1 00:00:00,000 --> 00:00:13,080 Thanks for meeting us at the Canadian Breakpoint, a Canadian infectious disease podcast by infectious 2 00:00:13,080 --> 00:00:14,680 disease physicians. 3 00:00:14,680 --> 00:00:19,600 I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases specialist 4 00:00:19,600 --> 00:00:21,200 from Saskatoon. 5 00:00:21,200 --> 00:00:26,180 For this episode, we welcome Carly Pozniak, pharmacist with the Saskatoon Positive Living 6 00:00:26,180 --> 00:00:33,800 Program to review game changing novel HIV antiretroviral cabanouva. 7 00:00:33,800 --> 00:00:34,800 Welcome Dr. Purewal. 8 00:00:34,800 --> 00:00:38,840 All right, so welcome to another episode of our podcast the Canadian Breakpoint. 9 00:00:38,840 --> 00:00:43,920 Today we have a very special guest Carly Pozniak, is a pharmacist that's worked with Positive 10 00:00:43,920 --> 00:00:48,760 Living Program since 2017 here in Saskatoon, Saskatchewan. 11 00:00:48,760 --> 00:00:53,720 She is a part of an interdisciplinary team that provides care to people living with HIV 12 00:00:53,720 --> 00:00:55,040 and hepatitis C. 13 00:00:55,040 --> 00:00:59,120 Aside from providing care to her wonderful patients, she enjoys sharing her knowledge 14 00:00:59,120 --> 00:01:04,440 in this area by precepting pharmacy students and residents each year. 15 00:01:04,440 --> 00:01:09,360 She's also an active member of the Canadian HIV and viral hepatitis pharmacist network 16 00:01:09,360 --> 00:01:14,680 CHAP, which is a group of pharmacists that collaborate together on various projects and 17 00:01:14,680 --> 00:01:16,040 publications. 18 00:01:16,040 --> 00:01:20,320 She's currently serving on the executive team as the CHAP secretary. 19 00:01:20,320 --> 00:01:25,960 So today she's joining us to talk a little bit about a new novel way that patients can 20 00:01:25,960 --> 00:01:32,500 receive their antiretroviral therapy for HIV in the form of injectables. 21 00:01:32,500 --> 00:01:34,560 So I want to welcome Carly today. 22 00:01:34,560 --> 00:01:39,040 And I actually know Carly very well because we work together here in Saskatoon. 23 00:01:39,040 --> 00:01:45,000 So she's done a lot of work with pediatrics as well as adult HIV. 24 00:01:45,000 --> 00:01:46,000 So thanks Carly. 25 00:01:46,000 --> 00:01:48,600 Thank you for having me. 26 00:01:48,600 --> 00:01:49,600 Perfect. 27 00:01:49,600 --> 00:01:56,120 So I want to start off with, I think a lot of us clinicians aren't really aware of Cabinuva. 28 00:01:56,120 --> 00:02:01,840 So that's what we're talking about is our HIV injectable drug that was recently put 29 00:02:01,840 --> 00:02:02,840 on the market. 30 00:02:02,840 --> 00:02:09,160 So I think for kind of a broader range of knowledge, because most of clinicians, including 31 00:02:09,160 --> 00:02:14,800 myself, who is an infectious disease specialist, but don't haven't, I haven't dealt with Cabinuva 32 00:02:14,800 --> 00:02:15,800 much. 33 00:02:15,800 --> 00:02:19,760 So I think why don't we start off with just giving us a little bit of a background as 34 00:02:19,760 --> 00:02:26,240 in what is Cabinuva and when it was, when was it put on the market and some of the indications 35 00:02:26,240 --> 00:02:30,000 and contraindications that we should be aware of. 36 00:02:30,000 --> 00:02:31,280 For sure. 37 00:02:31,280 --> 00:02:39,040 So as you said before, it is a brand new delivery form that we can use for patients in antiretroviral 38 00:02:39,040 --> 00:02:40,040 therapy. 39 00:02:40,040 --> 00:02:45,520 It's given by intramuscular injection into the bed of regions. 40 00:02:45,520 --> 00:02:48,080 So there's one injection per bottle. 41 00:02:48,080 --> 00:02:50,200 So there's basically two shots. 42 00:02:50,200 --> 00:02:53,400 It contains two drugs in it. 43 00:02:53,400 --> 00:02:56,960 Traditionally, we've used three antiretrovirals in a regimen. 44 00:02:56,960 --> 00:02:59,160 This one has two. 45 00:02:59,160 --> 00:03:01,160 And one of the meds is called Cabotegra. 46 00:03:01,160 --> 00:03:02,960 It's an integrase inhibitor. 47 00:03:02,960 --> 00:03:04,760 It's the newest in that class. 48 00:03:04,760 --> 00:03:08,960 And then the other medication we've had around for a while, it's called Rilpivirin. 49 00:03:08,960 --> 00:03:13,680 And it's one of the non-nucleoside reverse trans-intra-base inhibitors. 50 00:03:13,680 --> 00:03:20,080 So with this injection, because it's given in the bed of region, it does have to be administered 51 00:03:20,080 --> 00:03:22,600 by a health care professional. 52 00:03:22,600 --> 00:03:27,640 So that can kind of limit, you know, patients can't just take this home at the moment and 53 00:03:27,640 --> 00:03:28,640 administer themselves. 54 00:03:28,640 --> 00:03:37,240 So it does, I guess, require a certain amount of coordination with a site that is able to 55 00:03:37,240 --> 00:03:40,320 provide it and administer it. 56 00:03:40,320 --> 00:03:44,200 It was, it first came out that it could be given every month. 57 00:03:44,200 --> 00:03:48,920 And then later on, they approved every two month administration as well. 58 00:03:48,920 --> 00:03:55,160 So I think this is a huge advance for antiretroviral therapy because we're starting to get into 59 00:03:55,160 --> 00:04:00,240 kind of more long acting formulations of just more options for patients to choose from. 60 00:04:00,240 --> 00:04:03,600 It's maybe like the daily grind of taking pills. 61 00:04:03,600 --> 00:04:07,840 You know, someone might want to look at this route. 62 00:04:07,840 --> 00:04:13,840 So yeah, so I think you touched on a really important topic there is, you know, I think 63 00:04:13,840 --> 00:04:18,200 the ease of taking injectables versus taking daily medications. 64 00:04:18,200 --> 00:04:23,800 And so I think that's probably what made me more excited about it because I know, and 65 00:04:23,800 --> 00:04:28,000 we'll probably talk a little bit about eligibility and I'm not sure how it is in the pediatric 66 00:04:28,000 --> 00:04:36,160 world yet, but you can probably give us some kind of information in regards to that, I'm 67 00:04:36,160 --> 00:04:37,520 sure today. 