Plasma Human Immunodeficiency Virus 1 RNA and CD4+ T-Cell Counts Are Determinants of Virological Nonsuppression Outcomes With Initial Integrase Inhibitor-Based Regimens: A Prospective RESPOND Cohort Study

The prevalence of low-level viraemia and its association with virological failure in people living with HIV: a systematic review and meta-analysis

Low-level viraemia (LLV) following antiretroviral therapy (ART) in people living with HIV (PLWH) has not received sufficient attention. To the determine the prevalence of LLV and its association with virological failure (VF), we systematically reviewed evidence-based interventions for PLWH. We searched PubMed, the Cochrane Library, Embase, and Web of Science from inception to 22 May 2024. Cohorts with samples sizes smaller than 1000 in size were excluded. Data from 16 cohort studies, encompassing 13,49,306 PLWH, revealed a pooled prevalence of LLV of 13.81%. Relative risk (RR) and 95% confidence intervals (CI) identified the following risk factors for LLV: viral load (VL) ≥ 105 copies/mL at baseline (1.79, 1.11-2.88), AIDS-defined illness at baseline (1.24, 1.10-1.40), and protease inhibitor-based regimen at ART initiation (1.53, 1.45-1.62) are the risk factors for LLV. Conversely, CD4 count ≥200 cells/μL at baseline (0.90, 0.82-0.98), non-nucleoside reverse transcriptase inhibitor-based regimen (0.81, 0.68-0.96) and the integrase strand transfer inhibitor (INSTI)-based regimen (0.60, 0.42-0.85) were associated with a reduced risk of LLV. Pooling the adjusted hazard ratio (aHR) and the 95% CI, we found that LLV increased the risk of VF with rising VL among 96,711 PLWH (aHR 2.77, 95% CI 2.03-3.76) and increased the risk of all-cause mortality at high VL levels among 14,229 PLWH (aHR 1.66, 95% CI 1.16-2.37). Therefore, the prevalence of LLV in PLWH should not be overlooked. This study aims to guide better management strategies to improve clinical outcomes in patients with LLV.

HDL-C as a novel predictor of immune reconstitution in people living with HIV: insights from a baseline-to-dynamic change cohort study in China, 2005-2022

Background

High-density lipoprotein cholesterol (HDL-C) is a well-established marker of lipid metabolism and increasingly recognized as an indicator of inflammatory status. This study investigates HDL-C's role as a predictor of immune reconstitution in people living with HIV (PLWH).

Methods

We performed a prospective cohort study of 15,434 PLWH initiating antiretroviral therapy at the Third People's Hospital of Shenzhen, China, between 2005 and 2022. Baseline quartile grouping and Group-Based Trajectory Modeling (GBTM) explored the relationship between HDL-C and immune reconstitution. Restricted cubic spline plots identified nonlinear association.

Results

Over a median follow-up of 17.9 months, 9,609 PLWH achieved the CD4+ T-cell count of 500 cells/μL or higher. Multivariate-adjusted Cox proportional hazards regression model showed that hazard ratios (HR) [95% confidence intervals (CI)] for CD4+ T-cell recovery in Q2, Q3, and Q4 versus Q1 of the HDL-C were 0.94 (95% CI: 0.88-0.99), 0.92 (95% CI: 0.87-0.98), and 0.85 (95% CI: 0.80-0.91), respectively. GBTM identified two HDL-C trajectories: Low-floating and High-floating. Relative to Low-floating, High-floating demonstrated a reduced likelihood of CD4+ T-cell recovery (HR=0.86, 95% CI: 0.82-0.90, p < 0.001). A nonlinear association was observed between HDL-C and the outcome (p for nonlinear association = 0.037, p for overall < 0.001), with a threshold at 1.13 mmol/L. Negative correlations between HDL-C and CD4+ T-cell recovery were observed both below the threshold (HR=0.72, 95% CI: 0.57-0.92) and above the threshold (HR=0.78, 95% CI: 0.69-0.87) (both p < 0.05).

Conclusions

Our study highlights HDL-C's role in immune recovery, suggesting its potential in guiding prevention and treatment strategies for PLWH.

Efficacy and Safety of Dolutegravir/Lamivudine in Antiretroviral Therapy-Naive People Living With HIV-1 and With High-Level Viremia

BACKGROUND

Dual regimen dolutegravir/lamivudine (DOL/3TC) showed potent efficacy and favorable safety in both antiretroviral therapy-naive and therapy-experienced patients, but data from real life about naive people with high-level viremia are still lacking.

