Management of Viral Load Blips on Antiretroviral Therapy

Definition and Clinical Significance

A virological blip is defined as an isolated increase in HIV RNA levels to <1000 copies/mL with a return to undetectable levels while receiving ART, and is rarely associated with progression to virological failure, according to the American Medical Association 1, 2
Virological failure, in contrast, requires a confirmed HIV RNA level above 200 copies/mL on 2 consecutive measurements, as defined by the American Medical Association 1, 2

For a single blip <1000 copies/mL, the American Medical Association recommends not switching therapy immediately, assessing adherence rigorously, and repeating viral load testing to confirm return to undetectable levels 1, 2
The Centers for Disease Control and Prevention recommends considering resistance testing only if the blip is followed by persistent detectable viremia, there is a pattern of increasing viral loads, or clinical or immunologic deterioration occurs 2, 4
For confirmed virological failure, the American Medical Association recommends that dolutegravir plus 1 or 2 active NRTIs is superior to lopinavir plus 2 NRTIs, regardless of the presence of M184V mutation, and that resistance testing should guide the new regimen selection 1, 2

The American Medical Association notes that the M184V mutation is found in 80% of patients failing NNRTI-based regimens, making lamivudine resistance common in this setting 1, 2
The American Medical Association also recommends that current guidelines prefer integrase inhibitor-based regimens, such as dolutegravir or bictegravir, due to superior efficacy, tolerability, and higher genetic barrier to resistance 5, 3