Polycythemia in males living with HIV post dolutegravir and long term antiretroviral therapy

BackgroundDolutegravir based antiretroviral therapy (ART) is widely recommended as first line treatment for people living with HIV because of its potent viral suppression, high genetic barrier to resistance, and a favorable tolerability profile. Haematological adverse effects of ART are well recognized, most commonly anemia, particularly with zidovudine-containing regimens. However, erythrocytosis or polycythaemia is rarely described in association with dolutegravir, and available literature on this possible association remains limited. Case-presentationsWe describe a case series of four male patients living with HIV who developed persistent polycythemia after transition to dolutegravir-based regimens in accordance with National AIDS Control Organization guidelines. All our patients had been on long-term ART since childhood and were virologically suppressed with stable CD4 counts prior to regimen change. Haemoglobin levels progressively increased to >16.5 g/dL within 1 to 3 years of initiating dolutegravir, with peak values ranging from 17.4 to 17.8 g/dL. The patients remained asymptomatic, and leukocyte and platelet counts were largely within normal limits. Evaluation excluded common secondary causes of erythrocytosis including smoking, dehydration, renal dysfunction, and clinical features suggestive of myeloproliferative neoplasms. Liver and renal function parameters were stable, and no evidence of hypoxia or exogenous androgen use was identified. DiscussionThe temporal association between initiation of dolutegravir and rising haemoglobin levels is possibly suggestive of a drug-related effect or a haematological recovery phenomenon following sustained viral suppression. Proposed mechanisms include ART-associated increases in testosterone levels, enhanced erythropoietin production, reduced haemolysis, and improved bone marrow function. Although the patients were clinically stable, persistent polycythaemia may increase long term thrombotic risk and therefore may warrant periodic complete blood count monitoring. ConclusionThis case series highlights the need for awareness of this uncommon but potentially significant haematological observation in patients receiving dolutegravir-based ART and underscores the importance of systematic evaluation to exclude alternative aetiologies.