Human Immunodeficiency Virus Infection

A previously healthy 16-year-old boy presents with a 3-week history of fevers to 101 °C, painful swallowing, loss of appetite, fatigue, and myalgias associated with a 10-pound weight loss. Despite sleeping 12–15 hours every day, he doesn’t feel rested. He has been unable to attend school. He’s had no respiratory symptoms, nausea, or diarrhea. He denies smoking, vaping, alcohol consumption, or drug use. He is not aware of any sick contacts, has no recent pet or other animal exposures, and has not traveled. He has had oral and anal (receptive) sex with two older male partners, ages 18 and 24 years in past year with infrequent use of condoms. His older sexual partner started taking pre-exposure prophylaxis (emtricitabine-tenofovir alafenamide) for HIV-prevention “a while ago.” To his knowledge, neither of his sexual partners has ever had a sexually transmitted infected. Both are currently healthy. On physical examination, the adolescent appears pale and tired but remains cooperative throughout the visit. His temperature is 38.0 °C, with normal vital signs otherwise. The throat is injected with a moderate amount of white exudate present on the posterior pharyngeal wall. He has bilateral anterior and posterior cervical lymphadenopathy. The heart and lung examinations are normal. His abdomen is soft and nontender. The spleen is enlarged, extending nearly 3 cm below the left costal margin. Multiple shotty, nontender inguinal lymph nodes are present bilaterally. The skin is clear and the neurological examination is normal. Laboratory results show a total peripheral white blood cell count of 5900/μL with 72% neutrophils, 12% lymphocytes, 7% atypical lymphocytes, 5% monocytes, and 4% eosinophils. The blood hemoglobin is 14 g/dL, hematocrit is 42% and platelet count is 318,000/μL. Serum electrolytes are normal, and hepatic transaminases are mildly elevated. A rapid, point of care test for streptococcal pharyngitis is negative. A heterophile antibody screening test for infectious mononucleosis is negative. Epstein-Barr and cytomegalovirus-specific IgM and IgG antibodies are negative. Serologies for syphilis and hepatitis C are negative. He is hepatitis B surface antibody positive, indicating seroprotection following prior vaccination. Pharyngeal swabs for Neisseria gonorrhoeae and Chlamydia trachomatis testing are negative. Fourth-generation testing for infection with HIV-1 is positive. The patient is diagnosed with acute retroviral syndrome and scheduled for follow-up 2 days later. During the follow-up visit, repeat fourth-generation HIV testing is confirmed positive, the pre-treatment CD4+ T-lymphocyte count is 280 cells/μL, and the HIV-1 quantitative viral load is 654,000 copies/ml. The combination antiretroviral pill containing bictegravir, tenofovir alafenamide, and emtricitabine is prescribed to be taken once daily. The teen completes further new patient intake meetings with nursing, social services, and an adherence counselor. During his medical follow-up visit at 1 month, he states that he is tolerating the antiretroviral medication without any side effects and that his energy level is beginning to improve. Repeat laboratory studies done 3 months after starting the antiretroviral medications show an excellent response, with more than a two-log reduction in viral load to 5400 copies/ml and a CD4+ T-lymphocyte count of 620 cells/μL. When the patient was seen again 6 months after being diagnosed with HIV infection and starting on antiretroviral therapy, his energy level had returned to baseline, and he had regained 10 pounds. Results of repeat testing showed an undetectable viral load and a CD4+ T-lymphocyte count of 2480 cells/μL.