Page 85 - SAHCS HIVMed Journal Vol 20 No 1 2019

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 3 Case Report

Rapid emergence of resistance to antiretroviral

treatment after undisclosed prior exposure:

A case report

Authors: Introduction: Patients who disengaged from care may present as therapy naïve for antiretroviral
Theresa M. Rossouw 1 treatment (ART) initiation at a different site, without being recognised as being at an increased
Gisela van Dyk 1
Gert van Zyl risk of rapid treatment failure and HIV drug resistance.
2
Patient presentation: A 43-year-old woman, who gave no prior history of ART, was initiated
Affiliations:
1 Department of Immunology, on a standard first-line regimen of TDF, FTC and EFV. She had a poor response to treatment
University of Pretoria, with evidence of treatment failure at 12 months.
Pretoria, South Africa
Management and outcome: HIV-1 drug resistance tests showed no pre-treatment HIVDR
2 Division of Medical Virology, mutations, but revealed high-level drug resistance to all component drugs at 12 months. On
Stellenbosch University and investigation, viral load (VL) was recorded in 2012 and 2013, providing evidence of prior ART use.
National Health Laboratory
Service, Bellville, South Africa Conclusion: Linkage of patient therapy and laboratory information to unique patient identifiers
may allow health-care workers to identify patients who previously received ART and disengaged
Corresponding author:
Theresa Rossouw, from care. This will enable differentiated care when these patients reinitiate ART, which should
[email protected] involve expedited VL testing and more rapid transition to definitive second-line ART.
Dates: Keywords: HIV drug resistance; Antiretroviral therapy; Undisclosed prior treatment.
Received: 08 Mar. 2019
Accepted: 28 Mar. 2019
Published: 30 July 2019 Introduction
How to cite this article: HIV drug resistance (HIVDR) is a major public health concern, especially in the context of a large
Rossouw TM, Van Dyk G, treatment programme. Patients who disengage from care and then return to the health-care
Van Zyl G. Rapid emergence
of resistance to antiretroviral system without disclosing previous antiretroviral therapy (ART) are at increased risk of having
treatment after undisclosed pre-existing drug resistance. Unfortunately, patients rarely report prior ART use, and health-care
prior exposure: A case report. workers do not routinely ask and record this. All drugs in the current first-line regimen (TDF, FTC
S Afr J HIV Med. 2019;20(1), and EFV) have low genetic barriers, and hence, one or two mutations lead to diminished activity,
a965. https://doi.org/10.4102/
sajhivmed.v20i1.965 which can affect entire drug classes. HIV drug resistance testing is not currently available in
the South African public sector for patients initiating or failing first-line ART. Here we describe a
Copyright: case of a patient with undisclosed prior exposure to ART who had a complex HIVDR pattern at
© 2019. The Authors.
Licensee: AOSIS. This work treatment failure and highlight potential risk factors for rapid HIVDR emergence.
is licensed under the
Creative Commons Case description
Attribution License.
A 43-year-old woman presented to a clinic in Tshwane, South Africa, on 23 July 2014. She tested
HIV-positive and had a CD4 count of 14 cells/µL and HIV-1 viral load (VL) of 560 000 copies/mL.
She gave no prior history of ART and was initiated on a first-line regimen of TDF, FTC and EFV
on 06 August 2014. She attended all her visits on time and reported good adherence, but had a
poor response after 12 months of treatment: CD4 53 cells/µL and VL 186 000 copies/mL. The
6-month VL had not been performed. As part of a research project (ethics approval 469/2013), she
had a drug resistance test (DRT) with a validated in-house Sanger-based sequencing method
1
before the initiation of ART, which showed no HIVDR mutations, and again after 12 months,
which revealed six nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) and three non-
nucleoside reverse transcriptase inhibitor (NNRTI) mutations (Tables 1 and 2). A search of the
NHLS database for evidence of prior HIV-related testing revealed two VL results (2012 and 2013),
which precede her ART-initiation date (Figure 1).
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of the Faculty of Health Sciences of the University of Pretoria (ethics approval number 469/2013).
http://www.sajhivmed.org.za 78 Open Access