METHODS

We performed a retrospective cohort study of people living with HIV who were naive to antiretroviral therapy, had baseline HIV-1 RNA ranging from 100,000 to 500,000 copies/mL, and initiated DOL/3TC. Virologic efficacy and changes in immunologic parameters after 12 months of treatment were evaluated and compared with highly viremic people living with HIV who started a triple antiretroviral combination.

RESULTS

Inclusion criteria were met by 58 patients with median age of 43.4 years. At baseline, mean HIV RNA was 5.4 log 10 and mean CD4 T lymphocyte count was 488 cells/mm 3 . HIV RNA <50 copies/mL was obtained in 45 patients (77.6% in the intention-to-treat analysis) after 6 months and in 53 patients (91.4%) after 12 months. Reasons for treatment failure were virologic failure in 2 cases and adverse events in 3 cases. No significant changes in median value of lipids were reported, while there was a not significant increase in body weight (+1.18 kg). Virologic and immunologic response at month 12 in patients on DOL/3TC was comparable with that observed in 50 naive patients with high-level viremia and starting a triple antiretroviral therapy.

CONCLUSIONS

In this real-life cohort of naive patients with high-level viremia, DOL/3TC was associated with high virologic efficacy and good tolerability after 12 months, supporting use of this dual regimen also in persons with high initial viremia.

Virological History Predicts Non-sustained Viral Suppression With Long-Acting Cabotegravir and Rilpivirine Therapy, Independent of Pharmacokinetic Parameters

BACKGROUND

This study aimed to investigate factors contributing to non-sustained viral suppression, including intermittent viremia and persistent low-level viremia, during cabotegravir (CAB) plus rilpivirine (RPV) long-acting (LA) injectable therapy, with a focus on pharmacokinetics (PK).

METHODS

A prospective cohort study was conducted on people with human immunodeficiency virus (HIV, PWH) transitioning from stable oral antiretroviral therapy (ART) to bimonthly CAB + RPV LA. Standardized follow-up included close monitoring through blood sampling for plasma human immunodeficiency virus type 1 (HIV-1) viral load (VL) and multiple plasma drug concentrations measurements to analyze the connection between PK parameters and virologic outcomes.

RESULTS

Among 173 patients with a median (interquartile range [IQR]) follow-up of 11.1(7.1-13.2) months and 789 pre-dose measurements, 38.7% experienced VL ≥ 20 copies/mL, and 16.2% had levels ≥50 copies/mL. Intermittent viremia occurred in 34.7% of patients, and persistent low-level viremia in 4%. Virological failure developed in 2 cases. Predictors of non-sustained viral suppression included VL at HIV diagnosis (adjusted hazard ratio [AHR]: 1.49 per log10 VL, 95% confidence interval [CI]: 1.04-2.12, P = .027), detectable viremia on oral ART (AHR: 2.45, 95% CI: 1.29-4.65, P = .006), and the level of viral suppression at transition (AHR: 0.38, 95% CI: .19-.75, P = .004). We found a significant association between low trough concentrations of CAB and RPV and episodes of detectable viremia exceeding 50 copies/mL. However, none of the assessed PK covariates predicted non-sustained viral suppression in multivariable models.

CONCLUSIONS

Non-sustained viral suppression in PWH transitioning from stable oral ART to CAB + RPV LA was linked to preexisting factors before transition. Higher VL pre-ART and incomplete suppression on oral therapy increased the risk, independent of PK parameters.

Effect of Machine Learning on Risk Stratification for Antiretroviral Treatment Failure in People Living with HIV

Objective

Despite the widespread use of antiretroviral therapy (ART), HIV virologic failure remains a significant global public health challenge. This study aims to develop and validate a nomogram-based scoring system to predict the incidence and determinants of virologic failure in people living with HIV (PLWH), facilitating timely interventions and reducing unnecessary transitions to second-line regimens.

Methods

A total of 9879 patients with HIV/AIDS were included. The predictive model was developed using a training cohort (N = 5,189) and validated internally (N = 2,228) and externally (N = 2,462) with independent cohorts. Multivariable logistic regression, with variables selected through least absolute shrinkage and selection operator (LASSO) regression, was employed. The final model was presented as a nomogram and transformed into a user-friendly scoring system.

