Q and A

Question

How quickly does viral load drop on treatment?

I’ve been trying to understand on average, the daily rate of decrease in viral load following initial treatment.

I’m guessing that this changes over time and varies from case to case according to the chosen treatment, CD4 count and viral load level and possibly other factors.

However, supposing that the viral load is around 100,000, the CD4 count is around 400 and the treatment used is Atripla, could anyone please let me know the expected % decrease of viral load level per day at least within the 1st month of treatment?

Thank you for the help.

Answer

All HIV combinations (ART) quickly reduce viral load. ART starts working from the first dose Viral load is usually reduced by 90% (also referred to as 1 log) within the first few days. It then continues to fall but not as quickly (see below) until it becomes undetectable.

A log is a number mulitplied to the power of 10. So with a viral load of 100,000 copies/mL, a 1-log reduction would bring your viral load down to 10,000 copies/mL and a 3-log reduction would reduce it to 100 copies/mL. (See this factsheet).

You are right that individual factors will lead to difference rates of viral load reductions. These include:

  • How high your viral load was when you start ART.
  • The medicines in the combination (integrase inhibitors casuing the fastest drops).
  • The drug levels of this meds (related to adherence and how they absorb and processes drugs).
  • Good adherence – not missing doses.

UK and US guidelines recommend that your viral load should be undetectable within three months. However, many people achieve this within the first month, especailly if they are using an integrase inhibitor.

Some people take longer, especially if their viral load is very high when they start treatment.

Lots of studies have reported detailed early responses ART, including for efavirenz-based combinations like Atripla.

This decline is often referred to as having three main phases.

The first phase is very rapid – referred to in some studies as being the first few days and in others as within the first two weeks. This is where the actively infected CD4 cells are targeted. CD4 cells infected with HIV only live for a few days and when you start treatment this virus and these cells are quickly reduced.

This results in a viral load drop of perhaps 99% (2 logs) within two weeks.

The second phase, out to the first month is slower, as it is working on cells that live longer. This can easily reduce viral by another 90% (another 1 log reduction). In people with very high viral loads when they start treatment, this second phase may continue for longer until viral load becomes undetectable.

Some researchers also talk about a third phase decline which occurs even more slowly and gradually once your viral load is undetectable.

This relates to a reduction in the levels of infected CD4 cells that are latent (or resting). This pool of cells only slowly decreases over time.

This link is to a study from 2006 in people using efavirenz-based combinations. It reports an average viral load reduction of 1.9 logs after only 10 days on treatment.

This link is to an early study describing the two-phase viral load reductions.

This answer was updated in January 2016 from a question first posted on 15 September 2012.


Information on this website is provided by treatment advocates and offered as a guide only. Decisions about your treatment should always be taken in consultation with your doctor.

35 comments

  1. Hi Nono – there is no difference between 46 and 70 – these are still tiny levels. The US defines undetectable as anything below 200. This will not have any risk.

  2. Nono

    Hi my husband and I are in the process of IVF bu his rival load went from 46 to 76 what natural supplements can we use to lower it quickly to below 20 he is on Atripla.

  3. Roy Trevelion

    Dry skin can be a problem for HIV positive people, but this is often more related to HIV than HIV meds.

    In this guide you can find some tips for rash. They are as useful for dry skin too.

    Using moisturisers, such as aqueous cream and diprobase can help. And drinking plenty of fluids and eating a healthy diet for vitamins and minerals can improve your dry skin as well.

  4. Chidi

    I’m not sure but I feel my palms and feet are somewhat dried than usual whenever I rub them together since I started meds. Could this drugs be the reason? It happens sometimes and I’m wondering why. It could be my mind playing tricks but does the drugs make such happen? And again, I have lost weight that people see me and ask “hey u r reducing” Could this be the meds.

  5. Hi, HIV drugs are generally very safe for your liver. My main caution is if your liver is already damaged of ir you have viral hepatitis. Very rarely liver problmes occur, but routine monitoring should check your liver enzyme levesl are good.

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