Using the 2013 care checklist, we report a 39-year-old man who tested HIV positive on 9 January 2015 in a NIMART outpatient clinic of the Ministry of Health of Namibia in the Windhoek district. He complained of tiredness without any other associated symptoms, and the tuberculosis screening was negative with an unremarkable clinical examination. He was assessed as having a World Health Organization (WHO) stage 1 infection. His CD4 count was 96 cells/mm3, weight 76 kg, body mass index (BMI) 21 kg/m2, creatinine clearance of 60 mL/min and haemoglobin of 11.3 g/dL. He was counselled on the importance of good adherence, and continuity of care, a treatment supporter was designated and started on TDF, 3TC and EFV on 29 January 2015 with reportedly good tolerance. He is single, self-employed, and does not drink alcohol or smoke. Despite ongoing adherence counselling done at each follow-up, he defaulted to ART on 13 October 2015 and returned to care on 8 September 2016 as he was not well. At this time, his VL and CD4 were, respectively, 52,605 copies/mL and 19 cells/mm3. His adherence was intensified and began personalized enhanced adherence counselling and restarted the same ART regimen. Six months later, on 7 March 2017, he suppressed his VL. However, on 6 April 2017, he stopped his ARVs again due to stigma issues reported by the patient as a mark of disgrace and fear of abandonment. He came back on 7 February 2018, where he was started on an identical regimen on ART and took his ARVs only for 2 months. In July 2018, he continued with enhanced adherence counselling sessions and was reinitiated on the same regimen with a CD4 of 5 (0.9%) cells/mm3, a negative cryptococcal serum antigen and a BMI of 20 kg/m2.
He was diagnosed with oesophageal candidiasis, an AIDS-defining illness, and successfully treated with fluconazole. His VL on ART 6 months later, on 31 January 2019, was 11,229 copies/mL. Unfortunately, no consideration for a treatment switch was made at this moment. He was seen again on 29 February 2019 but followed up only on 21 June 2019 with another episode of oesophageal candidiasis and a CD4 of 3 (0.7%) cells/mm3 after he had stopped his treatment. The NIMART nurse who attended to the patient was well trained, NIMART certified, with about a year of experience in ART case management. On 25 June 2019, as the patient returned to the clinic with a complaint of being unwell, the NIMART nurse referred the man to an HIV expert who oversees complicated cases in the district. The cryptococcal serum antigen remained negative, the mini-mental state examination was normal, and the VL before restarting ART was 69,706 copies/mL. The man was immediately switched to the second-line ART, comprising TDF, Zidovudine (AZT), 3TC, Atazanavir/ritonavir (ATV/r), and was reinitiated cotrimoxazole and treated with fluconazole. The stigma and the adherence to ART were addressed through enhanced adherence counselling. The client took his ARVs and kept all his clinical appointments. Three months later, his VL (9 September 2019) was suppressed at 30 copies/mL, and his CD4 counts improved to 275/mm3 (Figure 1). With the introduction of dolutegravir (DTG) in Namibia in 2020, the ART regimen was simplified to AZT 3TC DTG in June 2020, and the patient has remained virally suppressed (VL < 40).