{"id":54062,"date":"2026-06-12T15:15:47","date_gmt":"2026-06-12T15:15:47","guid":{"rendered":"https:\/\/i-base.info\/htb\/?p=54062"},"modified":"2026-06-12T16:26:54","modified_gmt":"2026-06-12T16:26:54","slug":"consensus-guidelines-on-the-management-of-persistent-low-level-viral-load-in-people-living-with-hiv-2026","status":"publish","type":"post","link":"https:\/\/i-base.info\/htb\/54062","title":{"rendered":"New guidelines on persistent low-level viral load in people living with HIV (2026)"},"content":{"rendered":"<p><strong>Simon Collins, HIV i-Base<\/strong><\/p>\n<p><strong>New consensus guidelines on the definition and management of persistent low-level viraemia (LLV) have been developed by an international panel of more than 100 experts and are now published in Lancet HIV. [1]<\/strong><\/p>\n<p>Recommendations were developed following a scoping review that included 84 published papers on LLV and a questionnaire and Delphi panel discussions on key issues about definitions and management. Recommendations are based on the GRADE scale and consensus was defined as &gt;70% agreement with &gt;90% defined as a very high level of agreement.<\/p>\n<p>LLV is broadly defined as persistent viral load between 200 and 1000 copies\/mL and the guidelines provide practical guidance in deciding ongoing risk and management options. These include:<\/p>\n<ul>\n<li>Confirmation and further viral load and\/or resistance testing (when available).<\/li>\n<li>Deciding when LLV is due to viral replication vs ongoing replication.<\/li>\n<li>Management of drug resistance, including the M184V mutation in presence of 3TC or FTC.<\/li>\n<li>Adherence support &#8211; including impact on doctor\/patient relationship.<\/li>\n<li>Potential drug interactions &#8211; including with long-acting drugs.<\/li>\n<li>A broader clinical evaluation, including the role of compartmental reservoirs, including with neurological symptoms.<\/li>\n<li>Treatment switching and optimisation including when this is and isn\u2019t likely to help.<\/li>\n<li>Concerns for prevention and risk of ongoing transmission.<\/li>\n<\/ul>\n<p>The guidelines include the important differentiation between LLV being caused by viral production rather than ongoing viral replication and the differences in implications for clinical management. See Table 1.<\/p>\n<p>Importantly, viral production from latently infected cells is not related to adherence, doesn\u2019t carry a risk of developing drug resistance and won\u2019t respond to changing or intensifying of ART.<\/p>\n<p><strong>Table 1: Mechanisms and management of LLV<\/strong><\/p>\n<table>\n<tbody>\n<tr>\n<td width=\"141\">Cause of LLV<\/td>\n<td width=\"259\">Mechanism<\/td>\n<td width=\"200\">Management<\/td>\n<\/tr>\n<tr>\n<td width=\"141\">Viral production (non-suppressible viraemia)<\/td>\n<td width=\"259\">Latently infected cells are activated and produce viral RNA, proteins, or HIV particles, but new cells do not become infected due to the presence of ART\u00a0or because the produced virus is replication incompetent (defective).<\/td>\n<td width=\"200\">LLV will not be affected by switching or intensifying ART. There is no ongoing risk of viral evolution and drug resistance.<\/td>\n<\/tr>\n<tr>\n<td width=\"141\">Viral replication (suppressible viraemia)<\/td>\n<td width=\"259\">Replication is linked to sub-optimal ART caused by low adherence, new drug interactions, or development of drug resistance. New CD4 cells become infected and new replication cycles occur, resulting in viral evolution and risk of drug resistance.<\/td>\n<td width=\"200\">Interventions included dherence support, potential new drug interactions, drug resistance testing and switching\/intensifying ART to resuppress viral load.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>The guidelines recognise that differences in health facilities and health care structures limit approaches in different settings where LLV will carry different priorities.<\/p>\n<p>The document also discusses current knowledge gaps including:<\/p>\n<ul>\n<li>Best strategies to prevent viral failure with LLV.<\/li>\n<li>Whether proviral resistance testing can improve clinical outcomes.<\/li>\n<li>Better ways to distinguish LLV due to ongoing replication or clonal expansion.<\/li>\n<li>Defining viral load thresholds associated with viral failure with dolutegravir- and bictegravir-based ART.<\/li>\n<li>Understanding the psychological and behavioural impact of LLV.<\/li>\n<li>Whether the size of the viral reservoir is linked to risk of LLV.<\/li>\n<\/ul>\n<p>The guidelines are currently available free using the link below until the end of July 2026 without registration.<\/p>\n<h3>comment<\/h3>\n<p><strong>These guidelines are welcomed as LLV is one of the most difficult clinical challenges in the management of people on ART.<\/strong><\/p>\n<p><strong>One of the complications includes the growing awareness of relatively recent research showing different mechanisms unrelated to sub-optimal ART including from low adherence. [2]<\/strong><\/p>\n<p><strong>Although concerns over adherence can lead to re-suppression when LLV is linked to ongoing viral replication, this needs to be approached in a non-confrontational way to maintain the important trust in the relationship between a health provider and people living with HIV and receiving care.<\/strong><\/p>\n<p><em>Simon Collins was a community representative on the writing group for these guidelines.<\/em><\/p>\n<p>Reference<\/p>\n<ol>\n<li>Clemente T et al for the International Consensus Group on Clinical Management of Low-Level Viremia. Guidance on the clinical management of HIV-1 persistent low-level viraemia on antiretroviral treatment: a scoping review and an international Delphi consensus. The Lancet HIV. (11 June 2026).<br \/>\n<a href=\"https:\/\/doi.org\/10.1016\/S2352-3018(26)00107-4\">https:\/\/doi.org\/10.1016\/S2352-3018(26)00107-4<\/a><br \/>\n<a href=\"https:\/\/authors.elsevier.com\/c\/1nFoh8MsVolaYo\">https:\/\/authors.elsevier.com\/c\/1nFoh8MsVolaYo<\/a>\u00a0(free access until 31 July 2026)<\/li>\n<li>Viral reservoir can explain persistent low level viraemia with good adherence on ART. HTB (12 March 2019).<br \/>\n<a href=\"https:\/\/i-base.info\/htb\/35801\">https:\/\/i-base.info\/htb\/35801<\/a><\/li>\n<\/ol>\n<p>\n<\/p>","protected":false},"excerpt":{"rendered":"<p>Simon Collins, HIV i-Base New consensus guidelines on the definition and management of persistent low-level viraemia (LLV) have been developed by an international panel of more than 100 experts and are now published in Lancet HIV. [1] Recommendations were developed &hellip;<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[163,41,23,36],"tags":[],"class_list":["post-54062","post","type-post","status-publish","format-standard","hentry","category-early-access","category-treatment-strategies","category-guidelines","category-drug-resistance"],"_links":{"self":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/54062","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/comments?post=54062"}],"version-history":[{"count":7,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/54062\/revisions"}],"predecessor-version":[{"id":54069,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/54062\/revisions\/54069"}],"wp:attachment":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/media?parent=54062"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/categories?post=54062"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/tags?post=54062"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}