Viral load as low as 400 copies/ml six months after starting ART is associated with a significant ten-year mortality risk

Michael Carter
Published: 05 July 2017

A viral load as low as 400 copies/ml six months after starting HIV therapy is associated with a substantial ten-year mortality risk, investigators from the United States report in the online edition ofAIDS. People with a viral load between 400 and 999 copies/ml had a 20% mortality risk, similar to the 23% risk observed in people with a viral load between 1000 and 4 million copies/ml. In contrast, the mortality risk was only 14% for individuals who rapidly achieved complete viral suppression – a viral load below 20 copies/ml.

“A single viral load measurement collected six months after initiating ART [antiretroviral therapy] remains highly informative regarding the risk of death over 10 years,” write the authors.

The aim of ART is rapid and sustained suppression of viral load to below the limit of detection (between 50 to 20 copies/ml depending on testing assay). Treatment guidelines suggest that viral load should be undetectable six months after the initiation of treatment. Newer antiretroviral drug combinations, especially those containing an integrase inhibitor, suppress viral load more rapidly.

Ongoing low-level viral replication despite therapy is associated with the emergence of drug-resistant virus, causing treatment failure and an increase in the risk of HIV- and non-HIV-related illnesses. Small increases in viral load once complete suppression has been achieved, above the limit of detection on occasional tests, so-called viral load `blips`, do not predict treatment failure and are not problematic. This study looked at the failure of treatment to achieve viral suppression after six months.

Analysing viral load measurements taken six months after ART initiation, a team of US investigators sought to determine the level of low-level viraemia (up to 1000 copies/ml) which was associated with an increased risk of all-cause mortality over ten years.

Their study population consisted of approximately 8000 adults who initiated ART between 1998 and 2014. Study participants were followed until death or for up to ten years.

Median age at baseline was 40 years; 83% of participants were male; 62% were in the men who have sex with men risk group; 45% were white and 12% reported ever injecting drugs. The median pre-ART viral load was 75,000 copies/ml and the median year of ART initiation was 2007. Approximately a third of people had been diagnosed with AIDS before starting treatment.

The median period of follow-up was 6.2 years, during which time there were 863 deaths.

Over half (57%) of viral load measurements six months after starting therapy were below 20 copies/ml, with 15% measured at 1000 copies/ml or higher.

As expected, compared to a viral load below 20 copies/ml, a viral load above 999 copies/ml was strongly associated with an increased risk of all-cause mortality over ten years (HR = 1.96; 95% CI, 1.56-2.46). A slightly increased risk of mortality was discernible at a viral load as low as 130 copies/ml (HR = 1.39; 95% CI, 1.02-1.88).

“While we observed an increased hazard of death with low-level viral loads, discernible at 130 copies/ml,” write the authors, “this association was largely driven by the elevated mortality risk experienced by patients with viral load between 400 and 999 copies/ml.”

The average ten-year mortality risk for people with a viral load below 20 copies/ml was 13%, similar to the 14% risk observed in individuals with a viral load between 20 and 400 copies/ml. The ten-year mortality risk was 20% for people with a viral load between 400 and 999 copies/ml, comparable to the 23% risk for people with a viral load of 1000 copies/ml or higher.

“Low-level viral loads between 400 and 999 copies/ml shortly after starting ART appear to place patients at a significantly higher 10-year risk of death than patients with viral loads under 20 copies/ml, and occurrences of viral loads in this range may need to be treated similarly as viral load that exceed 1000 copies/ml,” conclude the authors. “Given the importance of rapidly achieving virologic suppression after initiating treatment, further investigation of the causes of unsuppressed viral loads between 400 and 999 copies/ml is warranted.”

The authors suggest that incomplete viral suppression six months after starting treatment may be a marker for several problems. Apart from lack of adherence to treatment or poor retention in care, incomplete viral suppression might be a consequence of undetected drug resistance, or of drug-drug interactions that lead to low levels of antiretroviral drugs. Planning in advance to prevent these problems from undermining treatment, and prompt investigation of any problems, are likely to improve the chances of viral suppression


  • September 27, 2016: National Gay Men’s HIV/AIDS Awareness Day (NGMHAAD), a national campaign highlighting the disproportionate impact HIV/AIDS has had on gay men. Despite only making up 2% of the population, 55% of people living with HIV in the U.S. identified as gay, bisexual, or other MSM. Learn more about services and ways to get involved.

