known whether taking EGRIFTA SV helps improve how well you take your antiretroviral medications. • It is not known if EGRIFTA SV is safe and effective in children, do not use in children. TM

Before using EGRIFTA SV , tell your healthcare provider if you: • Have or have had cancer. • Have problems with blood sugar or diabetes. • Have scheduled heart or stomach surgery. • Have breathing problems. • Are breastfeeding or plan to breastfeed. • Are taking any other prescription and non-prescription medicines, vitamins, and herbal supplements. TM

EGRIFTA SV may cause serious side effects including: • Increased risk of new cancer in HIV positive patients or your cancer coming back (reactivation). Stop using EGRIFTA SV if any cancer symptoms come back. • Increased levels of your insulin-like growth factor-1 (IGF-1). Your healthcare provider will do blood tests to check your IGF-1 levels while you are taking EGRIFTA SV . • Serious allergic reaction such as rash or hives anywhere over the body or on the skin, swelling of the face or throat, shortness of breath or trouble breathing, fast heartbeat, feeling of faintness or fainting, itching and reddening or flushing of the skin. If you have any of these symptoms, stop using EGRIFTA SV and get emergency medical help right away. TM

You should not take EGRIFTA SV if you: • Have a pituitary gland tumor, surgery, or other problems related to your pituitary gland, or have had radiation treatment to your head or head injury. • Have active cancer. • Are allergic to tesamorelin or any of the ingredients in EGRIFTA SV . • Are pregnant or become pregnant. If you become pregnant, stop using EGRIFTA SV and talk with your healthcare provider. • Are less than 18 years of age. TM

• Swelling or fluid retention. Call your healthcare provider if you have swelling, an increase in joint pain, or pain or numbness in your hands or wrist. • Increase in blood sugar (glucose) or diabetes. • Injection site reactions. Injection site reactions are a common side effect of EGRIFTA SV , but may sometimes be serious. • Increased risk of death in people who have critical illness because of heart or stomach surgery, trauma of serious breathing (respiratory) problems has happened when taking certain growth hormones. TM

The most common side effects of EGRIFTA SV include: • Pain in legs and arms • Muscle pain These are not all of the possible side effects of EGRIFTA SV . For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or to THERA patient support® toll-free at 1-833-23THERA (1-833-238-4372). This information is not intended to replace discussions with your doctor. For additional information about EGRIFTA SV , go to: www.egriftasv.com for the full Prescribing Information, Patient Information and Patient Instructions for Use, and talk to your doctor. For more information about EGRIFTA SV contact THERA patient support® toll-free at 1-833-23THERA (1-833-238-4372). TM

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ESA

BASICS

BY LIZ HIGHLEYMAN

WEIGHT GAIN

ASTING SYNDROME WAS a hallmark of AIDS in the early years of the epidemic, but today, weight gain is a more common problem. One study found that over half of people with HIV struggle with overweight or obesity. Women with HIV tend to put on more pounds than men, as do Black people compared with white people—meaning Black women are particularly prone to weight gain. Some studies suggest older people and people with a low CD4 T-cell count or a high viral load may be more likely to gain weight. People with HIV may experience different kinds of weight gain and fat buildup. Visceral fat accumulates deep within the belly surrounding the internal organs. This buildup of internal fat pushes up against the abdominal wall, resulting in a hard belly. Subcutaneous fat—which is soft and pinchable—accumulates beneath the skin, often around the belly, hips and thighs. In general, weight gain occurs when people consume more calories than they burn. People with HIV may gain weight as they return to health after starting treatment. HIV increases metabolic demands, and stopping viral replication reduces energy expenditure—leading to weight gain if food intake stays the same. Plus, people who feel better tend to eat more. But that’s not the whole story. Weight

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gain can occur even among people who start treatment early. Chronic HIV infection can trigger persistent immune activation and inflammation that throws off metabolism and leads to fat buildup. In recent years, there’s been a growing recognition that some people gain weight when they start antiretroviral therapy or switch regimens. Several studies show that people taking potent integrase inhibitors, such as dolutegravir, are more likely to gain weight. The newer form of tenofovir (tenofovir alafenamide, or TAF) is also more commonly associated with weight gain. MANAGING WEIGHT GAIN Excess body weight, especially visceral fat, is linked to a host of health problems. Fat, or adipose tissue, is metabolically active and produces hormones and cytokines that can trigger inflammation. Weight gain often goes hand in hand with metabolic problems, including high blood sugar and abnormal cholesterol and triglyceride levels. People with persistent inflammation and metabolic abnormalities are at greater risk for diabetes, cardiovascular disease, heart attacks and strokes. Visceral fat can accumulate around the heart and inside the liver and other organs. Over time, fat buildup in the liver can lead to cirrhosis, liver cancer and the need for a liver transplant;

excess weight is linked to other types of cancer as well. Obesity can also contribute to cognitive decline and pregnancy complications. What’s more, unwanted weight can have a negative effect on self-esteem, worsen depression and leave people less willing to start or stay on antiretroviral treatment. For all these reasons, it’s important to maintain a healthy weight—and preventing weight gain is easier than losing it. Lifestyle modification can often help. Experts recommend a balanced diet rich in plant-based foods and low in unhealthy fats, sugars and processed foods. Aim to move more and sit less. Federal guidelines recommend at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity per week along with musclestrengthening activities—but any amount of physical activity is better than none! Unfortunately, it can be difficult to lose weight—and especially to reduce visceral fat buildup—with changes in diet and physical activity alone. In some cases, medications may help. While unwanted weight gain can be distressing, it’s important not to delay or stop HIV treatment due to concerns about gaining weight. If you are putting on more pounds than you want, talk to your doctor about steps you can take to keep your weight under control. ■

ISTOCK

Keeping your weight under control lowers the risk of many health problems.

EARLY DEADLI NE : August 23

CALL FOR NOMINATIONS The 2021 POZ 100

POZ is seeking nominations for the 2021 POZ 100. The POZ 100 was established in 2010. This year’s list will celebrate Black advocates making a difference in the fight against HIV/AIDS and will include both people living with HIV and those who are HIV negative. To submit a nomination (self-nominations are welcome) and for more info, go to POZ.com/nominate.

