Risk Factors for Virologic Failure and Persistent Low-Level Viremia in People with HIV Experiencing Low-Level Viremia: Chongqing ART Cohort Study, 2019-2023

Huizheng Zhang¹Jinjin Liu²Zhen Zhang^1*Yuqi Huo^2*Wanting Zeng^3*

• ¹Chongqing Public Health Medical Center, Chongqing, China
• ²Affiliated Infectious Diseases Hospital of Zhengzhou University (Henan Infectious Diseases Hospital, The Sixth People’s Hospital of Zhengzhou), zhengzhou, China
• ³Department of Otolaryngology Head and Neck Surgery, Daping Hospital, Army Medical University, Chongqing, China

Background: Low-level viremia (LLV) during effective antiretroviral therapy (ART) presents ongoing management challenges globally, with reported prevalence rates of 10-46% in resource-limited settings. The clinical significance of LLV remains controversial: while some studies demonstrate that viral load (VL) levels exceeding 200 copies/mL predict virologic failure (VF), others report no significant association. This uncertainty underscores the need for clearer risk stratification in diverse clinical settings. Objective: To investigate risk factors for VF and persistent low-level viremia (pLLV) in HIV-1-infected individuals experiencing LLV. Design: A retrospective cohort study between January 2019 and December 2023, consisting of 1,214 individuals with LLV (defined as plasma HIV-1 RNA levels of 50-999 copies/mL detected at two consecutive time points following previously undetected viral loads) at a large specialized hospital in Chongqing, China. Methods: Clinical data, including demographics, ART regimens, adherence, baseline viral load (VL), CD4+ T-cell counts, and LLV characteristics, were extracted from medical records. Univariate and multivariate logistic regression models were used to identify factors associated with VF ( defined as one or more HIV VLs of ≥1000 copies/mL) and pLLV (defined as at least three consecutive measurements of VL within the range of 50 to 999 copies/mL)(1), with adjustments for potential confounders. Results: Among 1,214 participants with LLV, 2.64% (32/1,214) developed VF, and 28.09% (341/1,214) developed pLLV. Protective factors against VF included baseline VL <1,000 copies/mL (adjusted odds ratio [aOR] = 0.100, 95%CI: 0.013–0.765) and VL <200 copies/mL during LLV (aOR = 0.157, 95%CI: 0.071–0.540). Viral blips (transient LLV) independently predicted VF (aOR = 4.6775, 95%CI: 1.392–15.704). For pLLV, baseline VL <1,000 copies/mL remained protective (aOR = 0.569, 95% CI: 0.329–0.984), while primary education or lower was a risk factor (aOR=2.052,95%CI:1.014–4.194). Conclusions: VL levels during LLV and baseline VL predict VF risk, emphasizing the need for vigilant VL monitoring and adherence support.