Question

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.

301 comments

1. amanda • 9 December 2016

   Hi!I just recently found out that I am HIV positive.I went to the clinic today to fetch my ARVs,my blood tests came back and my CD4 count is 1038 and I am healthy,though I don’t know my viral load,do I start my ARVs today?

2. Simon Collins • 30 September 2016

   Hi Beza, because you had several question and these were not related to the original post, I answered this as a new question here:
   https://i-base.info/qa/12123

3. Beza • 30 September 2016

   hi Please help with the following questions

   i’m on Atripla for a month now, i just got results of my viral load from my doctor which is 176 CD4 was tested 3 weeks ago and was on 574 we started treatment before knowing my viral load. Anyway viral load came back and was 176.
   Question 1
   i started experiencing hand tremor and which was getting worse by the day i informed my doctor who ran Anaemia blood tested and it came back that i was lower then normal on iron so she’s put me on Neurobion tablets which consist of B1 100mg, B6 200mg and B12 200mg.(for 6months) She also prescribed Ferrous Forte (which is complete iron supplement for 6months) Is there anything else i can eat or take to help with this as it bothers me day 2 of taking these meds and i’m still experiencing hand tremor

   Question 2
   First 3 weeks on Atripla had little side effects for me within the first few 3 weeks ( i only suffered insomnia now and again and nose bleed within the first week which stopped) My question is, i have a blister inside my nostril which bleeds when i clean my nose, i’ve spoken to my doctor and she advised that i get any nasal spray to assist with this, will this help? is this a common symptom with Atripla or should i be worried? Im now extremely worried since my iron low could losing more blood the cause complication of my fatigue?

   Question 3
   Is it normal that fatigue will start a month later after treatment, as i’m feeling extremely tired throughout the morning, from waking up i start getting better around 12noon? ( i eat healthy and i haven’t started gym just yet ) i don’t want to change atripla yet as i feel it’s worked good for me

   Question 4
   i take smecta to help with diarrhoea especially on days where i go more then twice to the toilet is this ok? This was my doctors recommendation, she couldn’t explain why i have diarrhoea she said it could be from stress

4. Simon Collins • 19 September 2016

   Hi Tom, thanks – and great that your viral load is undetectable. You need to continue taking meds though. If you stop, viral load will come back very quickly – probably within a few days and usually in less than a week

5. Tom • 19 September 2016

   Hi, This is Tom. I am on treatment for HIV for the past two months. My viral load is undetectable. Does it mean that my HIV is cured. Can i stop my medicines. If i stop my medicines, will my viral load increase again or it will stay at the same undetectable stage.Expecting your reply soon.

6. Simon Collins • 11 September 2016

   Hi Amanda, great that your viral load is undetectable. This means there is so little HIV in your blood to be detected in a test. You are still HIV positive though. It means that your drugs are working well and that you don;t have drug resistance. It means if you continue taking treatment this combination can work for years.

   Your CD4 count is also likely to rise. The CD4 is less important now. Your CD4 count is already good and it is likely to go higher. You have to wait for the test result though – this can’t be predicted. On average, someone starting with a CD4 count of about 450 could see this increase by anything from 50 to 200 cells in the first 6 months.

7. amanda • 11 September 2016

   hi im Amanda. I started ART on January and my CD4 was 464 and on june the results came back as the virus is no discovered in my body (undetectable) – what does that mean? I want to know the estimate of my CD4 count to how many?

8. Simon Collins • 23 August 2016

   Hi Zinhle

   Please have a look at this answer.
   https://i-base.info/qa/7789

   Let me know if you still have questions.

9. zinhle • 23 August 2016

   I started treatment at a 1200 viral load and 383 cd4 count. Would like to know, how many weeks would it take for my viral load to be below 1000

10. Simon Collins • 16 August 2016

    Hi Tif. Viral load results need to be interpreted with your history. It this is likely to be a very recent infection (with the last six months) then viral load may still go lower. If this is likely to be an infection that happened several years ago, then it is more important that you start treatment. Anything over 100,000 is considered high enough to start treatment.
    Do you know your CD4 count? This is the other test done with viral load. The CD4 count is important to know whether the fever is a symptom related to HIV.