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Publications

Journal Article Review Ahead of print 3 citations

PubMed: 42276093 DOI: 10.1016/S2352-3018(26)00107-4

Guidance on the clinical management of HIV-1 persistent low-level viraemia on antiretroviral treatment: a scoping review and an international Delphi consensus.

Lancet HIV

Authors: Tommaso Clemente, Arjen J Stam, Olof Elvstam, Anna Maria Geretti, Richard Harrigan, Milosz Parczewski, Nicola E Mackie, Vincenzo Spagnuolo, Marije Hofstra, Francois Venter, Daniel R Kuritzkes, Josep M Llibre, Robert W Shafer, Jonathan Schapiro, Esteban Martinez, Cissy Kityo-Mutuluuza, Monique Nijhuis, Per Björkman, Charlotte Charpentier, Simon Collins, Huldrych F Günthard, Diego Cecchini, Antonella Castagna, Nele Brusselaers, Annemarie Mj Wensing

Affiliations

  • Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
  • Translational Virology, Department of Global Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands; Medical Microbiology and Infection Prevention, University Medical Center Amsterdam, University of Amsterdam, Amsterdam, Netherlands.
  • Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Infectious Diseases, Växjö Hospital, Växjö, Sweden.
  • Department of HIV Medicine, Royal Free London National Health Service Trust, London, UK; Department of Medicine of Systems, University of Rome Tor Vergata, Rome, Italy; Department of Infectious Diseases-Hepatology, Lazzaro Spallanzani National Institute of Infectious Diseases, Rome, Italy.
  • Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
  • Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University, Szczecin, Poland.
  • Department of HIV and Sexual and Reproductive Health, Imperial College Healthcare National Health Service Trust, London, UK.
  • Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
  • Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Cape Town, South Africa.
  • Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
  • Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
  • Division of Infectious Diseases and Fight Infections Foundation, Hospital Universitario Germans Trias i Pujol, Badalona, Spain.
  • Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA, USA.
  • National Hemophilia Center, Sheba Medical Center, Ramat Gan, Israel.
  • Infectious Diseases Service, Hospital Clinic de Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
  • Joint Clinical Research Centre, Kampala, Uganda.
  • Translational Virology, Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands; HIV Pathogenesis Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
  • Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Infectious diseases, Skane University Hospital, Malmö, Sweden.
  • IAME, Université Paris Cité, INSERM, Paris, France; Service de Virologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.
  • HIV i-Base, London, UK.
  • Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland; Institute of Medical Virology, University of Zurich, Zurich, Switzerland.
  • Unidad de Infectología, Hospital Cosme Argerich, Buenos Aires, Argentina; Helios Salud, Buenos Aires, Argentina.
  • Department of Women's and Children's Health, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden; Global Health Institute, University of Antwerp, Antwerp, Belgium.
  • Translational Virology, Department of Global Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands; Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Abstract

Despite the success of antiretroviral therapy, a subset of people with HIV experience low-level viraemia (LLV), a challenging condition with inconsistent definitions and management across settings. We conducted a scoping review of the literature and developed international consensus recommendations through a modified Delphi process involving a multidisciplinary panel of experts. Available evidence shows wide variability in definitions of persistent LLV, most commonly encompassing repeated viral loads between 50 and 1000 copies per mL. Outcomes associated with LLV are heterogeneous. Despite associations between LLV at 50-200 copies per mL and virological failure of more than 1000 copies per mL, resistance emergence or adverse clinical outcomes are inconsistent; stronger evidence links LLV of 200-1000 copies per mL to these endpoints. Based on these findings, we propose a pragmatic management framework that includes prompt confirmation of LLV, assessment of adherence and drug interactions, consideration of resistance testing (especially at viral loads of 200-1000 copies per mL), a broader clinical evaluation, individualised treatment optimisation (according to viral load strata, the genetic barrier to resistance of current and potential antiretroviral regimens, and the HIV resistance profile), and individual prevention strategies for viral loads of 200-1000 copies per mL. This international guidance aims to support clinicians in identifying when LLV requires action, reduce variability in clinical practice, and inform management strategies across diverse health-care settings.

MeSH

Hiv-1, Viral Load, Therapeutics, Hiv Infections