POZ July/August 2019 by Smart + Strong

A SMART+STRONG PUBLICATION JULY/AUGUST 2019 POZ.COM $3.99

H E A L T H ,

L I F E

Rising Above Living with cancer and HIV

Sean McKenna

H I V

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. 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. 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.

ABOUT BIKTARVY BIKTARVY is a complete, 1-pill, once-a-day prescription medicine used to treat HIV-1 in adults. 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,

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.

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.

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

Tell your healthcare provider about all the medicines you take:

Take BIKTARVY 1 time each day with or without food.

` Keep a list that includes all prescription and over-the-

GET MORE INFORMATION

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.

Get HIV support by downloading a free app at

MyDailyCharge.com

` 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, DAILY CHARGE, the DAILY CHARGE Logo, KEEP SHINING, LOVE WHAT’S INSIDE, GILEAD, and the GILEAD Logo are trademarks of Gilead Sciences, Inc., or its related companies. Version date: December 2018 © 2019 Gilead Sciences, Inc. All rights reserved. BVYC0102 01/19

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KEEP SHINING. 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. To learn more, visit BIKTARVY.com.

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 #POZ AT 25 SILVER ANNIVERSARY When POZ launched in 1994, effective treatment was still two years away. Much has changed for the better since then, but as stigma and lack of access to treatment both demonstrate, Y E A R S many challenges still remain for people living with HIV. Go to poz.com/25 for a look back at our coverage over the years, from celebrity profiles to personal stories.

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

For 25 years, POZ has covered the ups and downs of HIV research.

POZ OPINIONS COMMENTARY ON HIV/AIDS

POZ DIGITAL READ THE PRINT MAGAZINE ON YOUR COMPUTER OR TABLET

30 RISING ABOVE People living with HIV are also facing cancer as they age. BY LIZ HIGHLEYMAN 40 25 YEARS OF HIV RESEARCH Increasing mastery over the virus is a crowning achievement. BY BENJAMIN RYAN 4 FROM THE EDITOR I Won’t Back Down

HIV, and Brian Gaither, an HIV-negative gay man, confronts his own bigotry.

6 POZ Q+A

20 CARE AND TREATMENT

The Office of HIV and AIDS Malignancy at the National Cancer Institute coordinates cancer and HIV research.

A new two-drug regimen • details about cardiac dysfunction • copping to COPD • liver cancer prognosis

8 POZ PLANET

25 RESEARCH NOTES

A roundup of global HIV headlines • 25 years of Viva Glam and MAC milestones • POZ at 25: summer issues from the archives

Who with HIV is most likely to transmit the virus? • Trogarzo durability • macrophages and the quest for a cure • opioid overdoses among people who have HIV

17 EVERYDAY Milestones in the epidemic

28 SPOTLIGHT Remembering Andy Vélez on social media

18 VOICES Go to poz.com/digital to view the current issue and the entire Smart + Strong digital library.

Advocate Murray Penner describes how the Undetectable Equals Untransmittable message affected his journey living with

48 HEROES Mark Misrok is a cofounder and president of the National Working Positive Coalition.

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, 212 West 35th Street, 8th Floor, New York, NY 10001. Periodicals postage paid at New York, NY, and additional mailing offices. Issue No. 237. POSTMASTER: Send address changes to POZ, 212 West 35th Street, 8th Floor, New York, NY 10001. Copyright © 2019 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: BILL WADMAN; (MAGNIFYING GLASS) ISTOCK; (SPEECH BUBBLES) THINKSTOCK

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.

10th Annual POZ 100 The 2019 POZ 100 will celebrate trans advocates across the country who are making a difference in the fight against HIV/AIDS. This yearâ&#x20AC;&#x2122;s list will honor transgender, gender-nonconforming and nonbinary individuals who are living with HIV or who are HIV negative. Established in 2010, the POZ 100 recognizes individuals and organizations committed to ending the HIV/AIDS epidemic. For more information and to submit a nomination (self-nominations are welcome), go to POZ.com/nominate POZ.com/nominate.

Early Deadline: August 24

P07-19_POZ_100_ad_full_page_HY.indd 25

Don Sub â&#x20AC;&#x2122;t delay ! m nom it you r inat i o 201 for the n 9P O tod Z 100 ay!

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FROM THE EDITOR

I Won’t Back Down

Y E A R S

EDITOR-IN-CHIEF

ORIOL R. GUTIERREZ JR. MANAGING EDITOR

JENNIFER MORTON DEPUTY EDITOR

TRENT STRAUBE SENIOR EDITOR

KATE FERGUSON SCIENCE EDITOR

LIZ HIGHLEYMAN

4 POZ JULY/AUGUST 2019 poz.com

EDITOR-AT-LARGE

BENJAMIN RYAN COPY CHIEF

JOE MEJÍA ASSISTANT EDITOR

ALICIA GREEN ART DIRECTOR

DORIOT KIM ART PRODUCTION MANAGER

MICHAEL HALLIDAY CONTRIBUTING WRITERS

SHAWN DECKER, OLIVIA G. FORD, AUNDARAY GUESS, CASEY HALTER, DARYL HANNAH, MARK S. KING, ROD MCCULLOM, TIM MURPHY CONTRIBUTING ARTISTS

JOAN LOBIS BROWN, LIZ DEFRAIN, ARI MICHELSON, JONATHAN TIMMES, BILL WADMAN

anniversary, POZ will publish a retrospective book later this year. Titled POZ at 25: Empowering the HIV Community Since 1994, the book will be a smorgasbord. About half of the book will recap coverage of the contents of each issue. In addition, readers will find four original chapters. Each of these chapters will tell a similar narrative, but through a different lens. They are: research, celebrities, contributors and personal stories. We will print each of these book chapters in the magazine for you to preview. In this issue, we’re publishing a chapter written by POZ editor-at-large Ben Ryan that takes a look at 25 years of HIV research. Go to page 40 to read the excerpt. For all the progress that has been made in the fight against HIV, nothing has yet come along to prevent the inevitable. Effective treatment may save us from the virus, but we are all still human. So we say goodbye to Andy Vélez, a dear friend of POZ. Go to page 28 for more.

FOUNDER

SEAN STRUB LEGACY ADVISER

MEGAN STRUB ADVISORY BOARD

A. CORNELIUS BAKER, GUILLERMO CHACÓN, KATHIE HIERS, TIM HORN, PAUL KAWATA, NAINA KHANNA, DAVID MUNAR, DANIEL TIETZ, MITCHELL WARREN, PHILL WILSON PRESS REQUESTS

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POZ, 212 WEST 35TH STREET, 8TH FLOOR, NEW YORK, NY 10001, OR EDITOR-IN-CHIEF@POZ.COM

SMART + STRONG PRESIDENT AND COO

IAN E. ANDERSON EDITORIAL DIRECTOR

ORIOL R. GUTIERREZ JR. EXECUTIVE EDITOR

BOB BARNETT CHIEF TECHNOLOGY OFFICER

CHRISTIAN EVANS VICE PRESIDENT, INTEGRATED SALES

DIANE ANDERSON INTEGRATED ADVERTISING MANAGER

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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.

(GUTIERREZ) JOAN LOBIS BROWN; (ILLUSTRATION) ISTOCK

TESTED HIV POSITIVE IN 1992. I was 22 years old. I’ll never forget how devastated I was upon hearing the news. That was four years before effective treatment of the virus, so I believed that my fate was to die before age 30. Testing HIV positive today is a much different experience. The expectation of living a virtually normal life span is a reality for those who are newly diagnosed and have access to care and treatment. Planning for your future doesn’t have to be put on hold. Increasingly, the same can be said for people who receive a cancer diagnosis. The initial devastation of being told you have cancer is more often being replaced by the hope that new cancer treatments provide. Although cancer can be a potentially fatal disease, living with cancer is possible. Our cover guy, Sean McKenna, knows this to be true. As a long-term survivor of HIV, he has faced many battles, including skin cancer and anal precancer. Jill Cadman has battled colon cancer. Go to page 30 to read about living with cancer and HIV. As people living with HIV grow older, they’re also facing cancer. Some of those cancers are related to having HIV, but many are not. As a result, understanding cancer is vital for those of us who have the virus. Thankfully, there is a federal agency that coordinates research on the intersection of cancer and HIV. Go to page 6 to read about the Office of HIV and AIDS Malignancy at the National Cancer Institute. The arrival of new cancer treatments is rewriting the story of cancer survival. The same goes for living with HIV—as treatment for the virus has progressed, so has the improvement in quality of life. POZ has witnessed this process for the past 25 years. Since our first issue in 1994, we have chronicled the ups and downs of HIV research. From serious side effects to the ease of single-tablet regimens, POZ has reported all the details for our readers. To continue commemorating our 25th

Celebrating over 20 years of supporting the HIV community.

For more information about Serostim® and the support services offered, visit www.20PlusYears.com Let’s get social

www.Facebook.com/Serostim

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POZ Q+A BY ORIOL R. GUTIERREZ JR.

Human T cell (blue) under attack by HIV (yellow)

The Office of HIV and AIDS Malignancy at the National Cancer Institute coordinates cancer and HIV research.

NCI has played a major role in AIDS research since the beginning, conducting research both in HIV and HIV malignancies. OHAM was established in 2007 to coordinate its AIDS research and also to run certain programs directly. Having OHAM as a central office has greatly helped NCI to optimize its use of AIDS research funds.

grants to train investigators in subSaharan Africa to do research on malignancies associated with AIDS. In the past few years, this effort has been expanded with a sort of hybrid grant that combines funding of research in LMIC along with training and building of research capacity. We partner academic institutions in Africa—and, more recently, in Latin America—with U.S. institutions. People from the U.S. institutions often go to Africa and vice versa. The idea is that these countries can facilitate overall research in these cancers and also address issues of importance in LMIC. Examples of recent studies include the molecular biology of KS and how to best screen for cervical cancer in countries with limited health resources.

Of the many areas OHAM coordinates, let’s start with the consortia for HIV/AIDS research in low- and middle-income countries (LMIC).

Tell us about the AIDS Malignancy Consortium (AMC).

Low- and middle-income countries, especially those in sub-Saharan Africa, have a disproportionate amount of HIV/AIDS malignancies. This is in part because more people in those areas have viruses responsible for many of the cancers associated with HIV, such as KSHV, the cause of Kaposi sarcoma (KS). OHAM started with

Established in 1995, AMC conducts treatment-related clinical studies in HIV/ AIDS malignancies. For a number of years, AMC had sites only in the United

OBERT YARCHOAN, MD, IS DIRECTOR OF THE OFFICE OF HIV and AIDS Malignancy (OHAM) at the National Cancer Institute (NCI). In addition, he is a researcher at the NCI Center for Cancer Research. He studies AIDS-related malignancies, especially tumors caused by Kaposi sarcoma–associated herpesvirus (KSHV), which causes several serious diseases. He also studies HIV protease. Yarchoan was appointed as the first OHAM director in 2007. He has held several HIV-related positions throughout his career. He led the first clinical trials of the first effective therapies for HIV, including zidovudine (AZT), didanosine (ddI) and zalcitabine (ddC). He was a coinventor of ddI and ddC as AIDS therapies and led initial studies of combination therapy.

What is the mission of OHAM?

