HIV low-level viraemia: considerations for prevention and treatment in an era of highly effective and durable antiretroviral therapy regimens

Abstract

Introduction

Despite increasingly widespread acceptance of the (undetectable = untransmittable) U = U concept, uncertainty remains about the implications of suppressed viral loads (detected but ≤1000 copies/ml, also often referred to as low-level viraemia) for both sexual HIV transmission and individual patient outcomes.

Discussion

There has been no documented evidence of a transmission event when the index partner had a viral load <200 copies/ml, suggesting zero risk of sexual transmission. Additionally, the risk of sexual transmission when the index partner is taking medication as prescribed and has a viral load that is detectable but suppressed (≤1000 copies/ml) is negligible. The clinical implications, including drug resistance development, of persistent low-level viraemia in people with HIV (PWH) taking dolutegravir-containing antiretroviral therapy remains limited and relatively unknown; ongoing research and surveillance will be critical to monitor expanded scale-up of optimized treatment. To support widespread access to treatment monitoring for all PWH, viral load testing should be expanded using any combination of available viral load technologies and sample types, as they can all support the primary objectives of understanding the viral load of PWH, for both prevention and treatment.

Conclusions

PWH who have an undetectable or suppressed viral load should be celebrated and encouraged to maintain their treatment adherence and engagement in care, while ensuring that no remaining barriers exist for them to do so.