68 00:04:37,520 --> 00:04:43,760 But I think really looking at, you know, quality of care for patients, I think, you know, managing 69 00:04:43,760 --> 00:04:50,280 HIV patients myself, I find that compliance is sometimes an issue, especially in our teenager 70 00:04:50,280 --> 00:04:51,360 groups, right? 71 00:04:51,360 --> 00:04:53,880 And then, I mean, life gets hard, right? 72 00:04:53,880 --> 00:04:57,640 So with COVID, I mean, a lot of people can't even get access to care. 73 00:04:57,640 --> 00:05:06,400 And I know here in Saskatchewan, HIV has really skyrocketed in terms of our numbers in turn, 74 00:05:06,400 --> 00:05:10,720 like during the pandemic and whether that was, it's probably multifactorial, but I think 75 00:05:10,720 --> 00:05:18,120 it's something that drugs like this may help us curb that in the near future. 76 00:05:18,120 --> 00:05:23,400 So what are in terms of kind of, you mentioned the true drugs, why don't we talk a little 77 00:05:23,400 --> 00:05:25,760 bit about the indication for it? 78 00:05:25,760 --> 00:05:29,760 So what is like the ideal patient for this? 79 00:05:29,760 --> 00:05:35,160 And you can talk a little bit about eligibility, if that would, for us to clinicians to know 80 00:05:35,160 --> 00:05:37,120 kind of when to contact who. 81 00:05:37,120 --> 00:05:40,240 Great, who are we targeting here? 82 00:05:40,240 --> 00:05:47,360 Yeah, so presently, it's indicated for treating HIV one infection, and just in adults, though, 83 00:05:47,360 --> 00:05:50,880 ages 18 to 65. 84 00:05:50,880 --> 00:05:53,800 And I can talk a little bit more in a minute as well. 85 00:05:53,800 --> 00:05:57,400 They do have a trial ongoing in 12 to 18 year old patients. 86 00:05:57,400 --> 00:06:02,360 So I know as a pediatric infectious disease physician, probably very interested in that 87 00:06:02,360 --> 00:06:03,360 cohort. 88 00:06:03,360 --> 00:06:06,280 We can talk about that. 89 00:06:06,280 --> 00:06:09,520 Basically right now, it's sort of considered like a switch therapy. 90 00:06:09,520 --> 00:06:15,560 So the patients do have to be suppressed on antiretroviral therapy prior to initiating 91 00:06:15,560 --> 00:06:16,560 the injection. 92 00:06:16,560 --> 00:06:21,600 So we're looking for the patient to have less than 50 copies. 93 00:06:21,600 --> 00:06:28,760 In the trials that looked at this form of antiretroviral therapy, most patients were 94 00:06:28,760 --> 00:06:36,560 actually suppressed for six months or longer before they actually initiated the injectable. 95 00:06:36,560 --> 00:06:41,160 Not to say that you have to do that, I guess, in practice, but it does kind of promote a 96 00:06:41,160 --> 00:06:46,800 sense of that the patient is stable, getting their medications regularly, and can kind 97 00:06:46,800 --> 00:06:50,560 of commit to something like this as well. 98 00:06:50,560 --> 00:06:56,680 So in the beginning right now in Canada, in Europe, they've kind of taken the oral lead 99 00:06:56,680 --> 00:07:00,440 in phase out, they've taken that off the product monographs. 100 00:07:00,440 --> 00:07:03,680 You don't have to, there is evidence to skip that. 101 00:07:03,680 --> 00:07:08,680 But right now in Canada, there is an oral lead in phase with the oral form of Cabotrigavir 102 00:07:08,680 --> 00:07:13,040 and Rilpivirine that's given for four weeks. 103 00:07:13,040 --> 00:07:18,960 And the only purpose of doing that was to assess if there was any hypersensitivity reactions. 104 00:07:18,960 --> 00:07:23,480 And the EECS conference in the fall, they actually presented some information about 105 00:07:23,480 --> 00:07:24,480 that. 106 00:07:24,480 --> 00:07:30,120 And it has been found that there hasn't been any increase in hypersensitivity reactions. 107 00:07:30,120 --> 00:07:35,880 They've gone ahead, in your opinion, removed that, I guess you call restriction. 108 00:07:35,880 --> 00:07:41,000 But in Canada, if you're kind of going with the label, it's basically giving the oral 109 00:07:41,000 --> 00:07:45,040 form of Cabotigravir and Rilpivirine daily for four weeks. 110 00:07:45,040 --> 00:07:51,680 Now in some of our patients, we have considered going kind of off label, I guess you'd say, 111 00:07:51,680 --> 00:07:57,000 and if they're on a regimen, they're suppressed, just switching right from that to the injection. 112 00:07:57,000 --> 00:08:02,600 And the reason for that is one, you're getting extra kind of medication switches. 113 00:08:02,600 --> 00:08:07,080 So that kind of involves more follow up, more blood work, potentially more confusion for 114 00:08:07,080 --> 00:08:09,080 the patient. 115 00:08:09,080 --> 00:08:14,120 Rilpivirine orally does participate in a lot more drug interactions. 116 00:08:14,120 --> 00:08:20,240 So if anyone's on an antacid or something, an acid reducing medication, you can compromise 117 00:08:20,240 --> 00:08:22,520 Rilpivirine there. 118 00:08:22,520 --> 00:08:27,200 And again, for Rilpivirine, it is required to be taken with a meal. 119 00:08:27,200 --> 00:08:33,320 So for some of our patients in Saskatchewan, for example, who have food security issues, 120 00:08:33,320 --> 00:08:37,560 it's probably not a good approach to take for them to say you have to take this with 121 00:08:37,560 --> 00:08:41,720 a meal every time you take your oral meds. 122 00:08:41,720 --> 00:08:43,720 That's just not feasible for some of our patients. 123 00:08:43,720 --> 00:08:48,360 So there are a few, I guess, reasons why we might consider skipping that oral lead in 124 00:08:48,360 --> 00:08:53,920 phase if we're wanting to get someone going on the injectable. 125 00:08:53,920 --> 00:08:59,000 And I guess the perfect patient would probably be someone who's going to be able to commit 126 00:08:59,000 --> 00:09:03,920 to regular injection appointments and follow up and has kind of shown a track record of 127 00:09:03,920 --> 00:09:06,880 being stably suppressed. 128 00:09:06,880 --> 00:09:11,920 The biggest consideration, I guess, in that respect is that because this is an injectable 129 00:09:11,920 --> 00:09:15,800 medication, it has a really long PK tail on it. 130 00:09:15,800 --> 00:09:21,000 So once you have an injection of Capvenuba, it can actually last in your system for up 131 00:09:21,000 --> 00:09:22,880 to 12 months. 