6 POZ JULY/AUGUST 2019 poz.com

COURTESY OF SETH PINCUS, ELIZABETH FISCHER AND AUSTIN ATHMAN (NIAID/NIH)

VIRAL CONTROL

States but has now established sites in Africa and, even more recently, in Latin and South America. The U.S. sites were first in cities that were the initial focus of the AIDS epidemic, but they’re now opening new sites in areas where AIDS is advancing most. At first, most of their studies involved AIDS-defining malignancies, particularly KS and lymphoma. They are now also focusing on non–AIDS-defining malignancies and on incidental cancers that appear in people living with HIV. One major area of interest is anal cancer. The ANCHOR (Anal Cancer HSIL Outcomes Research) Trial is studying whether treatment of high-grade squamous intraepithelial lesion (HSIL), an anal cancer precursor, can prevent anal cancer and to assess treatment toxicities. Participants with HSIL are randomized into two groups. Participants in one will be observed closely for anal cancer, while participants in the other will be treated for HSIL. If ANCHOR shows there is an overall advantage in treating HSIL, then this will provide a rationale for HSIL screening. Of the about 5,060 people they want to enroll, there are more than half accrued, so it’s going well so far. One of the other things AMC has expertise in is looking at the interaction between AIDS drugs and cancer drugs. NCI has made a substantial effort recently to get people living with HIV into general cancer trials. By studying the interactions between new cancer drugs and HIV drugs, AMC can provide guidance to enable people living with HIV to participate in a variety of cancer trials and get access to promising new therapies.

COURTESY OF ROBERT YARCHOAN

Please describe the AIDS Cancer Specimen Resource (ACSR).

In the early ’90s, an NCI advisory committee noticed that a barrier to research was that scientists often had difficulty gaining access to samples of clinical material, such as tumor biopsies. NCI established ACSR to address this impediment. ACSR collects tissues from people living with or at risk for HIV malignancies and then distributes them, without cost, to investigators. They have thousands of samples and have given them out to hundreds of investigators.

What are AIDS-defining versus non– AIDS-defining cancers?

When AIDS first appeared, the Centers for Disease Control and Prevention established a definition to include the people who had the disease and exclude others. Persons were considered as having AIDS if they had a condition associated with immunodeficiency but no known cause of it. First KS and then certain aggressive lymphomas were considered AIDS-defining cancers. During those early years, many people with AIDS developed and died from these rare tumors. Cervical cancer was then added to the list. Effective treatment prevented or reversed immunodeficiency in people with HIV. They developed fewer AIDSdefining tumors. People lived longer and developed other tumors not clearly

against hepatitis B, and treat hepatitis B and/or C if present. HIV-positive individuals should discuss with their physicians whether they may benefit from the HPV vaccine and, if they are or have been smokers, whether to get screened for lung cancer. They should also discuss getting age-appropriate screening for colon and breast cancer. Finally, they should be aware that KSHV, the virus that causes KS, is excreted in saliva, so avoiding the use of saliva as a sexual lubricant may lower the risk of getting KSHV and developing KS. What’s ahead for cancer and HIV?

A lot of basic research and observations are being translated into better therapies. For example, research in immune therapy for cancer has recently exploded. Novel

“I encourage people to consider participating in clinical trials.” Robert Yarchoan

associated with immunodeficiency, such as anal cancer or Hodgkin lymphoma. These are non–AIDS-defining HIVassociated cancers. People living with HIV can also develop incidental cancers unrelated to HIV. The good news is that those who have the virus are living much longer, but cancer is still a major concern. What can we do to prevent cancer?

The most important step is to take effective treatment for HIV. Also, individuals who smoke should quit or reduce their smoking. Maintaining a good weight, exercising, avoiding sun exposure and excess alcohol, and eating a healthy diet can reduce the risk of certain cancers. They should also get recommended screening for cervical and anal cancer. They should make sure they are vaccinated

immune therapies, such as checkpoint inhibitors, are now yielding remarkable results in tumors that were previously felt to be untreatable by enabling the person’s immune system to fight the cancer. People questioned if these therapies would work in those with HIV. Clinical trials now under way are looking at this issue. There are other advances occurring in oncology that can benefit those with HIV who have or are at risk for cancer. I encourage HIV-positive people with cancer to consider participating in clinical trials, such as those run by AMC or by NCI at the Clinical Center in Bethesda, Maryland. By doing so, people can gain access to promising experimental therapies and to physicians with expertise and interest in HIV malignancies. At the same time, they can help others. Q

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POZ PLANET

AROUND THE WORLD A look at HIV-related headlines across the globe The Last Life Ball After a spectacular, star-studded 26-year run, the Vienna-based HIV fundraiser Life Ball held its last event this June. The reason, organizers say, is that progress in the fight against AIDS has been so successful that it is â&#x20AC;&#x153;increasingly difficult to find sponsors.â&#x20AC;? Life Ball has raised more than $34 million for HIV charities in Austria and across the globe, many of which say they still rely on funding from Life Ball. Pakistan Outbreak Nearly 500 people, mostly children, have tested positive for HIV in southern Pakistan. The culprits?

8 POZ JULY/AUGUST 2019 poz.com

Unsanitary medical conditions, reused syringes and the growing popularity of quack doctors. One physician, who is HIV positive, has been arrested in connection with the outbreak and is being investigated for spreading the virus on purpose. Mexico Meds Shortage After a new administration took over in December, it changed the way the government buys HIV meds and funds clinics. The overhaul has resulted in treatment shortages, forcing hundreds to go without antiretrovirals. Advocates also worry that the government is ending its funding of local community groups that

(LIFE BALL) HARALD KLEMM/LIFE BALL; (GLOBE AND RED RIBBON) ISTOCK

BY TRENT STRAUBE

Knowing the location of hot spots will allow policymakers and health care providers to better target their scarce resources to prevent, diagnose and treat HIV.

(IPHONE AND FLAG) ISTOCK; (SIDIBÉ) COURTESY OF BENJAMIN RYAN; (GRINDR IMAGES) COURTESY OF GRINDR (MODELS USED FOR ILLUSTRATIVE PURPOSES ONLY)

Critical Situation in Venezuela Amid a major political and economic crisis, people living with HIV in Venezuela aren’t able to access antiretrovirals—because the government is keeping the meds in a warehouse on a military base. Desperate and without their lifesaving HIV treatment, some Venezuelans have started taking a plant called guacimo, or bay cedar, to treat their virus. Others are fleeing the country; many have found support—and meds—in Peru. UNAIDS Ouster After a string of scandals at the agency, Michel Sidibé resigned as executive director of the United Nations Programme on HIV/AIDS (UNAIDS). Internal investigations stemming from reports of sexual assault involving the group’s deputy executive director had found UNAIDS was rife with favoritism, abuse and “defective leadership.” The negative press has already diminished donor countries’ faith and financial investment in the program. provide HIV treatment and prevention services.

Clockwise from top left: Life Ball 2018 outside Vienna City Hall; a screenshot of gay dating app Grindr; the flag of Venezuela; the former executive director of UNAIDS, Michel Sidibé

Human Gene Editing Last fall, Chinese scientist He Jiankui, PhD, announced that he had used CRISPR/Cas9 technology to edit the genes of human twin embryos to make the babies resistant to HIV (he altered the CCR5 gene so it couldn’t make coreceptors on immune cells that most types of HIV use to attach to and infect cells). Since then, the Chinese government has denounced the work as being in violation of ethics and scientific integrity; two gene-editing experts in the country have also criticized He.

African Hot Spots It turns out that HIV prevalence—the proportion of a population living with the virus—in sub-Saharan Africa varies greatly not only between countries but also within nations. Researchers made this discovery after dividing the nations into 5-squarekilometer sections and comparing HIV prevalence in each one.

Viral Load Tests The World Health Organization has given the green light to the first point-of-care test for HIV viral load. Developed by Abbott, the m-PIMA HIV-1/2 VL test is portable and easy to use in remote locations—such as some of those in Africa, Asia and Latin America—where people can’t easily access health care providers. The viral load test will allow people to monitor their current treatment and to make better decisions about their HIV care. It is not available in the United States. Grindr for Sale Security experts within the U.S. government have asked a Chinese company to sell its global gay dating app, Grindr, which was founded in the United States and remains popular here. Beijing Kunlun Tech acquired Grindr in early 2018. Now, privacy specialists worry the Chinese government could use the gay app for espionage or blackmail. What’s more, NBC reported that Grindr’s president, Scott Chen, wanted to allow HIV researchers to access Grindr user data. Kunlun has agreed to sell the app by June 2020.

poz.com JULY/AUGUST 2019 POZ 9

Introducing the new and improved

POZ.com

WEBSITE FEATURES INCLUDE: • Responsive design optimized for smartphones and tablets • Faster site for quicker load times • Redesigned for easier readability and navigation • Improved search function

POZ PLANET BY TRENT STRAUBE

MAC MILESTONES

ALL IMAGES: COURTESY OF MAC VIVA GLAM FUND

In 25 years, the MAC AIDS Fund has raised $500 million. It celebrates with an expanded mission—and a new name! When it comes to fighting the global HIV epidemic, MAC Cosmetics delivers way more than lip service. The company launched the MAC AIDS Fund 25 years ago and has since enlisted powerhouse celebs like Lady Gaga, Ariana Grande and Nicki Minaj to pucker up and pose in campaigns for Viva Glam lipsticks (100% of proceeds go to the cause). Since 1994, the fund has donated over $500 million, making it the largest non-pharmaceutical HIV/ AIDS funder. That breaks down to 9,713 grants issued to over 1,800 programs that reach 19 million people across 92 countries every year! As it celebrates these milestones and its 25th year, the fund announced an expanded mission that focuses on healthy futures and equal rights for women, girls and members of the LGBT community. It also debuted a new name: the MAC Viva Glam Fund. “We’re evolving our mission and changing the name of our fund in the U.S.,” writes Nancy Mahon, global director of the fund, in an article on Medium.com. “We’ll transform the U.S.-based foundation Clockwise from top from the MAC AIDS right: Winnie Fund to the MAC Viva Harlow in the 2019 Glam Fund to reflect campaign; past our broadened apads with celebs proach in the U.S. We’ll Shirley Manson, also be doubling down Elton John, Mary J. on support that adBlige, Taraji P. dresses the needs and Henson and Sia; three of the 18 inequities of commu“MACtivists” in the nities most impacted fund’s latest video; by the disease. ” the VIVA GLAM 25 To kick off this era, lipstick the fund debuted a socially minded campaign starring not one big-name celeb but 18 “MACtivists”—influencers, artists and activists such as Troye Sivan, Princess Nokia and Alex Mugler, who reflect the fund’s expanded mission. The fund is also honoring 10 of its heritage grantees with $25,000 grants and partnering with Planned Parenthood, GLAAD and Girls, Inc. In another move more visible to the public, the fund also launched a new logo, a limited-edition lipstick and a 25th anniversary campaign. Look for Winnie Harlow, the Canadian fashion model, America’s Next Top Model contestant and spokesperson for the condition vitiligo (a depigmentation of sections of the skin), as she poses in an homage to Viva Glam’s debut campaign from 1994, which starred RuPaul. Long live Viva Glam—shanté, you stay!

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POZ PLANET BY TRENT STRAUBE

POZ AT 25 A look at summer issues from the POZ archives

1999

2004

2009

2014

1994

1. JUNE/JULY 1994

2. AUGUST 1999

3. AUGUST 2004

Cover: POZ goes on location in Lyon, France, for dancer and choreographer Bill T. Jones. Inside: Profiles on Visual AIDS director Patrick O’Connell, New York City restaurateur Florent Morellet and the explicit, gay sex documentary Sex Is…. Plus: A look at the reemergence of tuberculosis as a public health threat and the rise of home HIV testing kits.

Cover: A peek inside the curious closets of artist Barton Lidice Beneš—you never know what or whom you’ll find. Inside: Puerto Rican officials are accused of embezzling federal AIDS funds; how to prevent parasites—and treat them. Plus: Special summer fiction: a short story on love and loss by Richard McCann.

Cover: Chloe Dzubilo leads a revolt against high HIV rates among transgender people and the medical community’s snickering disdain. Inside: A look at the biggest HIV/ AIDS demonstration in a decade: against the Bush administration’s abstinence-only prevention programs and lack of new AIDS funding. Plus: How open dialogue helped curb HIV rates in Uganda.

4. JULY/AUGUST 2009

5. JULY/AUGUST 2014

Cover: The inspiring story of 15-year-old rapper Noah Mushimiyimana, who journeyed from Rwanda to the bright lights of American Idol thanks to Keep a Child Alive. Inside: Images from photographer Kristen Ashburn’s book I Am Because We Are, which documents AIDS among African children. Plus: Tips for getting meds while behind bars.