CARE AND TREATMENT BY HEATHER BOERNER

TIVICAY, BIKTARVY ARE TOPS FOR TOTS Good news for parents: There are now more once-daily treatment options for the tiniest members of the HIV community. In the updated Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, the Department of Health and Human Services says that Tivicay PD (dolutegravir) and Biktarvy (bictegravir/tenofovir alafenamide/ emtricitabine) are the preferred medications for children living with HIV. Both require just oncedaily dosing. Twice-daily dosing is part of why Isentress (raltegravir) and Selzentry (maraviroc) were downgraded to alternatives this year. Specifically, the guidelines recommend waterdispersible Tivicay PD for treatment-experienced infants as young as 4 weeks old and Biktarvy for children at least 6 years old. Tivicay PD should be taken with two nucleoside reverse transcriptase inhibitors.

Tossing and turning, staring at the ceiling, mind running. Insomnia is all too common among people living with HIV. But if you have it, new data published in Open Forum Infectious Diseases suggest you might not be getting the medical care you deserve. The study gathered data from 357 people with HIV in the United Kingdom and Ireland. Most were white gay men. When the researchers looked at sleep apnea, insomnia and restless leg syndrome among people over 50 with and without HIV as well as a group of HIV-positive people younger than 50, a worrying trend stood out. One in five older people with HIV and 23% of younger HIV-positive people met the criteria for insomnia, compared with just 5% of older participants without HIV— a fourfold increased risk. And fewer than one third of HIV-positive people with insomnia reported receiving treatment for it, although treatment was more common among younger people. Antiretroviral therapy may account for some of the insomnia: 15% of those over 50 and 18% of those under 50 were taking efavirenz (sold alone as Sustiva and part of the Atripla combination pill), which is known to have neurological side effects, including anxiety and sleep problems. What’s more, insomnia was associated with worse physical and mental outcomes among people with HIV—regardless of age—compared with HIV-negative people. That includes more severe sleep disturbances and sleep-related impairment. “People with HIV are at substantially increased risk for insomnia compared to HIV-negative controls, and that prevalence of insomnia is not related to aging,” wrote the study authors.

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ALL IMAGES: ISTOCK (MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY)

Sleepless Nights? You’re Not Alone

CHOLESTEROL DRUGS BOOST SURVIVAL Want a heart-healthy boost? In addition to fish oil and niacin supplements, you may want to look into cholesterol-lowering drugs, like statins, fibrates or ezetimibe (Zetia). That’s because a recent study reported in BMC Infectious Diseases found that cholesterol-lowering drugs were linked to reduced mortality among people living with HIV compared with no treatment. The study was based on the experiences of 23,276 U.S. military veterans living with HIV who received care through the Veterans Health Administration between 1996 and 2011. All of them were on antiretroviral (ARV) treatment and had an undetectable viral load. Consistent use of statins was associated with a 52% reduction in mortality, while people who regularly used non-statin therapies, such as niacin, fish oil or fibrates, were 73% less likely to die. In contrast, researchers found no benefit for people taking blood pressure medications or aspirin. “The magnitude of the mortality benefit during consistent statin-free lipid-lowering therapy use was unexpected,” wrote Henning Drechsler, MD, an associate professor of internal medicine at the University of Texas Southwestern Medical Center, and colleagues. But there’s a caveat: The survival benefit lasted only as long as people kept taking the treatments. There was only “moderately reduced mortality risk” with inconsistent use of non-statin lipid medications and no reduction in cardiovascular risk, the authors wrote. These findings shouldn’t be taken as final, however. This study was conducted before the era of modern ARVs, when many HIV drugs caused severe side effects and sometimes couldn’t fully control the virus. And it took place before the advent of new drugs such as Descovy (tenofovir alafenamide/ emtricitabine), which has been associated with increased statin use due to elevated lipid levels. This was a retrospective study, not a randomized controlled trial— the gold standard of medical research. So it’s hard to know whether these benefits really were attributable to the cholesterollowering drugs and supplements. Plus, almost all the participants were men—but women living with HIV also have a higher rate of heart attacks than their peers. The REPRIEVE study, a randomized controlled trial of statin use among people with HIV, is underway and will provide more information.

PICK YOUR POISON What’s worse for HIV outcomes: smoking or heavy drinking? The answer might surprise you. Previous studies showed that heavy drinkers living with HIV were less likely to reach an undetectable viral load. But new research, published in the journal Drug and Alcohol Dependence, found the opposite. Researchers reviewed the medical records of 8,958 people living with HIV who received care at Kaiser Permanente Northern California. They found that smokers were 91% less likely to achieve viral suppression than nonsmokers. No such association between heavy drinking and viral load was found. The association between smoking and viral load held for everyone who smoked, no matter how often or how long they did so. And while 84% of study participants were engaged in HIV care and 92% had an undetectable viral load during the study period, smokers were 60% less likely to be linked to HIV care in the first place and 30% less likely to stay engaged in care, after adjusting for race, sex and socioeconomic status.

HIV AND COVID-19: Getting HIV Care Back on Track

LESSONS LEARNED FROM HIV HAVE INFORMED THE RESPONSE TO COVID-19, BUT HAS THE NEW FOCUS DERAILED HIV SERVICES? BY LIZ HIGHLEYMAN

HOSE FOLLOWING THE NEWS ABOUT

COVID-19 have no doubt seen some familiar faces. From National Institutes of Allergy and Infectious Diseases director Anthony Fauci, MD, and Centers for Disease Control and Prevention (CDC) director Rochelle Walensky, MD, PhD, to veteran AIDS activists around the world, prominent names in HIV are now leading the response to the new pandemic. Even as the crisis stage of COVID-19 begins to wind down for some people in the United States thanks to highly effective vaccines, these experts remain focused on familiar health disparities in this country and the need for health equity worldwide, drawing parallels to and applying lessons learned from HIV. One of these lessons is the key role of affected communities in responding to a health emergency.

