Page 83 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 3 of 4 Case Report

TABLE 2: HIV drug resistance test results.
2015 2016
Medicines Mutations Description of resistance Mutations Description of resistance
NRTI M41L, M184V, T215F M41L, M184V, T215F
Zidovudine Intermediate Intermediate
Lamivudine High level High level
Abacavir Intermediate Intermediate
Emtricitabine High level High level
Tenofovir Low level Susceptible
NNRTI A98G, K103N, E138A A98G, K103N, E138A
Nevirapine High level High level
Efavirenz High level High level
Rilpivirine Intermediate Intermediate
Etravirine Low level Low level
PI M46I, I54V, V82A M46I, I54V, V82A, L76V
Lopinavir High level High level
Atazanavir High level High level
Darunavir Susceptible Intermediate
INSTI† E138K, G140A, Q148R
Elvitegravir High-level resistance
Raltegravir High-level resistance
Darunavir High-level resistance
NRTI, nucleoside reverse transcriptase inhibitors; NNRTI, non-nucleoside reverse transcriptase inhibitors; INSTI, integrase strand transfer inhibitor.
†,Test done on 14 June 2018.

Ethical consideration retains activity against RAL- and EVG-resistant viruses. 9,10
Zimbabwe has not yet adopted the use of DTG as part of the
Analysis of routine clinical data is approved by the Medical preferred first-line ART regimens.
Research Council of Zimbabwe as part of a larger study,
International Epidemiological Databases to Evaluate AIDs Conclusion
(IeDEA Collaboration) (approval no. MRCZ/A/1336). Verbal
assent from adolescent and written informed consent from This is the first case of recorded four-class HIV drug resistance
parent were obtained. in Zimbabwe. This adolescent girl cannot be effectively treated
with any of the currently available ART regimens in Zimbabwe.
Discussion Prevention measures such as family planning intervention and
safe sex counselling are being taken to minimise the risk of
To our knowledge, this is the first report of a patient with a transmission of this multi-class resistant virus.
virus that has developed multi-class drug resistance to all
four standard classes of ART, including INSTIs, in Zimbabwe. This case emphasises the need for health workers to continue
This patient has HIV with high-level resistance to DTG after providing adherence counselling and support for patients
previous exposure to RAL. Recently, a case of multi-drug who are on ART. Transmission of four-class-resistant HIV is a
resistant HIV, including resistance to INSTIs, was reported potential public health disaster.
from Botswana and a similar case was reported earlier in
5
South Africa. Multi-drug resistant HIV could have developed
6
because of a variety of factors, including poor adherence to Acknowledgements
ART and inadequate psychosocial support – issues which are The authors would like to acknowledge the Ruedi Luethy
frequently encountered among adolescents living with HIV. 7 Foundation for providing all the resources required for
In this case, poor adherence was mainly because of poor medical management of this patient, and also acknowledge
family support and lack of motivation for ART when the the nurses and doctors of Newlands Clinic who were
patient felt clinically well. Poor adherence to previous ART involved in the care of this patient.
regimens could have led to exposure to DTG monotherapy.
Previous studies have shown that monotherapy with DTG
has a high rate of resistance selection in the integrase gene Competing interests
through different pathways in case of virologic failure. 8 The authors declare that they have no financial or personal
relationship(s) that may have inappropriately influenced
Integrase strand transfer inhibitors are one of the newest them in writing this article.
class of antiretroviral drugs to be approved for HIV treatment
and act by inhibiting the essential HIV protein integrase from Authors’ contributions
inserting the viral DNA genome into the host cell’s chromatin.
Raltegravir and EVG have been successful in clinical settings, L.C. and M.P. are the physicians looking after the patient.
but have low genetic barriers to resistance. Dolutegravir is C.C. and L.C. prepared the first draft of the case report. All
known to have a very high genetic barrier to resistance and authors read and approved the final manuscript.

http://www.sajhivmed.org.za 76 Open Access