Cover: How Antonio Muñoz fought back— and won—when his bosses treated him unfairly because of his HIV status. Inside: Instructions for filing an HIV discrimination case and a look at other legal tools available to you. Plus: A timeline of HIV discrimination cases and related laws, such as the Americans with Disabilities Act.

Go to POZ.com/25 for more 25th anniversary coverage! poz.com JULY/AUGUST 2019 POZ 15

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EVERYDAY BY JENNIFER MORTON

July 1

The U.S. Public Health Service opens the NATIONAL AIDS HOTLINE to respond to public inquiries about the disease. By the end of the month, it receives 8,000 to 10,000 calls daily. (1983)

The U.S. Food and Drug Administration (FDA) approves THE FIRST AT-HOME HIV TEST. It provides results within 40 minutes. (2012)

TERRENCE HIGGINS is one of the first people in the United Kingdom to die of AIDS-related causes. His friends create the Terrence Higgins Trust in his honor. Today, it’s the leading HIV and AIDS charity in the U.K. (1982)

August U.S. health officials declare THE NATION’S BLOOD SUPPLY is free of the virus that causes AIDS thanks to a new test that screens out contaminated blood. (1985)

(JETER) PAUL SMITH/FEATUREFLASH/DREAMSTIME.COM; ALL OTHERS: ISTOCK (MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY)

A federal judge orders Florida’s DeSoto County School Board to enroll brothers RICKY, ROBERT AND RANDY RAY—all of whom are living with hemophilia and HIV— in school. After the ruling, outraged residents refuse to allow their children to attend school, and on August 28, someone sets fire to the Ray house, destroying it. (1987)

MALAYSIA AIRLINES FLIGHT 17 is shot down while flying over eastern Ukraine, killing everyone aboard, including six prominent scientists and AIDS activists on their way to the 20th International AIDS Conference in Melbourne. (2014)

Drug counselor DAVID PURCHASE sets up the nation’s first needleexchange program on a sidewalk in Tacoma, Washington. Within five months, he exchanges 13,000 needles to prevent HIV. (1988)

THE FDA sanctions the first human testing of a candidate vaccine against HIV. (1987)

Actor MICHAEL JETER (Evening Shade, Sesame Street) dies of AIDS-related causes. (2003)

A group of minority leaders meets with U.S. Surgeon General C. Everett Koop, MD, to discuss concerns about HIV/AIDS in communities of color. The meeting marks the unofficial founding of the NATIONAL MINORITY AIDS COUNCIL. (1986)

San Francisco General Hospital opens WARD 5B, the first dedicated inpatient AIDS ward in the United States. Within days, all of its 12 beds are occupied. (1983)

The Pentagon declares that as of October 1, it will TEST ALL MILITARY RECRUITS FOR HIV and reject those who test positive for the virus. (1985)

AIDS is an everyday experience. These dates represent milestones in the AIDS epidemic. Some dates are known globally; others commemorate individual experiences. AIDS Is Everyday is an ongoing art project produced in conjunction with Visual AIDS to help break down the silence, shame and stigma surrounding HIV. Add a date about your history with HIV to our online calendar at poz.com/ aidsiseveryday-submit.

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VOICES BLOGS AND OPINIONS FROM POZ.COM

MY PATH In a blog post titled “My Path to U=U,” HIV advocate Murray Penner describes how the Undetectable Equals Untransmittable message affected his journey living with the virus. Below is an edited excerpt.

he confidential letter arrived in March 1986. “To Be Opened Only by Addressee” glared at me in red letters. I will never forget opening it and reading: “You should see a doctor immediately, as your blood test came back positive for HIV.” I contemplated my death. It took me months to summon enough courage to tell my partner, almost passing out as I said “HIV.” Thankfully, he was understanding and supportive. A visit to the health department confirmed I’d tested positive, while he tested negative. And so began my journey living with HIV, along with the blessings that culminate in my announcement that I am thrilled and humbled to be joining the Prevention Access Campaign as North America executive director. Despite the shame, fear and stigma I felt in 1986, I took control of my future by calling a doctor and talking openly. My doctor provided excellent care and emotional support during a painful and frightening period of my life. Craving information and a community, I called Project Inform. I received a call back from Marty Delaney who talked me through what I could expect and introduced me to a network of support. I connected with people living with HIV

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who helped others facing similar issues. I am privileged to have benefited from support and access to care. I benefited from effective treatment beginning in 1996. Too many of our friends did not. I am fortunate that newer medications have allowed me to maintain an undetectable viral load for 10 years. Like others who were undetectable, I came across a Swiss study in 2008 that concluded that individuals with an undetectable viral load could not sexually transmit the virus. I thought that was such a misguided concept. I felt the study must be wishful thinking. Bruce Richman’s Facebook message in early 2016 was equivalent to my connection to Project Inform. He discussed the need for the consensus statement he had developed to clear up mixed messages about risk and to confirm that undetectable equals untransmittable (U=U). At that time, I was serving as executive director of NASTAD [National Alliance of State and Territorial AIDS Directors]. Bruce pleaded for NASTAD to sign on to the consensus statement. I wanted the dream ignited by the Swiss study to become reality. With the support of my senior staff, I decided to take the leap and sign on.

Later, when I announced the endorsement to NASTAD’s board, members expressed concern that the Centers for Disease Control and Prevention had not yet agreed with the statement. I informed the board that it was our role to lead on U=U, which had unprecedented potential to reduce stigma, improve people’s well-being and prevent new transmissions. We did not need to wait for the government’s approval. NASTAD’s leadership agreed. U=U is only part of a one-two punch against shame and stigma. The other part is pre-exposure prophylaxis (PrEP), which is crucial for preventing new HIV cases. But in 2016, when I learned about U=U, it was my first real opportunity to shed my own stigma. A battle with prostate cancer motivated me to reevaluate my priorities. I decided to move beyond being defined by my story to tap into my passion. The decision meant saying goodbye to NASTAD and focusing on U=U. I bring to Prevention Access Campaign a focus to end HIV stigma. That determination will call on me to ensure that U=U is a valued basic concept in sexual health, improving the well-being of all people living with HIV and bringing us closer to ending the epidemic. Q

MY CHALLENGE In an opinion piece titled “Challenging My Own Bigotry,” Brian Gaither, an HIV-negative gay man and cofounder of the Pride Foundation of Maryland, confronts his past behavior. Below is an edited excerpt.

(BOTH IMAGES) ISTOCK

hen presidential candidate Pete Buttigieg told the assembled donors of the LGBTQ Victory Fund that he’d struggled with his sexuality so viscerally he wanted to cut it out of himself, I didn’t understand. I’ve never been that conflicted about being gay, certainly not in a way that caused me such deep emotional pain. But in his comments, I recognized something I do know. We gay men who are HIV negative very often feel that way about our brethren who are HIV positive. We treat them, collectively, as something we would cut away from ourselves if we could. From the time I became sexually active in college until many years later, I lived in total fear of HIV. I didn’t want it to be any part of my life. I wanted to live in a world of gay men who were HIV negative because gay men with HIV were a threat to “the rest of us.” Eventually, I became aware of what a self-centered bigot I was. The things that I had said, the attitudes they reflected and the ways I had behaved are still used to stigmatize gay men who are HIV positive. I was 25 years old the first time a friend disclosed his HIV-positive status

to me. He got tested. He was dealing with it. Unlike my friend, I was not dealing with it. I felt I’d failed, somehow, to keep the disease at bay. I panicked; I got tested. Not long after, I was dating a man who was smart, engaging and great in bed. We saw each other off and on for a few months. Then he went silent on me. Many months later I got a call back. He was sorry he’d been out of touch. He’d explain. I knew what he was going to say. When we stopped seeing each other, it wasn’t because of his status. We’ve been friends for the many years since, and I’m grateful for a relationship that has forced me to constantly challenge my bigotry. Spending time with him has shown me that HIV isn’t something I should want to avoid. Gay men will always be part of my life, and some of them will be positive. There’s nothing about the virus that makes them any less engaging, smart or great in bed. Since then, I’ve had a number of relationships with HIV-positive men. Each of them has begun, more or less, the same way. After about three or four dates, there’s a pause, then a sigh. “I have to tell you something first.”

I’d like to think I’ve gotten better with my responses. I recognize the hatefulness I once spread and the damage I caused. I’ve seen it in the eyes of men I’ve dated when they shared their status. I’ve sensed it in the anxiety of the moment just before they told me. I’ve also heard it in the voices of friends as they recounted stories of being cast aside after coming out as HIV positive. Every time a friend says he genuinely believed that “this guy would be different,” I know that his pain is a misery I, another gay man, have inflicted on him. But we should all know better. HIV is a part of our lives because gay men who are HIV positive are part of our lives. They are our friends, and medical science—including pre-exposure prophylaxis (PrEP) and the message of Undetectable Equals Untransmittable, or U=U—has made it easy for us all to be lovers. We continue to discriminate only because we choose to be ignorant. We owe it to one another to fight the general bigotry against HIV-positive men that persists in gay culture and to accept that each and every one of us could be with a man who makes us happy—regardless of his status. Q

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CARE AND TREATMENT BY BENJAMIN RYAN

New Two-Drug Regimen The Food and Drug Administration (FDA) has approved ViiV Healthcare’s fixed-dose, single-tablet regimen Dovato (dolutegravir/lamivudine) to treat HIV among those new to antiretroviral therapy whose virus does not have mutations associated with either of the drugs in the combination tablet. Dovato, which includes the integrase inhibitor dolutegravir (sold separately as Tivicay) and the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) lamivudine, is the second HIV regimen to include just two antiretrovirals rather than three or more, as has long been standard. It is the first two-drug regimen for those who have not previously received treatment for the virus. “As HIV moves firmly into the category of a chronic disease that is medically managed, it makes sense to treat patients with simpler and safer regimens,” says Anthony Mills, MD, chief medical officer of the Men’s Health Foundation in Los Angeles. “While three drugs were needed in the past to provide durable viral suppression, the evolution of more potent drugs with a higher genetic barrier to the development of resistance has led scientists and clinicians to question this age-old paradigm.” Dovato’s approval was based on findings from a pair of randomized, double-blind, controlled Phase III trials that together included 1,433 first-timers to HIV treatment. The participants were randomized to receive either the components of Dovato or a three-drug regimen of Tivicay plus Truvada (tenofovir disoproxil fumarate/emtricitabine). The two regimens suppressed HIV at a comparably high rate after 48 weeks.

CARDIAC DYSFUNCTION DETAILS HIV is associated with a high risk of various forms of cardiac dysfunction, according to a systematic review and meta-analysis of 63 reports from 54 studies that included 125,382 adults living with HIV. Out of a pooled 12,655 cases of cardiac dysfunction diagnosed among the participants, 12% were left ventricular systolic dysfunction (LVSD, which often leads to heart failure), 12% were dilated cardiomyopathy (a weakened left ventricle compromises the heart’s pumping capacity) and 29% were Grades I to III of diastolic dysfunction (abnormalities in part of the heart’s pumping process). Nearly 7% of the participants had clinical heart failure, which had a diagnosis rate of nine cases for each 1,000 cumulative years of study follow-

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up. Additionally, 11.5% of the cohort had one of the various forms of pulmonary hypertension, and 8% had some type of ventricular dysfunction. The researchers identified a trend in which studies that reported a higher rate of antiretroviral treatment or a lower AIDS diagnosis rate had a lower LVSD rate—suggesting that effective HIV treatment mitigates the risk of the condition. Diagnoses of the condition were less common in more recent studies. “Our study highlights that heart failure is an important complication of HIV,” says the study’s lead author, Sebhat Erqou, MD, PhD, a cardiologist at the Providence VA Medical Center in Rhode Island. “Main-

taining consistent medical follow-up can help in early identification and treatment of the disease for people living with HIV.”