“When officials couldn’t meet the needs of people with HIV in the beginning of the AIDS epidemic, activists formed community organizations to help patients, raise awareness, teach prevention and advocate for more government assistance,” says Monica Gandhi, MD, MPH, medical director of the Ward 86 HIV clinic at Zuckerberg San Francisco General Hospital, who has become a widely quoted expert on COVID-19. “Their efforts transformed the country’s response to the HIV epidemic and showed the vital role communities play in responding to health crises.” Another lesson is the importance of services that meet people where they are and recognize that they have complex life histories and needs that impact their overall health and well-being. It was never just about HIV—and today, it’s not just about COVID-19. When she was doing AIDS fieldwork in Africa, Diane Havlir, MD, chief of the University of California at San Francisco’s Division of HIV/AIDS, Infectious Diseases & Global Medicine, and her team brought HIV testing and rapid treatment, integrated with other health services, directly to people in migratory fishing communities in Kenya and Uganda, rather than requiring people to come to them. Years later, when it became clear that COVID-19 was hitting San Francisco’s Latino community hard, Havlir teamed up with retired HIV nurse Diane Jones—one of the founders of the country’s fi rst dedicated AIDS ward at San Francisco General Hospital— and the city’s Latino Task Force to create Unidos en Salud (United in Health). The group developed a community-facing program in the city’s Mission District that included walk-up coronavirus testing and door-to-door outreach. It generated data on the importance of asymptomatic infection, the high risk among Latino frontline workers and the utility of rapid testing to break chains of transmission. Unidos en Salud has vaccinated more than 24,000 individuals, 85% of them people of color. What’s more, the program provides food and supplies to people who test positive and need to quarantine and helps arrange fi nancial support through the city for those who have to miss work. “Our work in HIV taught us that genuine partnerships between community, scientists and policymakers are absolutely critical for an effective pandemic response,” Havlir says. “We also know that a

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HIV AND COVID-19 Although much remains to be learned about interactions between HIV and SARS-CoV-2, the coronavirus that causes COVID-19, being HIV positive itself does not appear to have as much of a direct effect on COVID-19 outcomes as some initially feared. But data are mixed. Some studies have found that people with HIV are at greater risk for more severe illness and are more likely to die from COVID-19 than their HIV-negative counterparts. One meta-analysis, which pulled together data from 22 studies that included nearly 21 million people in North America, Europe, Africa and Asia, found that HIV-positive people had a 78% higher risk of death from COVID-19 than HIVnegative people. Another meta-analysis of 19 studies showed a moderately increased risk. But other researchers have seen little or no difference. What is clear is that people living with HIV have a high prevalence of underlying health conditions and other cofactors—including being Black or Latino and over age 50— that put people at risk for poor COVID-19 outcomes. Several studies have shown that a majority of HIV-positive people have at least one comorbidity, such as obesity, diabetes or cardiovascular disease. In particular, people who are not on antiretroviral treatment, those who currently have a low CD4 T-cell count and those who had a very low CD4 count in the past may be at especially high risk. “Sometimes risk only becomes apparent after adjusting for age—an HIV-positive person who is age 50 or 60 might

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Diane Havlir, MD, at a have a risk equivalent to an HIVUnidos en Salud negative person who is 70 or 80,” COVID-19 testing site says Simon Collins of the Londonin San Franciso’s Mission District based treatment activist group HIV i-Base. “When we overlay other factors, the cumulative risks start to become much higher for some people than others.” The prospect of worse outcomes has led health officials and clinicians to urge people with HIV to get a COVID-19 vaccine as soon as they can. The good news is that the three vaccines authorized in the United States are safe and effective for most people living with HIV. Thanks to the efforts of advocates, HIV-positive people were included in vaccine clinical trials, though their numbers were small and those with compromised immunity were excluded. Although the vaccines have not been studied in HIVpositive people with a low CD4 count, it is known that people over age 80, organ transplant recipients and people on cancer chemotherapy can have weaker responses. It is therefore important for immunocompromised people to receive both doses of the Pfizer-BioNTech or Moderna vaccine on schedule, and researchers are studying whether adding additional booster doses might improve response.

PROFOUND EFFECTS Whether or not HIV itself worsens COVID-19 outcomes, it’s increasingly clear that the pandemic has had a detrimental impact on people living with HIV in other ways. COVID-19 has disrupted HIV services nationwide and around the world, threatening to set back recent progress in the fight against HIV/AIDS. “I think the effects have been profound,” says Gandhi.

PREVIOUS PAGES: (SARS-C O V-2 AND HIV) ISTOCK; THIS PAGE: (HAVLIR) COURTESY OF BARBARA REIS/UCSF

one-size-fits-all approach does not work, and we need to work hand in hand with communities to make sure advances in science are reaching the most affected populations.”

“There are three pillars of HIV control—prevention, testing and treatment—and all three of those were affected during COVID-19. I’m really concerned that the impact of this pandemic may stop us from keeping our eyes on the goal of combating HIV.” Early in the pandemic, people were advised to stay home and minimize contact with the health care system. What’s more, medical providers, clinics and hospitals, and laboratory facilities have diverted resources to the COVID-19 response. As a result, in-person appointments decreased, testing for HIV, viral hepatitis and sexually transmitted infections (STIs) declined, fewer people started or stayed on pre-exposure prophylaxis (PrEP), viral load monitoring was less frequent and people received less support to stay on antiretroviral treatment. The Fenway Institute in Boston, for example, saw an 85% decline in HIV and STI testing from January to April 2020. In San Francisco, both HIV testing and viral load monitoring declined by more than half after the city imposed its shelterin-place order. A large commercial lab processed nearly 700,000 fewer HIV tests nationwide from March to September 2020—a 45% drop. And a CDC analysis revealed a 78% decrease in office visits at eight HIV outpatient care sites from January to June 2020. Although testing and in-person appointments rose again after the initial crisis, they haven’t returned to pre-pandemic levels.

POZ COVID-19 READER SURVEY POZ FIRST SURVEYED ITS READERS IN JUNE 2020 to find out how they were affected by the COVID-19 pandemic; more than 400 people responded. A follow-up survey was conducted in April 2021; more than 300 readers responded. Most respondents were white gay men. In the earlier survey, almost everyone was concerned about contracting the new coronavirus: 44% said they were very concerned, and the same proportion were somewhat concerned. More than half (52%) said they were moderately affected by the pandemic, 22% were slightly affected, 19% were severely affected and just 7% were not at all affected. About a quarter said they had lost their job, and 5% had lost their health insurance. While 70% rated the federal government’s response to COVID-19 as poor—these earlier responses were from Donald Trump’s era—51% said their local government’s response was good or excellent.