132 00:09:22,880 --> 00:09:28,860 So if someone gets an injection and then decides, no, I'm not going to go with this, they are 133 00:09:28,860 --> 00:09:36,360 committed to taking oral medications thereafter for at least 12 months regularly to prevent 134 00:09:36,360 --> 00:09:39,140 developing two class resistance with Capvenuba. 135 00:09:39,140 --> 00:09:44,540 So intergrazing inhibitors plus the non-new class could be completely wiped out potentially. 136 00:09:44,540 --> 00:09:49,360 So that's definitely a consideration that, you know, something to talk about with patients 137 00:09:49,360 --> 00:09:55,560 when considering this as an option, just making sure they're aware of kind of these ins and 138 00:09:55,560 --> 00:10:00,480 outs before they commit to it, I guess. 139 00:10:00,480 --> 00:10:04,760 And currently is this a monthly injection, right? 140 00:10:04,760 --> 00:10:05,760 It is monthly. 141 00:10:05,760 --> 00:10:09,040 They have approved in Canada to give it every two months. 142 00:10:09,040 --> 00:10:13,800 I would say for our patients, I lean more towards doing the monthly injections to begin 143 00:10:13,800 --> 00:10:16,560 with just so you can kind of build up that steady state. 144 00:10:16,560 --> 00:10:22,000 I think there'd be a little bit less risk of having any viral breakthrough. 145 00:10:22,000 --> 00:10:25,320 And then maybe after, you know, six months or so, you could, if the patient wants to 146 00:10:25,320 --> 00:10:30,440 go down every two months schedule, I'd probably consider it at that point. 147 00:10:30,440 --> 00:10:33,760 You know, you can, you know, if the patient is suppressed, you can go right to the every 148 00:10:33,760 --> 00:10:36,480 two months, you know, administration schedule. 149 00:10:36,480 --> 00:10:41,920 But I personally kind of like to stick with every month and, you know, see how that goes. 150 00:10:41,920 --> 00:10:44,040 No, that's for sure. 151 00:10:44,040 --> 00:10:49,160 And in terms of, I know you mentioned like some of the contraindications or some of the 152 00:10:49,160 --> 00:10:52,760 things that we should think about when we're putting these patients on medications. 153 00:10:52,760 --> 00:10:57,560 Are there any comorbidities, like if they have liver dysfunction or renal dysfunction, 154 00:10:57,560 --> 00:11:01,280 anything like that, that we should be aware of as clinicians? 155 00:11:01,280 --> 00:11:02,280 For sure. 156 00:11:02,280 --> 00:11:03,280 Yes. 157 00:11:03,280 --> 00:11:08,360 If anyone has a creatinine clearance of less than 30 mils a minute, or if they're on dialysis, 158 00:11:08,360 --> 00:11:14,840 or if they have liver failure, so if they're at the childhood C level, I wouldn't consider 159 00:11:14,840 --> 00:11:19,640 Cabinuga for those patients. 160 00:11:19,640 --> 00:11:27,160 Same with if they have a chronic hep B infection, Cabotricavir and Rilpivirine both don't provide 161 00:11:27,160 --> 00:11:30,680 any coverage for hep B. So you could have a flare. 162 00:11:30,680 --> 00:11:36,280 In the trials, they did have that as an exclusion criteria, but I think there was one or two 163 00:11:36,280 --> 00:11:42,680 that somehow they weren't aware that the patient had hep B and made it in there. 164 00:11:42,680 --> 00:11:43,680 They had a flare. 165 00:11:43,680 --> 00:11:49,800 So definitely making sure you're aware of their hep B status and looking at ahead of 166 00:11:49,800 --> 00:11:57,960 time and do you need to have tenofibir in their atrial regimen to help control that. 167 00:11:57,960 --> 00:12:06,240 In terms of other contraindications, there were some treatment failures in the trials. 168 00:12:06,240 --> 00:12:09,520 And this is people who have perfect adherence. 169 00:12:09,520 --> 00:12:12,040 They're in a study. 170 00:12:12,040 --> 00:12:14,240 We're not having missed appointments, that kind of thing. 171 00:12:14,240 --> 00:12:19,680 And it kind of varied from 1 to 1.7% of a failure rate in people who were taking it 172 00:12:19,680 --> 00:12:21,000 perfectly. 173 00:12:21,000 --> 00:12:25,040 And what they did find, they kind of looked into that a bit more to see, well, what was 174 00:12:25,040 --> 00:12:27,080 happening with those particular patients? 175 00:12:27,080 --> 00:12:29,000 Why was there a breakthrough? 176 00:12:29,000 --> 00:12:34,840 They found people that had played A or some type of A virus. 177 00:12:34,840 --> 00:12:36,840 That was a factor. 178 00:12:36,840 --> 00:12:40,120 Now, we don't have a lot of that in North America. 179 00:12:40,120 --> 00:12:42,960 That's probably a subtype you'd see more in Russia. 180 00:12:42,960 --> 00:12:49,000 So it's probably not something we'll run into kind of in our neck of the woods here. 181 00:12:49,000 --> 00:12:54,360 The other thing they found, if the patient had a BMI that was greater than 30, and then 182 00:12:54,360 --> 00:13:00,320 also if they had any resistance associated mutations, you know, that they tried to screen 183 00:13:00,320 --> 00:13:04,760 for that ahead of time, of course, but sometimes there's something that's lurking in the background. 184 00:13:04,760 --> 00:13:09,240 So it was kind of a combination of all three of those that seemed to predispose people 185 00:13:09,240 --> 00:13:15,000 to having confirmed neurologic failures on this. 186 00:13:15,000 --> 00:13:19,840 Now with the BMI alone, if that's the only factor in the mix, you know, that they're 187 00:13:19,840 --> 00:13:24,440 above 30, that didn't increase the risk of failure. 188 00:13:24,440 --> 00:13:31,920 So you can still consider patients with a BMI greater than 30 to be on this medication. 189 00:13:31,920 --> 00:13:37,640 And does the BMI kind of, I'm just going back to thinking about like other injectables or 190 00:13:37,640 --> 00:13:43,400 anything like that when we talk about any injectable medications, does it relate to 191 00:13:43,400 --> 00:13:47,840 kind of the distribution, like the distribution of the drug? 192 00:13:47,840 --> 00:13:56,600 Is it a certain site that we're injecting that makes it difficult for those that have 193 00:13:56,600 --> 00:13:58,760 a BMI of greater than 30? 