LIVER CANCER PROGNOSIS

ALL IMAGES: ISTOCK

Copping to COPD Chronic obstructive pulmonary disease (COPD), a chronic inflammatory lung disease in which airflow from the lungs is obstructed, is associated with about a doubled risk of heart attack, or myocardial infarction (MI), among people living with HIV, according to a recent study. Compared with those who don’t have the virus, people with HIV are at higher risk for COPD. Among HIV-negative individuals, COPD is a known risk factor for cardiovascular disease, including heart attack. Whether COPD has a similar association among HIV-positive individuals has remained cloudy. To investigate this potential association, researchers analyzed data on 22,596 HIV-positive members of an ongoing cohort study. At the study period’s outset, the 895 participants with COPD were more likely to have smoked compared with the others. Another 451 study members were diagnosed with the condition during a median follow-up period of six years. A total of 704 study participants had heart attacks. After adjusting the data to account for various differences between the cohort members, including smoking and the duration of the habit, the study authors found that COPD was associated with a 2.08-fold higher risk of heart attack. “Smoking cessation is certainly important to improve health and decrease the risk of both COPD and MI,” says the study’s lead author, Kristina Crothers, MD, a professor of medicine at the University of Washington in Seattle. “Whether improved control of COPD might help decrease the risk for MIs is not known. [People with HIV] who have chronic respiratory symptoms, such as shortness of breath, cough or phlegm, especially if they have been smokers, should be evaluated for COPD.”

Among people with hepatitis C virus (HCV), HIV status has no apparent bearing on the rate of survival three years following a diagnosis of hepatocellular carcinoma (HCC, the most common type of liver cancer). Researchers analyzed data on 339 people with liver cancer and HIV/HCV coinfection who were members of a research cohort in Spain between 1999 and 2017. For a comparison group, the study authors selected 118 people with liver cancer who had HCV but not HIV and were patients of a liver unit at a Spanish hospital. The study participants were monitored every six months. During the study’s follow-up period, 73% of the combined cohort died following their liver cancer diagnosis, 91% of them from liver-cancerrelated causes. After adjusting the data to account for various differences between the cohort members, the study authors found that HIV was not associated with a significant difference in the rate of death 36 months after participants received their liver cancer diagnosis. Nor were age, sex, drinking more than five drinks daily or a lack of hep C cure associated with a difference in this mortality rate. What was clearly tied to a worse three-year survival rate was being diagnosed with liver cancer at a more advanced stage of the disease. Daniel S. Fierer, MD, an infectious disease specialist at the Icahn School of Medicine at Mt. Sinai in New York City who was not involved with the study, says it “lends further evidence for the need for regular surveillance in all patients— with or without HIV infection—who have advanced liver disease with twice-yearly ultrasounds [in order] to make the diagnosis of liver cancer at the earliest possible stage.”

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Got Ink? An estimated 3–5 million Americans are living with hepatitis C. Most don’t know it. Get tested today.

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Find out how at hepmag.com.

RESEARCH NOTES

(TROGARZO) COURTESY OF THERATECHNOLOGIES; ALL OTHER IMAGES: ISTOCK

BY BENJAMIN RYAN

PREVENTION

TREATMENT

CURE

CONCERNS

HIV Transmission

Trogarzo Durability

Role of Macrophages

Opioid ODs

Which subgroups of people with HIV are most likely to transmit the virus? According to estimates from the Centers for Disease Control and Prevention (CDC), in 2016, 1.1 million people in the United States were living with HIV, and 38,700 people contracted the virus. Researchers deduced that the 1% of the HIV population with an acute, or very recent, undiagnosed infection accounted for an estimated 4% of all new transmissions. The 14% with a chronic, or longer-term, undiagnosed infection accounted for 34% of transmissions. The 23% who were diagnosed but not in medical care for HIV accounted for 43% of transmissions. The 11% who were diagnosed and receiving medical care but had unsuppressed virus accounted for 20% of transmissions. Lastly, the 51% with an undetectable viral load presumably did not transmit the virus to anyone, as studies show that undetectable HIV is not transmittable.

Theratechnologies’ antibody treatment Trogarzo (ibalizumab-uiyk), approved in 2018 for those with multidrug-resistant HIV who are on a failing antiretroviral (ARV) regimen, is safe and effective over the long term. Approval was based on 48-week data from a Phase III trial; 27 of its participants continued for a second year of treatment. Throughout, they received biweekly Trogarzo infusions plus an optimized background regimen of daily oral ARVs. At the study’s outset, these participants had a median viral load of 21,700 and a median CD4 count of 102. The median viral load declined by 316-fold by week 25 and by 631-fold by week 96. At week 96 of treatment, 56% of the participants had a fully suppressed viral load, and the median CD4 count increased by 45. Trogarzo remained well tolerated at week 96, by which point no new safety concerns had arisen.

Macrophage immune cells, evidence now suggests, are a component of the viral reservoir. HIV cure research has principally focused on latently infected CD4 T cells as the reservoir’s backbone. These nonreplicating immune cells evade antiretrovirals, which work only on active cells. Researchers studied urethral tissue from 20 people with HIV who were designated male at birth and were undergoing gender confirmation surgery. All of them had an undetectable plasma viral load. Tests showed that HIV genetic material was integrated into their latently infected urethral macrophage cells. After these cells were treated with an activating agent meant to get them to start replicating again, they began producing viable copies of the virus. A CD4cell-activating drug did not prompt the macrophage cells to replicate. Based on these findings, experimental HIV cure therapies that use drugs that only reverse the latency of infected CD4 cells may miss the macrophage part of the reservoir.

Centers for Disease Control and Prevention (CDC) researchers analyzed data from the National HIV Surveillance System and found records indicating that 1,363 people with HIV died of opioid overdoses between 2011 and 2015. During that period, the annual death rate of the HIV-positive population as a whole declined by 13% while the opioid overdose death rate increased by 43%. The population’s opioid death rate rose in virtually all subgroups, including those separated according to age, sex, race, route of HIV transmission and U.S. Census region. (The opioid death rate did not rise in the West, however.) The opioid death rate per 100,000 people with HIV was highest among those 50 to 59 years old (42 deaths), women (35 deaths), whites (49 deaths), people who inject drugs (137 deaths) and those living in the Northeast (61 deaths). These findings highlight the need for harm reduction services for people with HIV.

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SPOTLIGHT BY JOE MEJÍA

R.I.P. Andy Vélez Andy Vélez (1939–2019) spent more than three decades on the front lines of activism. From the moment he joined ACT UP in 1987, the HIV-negative ally made his voice heard loud and queer and emboldened several generations of activists to follow suit. Andy didn’t only fight against HIV/AIDS, he also fought on behalf of LGBTQ rights and for health care access for all. Even as he joined the younger activists he had inspired and mentored at their own demonstrations, Andy remained an active member of ACT UP and, until his death, moderated the community resource POZ Forums. But best of all, Andy managed to channel his anger into action without even a hint of self-seriousness. As author and professor Dale Peck wrote in a tribute we couldn’t fit here (read it in full on Facebook): “Andy made activism seem like the most joyful, empowering and fulfilling way to be in the world: in service to one’s community, one’s ideals and a more hopeful, inclusive vision of society.” May Andy rest in peace; may we continue to resist in his honor.

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JAMEY GUY

Sean McKenna advocates for long-term survivors with HIV.

PEOPLE LIVING WITH HIV ARE ALSO FACING CANCER AS THEY AGE. BY LIZ HIGHLEYMAN

BILL WADMAN

AS A LONG-TERM SURVIVOR LIVING WITH HIV, Sean McKenna has faced numerous battles, including two episodes of skin cancer and several bouts of anal precancer. Jill Cadman, another long-timer, is living with HIV and Stage IV colon cancer. And they are not alone. “Almost every long-term survivor I know is dealing with HPV,” or human papillomavirus, which causes anal, cervical and oral cancer, McKenna says. “Our bodies are beaten down. So many of us in our 50s or 60s are experiencing things that don’t usually happen until the 70s or 80s.” Like McKenna and Cadman, a growing number of people with HIV are dealing with cancer as they age. But this is more about a shifting landscape than an overall rise or fall. Since the advent of effective antiretroviral therapy in the mid-1990s, the

AIDS-defining cancers—Kaposi sarcoma, non–Hodgkin lymphoma and cervical cancer—have dropped dramatically. But as people live longer, they have more time to develop other types of cancer. McKenna, now 56, was diagnosed with HIV in 1992, although he thinks he acquired the virus a decade earlier. Effective medications came along just in time, and eventually, he found a combination that kept his HIV in check. But that didn’t stop other problems. Twenty years ago, when he was trying to get his HIV under control, he was diagnosed with melanoma. Luckily, that spot was removed early and never spread. Then, in March 2018, after watching dermatolog y surgeon Sandra Lee’s TV show, Dr. Pimple Popper, he decided to see a dermatologist about a cyst that had been bothering him. An initial biopsy showed it was benign, but the lump got bigger and eventually was diagnosed as dermatofibrosarcoma protuberans, a rare tumor that develops

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HIV-RELATED CANCERS Most cancers develop over time as a result of exposure to cancer-causing factors in the environment and an accumulation of genetic mutations. People with HIV—who are twice as likely to smoke and who have more cancer-causing coinfections— are at higher risk. In addition, effective antiretroviral therapy means more HIV-positive people are living to the age when cancer typically occurs. According to the Centers for Disease Control and Prevention (CDC), just under half of people living with HIV in the United States are age 50 or older, and 16% are over 65. About half of all cancers occur in people 65 and older. Before combination therapy, AIDS-defining malignancies accounted for around 75% of all cancers among people with HIV; today, that figure is closer to 25%. But HIV-positive people are still more likely to develop these cancers than those in the general population, largely because many remain unaware that they have the virus and aren’t on treatment. “Cancer is a very important cause of mortality in HIVpositive men and women,” says Joel Palefsky, MD, of the University of California at San Francisco, who founded the first clinic devoted to anal cancer. “The AIDS-defining cancers have come down with antiretroviral therapy, but they’re not gone. And the non–AIDS-defining cancers have gone up.” In San Francisco, for example, HIV-related causes, including AIDS-defining cancers, still accounted for the largest proportion of deaths of HIV-positive people between 2014 and 2017, at 38%. Non-AIDS cancers came next, at 15%, followed by heart disease at 11%. The non-AIDS cancers with the greatest disparities between people with and people without HIV are caused by viruses,

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“WHEN I FOUND OUT I WAS HIV POSITIVE,

I TOLD EVERYONE, AND I DID THE SAME FOR CANCER.” including HPV; hepatitis B and C viruses (HBV and HCV), which can cause liver cancer; and Epstein-Barr virus (EBV), which causes some types of lymphoma, throat cancer and other malignancies. Researchers often classify cancers as AIDS-defining or non–AIDS-defining, but a more useful distinction may be whether or not they’re HIV-related. In fact, HPV cancers demonstrate how classification can be more about politics than science. In the late 1980s, some activists felt it was important to have a woman-specific condition included in the CDC’s definition of AIDS. As a result of their efforts, invasive cervical cancer was added, but anal cancer—essentially the same disease with the same cause—was not, which has had ongoing ramifications for screening and care. Studies show that people with HIV have more types of HPV on average—including types 16 and 18, which cause a majority of cervical and anal cancers—and are less likely to clear the virus naturally. In addition, they may experience more rapid progression of HPV-related disease, from low-grade cell changes to advanced dysplasia (known as high-grade squamous intraepithelial lesions, or HSIL) to invasive cancer.

