Meticulous plasma isolation is essential to avoid false low-level viraemia in Roche Cobas HIV-1 viral load assays

Low Level Viremia Is Associated With Serious non-AIDS Events in People With HIV

Background

The consequences of low-level viremia in people with HIV are unclear. We used data from the US Military HIV Natural History Study to examine the association of low-level viremia (LLV) and serious non-AIDS events (SNAEs).

Methods

Included participants initiated antiretroviral therapy after 1996 and had ≥3 viral loads (VLs) measured, using an assay with a lower limit of detection of <50 copies/mL, ≥6 months after antiretroviral therapy initiation. VLs were categorized as lower levels of LLV (51-199 copies/mL), higher level of low-level viremia (HLLV; 200-999 copies/mL), and (VF; ≥200 copies/mL on 2 or more successive determinations or a single VL ≥1000 copies/mL), and virologic suppression (VS; ie, VL <50 copies/mL). Viral blips (ie, VLs between 50 and 999 copies/mL that are preceded and succeeded by VL <50 copies/mL) were analyzed in the VS category. Cox proportional hazards models were used to examine the association of LLV and SNAEs, adjusted hazard ratios and 95% confidence intervals are presented.

Results

A total of 439 (17.4%) SNAEs were recorded among the 2528 participants (93% male, 40% Caucasian, 43% African American) followed for a median of 11 years. In 8.5% and 4.6% of the participants, respectively, LLV and HLLV were the highest recorded viremia strata. Compared with VS, SNAEs were associated with LLV (1.3 [1.2-1.4]), HLLV (1.6 [1.5-1.7]), and virologic failure (1.7 [1.7-1.8]).

Conclusions

The results of this study suggest that LLV is associated with the occurrence of SNAEs and needs further study.

Presentation to HIV care and antiretroviral therapy initiation and response in clinical practice from 2003 through 2013

Universal HIV screening and treatment initiation of HIV-positive persons are well-established standards. However, late presentation to care is a barrier to early antiretroviral therapy (ART) and prevention of HIV transmission. We sought to determine the immunodeficiency at presentation to care and characterize the initiation and response to ART among HIV-positive persons over 2003–2013 in our urban HIV clinical practice at the Cleveland Clinic. Using a retrospective cohort study design, we assessed the CD4 cell count of HIV-positive patients at entry into care for each year and evaluated the trend over time. For patients who initiated treatment, we assessed the pretreatment CD4 cell count, consistency of timing and regimen with US treatment guidelines, and HIV RNA level at one-year and last follow-up visits. Regression analyses were used to determine predictors of study outcomes. We found that the cohort (N = 452) median CD4 cell count at presentation to care was 297 cells/mm3 (inter-quartile range: 104–479 cells/mm3), without any significant change over time (P = 0.62), and with 37% and 21% of presentations being late and advanced, respectively. Guideline-consistency (85%–100%) and regimen-consistency (41%–100%) were moderate to high and improved over time. Virologic suppression (<400 copies/ml) at one year and last follow-up was high (79% and 92%) and associated with regimen selection and durability. We conclude that CD4 cell count at first presentation to HIV care remained less than 350 cells/mm3 for 11 years in our clinical practice, despite advances in HIV testing and treatment guidelines. Early diagnosis and linkage to care and treatment are critical for ending the HIV epidemic.