194 00:13:58,760 --> 00:14:03,240 I think something that can come into it a little bit, they presented in the fall that, 195 00:14:03,240 --> 00:14:08,520 you know, people with BMI greater than 30 recommend a longer needle. 196 00:14:08,520 --> 00:14:13,120 So it might be the fact that maybe it wasn't quite getting into the muscle in some of those 197 00:14:13,120 --> 00:14:15,040 folks too or not completely. 198 00:14:15,040 --> 00:14:16,520 So that's something we do recommend. 199 00:14:16,520 --> 00:14:20,840 It gets a two inch length of needle that they recommend you use. 200 00:14:20,840 --> 00:14:25,960 So with the Cabinuva package, there are needles and everything that come with it. 201 00:14:25,960 --> 00:14:31,640 But if you do need the longer length of needle, you'd have to get that ahead of time for the 202 00:14:31,640 --> 00:14:32,640 pain. 203 00:14:32,640 --> 00:14:35,240 So that's something that kind of came out with that. 204 00:14:35,240 --> 00:14:36,240 But yeah. 205 00:14:36,240 --> 00:14:37,240 All right. 206 00:14:37,240 --> 00:14:42,760 And I think, so I think I'm understanding a lot about the indications and the contribution 207 00:14:42,760 --> 00:14:47,400 and really like what an eligible patient is, even whether it was taking care of this patient 208 00:14:47,400 --> 00:14:50,280 in the community setting or in the hospital. 209 00:14:50,280 --> 00:14:56,160 Like obviously most of the HIV patients will be managed by subspecialists. 210 00:14:56,160 --> 00:15:01,560 So this obviously information is really, really good for us too. 211 00:15:01,560 --> 00:15:05,640 Obviously for me, a little premature because it hasn't been approved in the pediatric population 212 00:15:05,640 --> 00:15:09,400 yet, but definitely something to consider, especially when we're doing transition of 213 00:15:09,400 --> 00:15:10,400 care, right? 214 00:15:10,400 --> 00:15:17,360 So from transferring patients over to the adult side, something to consider. 215 00:15:17,360 --> 00:15:23,440 So whenever a new drug comes out, we always think about costs and that's an important 216 00:15:23,440 --> 00:15:24,440 thing. 217 00:15:24,440 --> 00:15:26,440 Is there a cost to the patient here? 218 00:15:26,440 --> 00:15:27,780 What type of coverage? 219 00:15:27,780 --> 00:15:32,560 And I guess like we'll probably know a little bit more about the Canadian healthcare system 220 00:15:32,560 --> 00:15:33,560 in terms of that. 221 00:15:33,560 --> 00:15:37,560 And probably if you can touch a little bit on that, that would be great. 222 00:15:37,560 --> 00:15:38,560 Yeah, for sure. 223 00:15:38,560 --> 00:15:43,680 Like you said, it's going to vary kind of where geographically the patient is located, 224 00:15:43,680 --> 00:15:48,360 but even in Canada from province to province, it can vary a little bit. 225 00:15:48,360 --> 00:15:56,080 But in Saskatchewan, for example, the provincial formulary did add it on and we do have universal 226 00:15:56,080 --> 00:15:57,960 antiretroviral drug coverage here. 227 00:15:57,960 --> 00:16:02,360 So that means any antiretroviral they add to our formulary, it'll be a hundred percent 228 00:16:02,360 --> 00:16:07,320 covered to the patient for the patient, no cost to the patient. 229 00:16:07,320 --> 00:16:12,720 The other, I guess, thing to consider too, anyone who has NHB coverage. 230 00:16:12,720 --> 00:16:14,880 So that's a federal program. 231 00:16:14,880 --> 00:16:20,200 So anyone who has treaty status and is eligible there for coverage, it's covered for them 232 00:16:20,200 --> 00:16:22,480 a hundred percent as well. 233 00:16:22,480 --> 00:16:26,880 So it kind of depends if the province, you know, the patient is living in has decided 234 00:16:26,880 --> 00:16:28,800 to add it onto the formulary. 235 00:16:28,800 --> 00:16:33,360 I know a few provinces in Canada have added it already, but there's still a few more that 236 00:16:33,360 --> 00:16:35,040 are probably considering it. 237 00:16:35,040 --> 00:16:42,520 I think most probably will end up adding it because it was, I guess, negotiated to be 238 00:16:42,520 --> 00:16:45,520 kind of a similar price to other regimens. 239 00:16:45,520 --> 00:16:51,120 So it's really not going to cost more than kind of our traditional regimens, which is 240 00:16:51,120 --> 00:16:52,120 good. 241 00:16:52,120 --> 00:16:55,400 You know, we don't have to feel bad about considering this as an option. 242 00:16:55,400 --> 00:17:00,200 It's not going to increase the cost of the health care system. 243 00:17:00,200 --> 00:17:06,320 I think it's probably around the $1,500 mark per month, kind of in that range, which is 244 00:17:06,320 --> 00:17:09,600 sort of what the other regimens cost. 245 00:17:09,600 --> 00:17:15,160 Some provincial formulars are able to negotiate a special price and so they might be able 246 00:17:15,160 --> 00:17:17,720 to get a better cost. 247 00:17:17,720 --> 00:17:19,240 So but that's confidential. 248 00:17:19,240 --> 00:17:22,040 I wouldn't be able to know what that price is. 249 00:17:22,040 --> 00:17:29,200 It's kind of a special agreement. 250 00:17:29,200 --> 00:17:38,880 In terms of so now, like obviously lots of physicians will see Cabanouva on like on somebody's 251 00:17:38,880 --> 00:17:43,480 PIP or, you know, documentation of their medication list. 252 00:17:43,480 --> 00:17:48,000 I guess for both like clinicians outside in the community, like family doctors, other 253 00:17:48,000 --> 00:17:51,720 pharmacists that may be working in the community that are not related to HIV. 254 00:17:51,720 --> 00:17:56,240 What are some of the things once the patient is on Cabanouva that we should all be looking 255 00:17:56,240 --> 00:17:57,920 for, like monitoring? 