Not everyone has had less sex during lockdown, and among those who remain at risk, some have had trouble accessing PrEP services. At Fenway, PrEP starts fell by 72% and unfilled PrEP prescriptions rose by 191% from January to April 2020. A survey by the American Academy of HIV Medicine found that although most people who stopped PrEP felt they no longer needed it, others did so because they lost their health insurance or did not have access to the required monitoring tests. In response, some providers have adopted new ways to help people get the care they need, including telemedicine visits, self-testing, mobile services, home delivery of medications, longer PrEP prescriptions with an extended interval between monitoring tests and STI treatment based on a description of symptoms without in-person exams or confirmatory tests. But telehealth isn’t for everyone. Many vulnerable individuals do not have a cell phone or computer, can’t afford data plans for fast internet access or lack privacy and are worried about others overhearing their calls or seeing their texts. At San Francisco General Hospital, Gandhi’s HIV clinic, which serves a largely disadvantaged population, pivoted to telephone visits during the city’s shelter-in-place order. But before long, she and her team saw the likelihood of viral suppression decrease by 31%; homeless people were especially

The second survey revealed that 19% of respondents had had COVID-19, up from just 4% in the first round. About a third said a family member had had COVID-19, and half knew someone who had died from it. Among those with COVID-19, 45% had mild symptoms, 30% had moderate illness and 25% had severe illness; more than a third (38%) said they were still experiencing COVID-19 symptoms. Nearly a quarter of respondents said they’d had difficulty accessing health services during the pandemic, and 71% had used telemedicine to connect with providers, but most (88%) had no difficulty filling their prescriptions for HIV medications. Over 80% had already received a COVID-19 vaccine, and among the rest, about 60% planned to do so. Most respondents said they had struggled somewhat (44%) or a lot (30%) during COVID-19, and 79% reported pandemic-related stress. While a majority rated their mental health as either fair (40%) or poor (18%), 32% reported that it was good, and 10% said it was excellent.

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likely to have a detectable viral load. “Telehealth didn’t end up working well for our population,” Gandhi says. “That connection to a human being matters.” After seeing this drop, Gandhi reinstated in-person visits, against the wishes of the city’s health department, with precautions in place to ensure the safety of clients and staff. “We kept ourselves safe, we were able to see almost all of our patients in person and we saw our outcomes improve,” she says. “I think closing down inperson care—especially for vulnerable patients—is one of the things we did completely wrong.” This experience informed her determination to focus on the full range of people’s medical, economic and social needs, not solely on COVID-19. Another example she cites is the detrimental impact of the pandemic on people who use drugs: Last year, San Francisco saw three times more deaths from drug overdoses than from COVID-19. In fact, Gandhi suggests, harm reduction is one area where the pandemic response has not taken into account lessons learned from HIV. “We didn’t tell people who were essential workers or who wanted to see family and friends how they could keep themselves safe. Instead, it was ‘Just say no.’” Harm reduction will become even more important now that a growing number of experts agree that SARS-CoV-2 will probably stick around as an endemic virus, like HIV.

Monica Gandhi, MD, MPH, director of the HIV clinic at Zuckerberg San Francisco General Hospital

first wave of the pandemic. Beyond these immediate effects, clinicians and advocates are also concerned about the long-term impact of the pandemic on people living with HIV, including depression and other mental health issues after more than a year of social isolation, lingering financial fallout, trauma from losing loved ones and chronic symptoms known as long COVID (see page 12). The global impact may be even greater as the pandemic persists, given that the COVID-19 response in low-income countries largely relies on infrastructure put in place for HIV. UNAIDS estimates that disruptions in HIV services due to COVID-19 could result in up to 293,000 additional HIV infections and 148,000 additional AIDS-related deaths between 2020 and 2022. “Diverting all of these resources has and will hurt people with HIV,” Gandhi says. “As the COVID-19 pandemic winds down in countries lucky enough to have access to the vaccines, we need to turn our attention to both global vaccine equity and back to HIV services. I think we’re learning—maybe more from COVID than we did from HIV—that we’re all interconnected. No one is safe until everyone is safe.” In the United States and around the world, COVID-19 has hampered HIV research, including trials of HIV vaccines, new antiretrovirals and cure approaches. HIV science laid the foundation for our understanding of the new coronavirus, from how the immune system attacks viruses to how to design effective vaccines. Although disruptions related to COVID-19 have partially derailed this research, experts hope that, ultimately, lessons learned from the new pandemic will in turn further the fight against HIV. “In the face of COVID-19, the global HIV community banded together to apply lessons learned from decades of pandemic response,” says International AIDS Society president Adeeba Kamarulzaman, MBBS, who will cochair the 2022 International AIDS Conference in Montreal, where the community will once again gather in person. “It is now critical to get the HIV response back on track. We owe it to the hundreds of thousands of people we still lose to AIDS-related illnesses every year.” ■

GETTING BACK ON TRACK In the short term, experts fear that reducing HIV prevention and care services will lead to worse outcomes, including disease progression and increased HIV transmission. A model based on gay and bisexual men in Baltimore estimated that disruptions in condom use, HIV testing, PrEP use, antiretroviral treatment initiation and viral suppression could lead to an 11% increase in new HIV infections over a year if sexual activity remains unchanged. Even more sobering, the model predicted that COVID-19–related declines in treatment and viral suppression could substantially increase HIV-related deaths. One hospital in London saw an increase in admissions of people with more advanced HIV disease during the second half of 2020. This led researchers to suggest that the rise might be attributable to people having difficulty accessing health care or reluctance to visit health facilities during the

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COURTESY OF MONICA GANDHI

“WE NEED TO TURN OUR ATTENTION TO BOTH GLOBAL VACCINE EQUITY AND BACK TO HIV SERVICES.”