Results

Key predictors in the scoring system included delayed ART initiation (6 points), poor adherence (7 points), ART discontinuation (6 points), side effects (9 points), CD4+ T cell count (10 points), and follow-up safety index (FSI) (9 points). With a cutoff of 15.5 points, the area under the curve (AUC) for the training and validation sets was 0.807, 0.784, and 0.745, respectively. The scoring system demonstrated robust diagnostic performance across cohorts.

Conclusion

This novel model provides an accurate, well-calibrated tool for predicting virologic failure at the individual level, offering valuable clinical utility in optimizing HIV management.

Efficacy and Safety Outcomes in Adults Initiating Dolutegravir/Lamivudine With High Viral Load in the GEMINI-1/-2 and STAT Trials

Through 144 weeks in GEMINI-1/-2 and 48 weeks in STAT, dolutegravir/lamivudine demonstrated high rates of virologic efficacy and a good safety profile in individuals naive to antiretroviral therapy across baseline viral load categories, including in those with very high baseline viral load (≥500 000 copies/mL). Clinical Trials Registration. NCT02831673/NCT02831764; NCT03945981.

Risk factors and clinical prediction models for low-level viremia in people living with HIV receiving antiretroviral therapy: an 11-year retrospective study

Objective

This study explores the risk factors for low-level viremia (LLV) occurrence after ART and develops a risk prediction model.

Method

Clinical data and laboratory indicators of people living with HIV (PLWH) at Hangzhou Xixi Hospital from 5 April 2011 to 29 December 2022 were collected. LASSO Cox regression and multivariate Cox regression analysis were performed to identify laboratory indicators and establish a nomogram for predicting LLV occurrence. The nomogram's discrimination and calibration were assessed via ROC curve and calibration plots. The concordance index (C-index) and decision curve analysis (DCA) were used to evaluate its effectiveness.

Result

Predictive factors, namely, age, ART delay time, white blood cell (WBC) count, baseline CD4+ T-cell count (baseline CD4), baseline viral load (baseline VL), and total bilirubin (TBIL), were incorporated into the nomogram to develop a risk prediction model. The optimal model (which includes 6 variables) had an AUC for LLV after 1-year, 3-year, and 5-year of listing of 0.68 (95% CI, 0.61-0.69), 0.69 (95% CI, 0.65-0.70), and 0.70 (95% CI, 0.66-0.71), respectively. The calibration curve showed high consistency between predicted and actual observations. The C-index and DCA indicated superior prediction performance of the nomogram. There was a significant difference in CD4 levels between LLV and non-LLV groups during the follow-up time. The dynamic SCR, ALT, TG and BG levels and occurrence of complications differed significantly between the high- and low-risk groups.

Conclusion

A simple-to-use nomogram containing 6 routinely detected variables was developed for predicting LLV occurrence in PLWH after ART.

Clinical, molecular, and drug resistance epidemiology of HIV in Jordan, 2019-2021: A national study

BACKGROUND

Limited epidemiologic studies have been conducted in Jordan describing the HIV epidemic. This study aimed to address this gap to inform HIV prevention and control.

METHODS

A nationally-representative cross-sectional study was conducted among adults living with HIV in Jordan. Laboratory testing included HIV viral load and next-generation-sequencing-based clinical genotype. Log-binomial regression estimated risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Among 231 (70%) participants, most were male (184/80%), and from Jordan (217/94%). Among 188 treatment-experienced-participants (>6 months), 165 (88%) were virally suppressed. High-level resistance was most frequent against nucleoside reverse transcriptase inhibitor (13/81%), and integrase-strand transfer inhibitor (INSTI) (10/62%) drugs among viremic (≥1000 HIV copies/mL) treatment-experienced participants with drug-resistant mutations (DRMs, n = 16). Common HIV subtypes (n = 43) were B (6/14%), A1 (5/12%), and CRF01_AE (5/12%); additionally, novel recombinant forms were detected. In multivariate analysis, independently higher risk for late diagnosis (n = 49) was observed with diagnosis through blood donation (vs check-up: RR 2.20, 95%CI 1.16-4.17) and earlier time-period of diagnosis (1986-2014 vs 2015-2021: RR 2.87, 95%CI 1.46-5.62).

CONCLUSIONS

Late diagnosis and INSTI resistance endanger national HIV prevention and treatment in Jordan-high-level resistance to INSTI suggests therapeutic drug monitoring is needed for treatment efficacy and conservation of treatment options.