256 00:17:57,920 --> 00:18:02,240 Is there any kind of ongoing lab work or is that something that's done pretty much by 257 00:18:02,240 --> 00:18:06,400 the HIV team that's administering it? 258 00:18:06,400 --> 00:18:09,880 Maybe some touch on like some of the side effects that would be good because I think 259 00:18:09,880 --> 00:18:13,760 lots of questions will come around about on that as well. 260 00:18:13,760 --> 00:18:19,080 Yeah, generally the monitoring site, like the lab work should be done by whoever is 261 00:18:19,080 --> 00:18:21,920 prescribing this medication. 262 00:18:21,920 --> 00:18:28,600 So the first thing you'd want to do is confirm that the patient is actually virally suppressed. 263 00:18:28,600 --> 00:18:34,520 Then you can go ahead and start them on the oral lead-in phase if you like for four weeks. 264 00:18:34,520 --> 00:18:39,840 And then at the end of that point, you would want to do another check for suppression before 265 00:18:39,840 --> 00:18:43,880 initiating the injectable. 266 00:18:43,880 --> 00:18:49,920 And then from there, I'd say one month out from any kind of med change, including Cabanouva, 267 00:18:49,920 --> 00:18:53,680 we like to do a viral load and see where things are at. 268 00:18:53,680 --> 00:18:57,640 And then from there, it's basically like any other antiretroviral regimen, you can check 269 00:18:57,640 --> 00:19:04,440 every three to six months to see where the viral load is sitting. 270 00:19:04,440 --> 00:19:08,440 In terms of anything else specific to this medication, I'd probably make sure you're 271 00:19:08,440 --> 00:19:13,480 getting some LFTs done, checking their renal function just to make sure they're still kind 272 00:19:13,480 --> 00:19:20,080 of following in the range where you'd be able to use this medication. 273 00:19:20,080 --> 00:19:26,680 And other kind of lab work like CDC, stuff like that, kind of your usual HIV blood work 274 00:19:26,680 --> 00:19:27,680 that we would do. 275 00:19:27,680 --> 00:19:28,680 So that's nice. 276 00:19:28,680 --> 00:19:31,520 It doesn't kind of amount to kind of... 277 00:19:31,520 --> 00:19:34,880 In the beginning, there might be a little bit of extra blood work that happens, but 278 00:19:34,880 --> 00:19:40,000 after that, it should kind of follow the same course as other regimens. 279 00:19:40,000 --> 00:19:45,000 In terms of tolerability, most patients reported that it was really well tolerated. 280 00:19:45,000 --> 00:19:50,280 The single most high, like the highest side effect that people reported were injection 281 00:19:50,280 --> 00:19:52,800 site reactions. 282 00:19:52,800 --> 00:19:59,340 So which, you know, as could be expected with this, a bit of, you know, a swelling or soreness. 283 00:19:59,340 --> 00:20:05,580 And so I guess warning the patient about that ahead of time, because it's likely to happen. 284 00:20:05,580 --> 00:20:11,800 Other side effects that could occur, headache, nausea, you know, that sort of thing. 285 00:20:11,800 --> 00:20:16,840 But in general, I think most people tolerate quite well and most only reported the injection 286 00:20:16,840 --> 00:20:17,840 site reaction. 287 00:20:17,840 --> 00:20:19,520 So that's kind of a... 288 00:20:19,520 --> 00:20:21,680 That's nice to know that it is so well tolerated. 289 00:20:21,680 --> 00:20:24,200 So maybe if you have a patient that's... 290 00:20:24,200 --> 00:20:28,000 We have the odd person that even though we've got really well tolerated oral options, they 291 00:20:28,000 --> 00:20:32,320 have continuous nausea and they can't seem to tolerate an oral origin. 292 00:20:32,320 --> 00:20:36,800 And maybe, you know, if you can get them suppressed, maybe this is an option, you know, just totally 293 00:20:36,800 --> 00:20:39,480 bypassing the oral route. 294 00:20:39,480 --> 00:20:43,280 That might be something that, you know, they might get a lot of benefit from. 295 00:20:43,280 --> 00:20:44,280 Okay. 296 00:20:44,280 --> 00:20:46,080 That makes sense. 297 00:20:46,080 --> 00:20:52,320 And is there any absolute reason that there's a reaction or anything that was probably, 298 00:20:52,320 --> 00:20:55,800 I would say more probably in the clinical trials that they saw? 299 00:20:55,800 --> 00:21:01,240 I'm not sure how much post-marketing surveillance has been kind of reported for those kind of 300 00:21:01,240 --> 00:21:02,960 side effects yet. 301 00:21:02,960 --> 00:21:08,240 But is there like one of the main reasons where if I'm a clinician that's out in the 302 00:21:08,240 --> 00:21:13,320 community, I get a phone call, somebody's on Cabinuva and they have a reaction, I would 303 00:21:13,320 --> 00:21:15,200 probably tell them to go to the emergency department. 304 00:21:15,200 --> 00:21:19,920 But is there something that, you know, is life threatening or anything like that, that 305 00:21:19,920 --> 00:21:21,560 would be worrisome in this case? 306 00:21:21,560 --> 00:21:28,040 I'd say if you happen to have a patient that had the kind of acutely flare up, that would 307 00:21:28,040 --> 00:21:29,040 be a situation. 308 00:21:29,040 --> 00:21:36,360 If in your lab work you see that they have a detectable viral load, I'd probably jump 309 00:21:36,360 --> 00:21:40,240 on that and switch them to something else. 310 00:21:40,240 --> 00:21:46,960 Preferably before, you know, early on before more mutations can kind of develop. 311 00:21:46,960 --> 00:21:52,840 Yeah, like any kind of intolerable adverse reactions, it is nice to see in the study 312 00:21:52,840 --> 00:21:57,840 they presented in the fall that they really didn't find there to be many hypersensitivity 313 00:21:57,840 --> 00:22:01,080 reactions to this medication. 314 00:22:01,080 --> 00:22:06,360 And then I guess as well if the patient became pregnant, I'd probably consider, you know, 315 00:22:06,360 --> 00:22:09,400 switching them to a regimen that has more safety data behind it. 316 00:22:09,400 --> 00:22:16,240 Even though it does have kind of a long, you know, half-life in the body, I would swap 317 00:22:16,240 --> 00:22:21,320 them to something else just that has a little bit more to it. 318 00:22:21,320 --> 00:22:22,320 Yeah. 319 00:22:22,320 --> 00:22:23,320 Perfect. 320 00:22:23,320 --> 00:22:26,840 And then I just wanted to touch on the topic of the viral suppression that we're talking 321 00:22:26,840 --> 00:22:27,840 about. 