Transmitted Resistance to All Integrase Inhibitors: A Rare Event, or the Tip of the Iceberg?

Researchers present the case of a 42-year-old woman who had a negative HIV test in August 2016 and was diagnosed with HIV infection in May 2018. She denied any history of antiretroviral therapy (ART), including pre- or postexposure prophylaxis. A pretreatment genotype, including integrase sequencing, was obtained and showed three major INSTI mutations: E138A, G140S, and Q148H. These were also demonstrated on a repeat genotype. Subsequent genotypic sequencing of the presumed source patient, an HIV-infected sexual partner, revealed the same integrase mutations, confirming that this almost certainly represented transmitted integrase resistance. The source patient's treatment history included raltegravir and dolutegravir.