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Low-level viremia and virologic failure in persons with HIV infection treated with antiretroviral therapy

Fleming, Juliaa; Mathews, W. Christopherb; Rutstein, Richard M.c; Aberg, Judithd; Somboonwit, Charurute; Cheever, Laura W.f; Berry, Stephen A.a; Gebo, Kelly A.a; Moore, Richard D.a for the HIV Research Network

doi: 10.1097/QAD.0000000000002306

Background: The clinical management of low-level viremia (LLV) remains unclear. The objective of this study was to investigate the association of blips and LLV with virologic failure.

Methods: We enlisted patients who newly enrolled into the HIV Research Network between 2005 and 2015, had HIV-1 RNA more than 200 copies/ml, and were either antiretroviral therapy (ART)-naive or ART-experienced and not on ART. Patients were included who achieved virologic suppression (≤50 on two consecutive viral loads) and had at least two viral loads following suppression. Blips and LLV (≥2 consecutive >51 copies/ml) were categorized separately into three categories: no blips/LLV, 51–200, 201–500. Cox proportional hazards regression was used to assess association between rates of blips/LLV and virologic failure (two consecutive >500).

Results: The 2795 patients were mostly male (75.4%), black (50.3%), and MSM (52.9%). Median age was 38 years old (interquartile range 29–48). Most patients (88.8%) were ART-naive at study entry. Overall, 283 (10.1%) patients experienced virologic failure. A total of 152 (5.4%) patients experienced LLV to 51–200 and 110 (3.9%) patients experienced LLV to 201–500. Both LLV 51–200 [adjusted hazard ratio (aHR) 1.83 (1.10,3.04)] and LLV 201–500 [aHR 4.26 (2.65,6.86)] were associated with virologic failure. In sensitivity analysis excluding ART-experienced patients, the association between LLV 51 and 200 and virologic failure was not statistically significant.

Conclusion: LLV between 201 and 500 was associated with virologic failure, as was LLV between 51 and 200, particularly among ART-experienced patients. Patients with LLV below the current Department of Health and Human Services threshold for virologic failure (persistent viremia ≥200) may require more intensive monitoring because of increased risk for virologic failure.

aJohns Hopkins University School of Medicine, Baltimore, Maryland

bUniversity of California San Diego, San Diego, California

cChildren's Hospital of Philadelphia, Philadelphia, Pennsylvania

dIcahn School of Medicine at Mt Sinai, New York, New York

eUniversity of South Florida, Tampa, Florida

fHealth Resources and Services Administration, Rockville, Maryland, USA.

Correspondence to Julia Fleming, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. E-mail:

Received 4 January, 2019

Revised 10 April, 2019

Accepted 11 April, 2019

Copyright © 2019 Wolters Kluwer Health, Inc.