Low Level Viremia Among People Living with HIV-1 in Nigeria

Background: HIV transmission can occur with viral load (VL) ≥200 copies/mL and low-level viremia (LLV) can lead to virologic failure; the level at which risk for virologic failure is conferred is uncertain. To better understand LLV prevalence and outcomes, we analyzed retrospective longitudinal data from a large cohort of people living with HIV (PLHIV) on ART in Nigeria.Methods: We estimated rates of virologic suppression (≤50 copies/mL), LLV (51–999 copies/mL), virologic non-suppression (≥1,000 copies/mL), and virologic failure (≥2 consecutive virologic non-suppression results) among PLHIV ≥18 years who initiated and received ≥24 weeks of ART during 2016–2021. We analyzed risk for LLV, virologic non-suppression, and virologic failure using log-binomial regression and mixed-effects logistic regression.Results: At first VL, LLV and virologic non-suppression occurred in 16.8% and 13.1%, respectively, of 402,668 patients. Patients with LLV had increased risk of virologic failure (aRR 2.20, CI 1.98 –2.43). Compared to patients with virologic suppression, patients with LLV, even at 51–199 copies/mL, had increased odds of LLV and virologic non-suppression at next viral load; patients on optimized ART (i.e., integrase strand transfer inhibitors [INSTIs]) exhibited lower odds than those on non-INSTIs for the same LLV range (e.g., VL ≥1,000 copies/mL following VL 400–999 copies/mL, INSTI: aOR 1.96, CI 1.79–2.13; non-INSTI: aOR 3.21, CI 2.90–3.55).Conclusions: Patients with LLV had increased risk of virologic non-suppression and failure. Programs should revise monitoring benchmarks and targets from <1,000 copies/mL to <50 copies/mL to strengthen clinical outcomes and track progress to epidemic control.Funding Information: No specific funding was received for the analysis. HIV program support was provided by the President’s Emergency Plan for AIDS Relief through the CDC.Declaration of Interests: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.Ethics Approval Statement: The study received ethical approval from the Nigeria National Health Research Ethics Committee, the Institutional Review Board of University of Maryland, Baltimore, and was reviewed in accordance with the U.S. Centers for Disease Control and Prevention (CDC) human research protection procedures and was determined to be non-research.