BILL WADMAN

in deep layers of the skin. “I got the call at a friend’s place, and it was very similar to the call I’d gotten years ago saying I had to come in to discuss the results of my HIV test,” he recalls. “Both times, I was caught completely off guard. I hung up the phone and asked myself, ‘Did he say what I thought he said?’” Last December, McKenna saw an oncologist who “cut a 5-inch hole” in his back. He needed a second skin graft to repair the wound, after losing the first graft to an infection. “They didn’t pay attention to the fact that I was a long-term HIV survivor,” he says, and didn’t prescribe him strong enough antibiotics to shore up his battered immune system. McKenna’s skin cancer appears to be cured, but things aren’t going so well elsewhere. He also deals with recurring anal dysplasia, or abnormal tissue changes caused by HPV, despite the fact that his viral load has been undetectable for years and his CD4 cells are above 1,000. He has had several precancerous lesions removed and has participated in clinical trials, including one that tested a topical Sean McKenna chemotherapy drug. had surgery “It was a real pain in the ass, and it didn’t to remove skin cancer. do much good,” he says. “I don’t know why this is so persistent—it’s the most uncomfortable thing in the world.”

A leading cause of cancer death in lower-income countries, invasive cervical cancer is relatively uncommon in the United States because regular screening can catch HPV-related cell changes early enough to be treated before they progress to cancer. In one of the greatest achievements in public health, cervical cancer rates plummeted by around 75% after the adoption of routine Pap testing in the 1950s. But anal cancer is a different story. The incidence of anal dysplasia and cancer has risen since the advent of effective HIV treatment. About half of HIV-positive men who have sex with men have HSIL, according to Palefsky, and they have an 80- to 100-fold greater risk of developing anal cancer compared with the general population. Women with HIV are at increased risk too. And, as McKenna learned, undetectable HIV and CD4 cell recovery don’t eliminate that risk. Anal screening is neither routinely done nor included in federal HIV guidelines, although it is part of New York’s state guidelines and has been adopted by some providers who see many gay men living with HIV. Some doctors are hesitant to provide anal screening—and insurers are reluctant to cover it—because of the lack of goldstandard evidence showing that early detection and treatment actually prevent anal cancer. “We know screening works in cervical cancer, and we adopted that system before we had proof that it worked,” Palefsky says. But the balance of benefits and harms is different for the two cancers. “If a woman has [cervical] HSIL, you can remove a large portion of the cervix. But you can’t do that in the anal canal, obviously.” Palefsky’s ANCHOR (Anal Cancer HSIL Outcomes Research) trial aims to supply the needed evidence. In this study, men and women diagnosed with HSIL will be randomly assigned to receive either immediate treatment or active monitoring. The study is currently recruiting participants in more than a dozen cities (visit AnchorStudy.org or call 844-HIV-BUTT). For younger individuals, a vaccine can prevent nine types of HPV. Although it works best before people become sexually active, the CDC recommends the vaccine for HIVpositive men and women through age 26, and the Food and Drug Administration (FDA) has approved it for those up to age 45. Liver cancer—caused by heavy alcohol consumption and fatty liver disease, as well as by chronic hepatitis B or C—is among the few cancers that are rising in the United States. According to the CDC, about a quarter of people with HIV have HCV coinfection. HIV-positive people have about a fourfold higher risk of liver cancer—and they may develop cancer at a lower stage of liver damage. Fortunately, hepatitis B can be prevented with a vaccine, and new antiviral medications can now cure almost everyone with hepatitis C. Beyond these viral cancers, people with HIV also have about twice the rate of lung cancer—the leading cause of cancer-related death for HIV-positive and HIV-negative people alike, says Michael Silverberg, PhD, MPH, of the Kaiser Permanente Division of Research. HIV-positive people are more likely to smoke, but their risk remains disproportion-

CANCER PREVENTION TIPS • Stay on effective HIV treatment. • Stop smoking. • Limit alcohol consumption. • Eat a low-fat, high-fiber diet. • Maintain a healthy weight. • Exercise regularly. • Protect yourself from the sun. • Get vaccinated against hepatitis B and HPV. • Get treated for hepatitis B or C. • Get recommended cancer screenings. For a list of cancer screening recommendations, read the online version of this story on POZ.com.

ately high even after controlling for smoking. A history of respiratory infections may be part of the reason for this, according to Silverberg. The link with immune deficiency might even hint that an unidentified virus plays a role in lung cancer. But, he says, “Smoking is such a strong risk factor that it probably explains most of the excess risk.” What’s more, several studies suggest that people with HIV may develop various cancers at earlier ages, may be diagnosed at more advanced stages of disease and may have poorer survival than HIV-negative people. Because of the strong association between HIV infection and the development of cancer, starting and staying on antiretroviral therapy is one of the best ways to prevent and control cancer among people living with HIV. The large START trial showed that people who started HIV treatment immediately rather than waiting until their CD4 count fell below 350 reduced their cancer risk by 64%. Effective treatment both limits damage to cancer-fighting immune cells and helps reduce cancer-causing inflammation. Regular screening is also important to catch cancer early, when it’s easier to treat. “There’s no strong evidence that any of the routine cancer screenings should be different for HIVpositive and HIV-negative people,” Silverberg says.

LIVING WITH CANCER Studies looking at the links between HIV and other nonviral cancer types have yielded mixed results. For example, rates of melanoma, kidney cancer, oral cancer and stomach cancer were found to be higher among people with HIV in some studies but not in others. And some cancers consistently appear to have no association with HIV—or may even occur less often in HIV-positive people—including breast cancer, prostate cancer and colon cancer. “Breast and prostate cancer are interesting stories,” Silverberg says. “HIV patients have an increasing burden as they age, but when you compare them to people without

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YOU MATTER AND SO DOES YOUR HEALTH Thatâ&#x20AC;&#x2122;s why starting and staying on HIV-1 treatment is so important. WHAT IS DESCOVYÂŽ? DESCOVY is a prescription medicine that is used together with other HIV-1 medicines to treat HIV-1 in people who weigh at least 77 lbs (35kg). DESCOVY is not for use to help reduce the risk of getting HIV-1 infection. DESCOVY combines 2 medicines into 1 pill taken once a day. Because DESCOVY by itself is not a complete treatment for HIV-1, it must be used together with other HIV-1 medicines.

DESCOVY does not cure HIV-1 infection or AIDS. To control HIV-1 infection and decrease HIV-related illnesses, you must keep taking DESCOVY. Ask your healthcare provider if you have questions about how to reduce the risk of passing HIV-1 to others. Always practice safer sex and use condoms to lower the chance QH UGZWCN EQPVCEV YKVJ DQF[ Ć&#x192;WKFU 0GXGT TGWUG QT UJCTG PGGFNGU QT QVJGT KVGOU VJCV JCXG DQF[ Ć&#x192;WKFU QP VJGO

IMPORTANT SAFETY INFORMATION What is the most important information I should know about DESCOVY? DESCOVY may cause serious side effects: â&#x20AC;˘ Worsening of hepatitis B (HBV) infection. DESCOVY is not approved to treat HBV. If you have both HIV-1 and HBV and stop taking DESCOVY, your HBV may suddenly get worse. Do not stop taking DESCOVY YKVJQWV Ć&#x201A;TUV VCNMKPI VQ [QWT JGCNVJECTG RTQXKFGT CU they will need to monitor your health. What are the other possible side effects of DESCOVY? Serious side effects of DESCOVY may also include: â&#x20AC;˘ Changes in your immune system. Your immune U[UVGO OC[ IGV UVTQPIGT CPF DGIKP VQ Ć&#x201A;IJV KPHGEVKQPU Tell your healthcare provider if you have any new symptoms after you start taking DESCOVY. â&#x20AC;˘ Kidney problems, including kidney failure. Your healthcare provider should do blood and urine tests to check your kidneys. Your healthcare provider may tell you to stop taking DESCOVY if you develop new or worse kidney problems. â&#x20AC;˘ 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. â&#x20AC;˘ 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 â&#x20AC;&#x153;tea-coloredâ&#x20AC;? urine, light-colored stools, loss of appetite for several days or longer, nausea, or stomach-area pain. The most common side effect of DESCOVY is nausea. Tell your healthcare provider if you have any side effects that bother you or donâ&#x20AC;&#x2122;t go away. What should I tell my healthcare provider before taking DESCOVY? â&#x20AC;˘ All your health problems. Be sure to tell your healthcare provider if you have or have had any kidney or liver problems, including hepatitis virus infection. â&#x20AC;˘ All the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Other medicines may affect how DESCOVY works. Keep a list of all your medicines and show it to your healthcare provider and pharmacist. Ask your healthcare provider if it is safe to take DESCOVY with all of your other medicines. â&#x20AC;˘ If you are pregnant or plan to become pregnant. It is not known if DESCOVY can harm your unborn baby. Tell your healthcare provider if you become pregnant while taking DESCOVY. â&#x20AC;˘ If you are breastfeeding (nursing) or plan to breastfeed. Do not breastfeed. HIV-1 can be passed to the baby in breast milk. 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. Please see Important Facts about DESCOVY, including important warnings, on the following page.

Ask your healthcare provider if an HIV-1 treatment that contains DESCOVYÂŽ is right for you.

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COURTESY OF JILL CADMAN

HIV of a similar age, we’re actually seeing a lower risk than you would expect.” But that doesn’t mean people with HIV are out of the woods, as these are among the most common cancers in the population at large. Jill Cadman, a longtime HIV treatment advocate and former editor for GMHC and The Well Project, was diagnosed with HIV in 1992. She started on sequential monotherapy, and when new drugs were approved, she put together an effective three-drug regimen. Her viral load has been undetectable for 20 years, her CD4 count is high, she has never been sick with opportunistic infections and she has had few side effects. “I was lucky there was always another drug available when I needed it,” she says. “In those early days, I would do bitter melon enemas and mistletoe from the buyers club. I don’t know how much that helped, but I stayed well until whatever drug I was taking stopped working, and then there would be something else. As the standard of care evolved, my treatment evolved along with it.” But Cadman’s experience with cancer treatment has been more frustrating. Cadman was diagnosed with Stage IV colon cancer in November 2017, at age 54. Her HIV doctor had noticed a decrease in her hemoglobin but couldn’t figure out why. She developed constipation and back pain and began losing weight. She’d previously had a colonoscopy at age 51, but the results were normal, and her gastroenterologist didn’t think she needed another so soon. Eventually, another doctor agreed to do a second one, which revealed a tumor in her colon. Scans showed that cancer had spread to her lungs. “I finally got an answer, and it was the worst possible thing,” she says. “Nobody, from the GI doc to the hematologist, seemed to be concerned enough about what was going on with me, even though I probably had a higher risk of cancer being long-term HIV-positive. I was too accepting when I was told that the second colonoscopy wasn’t necessary. If I had pushed harder and gotten it sooner, the cancer might have been found before it spread.” Cadman started on standard combination chemotherapy known as FOLFOX and had surgery to remove the colon tumor in December 2017. She continued the chemo regimen longer than expected—she says acupuncture kept neuropathy at bay, and homeopathy helped manage her nausea—but she finally had to stop taking one of the drugs because of side effects. Genetic testing showed that her cancer probably wouldn’t respond to any of the newer targeted therapies. “It’s been frustrating, because that wasn’t how it was with HIV—if a new drug came out, the only thing that would prevent you from taking it would be resistance,” she says. As indicated by Cadman’s experience, recommended cancer therapy for HIV-positive people on antiretroviral therapy is generally the same as for HIV-negative people. Yet according to the National Comprehensive Cancer Network (NCCN), people living with HIV are much more likely to receive no cancer treatment—a legacy of a time when they were sicker and HIV therapy was more complex.

