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) 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 an early study describing the two-phase viral load reductions.

This answer was updated in July 2020 from a question first posted on 15 September 2012.

293 comments

  1. Josh Peasegood

    Hi Naledi, this depends on their viral load. If it is below 200 there is no risk of transmission. This is proven by U=U: https://i-base.info/guides/testing/uu-undetectable-untransmittable

    Even if the viral load is not below 200, but still suppressed, the risk of transmission is still greatly reduced. Each exposure carries it’s own risk and this is further explained here: https://i-base.info/guides/testing/risks-for-transmission

  2. Naledi

    Hi.when an HIV positive person on ARV insert his penis in a Virgina and pulls if off without ejaculating can he infect his partner.

  3. Josh Peasegood

    Hi Danzy, yes it is possible you have an undetectable viral load. Guidelines suggest an undetectable viral load is often achieved within 3 months but for most this is within the first month. If you are undetectable when you ejaculated on your partners vagina they will not get HIV. If you are not undetectable there is a risk of them transmitting HIV. There is risk of HIV transmission regardless of ejaculation, though ejaculating will increase risk.

    Strict adherence is excellent. This is the best way to manage HIV. becoming undetectable and keeping your CD4 count high. Are you able to access a health clinic that will be able to test your viral load? Until you have a test to determine this you cannot consider yourself undetectable. Have you considered sex with a condom prior to finding out? If you do it prevents the risk of HIV transmission and other STIs.

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