HIV meds and rash

Question:

3/7/2018
I saw a 25 year-old male who presented with a drug rash likely due to his HIV medications. He was diagnosed with HIV in the fall of last year. A brief timeline includes the following. On 10/12, he was started on Genvoya which contains Elvitegravir (HIV-1 integrase strand transfer inhibitor), emtricitabine (HIV reverse transcriptase inhibitor -NRTI), and Tenofovir alafenamide (HIV NRTI which is converted in vivo to tenofovir). He was seen for a pruritic rash about 12 days later which was described as a maculopapular rash by another provider. He denied difficulty swallowing or breathing or swelling or lip, tongue, or throat. Genvoya was stopped. On 11/15, he was started on Triumeq which contains Abacavir and Lamivudine (NRTIs) and dolutegravir (HIV integrase strand transfer inhibitor). He reports a few hives during the first 2 weeks after starting Triumeq which resolved within 2 weeks. He denied swelling of the lip, tongue, or throat. He did not have any rashes for about 6 weeks and was not taking any antihistamines. He then developed a rash around 2/15 which was present all over his body.  

Pictures showed a classic maculopapular drug rash on his chest and his medication was stopped on 2/21. History did not suggest any other factors which could have led to rash. The next day, he was started on Darunavir (protease inhibitor), Ritonavir (protease inhibitor) and Truvada which contains emtricitabine and tenofovir (NRTIs). After the first dose, he developed mild shortness of breath which resolved on its own. After the second dose, he developed more burning on the chest where he already had a rash. These medications were stopped and he was sent to allergy. His liver enzymes and eosinophil count were normal and he did not have a fever. He did not have any blistering or peeling of his skin.

I would like input on his case to figure out the best approach so he can receive medications to treat his HIV. It seems some of his reactions are delayed type IV hypersensitivity reactions for which skin prick testing and desensitization do not have a role. Furthermore, we cannot challenge him to one of the medications at a time as this is not ideal in the treatment of HIV which requires all medications to be given at once to prevent resistance. Please let me know if you have any advice on how to proceed with this patient.