A Shot in the Dark
Clinical Vignette
A 34-year-old man presents to the HIV clinic after a new diagnosis of HIV-1 infection. He has been receiving long-acting injectable cabotegravir (CAB-LA) every 2 months for HIV preexposure prophylaxis (PrEP) for the past 14 months. His most recent injection was 6 weeks ago. He presented to urgent care 5 days ago with fever, pharyngitis, diffuse lymphadenopathy, and a maculopapular rash; a fourth-generation HIV antigen/antibody test was reactive, and a confirmatory HIV-1/HIV-2 differentiation assay was positive for HIV-1.
Baseline labs show HIV-1 RNA 64,000 copies/mL and CD4 count 410 cells/mm³. Standard reverse transcriptase and protease genotype testing has been sent, as well as integrase genotype testing, but results are not yet available. Hepatitis B surface antigen is negative, hepatitis C antibody is negative, and HLA-B*57:01 testing is pending. He is otherwise healthy, takes no other medications, and is eager to begin treatment immediately.
Question 1
Which of the following is the most appropriate initial antiretroviral regimen while genotype results are pending?
Select one option to submit your answer and view live poll results.
Question 2
The integrase genotype returns with no evidence of InSTI resistance mutations. What is the most appropriate next step in management?
Select one option to submit your answer and view live poll results.
References
Gandhi RT, Landovitz RJ, Sax PE, et al. Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations of the International Antiviral Society–USA Panel. JAMA. 2025;333(7):609-628.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. U.S. Department of Health and Human Services.
Landovitz RJ, Donnell D, Clement ME, et al. Cabotegravir for HIV Prevention in Cisgender Men and Transgender Women. N Engl J Med. 2021;385(7):595-608.