RICK GERHARTER

AIDS ACTIVISTS PAVE THE WAY THREE DECADES AGO, HIV advocates helped lay the groundwork for the response to COVID-19. On October 11, 1988, ACT UP descended on the Maryland headquarters of the Food and Drug Administration (FDA) demanding faster approval of HIV drugs. “There was this narrative that the FDA was killing us, and you just had to put your foot on the gas,” recalls ACT UP and Treatment Action Group veteran Gregg Gonsalves, PhD, now an assistant professor of epidemiology at Yale School of Public Health. Such actions—coupled with insider meetings—led to changes, including the FDA’s parallel track system (which enables patients with lifethreatening conditions to use experimental therapies while trials are underway) and accelerated approval (conditional approval based on surrogate markers). But fast approval proved to be a “double-edged sword,” Gonsalves says, resulting in an ongoing battle over how to balance the need for rapid access versus ensuring that new therapies are safe and effective. Once better AIDS treatments were approved in the mid-1990s, advocates aimed to make them available to all people living with HIV in the United States through initiatives like AIDS Drug Assistance Programs. But it would take years before these advances became available to people in poor countries. “The [2000] Durban AIDS conference was a wake-up

AIDS activists protest at the Food and Drug Administration’s headquarters in Rockville, Maryland, on October 11, 1988.

call for a lot of people who had not focused on the global epidemic and the stark inequalities in access to drugs,” Gonsalves recalls. Today, veterans of the AIDS fight are working alongside new advocates to ensure that history doesn’t repeat itself with COVID-19. “Now we’re in a sort of 1996 situation where we have vaccines that work for us, but people around the world are dying for lack of access,” says Gonsalves. “We’re seeing the same medical apartheid we screamed about 20 years ago.” According to the World Health Organization, more than 80% of the global COVID-19 vaccine supply has gone to high-income countries and less than 1% to low-income countries. While more than half of eligible Americans are now fully vaccinated, the rollout has barely begun in many poor countries. In May, President Joe Biden announced support for waiving patent protections for COVID-19 vaccines, but that’s only part of the solution. “It’s a three-legged stool. Another leg is technology transfer, and then we’re going to need

a World War II–style mobilization to really scale up production,” Gonsalves explains. “If we’re sitting on millions of doses, yeah, we should give them away, but that’s like a Band-Aid on a machete wound.” COVID-19, like AIDS, shows we can’t conquer a pandemic in just one country. While the lack of global access to HIV treatment was easy for many to ignore, that’s not the case with the latest health crisis. “In the old days, people could say, ‘Oh, treatment access in Africa is a nice thing, but it doesn’t affect me directly.’ But a raging viral epidemic outside the U.S. that can come back with variants that are resistant to current vaccines should concern everybody,” Gonsalves says. “We got caught with our pants down; we don’t have the ability to vaccinate the world right now,” he adds. “But if we can put a rover on Mars, we can set up a global network of companies that can make enough vaccines to protect the planet from a new pandemic—not just for today, but for tomorrow and the day after that.” —LH

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A DECADE AFTER LEARNING THAT ANTIRETROVIRALS PREVENT SEXUAL TRANSMISSION OF HIV, RESEARCHERS ADDRESS UNANSWERED QUESTIONS ABOUT BREASTFEEDING AND INJECTION DRUG USE. BY HEATHER BOERNER

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ACK IN 1988, MYRON “MIKE” COHEN, MD, OF

AIDS Clinical Trials Group 076 study to pull triple duty. In one trial, researchthe University of North Carolina (UNC), was ers put pregnant women on AZT after their fi rst trimester to see whether treatstudying the presence of gonorrhea in the ment would reduce viral load enough to HIV transmission to the fetus. genital tract when he had a conversation with prevent Then they administered the drug intraa scientist at a party that would change the course of venously to women during delivery to protect infants as they were being born his career and the lives of people living with HIV. and gave infants six weeks of pediatric doses of AZT to prevent transmission after birth. In other words, they offered treatment as prevenThe party was celebrating the upcoming publication of tion, pre-exposure prophylaxis (PrEP) through delivery and data showing that AZT (Retrovir, or zidovudine) didn’t only post-exposure prophylaxis (PEP) all at once. reduce HIV viral load in test tubes; the new study showed The hope was that AZT would cut mother-to-child transthat it also stopped the decline of CD4 cells in people with mission of HIV by maybe 40% or by half at most, said Lynne AIDS. It was there that Cohen met a researcher who offered Mofenson, MD, then associate branch chief for clinical reto share some AZT with him so he could study whether the search, pediatric, adolescent and maternal AIDS for the drug could change the presence of HIV in the genital tract. Eunice Kennedy Shriver National Institute for Child Health Twenty-three years later, in July 2011, Cohen stood on and Development at the National Institutes of Health. But a stage in Rome while more than 1,000 HIV activists, rewhat researchers discovered, on Presidents Day weekend in searchers and clinicians at the International AIDS Society 1994, was that the treatment reduced HIV transmission to Conference on HIV Pathogenesis, Treatment and Preveninfants by two thirds. tion gave him and his team a standing ovation. His HPTN “I was shocked,” Mofenson says. “That wasn’t U=U, 052 study had just provided a definitive answer to the question because AZT is not as potent as giving a three-drug regimen. Cohen had asked himself at that 1988 party: Does consistent, But with the use of potent therapy like we have today, I effective antiretroviral treatment diminish the presence of would say U=U [for mother-to-child transmission as well].” HIV in the body so much that people living with the virus don’t transmit it to their sexual partners? “It took time to generate the evidence,” says Cohen, now THE SCIENCE OF SEXUAL TRANSMISSION director of UNC’s Institute for Global Health and Infectious In 1999, Cohen and other physician-scientists published a Diseases and cochair of the HIV Prevention Trials Network paper in the journal AIDS puzzling over the varying rates (HPTN). “But it shifted people very quickly, almost overnight of HIV transmission via different routes and with different by public health standards.” antiretrovirals. It’s been 10 years since that study changed the HIV land“Antiviral therapy can be expected to reduce the transscape and ushered in a new way to think about and live with mission of HIV,” the study authors wrote. “Patients need to the virus. Since then, other studies have further solidified the be carefully informed about the significance of treatmentearlier findings, showing that whatever kind of sex people are induced reduction of genital shedding of HIV,” in particular having, if they have a durably undetectable viral load, they warning them that, at the time, not all drugs fully supdon’t transmit the virus. Now, researchers are trying to find pressed viral load. out if antiretroviral treatment can prevent all transmission of In 2008, the Swiss Federal Commission for AIDS issued HIV, including via breastfeeding and injection drug use. a statement to its colleagues, informing them of a change in how they should counsel their patients living with HIV. If people had an undetectable viral load SCIENTIFIC SIGNALS for at least six months, were supported to Of course, Cohen wasn’t alone in working engage in regular care and take medicaon the science behind the concept now tions daily, and they and their partners known as Undetectable Equals Untranshad no other sexually transmitted mittable (U=U). In fact, the fi rst hint infections, clinicians no longer had that treatment could prevent transto tell patients they needed to use mission came not from sex but from condoms. People with HIV who the exchange of blood and nutrimet those criteria “do not transmit ents between pregnant people and HIV sexually,” the statement said. their fetuses. At the time, other researchers, In 1991, sensing that they might including those at the Centers for not have another chance to study Disease Control and Prevention pregnancy and postpartum treatment (CDC) and the World Health Orgaand prevention, scientists launched the

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“Findings from PARTNER2…provided conclusive evidence that U=U is as applicable to gay, bisexual and other men who have sex with men as it is to male-female couples.”

