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

Clemente, Tommaso ; Stam, Arjen J ; Elvstam, Olof LU orcid ; Geretti, Anna Maria ; Harrigan, Richard ; Parczewski, Milosz ; Mackie, Nicola E ; Spagnuolo, Vincenzo ; Hofstra, Marije and Venter, Francois , et al. (2026) In The Lancet HIV
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... (More)

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.

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publication status
epub
subject
in
The Lancet HIV
publisher
Lancet Publishing Group
external identifiers
  • pmid:42276093
ISSN
2352-3018
DOI
10.1016/S2352-3018(26)00107-4
language
English
LU publication?
yes
additional info
Copyright © 2026 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.
id
e4ce1a9a-5df8-40ee-881b-137ee13bf8c6
date added to LUP
2026-06-12 08:21:50
date last changed
2026-06-17 12:37:12
@article{e4ce1a9a-5df8-40ee-881b-137ee13bf8c6,
  abstract     = {{<p>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.</p>}},
  author       = {{Clemente, Tommaso and Stam, Arjen J and Elvstam, Olof and Geretti, Anna Maria and Harrigan, Richard and Parczewski, Milosz and Mackie, Nicola E and Spagnuolo, Vincenzo and Hofstra, Marije and Venter, Francois and Kuritzkes, Daniel R and Llibre, Josep M and Shafer, Robert W and Schapiro, Jonathan and Martinez, Esteban and Kityo-Mutuluuza, Cissy and Nijhuis, Monique and Björkman, Per and Charpentier, Charlotte and Collins, Simon and Günthard, Huldrych F and Cecchini, Diego and Castagna, Antonella and Brusselaers, Nele and Wensing, Annemarie Mj}},
  issn         = {{2352-3018}},
  language     = {{eng}},
  month        = {{06}},
  publisher    = {{Lancet Publishing Group}},
  series       = {{The Lancet HIV}},
  title        = {{Guidance on the clinical management of HIV-1 persistent low-level viraemia on antiretroviral treatment : a scoping review and an international Delphi consensus}},
  url          = {{http://dx.doi.org/10.1016/S2352-3018(26)00107-4}},
  doi          = {{10.1016/S2352-3018(26)00107-4}},
  year         = {{2026}},
}