322 00:22:27,840 --> 00:22:34,160 So I know when I was reviewing the monograph myself earlier this year, you know, there's 323 00:22:34,160 --> 00:22:39,080 a huge topic regarding, you know, what is suppressible viral load? 324 00:22:39,080 --> 00:22:40,800 So is it less than 50 copies? 325 00:22:40,800 --> 00:22:44,960 Am I looking at, is it, you know, viral load not detected? 326 00:22:44,960 --> 00:22:48,000 I guess just for more of my information. 327 00:22:48,000 --> 00:22:51,040 And if we don't have that clear cut data, that's completely fine too. 328 00:22:51,040 --> 00:22:52,040 Yeah. 329 00:22:52,040 --> 00:22:56,760 So in the trial, they put a fairly firm cut off of less than 50 copies. 330 00:22:56,760 --> 00:23:02,480 So if you were 50 copies or above, they consider that, you know, not to be suppressed in these 331 00:23:02,480 --> 00:23:04,920 particular trials. 332 00:23:04,920 --> 00:23:12,000 I know in other trials of antiretroviral therapy, sometimes they'll consider even up to 200 333 00:23:12,000 --> 00:23:18,440 to be suppressed, but for these, you know, trials, they put the cut off at 50. 334 00:23:18,440 --> 00:23:19,440 So. 335 00:23:19,440 --> 00:23:20,440 Okay. 336 00:23:20,440 --> 00:23:21,440 Okay. 337 00:23:21,440 --> 00:23:25,200 That's good for us to know because, and in terms of, I guess, getting those first initial 338 00:23:25,200 --> 00:23:28,800 kind of viral loads and then monitoring the viral loads, and you might've said this and 339 00:23:28,800 --> 00:23:35,280 I may have missed that was once you're on Kavanuvah, how frequently am I monitoring 340 00:23:35,280 --> 00:23:38,840 or how frequently are you guys monitoring the HIV viral load? 341 00:23:38,840 --> 00:23:39,840 Yeah. 342 00:23:39,840 --> 00:23:45,200 So we would do it one month post-starting, the Kavanuv injection. 343 00:23:45,200 --> 00:23:49,120 And then if that looks good, we would do it at the three months mark and then every three 344 00:23:49,120 --> 00:23:51,800 to six months kind of after that. 345 00:23:51,800 --> 00:23:52,800 Yeah. 346 00:23:52,800 --> 00:23:56,000 And if you've got someone who's really stable on it, especially when you're coming close 347 00:23:56,000 --> 00:23:59,680 to a year from starting them, I'd probably start doing it every six months. 348 00:23:59,680 --> 00:24:05,520 You know, eventually some people might even do it once a year kind of thing, but three 349 00:24:05,520 --> 00:24:08,400 to six months is probably generally what you're looking at. 350 00:24:08,400 --> 00:24:09,400 Okay. 351 00:24:09,400 --> 00:24:12,000 So I guess like knowing the half-life and knowing that it's in your system for that 352 00:24:12,000 --> 00:24:15,120 long kind of is reassuring too. 353 00:24:15,120 --> 00:24:20,320 So it actually, another kind of plus, I guess, side of this would be that you don't have 354 00:24:20,320 --> 00:24:24,920 to do frequent lab work because right now a lot in our, at least in the pediatric population, 355 00:24:24,920 --> 00:24:29,760 kind of roughly every four months, they're having to get pokes for blood work and doing 356 00:24:29,760 --> 00:24:37,960 that from when you're a baby till your adult age is going to be, it's a drawback for sure. 357 00:24:37,960 --> 00:24:40,680 So, okay. 358 00:24:40,680 --> 00:24:47,960 And then in terms of, so what's a clinic that can you give us some like clinical examples 359 00:24:47,960 --> 00:24:56,440 of patients, maybe even one example of a patient that you've managed obviously with confidentiality 360 00:24:56,440 --> 00:24:58,920 here taking that into consideration? 361 00:24:58,920 --> 00:25:06,240 Yes, actually that is, we recently started a patient in December on Kavanuba and it was 362 00:25:06,240 --> 00:25:08,920 because of confidentiality concerns. 363 00:25:08,920 --> 00:25:13,480 So she was newly diagnosed really at this point. 364 00:25:13,480 --> 00:25:18,040 I don't know if she ever will be, but at this point isn't really wanting to share this information 365 00:25:18,040 --> 00:25:19,040 with others. 366 00:25:19,040 --> 00:25:21,600 She does live with other people in her house. 367 00:25:21,600 --> 00:25:27,280 So her concern was that she has a lot of oral and territorial sitting around that someone 368 00:25:27,280 --> 00:25:31,320 might see it, Google the name of it and find out kind of what's going on. 369 00:25:31,320 --> 00:25:39,560 So she was quite interested in trying this out because she's so concerned and even in 370 00:25:39,560 --> 00:25:43,680 the workplace, she was worried about people finding out there as well. 371 00:25:43,680 --> 00:25:50,440 So for her, I think it's been a really good switch. 372 00:25:50,440 --> 00:25:54,760 And she was also a little bit concerned about forgetting to take her pills every day. 373 00:25:54,760 --> 00:25:59,800 She did really well in the first bit and she got suppressed very quickly, but I think long 374 00:25:59,800 --> 00:26:04,200 term she was thinking day to day super busy with other things. 375 00:26:04,200 --> 00:26:05,640 She could have some misses. 376 00:26:05,640 --> 00:26:12,520 So she kind of wanted a less, I guess, involved kind of regimen and just get the shots once 377 00:26:12,520 --> 00:26:19,040 a month and forget about it until the next appointment. 378 00:26:19,040 --> 00:26:24,880 So basically kind of the ideal or the most eligible patient is that someone who is virally 379 00:26:24,880 --> 00:26:31,480 suppressed, obviously for many years would be preferable, right, because then you know, 380 00:26:31,480 --> 00:26:37,000 probably somebody who doesn't have too many comorbidities in terms of like the renal dysfunction 381 00:26:37,000 --> 00:26:39,480 that we talked about. 382 00:26:39,480 --> 00:26:45,280 And then the ideal patient in a lot of our clinics would be the ones that we worry about 383 00:26:45,280 --> 00:26:47,240 noncompliance and that type of thing. 384 00:26:47,240 --> 00:26:53,320 So obviously more of a structured setting, they would get the injectable and then be 385 00:26:53,320 --> 00:26:57,480 able to live their day to day life and don't really want to do blood work frequently and 386 00:26:57,480 --> 00:26:58,480 all that. 387 00:26:58,480 --> 00:27:04,800 So that's kind of what I'm understanding, which is a huge already like significant advantages, 388 00:27:04,800 --> 00:27:05,800 right? 