Jill Cadman and her dog, Carly

In 2018, NCCN issued new guidelines recommending that clinicians should offer cancer treatment to most people with HIV just as they would for those who are HIV negative. However, some cancer medications can interact with certain antiretrovirals—integrase inhibitors are less likely to cause problems—and some drugs can lower white blood cell counts, including CD4 cells. For these reasons, the guidelines stress the importance of collaborative care managed jointly by oncologists and HIV specialists. Drawing on her HIV expertise, Cadman sought out clinical trials, including a study of the immunotherapy drug Opdivo (nivolumab), but learned that most cancer trials are closed to people living with HIV. “People always say, ‘Oh, something new is going to come out—maybe there’s a trial you can enroll in,’” she says. “It never occurred to me that HIV would be an issue. It took away something that really gives you hope—that maybe you could enter a trial and help yourself and help others.” But that’s changing. Last November, at the urging of the American Society of Clinical Oncology and Friends of Cancer Research, the National Cancer Institute and the FDA expanded trial eligibility criteria to allow people with certain coexisting conditions, including HIV, impaired kidney or liver function and cancer that has spread to the brain. Cadman’s doctor urged her to stick with her chemotherapy

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regimen for the time being because it was still working. But a couple of months ago, facing low white blood cell and platelet counts, she and her doctor decided to stop the chemo. “They took all the cancer out of my colon, and it hasn’t come back. The nodules are just in my lungs, and my scans have been stable,” she says. “I may be overtreating. So now I’m not doing anything for three months and giving my bone marrow a break.” Still, when she hears about new drugs, Cadman checks her genetic test results to see whether she might be eligible for any of them. “I’m hoping that one day, just like with HIV, there will come a drug for me that, if it doesn’t cure me, will make the cancer chronic.”

COURTESY OF METUP

LOOKING TO THE FUTURE In some ways, cancer today looks like HIV in the mid1990s: on the brink of a breakthrough. The field is moving away from the traditional “slash, burn and poison” approach and toward precision therapies that target cancer with specific genetic mutations and immunotherapies that help the immune system fight cancer. These new treatments have already led to durable responses and longer survival for many patients. These treatments don’t yet work for everyone or for all types of cancer. But early research suggests that people living with HIV can benefit as much as HIV-negative people— and that they don’t experience worse side effects or setbacks like viral load rebound. Some research suggests that checkpoint inhibitors, a type of immunotherapy that unleashes cancer-fighting T cells, may help suppress HIV and even reduce the viral reservoir. Now that advocates have opened up more oncology trials to HIV-positive people, we have new opportunities to learn about optimal cancer treatment for this population. Palefsky urges people with HIV to join studies of cancer prevention and treatment for the sake of both their own health and the larger community. “Cancer is one of the next frontiers after antiretroviral therapy, and cancer control is one of the next big steps in keeping HIV-positive people healthy,” he says. Going beyond better treatment, people living with HIV and cancer have much to contribute in terms of lessons learned from advocating for themselves, fighting stigma and building support systems. “When I found out I was HIV positive, I told everyone, and I did the same for cancer. I’ve already had three people thank me because I scared them into getting checked, and they found something that needed to be removed,” says McKenna, who convinced GMHC to restart its Buddy Program with a focus on long-term survivors. “It does seem like there’s less support for people with cancer than for people with HIV,” he adds. “I want people who are long-term survivors—who are now facing other health issues—to have the same sort of support people had when they were dying from AIDS.” Q

CALLING ALL ADVOCATES THE CANCER WORLD HASN’T SEEN MUCH OF the in-your-face activism that helped turn the tide for people with HIV, but METUP—the Metastatic Breast Cancer Exchange to Unleash Power—is changing that. After countless fund-a-thons and pink-ribbon promotions, metastatic breast cancer remains invariably fatal, despite advances in prevention and curing early cancer. “In the last 30 years, the needle wasn’t moving,” says METUP president Susan Rahn, who was diagnosed with metastatic breast cancer at age 43. “The same number of people are dying. We need to start making more noise.” Founded by cancer patients Beth Caldwell and Jennie Grimes, METUP held its first action in April 2015—a die-in at the Living Beyond Breast Cancer conference in Philadelphia. An early member was part of the LGBT community and made connections with people from ACT UP. “It was like a funeral, as person after person lay down and Jennie read a eulogy about 108 people a day dying—similar to the number of AIDS deaths at the height of the epidemic,” Rahn recalls. “All of us on the ground were in tears because we all knew we would be in that position.” METUP wants researchers to focus more on people with advanced cancer and demands that the FDA work faster to approve new treatments. “In the emergency room, they’re not going to take someone with a broken bone before someone with a gunshot wound,” Rahn says. “Forget about a cure—if we can figure out how to make cancer chronic and have a decent quality of life, I’m good with that.” Advocates for people with cancer and people with HIV have often worked side by side—such as opposing Medicare changes that would limit access to treatments for both diseases—but they’re increasingly working hand in hand as well. Longtime AIDS activist and Treatment Action Group executive director Mark Harrington recently gave a talk on treatment activism at the National Breast Cancer Coalition’s annual summit. “It was wonderful to meet these fierce, determined, scientifically grounded and politically focused activists and survivors,” Harrington says. “In the current political environment, it is critical for disease-specific research advocates to work together to ensure the protection and expansion of federal funding streams for all research.” Rahn concurs: “The more voices we have together making noise, the better heard we’re going to be. There’s more power in numbers.”

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CREDIT

THE INCREASING MASTERY OVER THE VIRUS IS ONE OF HUMANITY’S CROWNING ACHIEVEMENTS. BY BENJAMIN RYAN

When POZ magazine was founded in 1994, the U.S. AIDS crisis was just reaching its peak. By the following year, half a million Americans had been diagnosed with the disease and nearly two thirds of them were already dead. And so, marrying the take-no-prisoners activism of ACT UP with the tenacious truth-seeking of a counterClockwise from top, cultural publication, POZ’s scrappy staff and coverage from POZ: feature story from cadre of writers armed themselves with the the July/Aug 2016 issue; article from power of the pen against a potentially indefithe Oct 1997 issue; drug chart from the nite holocaust. July/Aug 2014 issue poz.com JULY/AUGUST 2019 POZ 41

Drug Development Today, the bedrock of the fight against HIV is the healthy crop of 28 approved antiretrovirals (ARVs) that fall into five classes as well as the 13 single-tablet regimens (STRs) that require only once-daily dosing. For those with multidrug-resistant virus, the antibody therapy Trogarzo (ibalizumab) recently became available. Additionally, HIV regimens may include either of two “boosters,” Norvir (ritonavir) and Tybost (cobicistat), which increase the levels of ARVs in the body. During the contrastingly impoverished early 1990s, hopes that the paucity of ARVs available at the time would significantly extend the lives of people with AIDS were progressively dashed. It turned out that treating HIV with only one or two medications from the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) class—the first, Retrovir (zidovudine, or AZT), was approved in 1987—wasn’t enough to beat back the virus. In fact, such treatment often wound up spawning viral resistance to the medications, thus narrow-

42 POZ JULY/AUGUST 2019 poz.com

ing an individual’s future treatment options. Then, in December 1995, the Food and Drug Administration (FDA) approved Invirase (saquinavir), the first protease inhibitor. In June of the following year, Viramune (nevirapine) hit the market as the first non-nucleoside reverse transcriptase inhibitor (NNRTI). Finally, HIV clinicians could prescribe “cocktails” of three ARVs, which proved to be enough of a multipronged assault to render the virus undetectable in the body—as confirmed by the newly approved viral load test. Between 1996 and 1997, AIDS deaths plummeted 47% in the United States. The rub was that some of those ARVs were highly toxic and caused devastating side effects, such as lipodystrophy and diabetes. Additionally, treating HIV required taking numerous pills per day according to rigid schedules and onerous food-intake protocols. Such burdens compromised people’s adherence to their ARV regimens, which in turn fueled viral rebound and resistance. The 2000s brought increasing relief as newer drugs proved ever more tolerable and simpler to take and required less strict adherence to keep viral resistance at bay. Atripla (efavirenz/tenofovir disoproxil fumarate/emtricitabine)

PREVIOUS PAGES: (FOLDER) ISTOCK

Then came a miracle. In 1996, the first effective combination regimens to treat HIV became available, kick-starting the Lazarus era of the epidemic practically overnight. This reprieve was 15 years in the making—AIDS was first officially identified in 1981—and was the result of the dogged efforts of activists and scientists who were determined to outsmart one of the most destructive and wily viruses to affect the human race. For a quarter-century now, POZ has provided readers a front-row seat to an astonishing parade of scientific advancements—as well as humbling setbacks— in the worldwide effort to control the Top: coverage global HIV pandemic. It’s no hyperbole from the to claim that the ever-refined collective April 2003 issue; mastery that scientists have gained over bottom: the virus during this period represents from the one of the all-time greatest achieveOct 1998 issue ments of human ingenuity. But the great work is only beginning. Quality of life for people living with HIV has certainly improved, but the challenges the thousands of HIV researchers toiling around the globe still face are mammoth and sprawling. Vanquishing this particular virus is not merely a matter of developing effective treatments, preventives, vaccines and cure therapies. Epidemic-ending success will require solving the byzantine sociocultural and geopolitical puzzles of how a microscopic sphere encasing a collection of RNA could exploit the myriad weaknesses and faults of societies in order to infect some 77 million people to date, killing nearly half of them. If the past 25 years of scientific advancements in this field are any guide, the future looks bright.

The Treatment-Initiation Conundrum

Top: was approved in 2006 as the first pre-exposure STR. The following year, the FDA prophylaxis green-lit Isentress (raltegravir), the coverage from the Oct/Nov first of the highly potent and well2014 issue; tolerated integrase inhibitors. bottom: Thanks to these pharmaceutical Undetectable Equals advancements and improvements Untransmittable in the overall care of people with coverage from the March HIV, life expectancy for those on 2019 issue ARV treatment today is approaching normal. Nevertheless, researchers continue to refine and improve the HIV treatment tool kit. The past two years have seen the first STRs that include only two ARVs: Juluca (dolutegravir/rilpivirine) and Dovato (dolutegravir/lamivudine). A long-acting injectable regimen, dosed monthly, will likely gain approval in late 2019. And further down the road, long-acting antibody treatments might require dosing as seldom as two to four times per year.

At the dawn of the triple-combination ARV era, “hit early, hit hard” was the defining treatment ethos—influenced, in part, by a faulty belief that long-term fully suppressive therapy would eventually cure HIV. In 1998, the Department of Health and Human Services (HHS) recommended starting ARVs once an individual’s CD4 count had dropped to 500 or below. Three years later, in an effort to spare people with HIV the devastating side effects of those early ARVs as much as possible and also to mitigate the emergence of drug resistance, HHS did an about-face. The agency now advised ARV treatment only after CD4s had dropped to an AIDS-defining 200 or lower. During these trying times, various studies found that people could take periodic breaks, known as drug holidays, from their ARV regimens without lasting immune-system damage. The randomized controlled SMART study, launched in 2002, aimed to confirm such findings using gold-standard research. But in 2006, the landmark trial was terminated years ahead of schedule because it had become evident that drug holidays were actually associated with a higher risk of HIV disease progression and death. SMART’s stunning findings rocked the HIV research world, in particular because of the discovery that interrupting treatment fueled harmful inflammation—which is itself associated with various health risks. The study ultimately set the stage for the randomized controlled START trial, which began in 2011 and sought to determine whether there was a net health benefit to beginning ARVs with CD4s above 500 versus waiting until the count declined to 350 or below. In an episode of randomized-controlled-trial déjà vu, the START administrators canceled that study’s deferredtreatment arm in 2015, more than a year ahead of schedule. Going on HIV treatment early, it had already become clear, reduced the risk of AIDS-defining illnesses and other serious maladies. (The trial continues to monitor participants to assess any differences in long-term health outcomes between those who started treatment immediately and those who did so on a delayed basis.) Upon the START trial’s release, HHS, which had raised the CD4 threshold for an ARV initiation recommendation to 350 CD4s in 2008 and then to 500 CD4s in 2010, promptly advised universal treatment. After two decades, the HIV treatment protocol had come full circle.

