Hi Alok!
I agree with Adam, that most likely the patient does not have enough drug in their system to develop resistance. so something is very telling to me on the labs you show. it looks like they were not detected for a very long time, then viral load shot up to 18387, then back to undetectable then a few times pretty high. so it appears the patient's viral set point is in the 10s of thousands. this is normal when someoen comes off meds totally. when someone has resistance, basically all of the virus that CAN be killed off will be, and there will actually be a much smaller number of virus, sometimes in the thousands. now the longer the person is on a failing regimen and the longer the resistant virus has time, it will then become higher and higher, but that doesnt strike me as what is happening.
one question I have, is there a reason this patient is on twice daily darunavir and dolutegravir vs once a day? I see they have only been on ATV as a PI and NVP as an NNRTI, and I would not expect to have PI mutations to DRV so you COULD do once daily DRV at 800mg and once daily DTG. unless this patient is also on other medications that have drug interactions causing you to have them on a twice daily regimen. yeah this def seems like someone who is just struggling with adherence and might not want to admit issues.
Best
Angela
------------------------------
Angela Kapalko
Physician Assistant Chairperson for AAHIVM
Philadelphia FIGHT CommunityHealth Centers
Philadelphia PA
akapalko@fight.org------------------------------
Original Message:
Sent: 05-15-2022 02:55
From: Alok Vashishtha
Subject: A unique case of drug resistance
Dear All.
I am Dr Alok Vashishtha from Haridwar, India.
A 24 year old boy case history was received by us for opinion on 10th April 2022. This boy is on ART from 04th January, 2006. The treatment history is provided in table below. As his HIV-1 Drug Resistance Testing was never done before, so we got it done and it showed resistance to no drugs. Genotype Resistance Test report attached in two parts for reference. We thought it as the case of non-adherence and with detailed enquiry patient told us that he was taking Darunavir 600 mg + Ritonavir 100 mg only once daily. So we made it now to twice daily and will repeat HIV RNA Quantitative RT-PCR after 6 weeks. My concern is why Genotype resistance testing is showing all drugs susceptible. Just to add that we got Genotype resistance testing repeated at another lab and it showed same pattern.
Looking forward your valuable opinion for our patient.
Treatment history of patient:
DD-MM-YYYY | Absolute CD4 counts | HIV RNA QUANTITATIVE RT-PCR (Copies/ml) | MEDICATIONS |
04-07-2006 | 173 | ND | D4T, 3TC, NVP |
01-09-2007 | 775 | ND | AZT, 3TC, NVP |
01-07-2008 | 788 | ND | AZT, 3TC, NVP |
08-10-2009 | 941 | ND | AZT, 3TC, NVP |
27-09-2010 | 996 | ND | AZT, 3TC, NVP |
06-01-2012 | 1123 | ND | AZT, 3TC, NVP |
13-09-2013 | 946 | ND | AZT, 3TC, NVP |
08-11-2014 | 759 | ND | AZT, 3TC, NVP |
09-11-2015 | 675 | ND | AZT, 3TC, NVP |
10-05-2016 | 471 | ND | AZT, 3TC. NVP |
24-03-2017 | 504 | 18387 | ATV/r, TDF, STC |
25-09-2017 | 375 | ND | ATV/r, TDF, 3TC |
09-12-2018 | 379 | ND | ATV/r, TDF, 3TC |
28-10-2018 | NA | 128 | ATV/r, TDF, 3TC |
27-03-2019 | 432 | ND | ATV/r, TDF, 3TC |
16-10-2019 | 226 | 43721 | ATV/r, TDF, 3TC |
24-02-2020 | 207 | ND | ATV/r, TDF, 3TC |
13-01-2021 | 165 | 97730 | DRV/r, DTG (12 hourly) |
13-12-2021 | 128 | 84503 | DRV/r, DTG (12 hourly) |
With best regards
Dr Alok Vashishtha
MBBS, MDHM, FIHM, AAHIVS
Centre for Infectious Diseases,
Haridwar, India