Management of Detectable HIV RNA in Patients on Antiretroviral Therapy

Defining Virologic Failure

The International Antiviral Society-USA (IAS-USA) defines virologic failure as HIV RNA >200 copies/mL on at least two consecutive measurements, with the American College of Physicians recommending confirmation before any treatment modification 1, 2, 3
A single detectable HIV RNA value between 50-200 copies/mL may represent a "blip" rather than true virologic failure, according to the IAS-USA guidelines 2, 3
Virologic blips rarely progress to virologic failure, and switching antiretroviral therapy (ART) in this setting is not recommended by the IAS-USA 2, 3

The Centers for Disease Control and Prevention (CDC) recommend obtaining a confirmatory HIV RNA measurement within 4 weeks to assess for true virologic failure 1
Poor adherence is the most common cause of detectable viremia, and evaluating barriers to adherence is crucial, including medication access and affordability, dosing schedule conflicts, and psychosocial factors, as suggested by the World Health Organization (WHO) 1, 2, 3
Recent infections or vaccinations can cause transient increases in HIV RNA, which do not represent true virologic failure, according to the CDC 1, 4, 5, 6, 7

The IAS-USA recommends considering changing therapy only if confirmed virologic failure occurs, defined as HIV RNA >200 copies/mL on two consecutive measurements separated by at least 4 weeks 1, 2, 3
If confirmed failure develops, the IAS-USA suggests obtaining HIV genotype testing, including integrase resistance testing, while the patient remains on the failing regimen 1, 2
For integrase inhibitor failure with resistance mutations, the IAS-USA recommends considering alternative regimens, such as dolutegravir or a boosted PI regimen with 2 NRTIs, as suggested by the European AIDS Clinical Society (EACS) 2

The IAS-USA states that no specific modifications to HIV treatment guidelines are needed based on transgender status alone, but ensuring no drug-drug interactions with gender-affirming hormone therapy is essential, as recommended by the WHO 1, 2, 3
Biktarvy's minimal interaction profile makes it particularly suitable when multiple medications are used, according to the IAS-USA 8

The CDC recommends repeating HIV RNA in 4 weeks, and if the repeat value is <50 copies/mL, resuming routine monitoring every 3-6 months, as suggested by the American College of Physicians 1, 9
If the repeat value remains 50-200 copies/mL, the CDC suggests continuing the current regimen with intensive adherence support and close monitoring 1
Only if HIV RNA rises to >200 copies/mL on repeat testing should resistance testing and regimen change be considered, according to the IAS-USA 1, 2, 3