Our index case is a 13-year-old male from a rural area in who acquired HIV through vertical transmission. The mother tested negative during antenatal care, but she was not tested at delivery. He was diagnosed with HIV and pulmonary tuberculosis in 2010, started tuberculosis treatment and later on ART. As per the national guidelines, abacavir, 3TC and ritonavir-boosted lopinavir (LPV/r) syrups were initiated but it is unclear if he received ritonavir super-boosting during his tuberculosis treatment to overcome the inducing effect of rifampicin. He was diagnosed with tuberculosis again in 2013, again without documentation that LPV/r was super-boosted with ritonavir during treatment. Since ART initiation, he has never been virally suppressed, despite ongoing enhanced adherence support.
Figure 1 shows the HIV viral load (VL) and CD4 count timeline after ART initiation with no evidence of viral suppression defined as < 50 copies/mL. HIV VL is in log10 copies/mL (right vertical axis) and CD4 count is in cells/microL (left vertical axis). HIV VL >= 1000 copies/mL (>= 3 log10 copies/mL) is defined as virological failure.
In 2018 HIV drug resistance (DR) genotyping was performed, showing only M184V mutation with no protease resistance mutations, which suggested suboptimal adherence. He was switched to zidovudine (AZT) and 3TC, and was started on LPV/r paediatric tablets. The patient received continuous enhanced adherence counselling by the attending doctor and via the social worker. In January 2020, LPV/r was switched to DTG in an attempt to simplify the regimen and decrease the pill burden; however, he remained on AZT/3TC as he weighed 28 kg. The VL at the time of the switch was 529 copies/mL and hence a HIV DR test was not performed. However, he remained unsuppressed and admitted to often forgetting his medication as he lacked a treatment supporter.
There were major social issues impacting adherence; he is the product of rape by his mother's older cousin. Being a teen mom, and not having disclosed the rape issue to her mother proved to have affected the patient's mother, as well as her ability to provide optimum care for her child. She was the primary caregiver living with the maternal grandmother and was responsible for bringing him for his hospital appointments, but would sometimes not be available to bring him, and occasionally the patient's biological father would accompany the patient to hospital but identified himself as the patient's uncle. In 2017, the father became ill, and the grandmother (not knowing the issues around the rape) took him into their home, resulting in family conflict and missed hospital appointments. In 2019, both the patient's biological parents died due to AIDS-related complications. Upon discovering for the first time at her daughter's funeral that her nephew had raped her daughter and infected her with HIV, the patient's grandmother struggled to accept the situation. As a result, the grandmother avoided involving herself in the healthcare of her grandson including supervising him when taking treatment, or accompanying him to hospital, making addressing the adherence issues and disclosure difficult, requiring a home visit by the social workers.
Due to poor adherence and patient not suppressing for two years on the DTG-based regimen, despite enhanced adherence counselling, HIV DR was done in April 2022 which showed M184V again and the development of InSTI mutations (major T66TI, G118R, E138K, minor M50I), conferring high-level resistance to DTG (refer to Table 1).
The third-line regimen commenced in May 2022 was TDF, emtricitabine and ritonavir-boosted darunavir once daily. The viral load done after one month was 473 copies/mL with a 2 log10 drop.