Prevention Most of the HIV prevention modalities developed since the early years of the epidemic, when condoms were the only

poz.com JULY/AUGUST 2019 POZ 43

What is SYMTUZA® Used For? SYMTUZA® is a prescription medicine that is used without other antiretroviral medicines to treat Human Immunodeficiency Virus-1 (HIV-1) infection in adults who: • have not received anti-HIV-1 medicines in the past, or • when their healthcare provider determines that they meet certain requirements. HIV-1 is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). It is not known if SYMTUZA® is safe and effective in children under 18 years of age. Take SYMTUZA® exactly as your healthcare provider tells you. Do not change your dose or stop taking SYMTUZA® without talking to your healthcare provider. If you have difficulty swallowing, the tablet may be split using a tablet-cutter. After splitting the tablet, the entire dose (both halves) should then be taken right away. Do not miss a dose of SYMTUZA®. When your SYMTUZA® supply starts to run low, get more from your healthcare provider or pharmacy. This is very important because the amount of virus in your blood may increase if the medicine is stopped for even a short time. The virus may develop resistance to SYMTUZA® and become harder to treat. What are the most serious risks with SYMTUZA®? SYMTUZA® can cause serious side effects including: Worsening of hepatitis B virus (HBV) infection. Your healthcare provider will test you for HBV before starting treatment with SYMTUZA®. If you have HBV infection and take SYMTUZA®, your HBV may get worse (flare-up) if you stop taking SYMTUZA®. If you stop taking SYMTUZA®, your healthcare provider will need to check your health often and do blood tests regularly for several months to check your HBV infection or give you a medicine to treat your HBV infection. Tell your healthcare provider about any new or unusual symptoms you may have after you stop taking SYMTUZA®. What are the important warnings? • SYMTUZA® may cause severe liver problems that 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, vomiting, or stomach area pain • SYMTUZA® may cause severe or life-threatening skin reactions or rashes. Stop taking SYMTUZA® and call your healthcare provider right away if you develop any skin changes with the following symptoms: fever, tiredness, muscle or joint pain, blisters or skin lesions, mouth sores or ulcers, and/or red or inflamed eyes, like “pink eye” (conjunctivitis) • SYMTUZA® can cause new or worse kidney problems, including kidney failure What should I tell my healthcare provider? Before taking SYMTUZA®, tell your healthcare provider about all of your medical conditions, including if you: • have liver problems (including hepatitis B or hepatitis C) • have kidney problems

• are allergic to sulfa (sulfonamide) • have diabetes • have hemophilia

• Are pregnant or plan to become pregnant. SYMTUZA® should not be used in pregnant women. It is not known if SYMTUZA® will harm your unborn baby

• Are breastfeeding or plan to breastfeed. You should not breastfeed if you have HIV-1 because of the risk of passing HIV to your baby. Do not breastfeed if you take SYMTUZA®

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some medicines interact with SYMTUZA®. Keep a list of your medicines to show your healthcare provider and pharmacist. Do not start taking a new medicine without telling your healthcare provider. Who should not take SYMTUZA®? • Do not take SYMTUZA® with any of the following medicines: alfuzosin, carbamazepine, cisapride, colchicine (if you have liver or kidney problems), dronedarone, elbasvir and grazoprevir, ergot-containing medicines (such as: dihydroergotamine, ergotamine tartrate, methylergonovine), lomitapide, lovastatin or a product that contains lovastatin, lurasidone, oral midazolam (when taken by mouth), phenobarbital, phenytoin, pimozide, ranolazine, rifampin, sildenafil when used for pulmonary arterial hypertension (PAH), simvastatin or a product that contains simvastatin, St. John’s wort (Hypericum perforatum) or a product that contains St. John’s wort, or triazolam • Serious problems can happen if you take any of these medicines with SYMTUZA® What are the possible side effects of SYMTUZA®? SYMTUZA® may cause serious side effects including: • Immune system changes (Immune Reconstitution Syndrome) can happen in people taking HIV-1 medicines • 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 • Diabetes and high blood sugar • Changes in body fat can happen in people taking HIV-1 medications • Increased bleeding in people with hemophilia, which can happen when taking protease inhibitors. The most common side effects are: • diarrhea • gas • stomach problems • nausea • rash • headache • fatigue These are not all of the possible side effects of SYMTUZA®. Tell your healthcare provider if you have any side effect that bothers you or that does not go away. What important facts should I know? This information is not complete. To get more information: • Talk to your healthcare provider or pharmacist • Visit www.SYMTUZA.com to read over the FDA-approved product labeling and patient information cp-60855v4

Please read above Important Brief Summary, including important warnings for SYMTUZA®, and discuss any questions you have with your doctor. You may report side effects to the FDA at 1-800-FDA-1088 or to Janssen Products, LP at 1-800-JANSSEN (1-800-526-7736).

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STAY YOU

BE RESILIENT

Your resilience matters. So does your HIV treatment. It’s important to take your HIV medication every day, because missing even a few doses may lead to drug resistance and may cause it to stop working. SYMTUZA® is a treatment with a high barrier to drug resistance to help you keep ﬁghting HIV with just one pill a day. Ask your doctor about

DON’T RISK RESISTANCE. TAKE THE KNOW YOUR RISK QUIZ—visit SYMTUZA.com/Quiz

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option, are based upon what’s known as the biomedical prevention of HIV—the use of medications to thwart transmission. A major study released in 1994 found that giving AZT to pregnant women with HIV prevented mother-to-child transmission of the virus. Not long after that drug’s 1987 release, health care workers began taking a course of ARVs following a potential exposure to HIV on the job. By 2005, enough research supported the use of post-exposure prophylaxis (PEP)—in which an individual starts a month of a triple-ARV regimen within 48 to 72 hours of a potential exposure to HIV—for the Centers for Disease Control and Prevention (CDC) to finally expand its PEP guidelines to include sexual as well as occupational exposure. Research fi ndings from the mid-1990s indicated that providing clean needles and syringes to people who inject Top: coverage of drugs through syringe services the “Berlin programs reduced their risk of HIV. Patient” from the June Beginning in 2011, a trio of major 2011 issue; studies, HPTN 052, PARTNER and bottom: Opposites Attract, released a progresupdate on cure research sive avalanche of data supporting from the the hypothesis that successful HIV Jan/Feb treatment prevents transmission. 2019 issue By the time PARTNER announced fi ndings from its second phase in 2018, a global scientific consensus had solidified: People with HIV who maintain an undetectable viral load cannot transmit the virus through sex. Meanwhile, in 2010, the randomized controlled iPrEx study found that HIV-negative people who took Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP) greatly reduced their HIV acquisition rate. Researchers would subsequently estimate that daily use of the tablet cuts the risk of HIV by more than 99% among men who have sex with men (MSM) and by at least 90% among women. More recently, the French IPERGAY study confi rmed that taking Truvada doses only during the 72-hour period surrounding the time of sex is also highly effective as PrEP for MSM. By the end of 2019, the FDA will likely approve a new PrEP option: Descovy (tenofovir alafenamide/emtricitabine), which has the same components as Truvada but with an updated version of the drug tenofovir that is linked to improved markers of bone and kidney health. (It is not known whether using Descovy over Truvada would actually prevent fractures or kidney disease.) A long-acting injectable form of PrEP given every eight weeks may also hit the market by about 2023. Researchers are further investigating long-acting antibody shots as PrEP and, much further back in the pipeline, implants that slowly release preventive medication over a period of months. The quest for an HIV vaccine has proved particularly

46 POZ JULY/AUGUST 2019 poz.com

frustrating, beset as it has been with repeated failures of major research efforts since the fi rst Phase III trial launched in 1998. Only a single late-stage vaccine study—conducted in Thailand and published in 2009—showed any efficacy: a 31% reduction in HIV risk. Investigators have since sought to build on that result and develop a more potent product. Today, two late-stage trials of vaccines are under way, and experts are hopeful the candidates will prove at least 50% effective—powerful enough to justify a global rollout by the mid-2020s. A trio of randomized controlled trials conducted in subSaharan Africa and published in the mid-aughts found that voluntary medical male circumcision lowered the risk of female-to-male HIV transmission by about 60%. This finding has led to a concerted push to circumcise millions of males throughout the continent, which has been tied to declining HIV rates among both women and men. After decades of efforts to develop microbicides to prevent HIV—ARV-infused gels, inserts, rectal douches and the like—researchers have suffered numerous stumbles and setbacks and have succeeded with only one product thus far: a monthly vaginal ring. Currently awaiting regulatory approval,

Top: from the April 2002 issue; bottom: from the June 2002 issue

individual’s own cells in an attempt to foster an HIV-resistant immune system like Brown’s—but without the need for potentially fatal cancer treatment such as he received. A third tactic is called “block and lock,” the goal of which is to keep latently infected cells in an indefinite resting state so they never wake up and churn out new virus.

Other Health Conditions

the ring provides at least a modest level of protection against the virus. Meanwhile, U.S. funding priorities are shifting away from microbicide research, a change that calls into question the future of other such preventive products in the pipeline.

Cure In 2008, the news that a man dubbed “the Berlin Patient” and later identified as Timothy Ray Brown had been cured of the virus jolted the once-sleepy HIV cure research field into action. As treatment for his leukemia, Brown had received stem cell transplants from a donor born with a genetic abnormality that rendered his immune cells resistant to HIV. Members of the burgeoning HIV cure research field, backed by swelling fi nancial support, are tasked with the challenge of outsmarting a virus that hides in long-lived resting immune cells. Collectively known as the viral reservoir, these latently infected immune cells remain under the radar of standard ARV treatment, which works only on actively replicating cells. The long road toward achieving some form of widely replicable cure, viral remission or post–ARV treatment control of HIV is currently following several paths. One strategy, called “kick and kill,” seeks to roust latent cells from their slumber and then finesse the immune system into attacking such cells. Another approach involves genetically modifying an

Even when people with HIV maintain an undetectable viral load on ARVs, they have a higher risk of developing a host of conditions, many of which are related to aging but tend to strike those with the virus at ages younger than those seen among the general population. These health problems, the incidence of which is driven in part by the overall aging of the HIV population, include cardiovascular disease, various cancers, diabetes, high cholesterol and blood pressure, kidney and liver disease, chronic pain, cognitive decline, bone loss and gastrointestinal problems. Scientists believe that the chronic inflammatory state associated with even well-treated HIV contributes to many of these outcomes. A major ongoing randomized controlled trial called REPRIEVE, set to complete in 2023, is seeking to determine whether prescribing a cholesterol-lowering statin to people with HIV will temper such inflammation and in so doing reduce the risk of cardiovascular disease and various other health conditions as well as the risk of death. The HIV population has high rates of other risk factors that fuel major diseases, in particular smoking, as well as coinfection with hepatitis B and C viruses (HBV and HCV). Fortunately, newer hepatitis C treatments have made HCV infection readily curable, and HBV is not only treatable but also vaccine preventable. Additionally, ARVs themselves, especially the oldest ones, have been tied to myriad health problems. Mental illness and substance abuse disorders may also compromise the health and well-being of HIV-positive individuals. Compounding all these negative impacts, many people with the virus are low-income and struggle with their basic needs, such as accessing proper food and nutrition, housing, transportation, child care and health care. In response to such complex concerns, research into improving the care and treatment of HIV increasingly takes a cross-disciplinary, holistic approach that seeks to address the totality of each individual’s unique needs. The ultimate goal is to provide the most robust and comprehensive support for those living with the virus in the hope that they don’t just live a long and healthy life but truly thrive throughout the years. Q

An excerpt from POZ at 25: Empowering the HIV Community Since 1994 by Smart + Strong. Copyright © 2019 by CDM Publishing, LLC. All rights reserved. Go to POZ.com for more. poz.com JULY/AUGUST 2019 POZ 47

HEROES BY ALICIA GREEN

Employment Needs

48 POZ JULY/AUGUST 2019 poz.com

Mark Misrok addresses employment and HIV.

