Second line Treatment Options in Resource Limited

RVD - diagnosed in 2017

- failed first line

- - multiple defaults while on TenvirEM, EFV

- VL not suppressed after restarting same regime since April 2019

- HIV drug resistance test 23/9/2019:

PI - all susceptible

NRTI - susceptible top AZT / high level resistance to 3TC, FTC / intermediate resistance to ABC / low level resistance to TDF, DDI, D4T

NNRTI - high level resistance to EFV, NVP

- Changed to Combivir/Kaletra on 25/11/2019

not compliant to combivir/kaletra since April 2020.

Compliance issues: Pill burden & stigma of taking meds at work.

-  VL (September 2021): 97481 (log 4.98)

- CD4 (September 2021): <35

switched to combivir / atazanavir/ ritonavir since 30/9/2021 till now

Current issue

1. Advanced RVD - on second line and concerned of possible PI resistance

2. Persistent MAC bacteremia

Culture history:

MycoF culture (19/9/19): AFB 3+, culture mycobacterium avium

Repeat mycoF culture (4/10/19): NGD42

Repeated mycoF lytic culture (April 2021):positive

MycoF lytic culture (June 2021): positive

MycoF lytic culture (6/9/2021): positive

MycoF lytic culture (20/9/2021): positive, AFB seen

Repeated blood mycoF culture on 17/10/2021 - no growth after 30 days

Treatment history:

Started Akurit-4 + B6 + Azithromycin on 30/9/2019

Changed to rRfabutin + ETH + Azithromycin on 25/11/2019 (because of potential interaction between Kaletra + Rifampicin)

Current regime: Azithromycin, Ethambutol, Rifabutin (1/10/2021)

plan to switch to Tab DTG 50mg OD + T.Atazanavir 300mg + Ritonavir 100mg ( ATZ due to reduce pill burden)

long-acting ARVs & many STRs are not available