Asian study links low-level viraemia with treatment failure in children living with HIV
Children living with HIV and on treatment, with detectable but low-levels of virus in their blood, are at an increased risk of viral failure.
Episodes of low-level viral replication are associated with viral failure among children living with HIV on antiretroviral treatment (ART), finds an eight-year study from Asia.
It’s not uncommon for people living with HIV who are on treatment to experience small increases in viral load that are not high enough to be classed as a viral failure. These small increases are known as ‘low-level viraemia’ (LLV). LLV can occur briefly, after which viral suppression returns – also known as a ‘blip’ – or it can persist over time.
To assess the impact of LLV on children living with HIV, researchers followed around 500 children and adolescents (aged under 18) in Asia between 2008 and 2016. Participants were from Cambodia, Malaysia and Thailand and were around eight years’ old when they first started treatment, at which point around half had been living with an advanced stage of HIV.
When the study began, all children had been on first-line ART for at least 12 months and all were virally suppressed. In line with international standards, LLV was defined as between 50 to 1000 viral copies/mL of blood, while viral failure was defined as above 1000 copies/mL.
After six years, around a fifth (17%) of the children had experienced LLV at least once, of whom around 40% had multiple episodes. Among those with a single LLV episode, 89% of the events were considered ‘low magnitude’ (50 to <400 copies/mL). Among children with multiple episodes of LLV, 84% of events were in this threshold.
Being female, living in Malaysia (compared to Cambodia), having family members other than biological parents or grandparents as a primary caregiver, and having a low baseline CD4 count were all associated with an increased risk of LLV.
Overall, 115 children (23%) in the study developed viral failure. Viral failure was greater among children who had experienced LLV than those who had not. In total, 34 children who experienced viral failure had previously experienced LLV. Of these, 21 (62%) had experienced a single LLV episode, and 13 (39%) had experienced multiple LLV episodes.
The study did not include data on treatment adherence or pill counts so researchers were not able to assess the association between these factors and LLV among the children.
Despite this, the findings suggest there may be a need to strengthen adherence support for children living with HIV so they remain virally suppressed at all times. Viral load monitoring may also be warranted to prevent and detect viral failure among HIV-positive children.