Characteristics of drug resistance mutations in ART-experienced HIV-1 patients with low-level viremia in Zhengzhou City, China

Although most people living with HIV (PLWH) receiving antiretroviral therapy (ART) achieve continuous viral suppression, some show detectable HIV RNA as low-level viremia (LLV) (50-999 copies/mL). Drug resistance mutations (DRMs) in PLWH with LLV is of particular concern as which may lead to treatment failure. In this study, we investigated the prevalence of LLV and LLV-associated DRMs in PLWH in Zhengzhou City, China. Of 3616 ART-experienced PLWH in a long-term follow-up cohort from Jan 2022 to Aug 2023, 120 were identified as having LLV. Of these PLWH with LLV, we obtained partial pol and integrase sequences from 104 (70 from HIV-1 RNA and 34 from proviral DNA) individuals. DRMs were identified in 44 individuals. Subtyping analysis indicated that the top three subtypes were B (48.08%, 50/104), CRF07_BC (31.73%, 33/104), and CRF01_AE (15.38%, 16/104). The proportions of nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and integrase strand transfer inhibitors (INSTIs) associated DRMs were 23.83% (24/104), 35.58% (37/104), 5.77% (6/104), and 3.85% (4/104), respectively, which contributed to an overall prevalence of 42.31% (44/104). When analyzed by individual DRMs, the most common mutation(s) were V184 (18.27%, 19/104), followed by V179 (11.54%, 12/104), K103 (9.62%, 10/104), Y181 (9.62%, 10/104), M41 (7.69%, 8/104), and K65R (7.69%, 8/104). The prevalence of DRMs in ART-experienced PLWH with LLV is high in Zhengzhou City and continuous surveillance can facilitate early intervention and provision of effective treatment.

Detectable Virological Load and Associated Factors among People Living with HIV on Antiretroviral Treatment: A Retrospective Study

The complete and prolonged suppression of viral load is the primary objective of HAART in people living with HIV. Some people may experience therapeutic failure, while others may achieve virological suppression but are unable to maintain it, developing persistent or single detection of low-level viremia. This study aims to evaluate the determinants of a detectable viral load among patients on HAART to identify and address them promptly. In this retrospective study, all patients referring to the Infectious Disease Operative Unit of the Vito Fazzi Hospital in Lecce, Puglia, older than 18 years, receiving HAART for at least 12 months as of 30 June 2022, were included. For each patient, demographic characteristics such as age, sex, educational level, stable relationship, cohabitation, employment status, and information relating to habits and lifestyles such as physical activity, use of drugs, and substances or supplements for sport, abuse of alcohol, and smoking were collected. Degree of comorbidity was quantified according to the Charlson Comorbidity Index, and the presence of obesity and the COVID-19 infection was also considered. Univariable and multivariable logistic regression models were used to assess the association between patients' characteristics and the outcome. In the multivariable logistic regression model, the odds were lower for the duration of therapy (OR: 0.96; p = 0.0397), prescriber's perception of adherence to therapy (OR: 0.50; p < 0.0001), and Nadir CD4+ T-cell count (OR: 0.85; p = 0.0329), and higher for the presence of AIDS (OR: 1.89; p = 0.0423) and COVID-19 (OR: 2.31; p = 0.0182). Our findings support the early initiation of HAART to achieve virological suppression. Additionally, measures to improve adherence to therapy should be adopted to ensure better outcomes for patients.

Clinical significance and management of low-level HIV viremia in the era of integrase strand transfer inhibitors

BACKGROUND

People living with HIV (PLWH) and receiving antiretroviral therapy (ART) have a goal of achieving and maintaining viral suppression; however, the existence of PLWH that show events of low-level viremia (LLV) between 50 and 1000 copies/mL and with different virological consequences have been observed. Moreover, some reports indicate that LLV status can lead to residual immune activation and inflammation, leading to a higher occurrence of non-AIDS-defining events (nADEs) and other adverse clinical outcomes. Until now, however, published data have shown controversial results that hinder understanding of this phenomenon's actual cause(s) and origin(s). Integrase strand transfer inhibitors (INSTIs)-based therapies could lead to lower LLV over time and, therefore, more effective virological control.

OBJECTIVES

This review aims to assess recent findings to provide a view of the clinical significance and management of low-level HIV viremia in the era of INSTIs.

Investigating rates and predictors of viral blips, low-level viraemia and virological failure in the Australian HIV observational database

OBJECTIVES

Australia has made significant progress towards achieving the UNAIDS's 95-95-95 cascade targets including HIV viral suppression. To investigate the burden of HIV viraemia, we assessed viral blips, low-level viraemia (LLV) and virologic failure (VF) in an Australian cohort.