BILL WADMAN

When he tested positive in 1989, Mark Misrok didn’t expect to live a full life or have a career. “I spent many years just taking jobs that helped me survive and that I coped with,” explains Misrok, an HIV advocate who now lives in New York City. One of those jobs was driving a cab in San Francisco. After several years, though, Misrok wanted to transition to another occupation but felt trapped by a lack of skills and valuable experience. So in 1992, he visited San Francisco’s Positive Resource Center (PRC), which had an employment services program for people living with HIV. Misrok started out at PRC as a client but soon became a volunteer. Three years later, he was hired as director of that employment program, a position he held until 2007. With the introduction of protease inhibitors in the late 1990s, people with HIV began to feel healthy enough to return to work. As a result, the program expanded to address a broader range of employment needs. “Across all those years, it was a very powerful experience for me to work one-on-one with almost 2,000 people seeking a range of employment assistance,” Misrok says. In 2003, Misrok connected with a group of advocates focused on strengthening responses to the employment needs of people with HIV across the United States. Together, they formed the National Working Positive Coalition (NWPC). He served as president of NWPC’s board of directors for 14 years before becoming executive director last year. “I have helped lead their advocacy, research and capacity-building activities across most of the history of the organization,” he says. The coalition’s current projects include working with two HIV groups on a three-year grant that focuses on the employment needs and strategies of people with HIV over 50 and collaborating with the Southern University at Baton Rouge in Louisiana to improve responses to the employment needs of African Americans with HIV in the area. On September 18, the coalition is partnering with the New York City Department of Health and Mental Hygiene and community members to present Career Power Source 2019. (To register, go to bit.ly/cpsny.) The event is the “largest-ever daylong employment conference for people living with or at greater risk for HIV,” according to Misrok. It will feature workshops, résumé development, headshot photography, career coaching and more. Misrok’s goal is to help people with HIV make well-informed and self-determined decisions about employment and understand the range of opportunities they can pursue. “Too many of us have been or felt trapped in poverty because of living with HIV,” Misrok explains. “Access to the information, services and resources that can broaden our options must be made available to us.”

3 WORDS EVERYONE SHOULD KNOW. PrEP

PEP

Undetectable

Pre-Exposure Prophylaxis: “Pre” means “before” and “Prophylaxis” means “prevention.” PrEP means taking prescription medicines every day before you are exposed to HIV to help reduce the risk of getting HIV. PrEP is for people who are HIV negative and are at risk of getting HIV through sex.

Post-Exposure Prophylaxis: “Post” means “after.” PEP means taking prescription medicines daily, immediately after being exposed to HIV, for 28 days to help reduce the risk of infection. You need to start taking it within 72 hours after exposure. So go to a doctor or healthcare center right away.

If you have HIV, the goal is to get your viral load to undetectable. This means there’s so little virus in the blood that a test can’t measure it. There’s no cure, but getting to and staying undetectable can help reduce the risk of passing HIV through sex. How do you get to undetectable? By starting HIV treatment and taking it every day exactly as prescribed.

HIV INFORMATION MATTERS, TOO. Check out HelpStopTheVirus.com for more prevention information. And watch videos about HIV medicines, testing, and the importance of sticking to daily treatment.

5 Reasons to Stick to HIV Treatment

Testing Season

Fight Back With HIV Treatment

HelpStopTheVirus.com

Ask a healthcare provider about all the ways you can help prevent HIV. GILEAD and the GILEAD Logo are trademarks of Gilead Sciences, Inc. All other marks are the property of their respective owners. © 2019 Gilead Sciences, Inc. All rights reserved. UNBC6347 06/19

H E A L T H ,

L I F E

H I V

Antiretroviral (ARV) options abound for both those who are new to HIV treatment and those who are experienced. This quick-reference chart compares medication options, including adult dosing and dietary restrictions.

*Generic version available in the U.S.

â&#x20AC;

To be phased out by 2020

CIMDUO

ATRIPLA

(tenofovir disoproxil fumarate + lamivudine)

(efavirenz + tenofovir disoproxil fumarate + emtricitabine)

APTIVUS

EDURANT

Two 250 mg capsules plus two 100 mg Norvir tablets twice a day. Aptivus plus Norvir should be taken with food.

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

(rilpivirine)

(tipranavir)

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

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.

COMBIVIR *

INTELENCE

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

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

(etravirine)

CRIXIVAN

(bictegravir + tenofovir alafenamide + 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

Single-Tablet Regimens

(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.

DESCOVY

(tenofovir alafenamide + emtricitabine)

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

EMTRIVA

(emtricitabine; FTC)

One 200 mg capsule once a day. 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.

EVOTAZ

(atazanavir + cobicistat)

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

EPIVIR *

(lamivudine; 3TC)

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 (HBV) but at a lower dose. People living with both viruses should use the HIV dose.

INVIRASE

(saquinavir)

Two 500 mg tablets plus one 100 mg Norvir tablet twice a day. Take with food or within two hours after a meal.

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.

GENVOYA

(elvitegravir + cobicistat + tenofovir alafenamide + emtricitabine)

Two 400 mg capsules every eight hours, or two 400 mg capsules with either one or two 100 mg Norvir tablets twice a day. Drink at least 48 ounces of water daily to prevent kidney stones. Without Norvir: Take on an empty stomach (no food two hours before or one hour after dosing) or with a low-fat snack. With Norvir: Take with or without food.

RETROVIR *

(zidovudine; AZT)

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

Protease Inhibitors

(rilpivirine + tenofovir disoproxil fumarate + emtricitabine)

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

COMPLERA

(indinavir)

PIFELTRO

(doravirine)

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

RESCRIPTOR â&#x20AC; (delavirdine)

Two 200 mg tablets three times a day, or four 100 mg tablets three times a day. Take with or without food. Discontinued by manufacturer; phaseout to be completed by 2020.

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.

VIRAMUNE * (nevirapine)

One 200 mg Viramune immediate release (IR) tablet once a day for the first 14 days, then one 400 mg Viramune extended release (XR) tablet once a day. Take with or without 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.

ibitors

BIKTARVY

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

(zidovudine + lamivudine)

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

(Pills not shown actual size)

(elvitegravir + cobicistat + tenofovir alafenamide + emtricitabine)

VIRAMUNE * (nevirapine) (lopinavir + ritonavir)

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

RETROVIR *

(zidovudine; AZT)

One 300 mg tablet twice a day. 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.

JULUCA

TRIZIVIR *

LEXIVA

One tablet twice a day. Each tablet contains 300 mg abacavir + 300 mg zidovudine + 150 mg lamivudine. Take with or without food. Should be used only by individuals who are HLA-B*5701 negative.

Two 700 mg tablets twice a day, or two 700 mg tablets plus one or two Norvir tablets once a day, or one 700 mg tablet plus one Norvir tablet twice a day (recommended for individuals who have used other PIs in the past). Take with or without food.

(fosamprenavir)

(abacavir + zidovudine + lamivudine)

(dolutegravir + rilpivirine)

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

One 200 mg Viramune immediate release (IR) tablet once a day for the first 14 days, then one 400 mg Viramune extended release (XR) tablet once a day. Take with or without food.

KALETRA

Entry Inhibitors

GENVOYA

Protease Inhi

with or without food. Should be used only by individuals who are HLA-B*5701 negative.

FUZEON

(enfuvirtide)

One 90 mg (1 ml solution) subcutaneous injection twice a day. Take with or without food. Fuzeon comes as a white powder that must be mixed with sterile water in a vial each day.

ODEFSEY

(rilpivirine + tenofovir alafenamide + emtricitabine)

PREZCOBIX

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

(efavirenz + tenofovir disoproxil fumarate + lamivudine)

One tablet of either Symfi or Symfi Lo (above) once a day. Each tablet of Symfi contains 600 mg efavirenz + 300 mg tenofovir disoproxil fumarate + 300 mg lamivudine. Each tablet of Symfi Lo 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.

Single-Tablet Regimens

SYMTUZA

(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.

(didanosine, ddl)

One 400 mg capsule once a day. (One 250 mg capsule once a day for those weighing less than 133 lbs.) Take on an empty stomach (two hours after or one hour before a meal). Brand-name product discontinued; phaseout to be completed by 2020.

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.

One 800 mg tablet (or two 400 mg tablets) plus one 100 mg Norvir tablet, or one 150 mg Tybost 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.

Entry Inhibitors

(darunavir)

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

TROGARZO (ibalizumab)

REYATAZ *

Administered intravenously as a single loading (or initial) dose of 2,000 mg followed by a maintenance dose of 800 mg every two weeks.

(atazanavir)

Two 200 mg capsules once a day, or one 300 mg capsule plus one 100 mg Norvir tablet, or one 150 mg Tybost tablet once a day. Take with food.

VIREAD *

VIRACEPT

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

Two 625 mg tablets twice a day, or five 250 mg tablets twice a day, or three 250 mg tablets three times a day. Take with food.

(tenofovir disoproxil fumarate)

(nelfinavir)

ISENTRESS (raltegravir)

ZERIT * â&#x20AC;

(stavudine; d4T)

One 40 mg capsule twice a day. (One 30 mg capsule twice a day for those weighing less than 133 lbs.) Take with or without food. Brand-name product discontinued; phaseout to be completed by 2020.

TRIUMEQ

(dolutegravir + abacavir + lamivudine)

PREZISTA

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.

ZIAGEN *

TYBOST

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

(abacavir)

(cobicistat)

Integrase Inhibitors

SYMFI AND SYMFI LO

VIDEX EC * â&#x20AC;

SELZENTRY (maraviroc)

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

Protease Inhibitors

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.

(tenofovir disoproxil fumarate + emtricitabine)

PK Boosters

(elvitegravir + cobicistat + tenofovir disoproxil fumarate + emtricitabine)

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

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

STRIBILD

(darunavir + cobicistat)

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. 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.

3 WORDS EVERYONE SHOUL

IT STARTS WITH

KNOWING YOUR STATUS. The only way to know your status is to get tested for HIV.

IF YOUR RESULT IS POSITIVE . . .

IF YOUR RESULT IS NEGATIVE . . .

It’s okay to feel overwhelmed or confused. But HIV treatments can help people live longer, healthier lives. Talk to a healthcare provider as soon as possible after diagnosis. There’s no cure for HIV, but by starting, sticking to, and staying on daily treatment, HIV can be a manageable disease for many people.

There are things you can do to stay that way. Use condoms, get retested regularly, and talk to a healthcare provider about HIV prevention medicines for PEP (Post-exposure Prophylaxis) and PrEP (Pre-Exposure Prophylaxis).

PrEP

PEP

Post-Exposure Pr “Post” means “af means taking pre medicines daily, immediately afte exposed to HIV, days to help redu risk of infection. to start taking it 72 hours after ex So go to a docto healthcare cente away.

HIV TREATMENT HELPS PROTECT EVERYONE.

HIV INFORMATION MATTERS,

Starting and sticking to HIV treatment can lower the amount of virus in the body to undetectable. According to current research, starting and sticking to treatment every day can help you get to and stay undetectable, which means there’s effectively no risk of spreading HIV through sex. It’s called Treatment as Prevention, or TasP. So, HIV treatment can help protect everyone, positive and negative.

Check out HelpStopTheVirus.com for more pr about HIV medicines, testing, and the importa

5 Reasons to Stick to HIV Treatment

Testing Se

HelpStopThe

Ask a healthcare prov ways you can help

LD KNOW.

rophylaxis: fter.” PEP escription

er being for 28 uce the You need within xposure. or or er right

Undetectable If you have HIV, the goal is to get your viral load to undetectable. This means there’s so little virus in the blood that a test can’t measure it. There’s no cure, but getting to and staying undetectable can help reduce the risk of passing HIV through sex. How do you get to undetectable? By starting HIV treatment and taking it every day exactly as prescribed.

I AM LIVING WITH HIV.

I AM HIV NEGATIVE.

YES!

, TOO.

revention information. And watch videos ance of sticking to daily treatment.

eason

SHOULD HIV PREVENTION MATTER TO ME?

PREVENTION MATTERS TO EVERYONE. See how we can all help stop the virus in our bodies and communities.

Fight Back With HIV Treatment

eVirus.com

vider about all the p prevent HIV.