Significance of Low-Level Viremia Indication in HIV

Segment Description: Joseph Eron, MD; Paul Sax, MD; W. David Hardy, MD; Eric S. Daar, MD; Ian Frank, MD, consider the significance of low-level viremia indication.

Joseph Eron, MD: Let’s spend maybe just a couple of minutes talking about low-level viremia, which is a topic that I hate.

Paul Sax, MD: But you’ve made it sound so exciting.

Joseph Eron, MD: A topic that I hate.

Paul Sax, MD: I’ll tell you how you’re supposed to do that. It’s a fascinating topic.

W. David Hardy, MD: Let’s do it more.

Joseph Eron, MD: Ian, you introduced it. We have to be succinct, though, because we do want to talk about new drugs.

Ian Frank, MD: I have a handful—or maybe a couple of handfuls—of patients who, at every viral load determination, have a viral load that is measurable between generally 20 and 100 copies/mL. I have gotten archive-resistance tests, resistance tests on DNA—so not on the virus in plasma, which has shown wild-type virus. And we know that there are data that show that these individuals with viral loads of less than 200 copies/mL are not failing on therapy, that this is probably a virus that’s being released from a latent reservoir, not perpetuating ongoing infection, because the antiretrovirals are preventing infection of uninfected cells. Nonetheless, it just makes me nervous to see this at every visit.

Paul Sax, MD: Even though it makes us all nervous, 1 somewhat reassuring thing is that the studies of treatment as prevention all used thresholds higher than 200 copies/mL as their cutoff for virological control.

There has never been a case report of someone transmitting who has a viral load of 97 copies/mL, for example. So I think we can at least share that with patients. But it does bother them. One of my former colleagues, he actually used to order the bDNA [branched DNA] test solely to get rid of these low-level detectable viruses. It was less sensitive. I just assume order a more accurate, more reliable test.

Joseph Eron, MD: And I think that probably, for a lot of the people listening, don’t make any decision on a single test, which Eric said. Low-level viremia between 50 and 200 copies/mL is a complicated topic, and you would certainly repeat those values. Sometimes it’s just the lab, right?

Eric S. Daar, MD: Yeah.

Joseph Eron, MD: You could take the same sample and get those values. I think most of us think about switching therapy with reproducible viral loads greater than 200 copies/mL. Is that safe to say?

W. David Hardy, MD: Good point.

Paul Sax, MD: And no intensification. Note, do not intensify. Don’t add drugs to these regimens.