METHODS

We studied the proportion of people with viral suppression, viral blips, LLV and VF in the Australian HIV observational database (AHOD) between 2010 and 2021. The association between blips or LLV, and VF was investigated using Cox regression, and predictors of viral blips and LLV were assessed using repeated-measured logistic regression.

RESULTS

Among 2544 AHOD participants who were in follow-up and on antiretroviral therapy (ART) from 1 January 2010 (88.7% male), 444 had experienced VF (incidence rate: 2.45 [95% CI: 2.23-2.69] per 100 person-years [PY]) during 18,125 PY of follow-up (a median of 7.6 years). The proportion of people with VF decreased over time, whereas rates of blips and LLV remained stable. Participants with blips (hazard ratio, 2.89; 95% CI: 2.31-3.61) and LLV (4.46; 95% CI: 3.38-5.89) were at increased risk of VF. Hepatitis B co-infection, longer documented treatment interruption duration, younger age and lower CD4 at ART initiation, and protease inhibitors-based initial regimen were associated with an increased risk of VF. Common predictors of blips and LLV such as higher HIV-1 RNA and lower CD4 at ART initiation, longer treatment interruption, more VL testing and types of care settings (hospitals vs. sexual health services) were identified.

CONCLUSIONS

Blips and LLV predict subsequent VF development. We identified important predictors of HIV viraemia including VF among individuals on INSTI-based regimens to help direct HIV management plans.

Integrated analysis of viral blips, residual viremia, and associated factors in people with HIV: Results from a retrospective cohort study

The etiology of viral blips is not yet fully elucidated. One of the hypotheses is that blips reflect variations in residual viremia (RV) near the detectability threshold. In this study, we evaluated whether RV is associated with viral blips and which factors are associated with RV. All treatment regimens in 2010-2020 consisting of two nucleos(-t)ide reverse transcriptase inhibitors and one anchor (integrase strand transfer inhibitor [INSTI], non-nucleoside reverse transcriptase inhibitor [NNRTI], or protease inhibitor [PI]) in people with HIV (PWH) were evaluated for RV (detectable viremia <50 cp/mL) and blips (isolated viral loads [VLs] 50-499 cp/mL between measurements <50 cp/mL). All medical records were reviewed and regimens in which a VL ≥ 50 cp/mL was deemed to result from non-adherence (based on the documented conclusion by the treating physician) were excluded. Factors associated with blips and RV were identified using generalized linear mixed models. In total, 24 518 VLs from 1658 PWH were analyzed. VLs were measured during INSTI- (n = 5119; 20.9%), PI- (n = 8935; 36.4%), and NNRTI-use (n = 10 464; 42.7%). VLs were categorized as blips in 1.4% (n = 332). The 24,186 non-blip VLs were RNAneg (no RV) (n = 15 326; 63.4%), 1-19 cp/mL (n = 6318; 26.1%), 20-49 cp/mL (n = 1620; 6.7%), or <50 cp/mL with an unknown RV level (n = 922; 3.8%). In 193/1658 PWH (11.6%), the RV level was RNAneg in all VLs assessed. RV 1-19 cp/mL and 20-49 cp/mL (vs. RNAneg ) were significantly associated with subsequent viral blips (respective odds ratio 2.66 and 4.90 [95% confidence intervals: 1.98-3.58 and 3.41-7.04]). Zenith VL and use of PIs (vs. INSTIs/NNRTIs) were associated with higher RV and blip odds. This large cohort study showed that blips were associated with higher preceding RV. Both the anchor type and factors previously linked to the latent viral reservoir were associated with RV, suggesting blips having a multifactorial origin.

HIV drug resistance in the era of contemporary antiretroviral therapy: A clinical perspective

Contemporary antiretroviral therapy (ART) regimens have high barriers to the development of drug resistance. However, resistance to earlier antiretrovirals and uncommon cases of resistance to contemporary ART illustrate the continued need for good clinical management of HIV drug resistance. Here, we describe HIV drug-resistance mechanisms, the interaction of HIV drug-resistant mutations and the patterns of drug resistance to contemporary ART. We then provide guidance on the management of HIV drug resistance, including how to limit the development of resistance and manage virologic failure that is complicated by resistance. To complement this, links to resources and treatment guidelines are provided that can assist with the interpretation of HIV drug resistance test results and optimal ART selection in the clinic.