Skill Checkup: An Asymptomatic 31-Year-Old Man With HIV Is Experiencing Increased Viremia Following Treatment

Antonio Di Biagio, MD


August 14, 2023

The Skill Checkup series provides a quick, case-style interactive quiz, highlighting key guideline- and evidence-based information to inform clinical practice.

An asymptomatic 31-year-old man in Italy was diagnosed with HIV infection during a routine clinic visit. At diagnosis, his CD4 count was 342 cells/µL, and his plasma HIV-1 RNA viral load was 268,000 copies/mL. He was negative for hepatitis B surface antigen.

Considerably anxious about his new positive HIV status, the patient was very motivated to begin treatment. He indicated that he was confident he could take a few pills a day; he shared that he takes a supplement daily without fail, and he was diligent about daily home exercises when he needed physiotherapy after a sports injury a few years ago.

Antiretroviral therapy (ART) was initiated, consisting of nucleotide/nucleoside reverse transcriptase inhibitors (NRTIs), tenofovir alafenamide fumarate (TAF) and emtricitabine (FTC), in combination with the integrase strand transfer inhibitor (INSTI) dolutegravir (DTG).

When results of his baseline genotype testing were available, they confirmed that his virus was not resistant to antiretroviral (ARV) HIV drugs at the time of infection. Eight weeks after treatment initiation, his HIV viral load had decreased to 3528 copies/mL. After a steady decline in HIV RNA levels and an increase in CD4 count, monitoring at 18 months after treatment initiation revealed an unexpected increase in viremia, with an HIV viral load of 491 copies/mL. He receives counselling on the importance of adherence at every visit, and it is confirmed that he has been adherent to his ART regimen from the beginning. He is nervous about the current backslide in his disease management.


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