U.S. HIV Group Spends 25% of Time With High Viral Load

November 2015

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Statistical analysis that accounts for several viral load risk factors at the same time linked being in some of these groups with a longer time above 1500 copies, regardless of whatever other risk factors someone had. The analysis expresses differences between groups as an adjusted rate ratio (aRR). An aRR above 1.0 indicates longer time with a viral load above 1500 when comparing one group with another, and an aRR below 1.0 indicates shorter time with a viral load above 1500. For example, a rate ratio of 1.38 (16- to 39-year-olds versus 40- to 49-year-olds in the list below) means the younger groups spent 38% more time with a viral load above 1500 copies than the older group, regardless of other factors that might affect viral load.

  • First measured viral load above 1500 versus below 1500: aRR 4.03
  • More than 25% of viral load pairs measured more than 6 months apart versus 10% to 25% of viral load pairs measured more than 6 months apart: aRR 2.04
  • More than 25% of viral load pairs measured more than 6 months apart versus fewer than 10% of viral load pairs measured more than 6 months apart: aRR 1.52
  • CD4 count below 350 versus above 350 at first viral load measure: aRR 1.15
  • 16 to 39 years old versus 50 to 85 years old: aRR 1.38
  • 40 to 49 years old versus 50 to 85 years old: aRR 1.18
  • Black versus white: aRR 1.24
  • Gay/bisexual men versus heterosexual men: aRR 0.94 (6% less time spent above 1500 by gays)
  • Injection drug use versus no injection drug use: aRR 1.21
  • Ryan White/charity support versus private insurance: aRR 1.33
  • Medicaid versus private insurance: aRR 1.40
  • Medicare versus private insurance: aRR 1.29

The study included 1779 trial participants in the additional analysis of how antiretroviral use affected time spent with a viral load above 1500 copies. Trial participants were similar to the larger observational group (discussed just above) in age, sexual orientation, CD4 count, and most other factors except for race: 72% of trial participants were black, compared with 64% of the observational cohort. The median observation period in trial participants measured 1032 days, and these people had a median of 11 viral load measures.

Among all trial participants, viral load exceeded 1500 copies 26% of the time per person, or 95 days per year per person. This rate is similar to the 23% seen with the observational cohort (above). People not taking antiretroviral therapy when they entered the study period or in the next 12 months spent 58% of their time with a viral load above 1500 copies. In contrast, people who started antiretroviral therapy in the first 12 months of observation time spent 45% of their time with a viral load above 1500. And people already taking antiretrovirals when they entered the study spent 21% of their time with a viral load topping 1500. People who had just begun care at one of the six clinics spent 34% of their time with a viral load exceeding 1500 copies.


What the Results Mean for You

This large study of HIV-positive people in care in the United States found that they spent about 25% of the time with a viral load above 1500 copies -- even though 90% took antiretroviral therapy at some point. A viral load above 1500 copies signals a higher chance of passing HIV to a sex partner and so contributing to the almost 50,000 new HIV infections seen yearly in the United States. Time spent with a viral load above 1500 copies was even greater -- 58% -- in people not taking antiretroviral therapy.

Only about 10% of this study group did not take antiretroviral therapy during the study period. That low percentage reflects advice from U.S. HIV treatment experts, who recommend that everyone with HIV infection start therapy regardless of their CD4 count or viral load.5 Antiretroviral combinations available today are stronger, safer, and easier to take than combinations available 10 or 15 years ago. If everyone in this study group took antiretrovirals and didn't miss many doses, the average time spent with a viral load topping 1500 copies would be lower -- and so the group's overall risk of spreading HIV infection would be lower.

Besides this community-wide benefit of having a viral load below 1500, having a lower load (and higher CD4 count) cuts chances that the individual patient will get AIDS diseases and some non-AIDS diseases. The antiretroviral treatment goal for anyone taking antiretroviral therapy should be a viral load below 40 or 50 copies. A load that low means HIV has stopped multiplying in the body, although HIV remains in resting T cells and will become active again if antiretroviral therapy stops.

The study also identified several groups that spent more time with a viral load over 1500 than comparison groups:

  • People not taking antiretrovirals (almost everyone not on treatment will have a detectable viral load, and often a high viral load)
  • People who go a longer time between viral load measures (possibly because they are missing clinic appointments)
  • People younger than 40 (a group that sometimes fails to take antiretroviral drugs regularly)
  • Blacks (perhaps because of poor access to health care)
  • People without private health insurance (who are poorer and so may have poor access to health care and more overall health problems than wealthier people)

Despite possible social and economic disadvantages, people in these groups should find the motivation to get care for their HIV infection, stay in care, start antiretroviral therapy, and take antiretrovirals on time, as their provider instructs. HIV providers can connect patients with a case manager, who will help with problems involving insurance, transportation, and child care. People who follow those steps are now living almost as long -- or as long as -- people without HIV infection. At the same time they're cutting the chance of passing HIV to sex partners.

A final note: having a low or undetectable viral load does not eliminate the chance of passing HIV to sex partners. Everyone with HIV should use condoms during sex -- to prevent transmission of HIV as well as other dangerous sexually transmitted infections. Condoms also protect the HIV-positive partner from picking up dangerous sexually transmitted diseases.


  1. Marks G, Gardner LI, Rose CE, et al. Time above 1500 copies: a viral load measure for assessing transmission risk of HIV-positive patients in care. AIDS. 2015;29:947-954.
  2. Attia S, Egger M, Muller M, Zwahlen M, Low N. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23:1397-1404.
  3. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921-929.
  4. Tovanabutra S, Robison V, Wongtrakul J, et al. Male viral load and heterosexual transmission of HIV-1 subtype E in northern Thailand. J Acquir Immune Defic Syndr. 2002;29:275-283.
  5. HHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Last updated April 8, 2015.
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This article was provided by The Center for AIDS Information & Advocacy. It is a part of the publication HIV Treatment ALERTS!. Visit CFA's website to find out more about their activities and publications.

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