THE MAKING OF A MOVEMENT In 2012, a year after the HPTN 052 results were announced, Bruce Richman, a Harvard-trained attorney and social branding expert living with HIV, learned that he could no longer transmit the virus. His HIV viral load was undetectable by modern tests and had been since 2010. So when his doctor told him he didn’t need to worry after a condom broke, he didn’t believe it. He trusted his doctor, he wrote in a 2016 POZ blog post, but his partner in the broken condom incident “was now terrified of me,” according to Richman, who had long ago given up the idea that he’d ever feel really safe during sex again. But here he was, and doctors were still reluctant to tell their patients about the science. One called Richman “a danger to gay men’s holistic health” when he tried to talk about the research. That’s when he knew the science needed to move from the pages of medical journals to the streets—and into the lives of people with HIV. It took four more years after his eye-opening talk with his doctor for the movement to really get off the ground. In 2016, the Prevention Access Campaign (PAC) was born. Suddenly, the abstract language of “treatment as prevention” was rendered concrete. Richman and a core team of founding task force members used his branding expertise to

(COHEN) LIZ HIGHLEYMAN; (MOFENSON) COURTESY OF SUBJECT

nization, issued statements calling the Researchers Myron Cohen, Swiss Statement premature. Other doctors MD, (top) were more blunt. They called it hasty, irreand Lynne Mofenson, MD sponsible and unscientific. It would be another three years before Cohen and his team stood on the stage at the conference in Rome to present the results from HPTN 052. But when they did, those findings confirmed what the Swiss Statement proposed. In a trial of 1,763 mixed-status couples in which half of the HIV-positive partners started antiretroviral treatment right away and half waited for their CD4 cells to fall, the risk of HIV transmission was 96% lower in the immediate treatment arm. And when the researchers reported the final data in 2015, they showed that the one HIV transmission in the early treatment group occurred before the participant had reached an undetectable viral load. This was it: Just as with women and their babies, HIV treatment prevented transmission of the virus via vaginal sex. Science Magazine named this discovery 2011’s Breakthrough of the Year. Since then, data have continued to accumulate about sexual transmission. While HPTN 052 was open to all couples, Cohen says only heterosexual couples ended up participating. So whether people having “gay sex” would receive the same benefit from treatment remained an open question. Or, actually, Cohen puts it another way. “It’s not about heterosexual or homosexual,” he says. “It’s about anal intercourse. We know that the biology of transmission from anal intercourse is different than penile-vaginal intercourse. So what was really missing was the empirical evidence that the drugs are distributed in such a way and the sexual behaviors are taking place in such a way that the same benefits would be realized with anal intercourse.” It took only three more years for those data to start to come through. Results from the PARTNER study, reported at the 2014 Conference on Retroviruses and Opportunistic Infections and published in 2016, showed that regardless of the kind of condomless sex they had, gay and straight couples had zero cases of HIV transmission that were genetically linked to their partner when the HIV-positive partner was on suppressive treatment and had a viral load below 200. The Opposites Attract trial, set primarily in Australia, reached the same conclusion in a study that enrolled more than 400 mixed-status gay male couples. As long as a person living with HIV had an undetectable viral load, he didn’t transmit the virus to his partner. Then the PARTNER2 trial, presented at the 2018 International AIDS Conference in Amsterdam, offered further evidence: No genetically linked HIV transmissions resulted from more than 77,000 condomless sex acts among 800 gay couples. That study’s lead investigator, Alison Rodger, MD, of University College London, announced in the large conference hall, “If you are on suppressive [antiretroviral therapy], you are sexually noninfectious. The risk is zero.” Soon thereafter, the CDC issued a statement declaring,

launch U=U. One of the team’s goals, according to Richman, was to “help agencies catch up with and communicate the science” in a way that would mean something to people affected by HIV. A U=U consensus statement issued in 2016 was similar to the one the Swiss commission issued back in 2008: People with HIV on antiretroviral treatment with an undetectable viral load in their blood have a “negligible to nonexistent” risk of sexual transmission of HIV. PAC later launched a messaging guide that discouraged the media and clinicians from using the word negligible to describe the risk; the language has since changed to “zero risk” to reflect the additional research. Since then, the U=U consensus statement has expanded from its eight original signatories to now include more than 1,025 groups in 102 countries. Bryan C. Jones, the founder of the DIRT (Direct Inspiring Reachable Teachable) advocacy movement, is an activist who had been living with HIV for decades and never thought U=U would apply to him. Like many people with lots of medications under their belt, Jones didn’t have a fully suppressive regimen available to him. His CD4 cells were at 150, and he had a viral load of 250,000. Jones didn’t think he’d live long enough, he says, to see U=U impact his own life. But then Selzentry (maraviroc) came out in 2007. Within two weeks of starting the new drug, his viral load evaporated and his T cells started to rise. All of a sudden, U=U was relevant to him too. For Jones, the science behind U=U and the community-led movement not only mean that almost anyone could reach U=U as new antiretrovirals continue to be approved but they also give power to people living with HIV. “Understanding what your medication is doing for you is something that gives you respect for the medication and is part of your acceptance of the condition. And that respect for the medicine and knowing what adherence to the medication can do are more powerful than just taking a pill,” he says. “It’s time for us to embrace the science, use it to our advantage and use it to celebrate each other.”