389 00:27:05,800 --> 00:27:12,040 So especially dealing with chronic conditions like HIV, like we're aware of their people, 390 00:27:12,040 --> 00:27:13,040 it's tough. 391 00:27:13,040 --> 00:27:17,240 Like you don't have the ability to, as much as you want to live like your normal life, 392 00:27:17,240 --> 00:27:22,560 I think HIV medications have revolutionized that over the years and we're grateful for 393 00:27:22,560 --> 00:27:23,560 that. 394 00:27:23,560 --> 00:27:30,360 But definitely, if we can get towards, you know, even decreasing all of those drawbacks 395 00:27:30,360 --> 00:27:33,400 of taking medications, blood work, etc. 396 00:27:33,400 --> 00:27:35,040 I think we're winning. 397 00:27:35,040 --> 00:27:40,480 So that's a yeah, moving towards improving, you know, just quality of life. 398 00:27:40,480 --> 00:27:44,800 Thank you so much on, you know, taking pills every day. 399 00:27:44,800 --> 00:27:51,560 I know some practitioners, the tendency with this injectable form is to think of some of 400 00:27:51,560 --> 00:27:55,120 their patients that they've been struggling with adherence, they're thinking, okay, if 401 00:27:55,120 --> 00:27:58,400 we can get them on this, you know, then we can keep them suppressed because they only 402 00:27:58,400 --> 00:28:01,920 have to come in once a month to get the injection. 403 00:28:01,920 --> 00:28:07,920 But I would definitely say to caution around around that idea, just because, you know, 404 00:28:07,920 --> 00:28:12,600 they are going to have to be suppressed before you can actually even start the injection. 405 00:28:12,600 --> 00:28:17,400 And then you do have to be able to get a hold of the patient, they have to be reachable. 406 00:28:17,400 --> 00:28:23,640 So that involves, you know, having some, you know, access to a phone or a computer or something. 407 00:28:23,640 --> 00:28:26,200 So that you can follow up with the patient. 408 00:28:26,200 --> 00:28:30,720 And the real risk is if they aren't coming to their appointments, you kind of have a 409 00:28:30,720 --> 00:28:35,960 seven day window where you can get the injection from your cancer, January 10, as your treatment 410 00:28:35,960 --> 00:28:41,640 date, you know, every month on the 10th, you're supposed to come in for your, your injection 411 00:28:41,640 --> 00:28:42,640 appointment. 412 00:28:42,640 --> 00:28:47,920 And then you have a bit of a seven day window to work with that you can still get the injection. 413 00:28:47,920 --> 00:28:52,840 If they go outside of that, though, then you're starting to risk, you know, that two class 414 00:28:52,840 --> 00:28:58,440 resistance I talked about earlier, which can really limit your options, still have some 415 00:28:58,440 --> 00:29:03,920 NRTIs to work with and the protease inhibitors, but you know, who wants to be on a protease 416 00:29:03,920 --> 00:29:04,920 inhibitor anymore? 417 00:29:04,920 --> 00:29:06,920 You don't have to be. 418 00:29:06,920 --> 00:29:07,920 Exactly, right? 419 00:29:07,920 --> 00:29:08,920 Yeah. 420 00:29:08,920 --> 00:29:12,920 And you don't want to lose that integrase inhibitor class. 421 00:29:12,920 --> 00:29:14,360 So I mean, you know that those drugs are great. 422 00:29:14,360 --> 00:29:16,920 So yeah, yeah, yeah, that's fair. 423 00:29:16,920 --> 00:29:17,920 Okay. 424 00:29:17,920 --> 00:29:24,560 And then in terms of, I guess, if there's any like kind of other clinical evidence that 425 00:29:24,560 --> 00:29:29,760 you want to share with us today, that's, that would be helpful to anything that, you know, 426 00:29:29,760 --> 00:29:31,560 we didn't touch on today. 427 00:29:31,560 --> 00:29:32,560 Yeah. 428 00:29:32,560 --> 00:29:39,280 I'd say there is one trial going on called the MoCA trial, and that is in the 12 to 18 429 00:29:39,280 --> 00:29:47,120 year old cohort, and it's going to be presented at the IAS conference in July this year. 430 00:29:47,120 --> 00:29:51,120 And there's going to be a special PEDS workshop that they're going to be presenting this and 431 00:29:51,120 --> 00:29:56,400 mostly I think the information they'll be sharing is around the PK data, the safety and 432 00:29:56,400 --> 00:29:57,960 the acceptability results. 433 00:29:57,960 --> 00:30:04,680 So I think that's definitely something that we'll be looking forward to seeing because 434 00:30:04,680 --> 00:30:10,160 it seems to be we're always kind of limited in our options for our pediatric population. 435 00:30:10,160 --> 00:30:16,440 So any kind of new things that kind of come along that might be options are welcome, I 436 00:30:16,440 --> 00:30:17,440 think. 437 00:30:17,440 --> 00:30:18,440 So yeah, 438 00:30:18,440 --> 00:30:19,440 so that's exciting. 439 00:30:19,440 --> 00:30:26,320 I'm really, really excited to see where Cabanuba is going to take us, especially with HIV care 440 00:30:26,320 --> 00:30:28,480 here in Saskatchewan. 441 00:30:28,480 --> 00:30:34,880 I think it's something that is important because we know that we we've had an increase in number 442 00:30:34,880 --> 00:30:41,280 of our cases, compliance, definitely because we have a lot of remote rural areas. 443 00:30:41,280 --> 00:30:44,820 So access to health care is a challenge. 444 00:30:44,820 --> 00:30:48,520 So I guess the last kind of thing I want to touch on is it might be different in different 445 00:30:48,520 --> 00:30:54,720 centers, but here in Saskatchewan, which you're probably more familiar with is, if is this 446 00:30:54,720 --> 00:30:56,640 something that can be done at different sites? 447 00:30:56,640 --> 00:31:01,800 So like is Regina and Saskatoon doing kind of the injectables or is it something the 448 00:31:01,800 --> 00:31:05,400 patient has to be referred to the ID group here in Saskatoon? 449 00:31:05,400 --> 00:31:10,200 Yeah, so the Regina ID group is using it there. 