Question
How quickly does viral load drop on treatment?
5 July 2020. Related: All topics, CD4 and viral load, Starting 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.
Hi, I found out at 7months of pregnancy that m HIV positive and by that time my viral load was 42279, so been wondering that so far how many logs did my virus decreased, I started at 26 march
Hi Cain,
When someone starts taking ARVs their viral load should become undetectable within 1-3 months of starting treatment. How long have you been on meds for?
This is really interesting. I’m on tivicay 50mg and emtricitabine/tenovofir disoproxil 200mg/245mg the starting viral load of 5171 and cd4 if 81 before starting treatment. What would you think my viral load would be now or how long will it take to become undetectable?
Hi Angel, thanks. How many viral load results has you partner have. When were they diagnosed and when did they start treatment?
You are right that without knowing what this was before starting ART, it is difficult to interpret these results.
Talking to your partner is important. They might have been taking every dose, but just started with a very high viral load before treatment.
I want to ask that is it possible for a viral load to decrease if it’s abt 11,000. Does this means that my partner has defaulted or what? One problem is just we don’t know the viral load b4 taking the treatment.
Hi Grace,
ARVs need to be taken daily. If your husband is missing 3 doses a week he’s risking his health. His HIV won’t be controlled if he doesn’t take his meds daily. He’s at risk of developing resistance to his medication (this is, if he hasn’t already) and his viral load rising. If he’s having issues with adherence this is something to talk to his doctor about. He might also need some support with his drinking.
Hie, my husband always skip drugs 3 days a week, or let me say every week end coz he takes alcohol too much, so can this affect his drug reaction?
Thanks
Hi Stephen,
No this isn’t something that you should be worried about as your viral load wouldn’t have rebounded in 3 days. Also as your partner is using PrEP, (as long as they are using it correctly) even if your viral load had rebounded they’d be protected as that’s what PrEP is for.
I am undetectable and on Biktarvy but missed 3 days of ARV. I continued adhering to the regimen thereafter. My HIV negative long distance partner on Descovy PreP came for a surprise visit a month after my missed doses and we had sex, but now he’s worried that I might’ve been detectable after missing 3 doses even after a month of adherence in between. Is this something we should be worried about?
Hi Azola,
Viral loads don’t increase due to stress. If you’re taking your meds are prescribed, this could be a lab error, are you able to have another test done?