people living with HIV. But that trial didn’t have enough participants to provide definitive proof of U=U when sharing injection equipment. Then there’s the ongoing question of how undetectable, exactly, one has to be to reap the benefits of U=U. All the studies on sexual transmission show that a viral load below 200 is sufficient to prevent transmission. But for pregnant people, maintaining a viral load below 50 before, during and after pregnancy is essential to eliminate transmission to the baby. And for breastfeeding, it’s unclear how low that would need to go. Mofenson, now a pediatric HIV scientific adviser at the Elizabeth Glaser Pediatric AIDS Foundation, says two incidents of HIV transmission via breast milk from women with viral loads below 50 have been reported. The risk of transmission via breastfeeding is vanishingly low—less than 1%—but it’s still there. That could change, Mofenson says, with better research on antiretroviral therapy during pregnancy and postpartum. For instance, we know that antiretrovirals eliminate HIV from the fluid around the cells in breast milk, but does it eliminate the virus within those cells themselves? And some medications concentrate more in breast milk than others. So what would be the ideal drug cocktail that concentrates well in breast milk, keeps viral load below 50 throughout pregnancy and postpartum, is safest for the fetus and will eliminate that niggling residual risk? Could injectable treatments fit the bill? No one knows, Mofenson says. Studies of new antiretrovirals in pregnancy and postpartum lag behind approval for nonpregnant people by a median of six years. If trial protocols were revised to begin the preclinical research into potential birth defects earlier, pregnant women could more easily participate and remain in clinical trials. That would give researchers data that could answer those questions. “You could look at what is the [drug] penetration into breast milk; you could look at genital penetration in the vagina,” she says. “I don’t think we have to prove transmission anymore. What we have to do is find the safest, easiest regimen for pregnant women.” For Cohen, who is now bringing lessons on prevention, treatment and cure to COVID-19 research, the story of modern HIV treatment is “pretty much perfect.” “The data always move in the same direction,” he says. “The dissipation of the fear and stigma—that’s not complete, but they’re not independent of all we’ve just talked about. They’re not independent of the development of the drugs and the recognition that drugs prevent transmission, the recognition that the drugs allow people to lead normal lives. So it’s just a different world we’re living in.” ■

“WHAT WE HAVE TO DO IS FIND THE SAFEST, EASIEST REGIMEN.”

UNANSWERED QUESTIONS The future of U=U seems pretty bright, but a few issues still need to be worked out. For instance, treatment prevents sexual transmission of HIV among people who inject drugs, but we don’t know exactly how much it prevents transmission via shared drug injection equipment. Some population-level studies show an association between HIV transmission rates and lower viral load in communities of people who inject drugs, and the HPTN 074 trial saw zero transmissions to injection partners of

poz.com JULY/AUGUST 2021 POZ 31

HEROES BY ALICIA GREEN

Fight With Us

32 POZ JULY/AUGUST 2021 poz.com

Daﬁna Ward ampliﬁes the voices of people living with HIV in the South.

ANGELA HOPPER

As a legal fellow in the early 2000s, Dafina Ward worked on a class-action lawsuit seeking access to health care for incarcerated people in rural county jails. “That was the first time I had ever heard about someone not having access to their HIV medications,” says Ward, 44, the executive director of the Southern AIDS Coalition (SAC). “That’s how my interest in this work and advocacy, specifically around health care in the South, started.” Ward’s work as a lawyer intersected with social justice concerns, particularly how to improve access to resources for the most vulnerable populations. In 2007, Ward, who is HIV negative, started doing consulting work around developing funds and raising money to support HIV prevention programs in Alabama. In 2010, Ward joined AIDS Alabama as project director of Beauty Knowing, an intervention she created to target cosmetology students in Alabama, with a specific focus on Black women. “Because of the rates of HIV among young Black women, it just felt like going into cosmetology schools was a great fit,” Ward says. She served as the organization’s director of prevention and community partnerships from 2012 to 2015. Ward then pursued work in the health care sector before returning to HIV advocacy years later. She currently lives in South Carolina. In 2019, Ward was appointed interim executive director of SAC, which works to end the HIV epidemic in the South. That same year, she helped launch Southern HIV/AIDS Awareness Day—observed every August 20. “It has allowed us to have conversations around some of the challenges that may be more unique to the South than other places and to lift up the voices of people living with HIV in the South,” she says. One such challenge is Medicaid. Ward explains that Medicaid expansion in the South is key to improving access to health care for at-risk communities in the region. Other priorities include increasing the availability of safe, suitable and affordable housing and repealing HIV criminalization laws, she says. “People with HIV need access to training and vocational rehabilitation services that are going to help them secure employment,” Ward adds. Since last December, Ward has served as SAC’s executive director, ensuring that the organization fulfills its mission as it pertains to policy advocacy, grant work, technical assistance and leadership development. “We see ourselves as a megaphone and bridge,” explains Ward. “We want to amplify [the voices of people living with HIV] and build relationships with entities addressing needs in rural communities.” For Ward, that means empowering people to be their own advocates and showing them how to be a part of ending the HIV epidemic. This year marks the 20th anniversary of SAC’s founding. To note the milestone, the organization will unveil its strategic vision for the next five years, including how to get more Southerners involved in its efforts. “We want more folks to be in this fight with us,” Ward says. “If we want to end the epidemic on a national level, everyone has to care about what happens in the South. The South needs to be a priority for everyone.” ■

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H I V

This quick-reference chart compares antiretroviral (ARV) options for the treatment of HIV, including adult dosing and dietary restrictions. Visit poz.com/drugchart for more info.

CIMDUO

tenofovir disoproxil fumarate + lamivudine

One tablet once a day. Each tablet contains 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take with or without food.

efavirenz + tenofovir disoproxil fumarate + emtricitabine

COMBIVIR *

zidovudine + lamivudine

One tablet twice a day. Each tablet contains 300 mg zidovudine + 150 mg lamivudine. Take with or without food.

BIKTARVY

bictegravir + tenofovir alafenamide + emtricitabine

One tablet once a day. Each tablet contains 50 mg bictegravir + 25 mg tenofovir alafenamide + 200 mg emtricitabine. Take with or without food.

Complete Regimens

cabotegravir + rilpivirine

A long-acting injectable regimen administered as two intramuscular injections every four weeks (or eight weeks pending FDA approval) after a one-month lead-in period with oral Vocabria (cabotegravir) + Edurant (rilpivirine). Take with food.

COMPLERA

rilpivirine + tenofovir disoproxil fumarate + emtricitabine

One tablet once a day. Each tablet contains 25 mg rilpivirine + 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take with a meal.

DELSTRIGO

doravirine + tenofovir disoproxil fumarate + lamivudine

One tablet once a day. Each tablet contains 100 mg doravirine + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take with or without food.