Global Female Condom Day!!



Get excited! Global Female Condom Day is quickly approaching!


In less than a month, we will celebrate the 5th annual Global Female Condom Day! In years past, we shared stories through the “Female Condoms Are …” film festival and showed the need for female condoms by Dancing for Demand. Now in 2016, even as the prevention landscape evolves to include the HIV prevention pill PrEP, the need for multi-purpose technology continues. We want you to share your vision for the future of female condoms.

What is the next step for female condoms? Where can this tool fit in the future of HIV and pregnancy prevention? On September 16, advocates across the globe will tweet and text responses to these questions. Stay tuned for specifics about how to take part in our worldwide vision for the future on September 16. In the meantime, here’s what you can do right now to prepare:

  • Sign on to officially endorse GFCD as an organization or an individual
  • Lend your support to a campaign to make female condoms easier to access to the United states
  • Tell us how you promote FCs all year long
  • Let your networks on social media know that GFCD 2016 is coming September 16 by using the hashtags #FemaleCondoms and #GFCD2016
  • Become inspired by fellow advocates who champion female condoms as a prevention option in their communities

Watch your inbox next week for more ways to participate in our online day of action on September 16 and for a full social media toolkit. We can’t wait to hear your vision for the future!


“License to Discriminate” Legislation Angers LGBTQ Community

On July 12th, exactly one month after the horrifying massacre at the Pulse nightclub in Orlando, Florida the Committee on Oversight and Government Reform held a hearing on H.R. 2802, the First Amendment Defense Act (FADA). I attended this hearing on behalf of AIDS United.

Although its proponents will not say so, the purpose of FADA is to allow individuals, nonprofits, and federal employees to discriminate against LGBTQ people on the basis of their religious beliefs and/or moral convictions without federal intervention. The act would prohibit the federal government from taking any action, such as revoking tax-exempt status, against entities who discriminate against others based on their beliefs that marriage should be between one man and one woman or that sex should be confined to marriage. Opponents of the bill are calling it a “license to discriminate” because it legalizes discrimination against the LGBTQ community. This act not only negatively affects the LGBTQ community, it also would place undue burden on single mothers and unmarried couples.

The hearing hosted a comprehensive panel including Senator Mike Lee (R-UT) and pro-LGBTQ advocates such as Jim Obergefell, the lead plaintiff in the Supreme Court case Obergefell v. Hodges that nationally legalized same sex marriage, former Congressman Barney Frank, and Katherine Franke, the Isidor and Seville Sulzbacher professor of law and the director of the Center for Gender and Sexuality Law at Columbia Law School.

Many members of the committee and panel criticized the inopportune timing of the hearing. Representative Elijah Cummings (D-MD) remarked, “To say this meeting is tone deaf is the understatement of the year.” According to Representative Cummings, 80 letters were submitted and disregarded asking the committee to postpone the meeting to a different day.

Obergefell noted, “Today, exactly one month after this horrifying event, I am appearing before this Congressional committee to discuss a bill that would authorize sweeping, taxpayer-funded discrimination against LGBT people. I think that is profoundly sad.”

I and others in the LGBTQ community found this hearing insulting not just because of its poorly planned date, but also because of the detrimental effects the bill would have on our community. In his opening remarks, Rep. Frank explained how this bill is very personal to him and described a scenario in which the bill would allow discrimination against same-sex couples; if nonprofit developers wanted to use government funding to build housing and chose to exclude same-sex couples from that housing because same-sex marriage goes against the religious beliefs of the organization, the government would be prohibited from denying the organization federal funds due to this bill.

