HIV: how to manage low-level viraemia in people living with HIV

Article Details

Emily K Hanners, Jessica Benitez-Burke, Melissa E Badowski

Article Type


Related Articles

Article Page


Background: People living with HIV (PLWH) and receiving antiretroviral therapy (ART) have a goal of achieving and maintaining viral suppression; however, low-level viraemia (LLV) (HIV-RNA viral load levels of 50–999 copies/mL) persists in certain patients despite consistent medication adherence, lack of drug interactions and no genotypic resistance. This is a narrative review of the growing evidence of LLV in PLWH to determine risk factors and ART management strategies and to discuss the implications of LLV on the development of future virological failure.

Methods: A systematic, comprehensive literature search was completed in the English language using PubMed, Google Scholar and bibliography review to gather information about LLV in PLWH between July 2014 and June 2021. The following keywords were used as search terms: “low-level viremia”, “HIV”, “viral blip”, “intensification”, “genotyping”, “adherence” and “resistance.”

Results: Of 66 studies examined, 39 were analysed and included in this review. All trials included were published between 2014 and 2021. Eleven studies assessed risk factors for LLV. Identified risk factors were low CD4+ T cell nadir counts at baseline, higher baseline viral load measurements, medication non-adherence, non-nucleoside reverse transcriptase inhibitor use and others. Three studies assessed genotyping and concluded that the interpretation of both historical RNA genotype resistance testing and current proviral DNA genotype resistance testing in patients with LLV is appropriate. Seven studies were evaluated and determined that modifying or intensifying ART regimens resulted in decreased incidence of virological failure.

Conclusion: This compilation of reviewed data gives a framework for the management of PLWH with LLV. Currently, there are no clear or definitive treatment directions for LLV provided in guidelines. Complicating this topic further is the unclear and varying definitions of LLV. Future research is needed on this topic but patients presenting with LLV should have their medication adherence assessed, drug interactions checked and ART intensified, where appropriate.

Keywords: ART, genotyping, HIV, low-level viraemia, risk factors.

Citation: Hanners EK, Benitez-Burke J, Badowski ME. HIV: how to manage low-level viraemia in people living with HIV. Drugs Context. 2022;11:2021-8-13.

Contributions: All authors (EKH, JBB, MEB) contributed significantly to the creation of this manuscript from design to writing. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole and have given their approval for this version to be published.

Disclosure and potential conflicts of interest: The authors declare that they have no conflicts of interest relevant to this manuscript. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at:

Acknowledgements: None.

Funding declaration: There was no funding associated with the preparation of this article.

Copyright: Copyright © 2022 Hanners EK, Benitez-Burke J, Badowski ME. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0 which allows anyone to copy, distribute and transmit the article provided it is properly attributed in the manner specified below. No commercial use without permission.

Correct attribution: Copyright © 2022 Hanners EK, Benitez-Burke J, Badowski ME. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0.

Article URL:

Correspondence: Melissa E Badowski, Section of Infectious Diseases Pharmacotherapy, Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, IL, USA. Email:

Provenance: Invited; externally peer reviewed.

Submitted: 31 August 2021; Accepted: 29 October 2021; Publication date: 1 March 2022.

Drugs in Context is published by BioExcel Publishing Ltd. Registered office: Plaza Building, Lee High Road, London, England, SE13 5PT.

BioExcel Publishing Limited is registered in England Number 10038393. VAT GB 252 7720 07.

For all manuscript and submissions enquiries, contact the Editorial office

For all permissions, rights and reprints, contact David Hughes

Download free full text PDF