DOVATO

dolutegravir + lamivudine

One tablet once a day. Each tablet contains 50 mg dolutegravir + 300 mg lamivudine. Take with or without food.

tenofovir alafenamide + emtricitabine

One tablet once a day. Each tablet contains 25 mg tenofovir alafenamide + 200 mg emtricitabine. Take with or without food.

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs, or nukes)

CABENUVA

DESCOVY

EMTRIVA *

emtricitabine (also known as FTC)

One 200 mg capsule once a day. Take with or without food.

EPIVIR *

lamivudine (also known as 3TC)

(Pills not shown actual size)

EDURANT rilpivirine

One 25 mg tablet once a day. Take with food.

INTELENCE etravirine

One 200 mg tablet twice a day. Take with food.

PIFELTRO doravirine

One 100 mg tablet once a day. Take with or without food.

SUSTIVA * efavirenz

One 600 mg tablet once a day, or three 200 mg capsules once a day. Take on an empty stomach or with a low-fat snack. Dose should be taken at bedtime to minimize dizziness, drowsiness and impaired concentration.

EVOTAZ

EPZICOM *

abacavir + lamivudine

One tablet once a day. Each tablet contains 600 mg abacavir + 300 mg lamivudine. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

RETROVIR *

zidovudine (also known as AZT)

One 300 mg tablet twice a day. Take with or without food.

TEMIXYS

tenofovir disoproxil fumarate + lamivudine

One tablet once a day. Each tablet contains 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take with or without food.

atazanavir + cobicistat Protease Inhibitors (PIs)

ATRIPLA *

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs, or non-nukes)

*Generic version available in the U.S.

One tablet once a day. Each tablet contains 300 mg atazanavir + 150 mg cobicistat. Take with food.

KALETRA *

lopinavir + ritonavir

Two tablets twice a day, or four tablets once a day, depending on HIV drug resistance. Each tablet contains 200 mg lopinavir + 50 mg ritonavir. Take with or without food.

PREZCOBIX

darunavir + cobicistat

One tablet once a day. Each tablet contains 800 mg darunavir + 150 mg cobicistat. Take with food.

TRUVADA *

GENVOYA

PREZISTA

tenofovir disoproxil fumarate + emtricitabine

elvitegravir + cobicistat + tenofovir alafenamide + emtricitabine

darunavir

One tablet once a day. Each tablet contains 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take with or without food.

One tablet once a day. Each tablet contains 150 mg elvitegravir + 150 mg cobicistat + 10 mg tenofovir alafenamide + 200 mg emtricitabine. Take with food.

One 800 mg tablet (or two 400 mg tablets) plus one 100 mg Norvir tablet once a day, or one 600 mg tablet plus one 100 mg Norvir tablet twice a day, depending on drug resistance. Take with food.

REYATAZ *

VIREAD *

atazanavir

tenofovir disoproxil fumarate

Two 200 mg capsules once a day, or one 300 mg capsule plus one 100 mg Norvir tablet once a day. Take with food.

One 300 mg tablet once a day. Take with or without food.

JULUCA

dolutegravir + rilpivirine

One tablet once a day. Each tablet contains 50 mg dolutegravir + 25 mg rilpivirine. Take with a meal.

ZIAGEN * abacavir

ISENTRESS

One 300 mg tablet twice a day, or two 300 mg tablets once a day. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

raltegravir

rilpivirine + tenofovir alafenamide + emtricitabine

One tablet once a day. Each tablet contains 25 mg rilpivirine + 25 mg tenofovir alafenamide + 200 mg emtricitabine. Take with a meal.

RUKOBIA

fostemsavir

One 600 mg tablet twice a day for people with HIV treatment experience. Take with or without food.

STRIBILD

TIVICAY

dolutegravir

One 50 mg tablet once a day for those first starting ARV therapy or for those who have not used an integrase inhibitor in the past. One 50 mg tablet twice a day for treatment-experienced individuals who have HIV that is resistant to other integrase inhibitors and when taken with certain ARVs. Take with or without food.

VOCABRIA cabotegravir

SELZENTRY maraviroc

One 150 mg, 300 mg or 600 mg tablet twice a day, depending on other meds used, for people with HIV treatment experience. Take with or without food.

One 30 mg tablet taken once a day with once-daily Edurant for a month as a lead-in regimen before switching to Cabenuva injections or for short-term treatment. Take with food.

These antiretroviral medications are rarely prescribed and no longer recommended:

SYMFI AND SYMFI LO

efavirenz + tenofovir disoproxil fumarate + lamivudine

APTIVUS

One tablet of either Symfi or Symfi Lo once a day. Each tablet of Symfi contains 600 mg efavirenz + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Each tablet of Symfi Lo (above) contains 400 mg efavirenz + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Take on an empty stomach. Dose should be taken at bedtime to minimize dizziness, drowsiness and impaired concentration.

tipranavir

TROGARZO ibalizumab

A long-acting injectable administered intravenously as a single loading dose of 2,000 mg followed by a maintenance dose of 800 mg every two weeks for people with HIV treatment experience.

CRIXIVAN indinavir

FUZEON

enfuvirtide

INVIRASE saquinavir

SYMTUZA

LEXIVA

NORVIR * ritonavir PK Boosters

Complete Regimens

One tablet once a day. Each tablet contains 150 mg elvitegravir + 150 mg cobicistat + 300 mg tenofovir disoproxil fumarate + 200 mg emtricitabine. Take with food.

Entry Inhibitors

elvitegravir + cobicistat + tenofovir disoproxil fumarate + emtricitabine

Integrase Inhibitors

ODEFSEY

Six 100 mg tablets twice a day. The full dose of Norvir is rarely used. It is most often used at lower doses to boost the levels of other ARVs in the blood. Take with food.

One tablet once a day. Each tablet contains 50 mg dolutegravir + 600 mg abacavir + 300 mg lamivudine. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

TRIZIVIR

abacavir + zidovudine + lamivudine

VIRACEPT nelfinavir

TRIUMEQ

dolutegravir + abacavir + lamivudine

fosamprenavir

VIRAMUNE TYBOST

cobicistat

One 150 mg tablet once a day in combination with ARVs that require boosting. Used only to boost other drugs. Take with food.

nevirapine

ZERIT

stavudine

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