Resistance to second generation INSTI although rare, can occur and has been reported to be a cause of inadequate response to antiretroviral therapy in patients.[7] Known risk factors to DTG resistance include infection with a non-B subtype of HIV-1, a high viral load, low CD4 cell count,[8] and insufficient adherence to antiretroviral therapy.[9] Common INSTI RAMS include R263K, Q148H/R/K, G118R, G140A/S/C, E138A/K/T, N155H, and Y143C/R.[7] This report presents a case of an accessory mutation, linked to DTG resistance, likely acquired by transmission from the patient's HIV infected partner. Here, CD4 is linked to infection.