450 00:31:10,200 --> 00:31:15,040 And I think they have a pharmacy that they have a bit of a relationship set up with who 451 00:31:15,040 --> 00:31:21,680 is kind of trained about this medication and monitoring it and administering and everything 452 00:31:21,680 --> 00:31:22,680 like that. 453 00:31:22,680 --> 00:31:28,000 So they kind of set up there in Saskatoon that we just recently set up with a community 454 00:31:28,000 --> 00:31:33,640 pharmacy that will kind of offer patients, you know, if you technically in Saskatchewan 455 00:31:33,640 --> 00:31:36,680 you can go anywhere to receive your antiretrovirals. 456 00:31:36,680 --> 00:31:41,640 But the fact is that this medication is a bit different and whoever is kind of involved 457 00:31:41,640 --> 00:31:46,760 in the administration of it is going to have to kind of have a special know how, you know, 458 00:31:46,760 --> 00:31:48,060 to get it to the patient. 459 00:31:48,060 --> 00:31:54,880 So we're kind of working on increasing locations that patients can access this. 460 00:31:54,880 --> 00:32:01,320 We have, you know, started patients off with a first dose with our clinic staff. 461 00:32:01,320 --> 00:32:05,120 But like you said, we're facing, you know, ever increasing numbers. 462 00:32:05,120 --> 00:32:08,760 We don't have enough staff to kind of deal with the present situation. 463 00:32:08,760 --> 00:32:12,960 So to add in something like this probably wouldn't be feasible for us. 464 00:32:12,960 --> 00:32:19,380 So I know a lot of other centers in Canada are kind of facing the same situation. 465 00:32:19,380 --> 00:32:22,480 So with the CHAP group it's kind of been a hot topic. 466 00:32:22,480 --> 00:32:27,200 People are asking how are you rolling this out and what are you guys doing? 467 00:32:27,200 --> 00:32:32,000 And it sounds like a lot of people are looking to community programs. 468 00:32:32,000 --> 00:32:36,520 Some places have infusion clinics and so people who have, you know, RA and they're getting 469 00:32:36,520 --> 00:32:42,240 those TNEP inhibitors, they're kind of approaching those places too because they kind of have 470 00:32:42,240 --> 00:32:46,160 beds and things set up for administering medication there. 471 00:32:46,160 --> 00:32:48,360 So those are some places. 472 00:32:48,360 --> 00:32:54,080 I know in Toronto they've got a very special program where they offer the service to actually 473 00:32:54,080 --> 00:32:57,200 come to the patient's home and administer the injection. 474 00:32:57,200 --> 00:32:59,000 So that's a pretty cool idea. 475 00:32:59,000 --> 00:33:03,760 Obviously you have to have the resources there to do that. 476 00:33:03,760 --> 00:33:06,720 That would be the ideal, you know, bring it right to the patient. 477 00:33:06,720 --> 00:33:11,400 But, you know, so that's kind of how we're planning to roll it out, just kind of connecting 478 00:33:11,400 --> 00:33:17,960 with some community partners and making sure that they're kind of up to speed on this medication 479 00:33:17,960 --> 00:33:23,040 and how to obtain it and lots of things. 480 00:33:23,040 --> 00:33:24,520 So lots of new exciting things. 481 00:33:24,520 --> 00:33:32,240 I think Cabinuba and, you know, since it's been on the market and coming into formulary, 482 00:33:32,240 --> 00:33:37,240 something that we'll probably see more, become more familiar with over the next few years 483 00:33:37,240 --> 00:33:38,240 here. 484 00:33:38,240 --> 00:33:43,240 I think the underlying thing for, you know, because we have a vast audience across North 485 00:33:43,240 --> 00:33:48,240 America, but especially across Canada, I would say, you know, if there is a patient that 486 00:33:48,240 --> 00:33:52,940 is eligible, kind of what we talked about today, reaching out to the infectious disease 487 00:33:52,940 --> 00:34:00,080 group in that center, discussing with specific HIV pharmacists in that center would be a 488 00:34:00,080 --> 00:34:05,240 good approach, initial approach to see if they can get some more information if that 489 00:34:05,240 --> 00:34:08,880 patient is eligible and that type of thing. 490 00:34:08,880 --> 00:34:13,440 So I think that gives me a lot of information for sure. 491 00:34:13,440 --> 00:34:18,040 I think I learned a lot during this episode and I really want to thank you, Carly, for 492 00:34:18,040 --> 00:34:22,120 taking the time out today to come on the podcast. 493 00:34:22,120 --> 00:34:32,320 It's an initiative that we started to help clinicians, pharmacists, family doctors, pediatricians, 494 00:34:32,320 --> 00:34:38,240 disease specialists, microbiologists to really just bring out hot topics like Kabanuva because 495 00:34:38,240 --> 00:34:42,240 a lot of us don't have the time to sit and, you know, discuss all of these things with 496 00:34:42,240 --> 00:34:48,360 our pharmacists who are super educated on this topic compared to a lot of us. 497 00:34:48,360 --> 00:34:54,800 And so I think, you know, bringing it all together in one episode here was something 498 00:34:54,800 --> 00:34:58,380 that I was looking forward to doing and I think you did a fantastic job. 499 00:34:58,380 --> 00:35:07,000 So thank you so much for educating us today and we'll definitely all be in touch with 500 00:35:07,000 --> 00:35:14,440 you for sure regarding future updates on this and maybe in the next few months to years 501 00:35:14,440 --> 00:35:21,880 we can kind of see what other case studies, case series or RCTs that come out of using 502 00:35:21,880 --> 00:35:22,880 Kabanuva. 503 00:35:22,880 --> 00:35:23,880 For sure. 504 00:35:23,880 --> 00:35:24,880 Yeah, thanks for having me. 505 00:35:24,880 --> 00:35:29,320 I'm always happy to share info on new things that are coming out in this area. 506 00:35:29,320 --> 00:35:31,320 So that's great. 507 00:35:31,320 --> 00:35:32,320 Thanks. 508 00:35:32,320 --> 00:35:36,820 A special thanks to Carly for joining us and thank you Dr. Pirawel. 509 00:35:36,820 --> 00:35:43,600 Follow us on Twitter at CA Breakpoint and email us at thecanadianbreakpoint at gmail.com 510 00:35:43,600 --> 00:35:47,900 to suggest infectious disease topics or discussions you'd like to hear. 511 00:35:47,900 --> 00:35:55,320 We look forward to seeing you again at the Canadian Breakpoint.