Meanwhile, Senator Lee, argued its purpose is to ensure no American is forced to choose between their religious beliefs and being eligible for nonprofit tax-exempt status and access to federal grants. Ms. Franke repeatedly reminded the committee that these religious protections already exist through the First Amendment. Obergefell added that no church or clergy in this country have ever been forced to marry a couple that would violate their religious beliefs. Further, various religious-affiliated organizations across the nation voiced their opposition to the FADA bill. Franke concluded, “FADA is a solution looking for a problem.”

Not only is this legislation unnecessary, but it also prohibits the federal government from protecting same-sex couples from discrimination by entities such as nonprofits and foster care agencies. If passed, this legislation would start a dangerous precedent of federally-sanctioned discrimination against marginalized groups of people in the name of religious freedom. The First Amendment already guarantees religious freedom in this country, but there is currently no federal legislation protecting members of the LGBTQ community from discrimination. While this bill is unlikely to pass during the Congress, Republican Presidential Nominee Donald Trump recently said he would sign FADA into law if he were president. During a time where there is increased violence against the transgender community and on the anniversary of the tragic Orlando shooting targeting LGBTQ people, it is disgraceful that elected officials are even considering such legislation.


Enough is Enough!! We need to stop violence against LGBTQ. To many years of seeing how discrimination has hurt so many. I lived most of my life in New York City and saw how the Gay community was treated, “Horrible”! The only time I saw and heard some form of peace was when I used to dj at dance a teria, Palladium, 54 and my hangouts in soho area. I used to work on gay night, not to many dj’s where available on certain nights. I must say it was a privilege and honor to spin my music and give so many the freedom & happiness, even though it was for a couple of hours.

Thank you, LGBT for allowing me to learn so much about your world and learn how discrimination can hurt so many!!!

I will always fight for your cause!!!


Peace, Love, Happiness to all!!


Documentary About HIV/AIDS in the 1980s to Debut on CNN






Michael S. Gottlieb, M.D., Immunologist, UCLA Medical Center

CNN will present “The Fight Against AIDS” on Thursday, May 12, 2016, at 9 p.m. as part of its documentary series The Eighties. The seven-part series focuses on the events that shaped the ’80s—a decade that included President Ronald Reagan, the end of the Cold War, Wall Street corruption, the tech boom, the expansion of television and the beginning of the AIDS crisis.

“The Fight Against AIDS” chronicles the history of HIV/AIDS through archival footage and interviews with journalists, historians, doctors, researchers, celebrities and activists. It traces the AIDS crisis from the epidemic’s beginning—when young, sexually active gay men, Haitian refugees, drug users and hemophiliacs were among the first known cases—to the panic and hysteria that resulted from the uncertainty, misinformation and ignorance surrounding the virus; and on to Hollywood’s involvement and gay-rights activists’ struggles to pressure the government to find a treatment and cure.

Highlights include the development of test kits, the impact of Rock Hudson’s AIDS diagnosis upon public awareness, the harassment of Ryan White and his subsequent activism, the Reagan controversy, and the mobilization of the LGBT community. The documentary, however, touches only briefly upon the epidemic in Black America, which the media and many other mainstream organizations largely ignored.

Gay-rights activists Cleve Jones and Larry Kramer; immunologist Dr. Anthony S. Fauci, who has been director of the National Institute of Allergy and Infectious Diseases since 1984; immunologist and HIV researcher Dr. Michael Gottlieb; and Black AIDS Institute founder, president and CEO Phill Wilson are among the pioneers in fighting the epidemic who are featured in the episode, which is definitely worth watching.

April Eugene is a Philadelphia-based writer.




United States Conference On AIDS 2015

We Make the Change!

HIV Prevention

Approximately 15 Floridians become infected with HIV every day. We still have much work to do and, to be successful in the fight, we must do it together. Remember, each of us is part of the solution to end this epidemic.


A wide range of symptoms is associated with HIV/AIDS. Many symptoms are not necessarily due to the breakdown of the immune system, but are the result of opportunistic diseases and infections and their manifestations. Two common manifestations are Pneumocystis Pneumonia (PCP) — a lung disease in which victims experience shortness of breath, a non-productive (dry) cough, anemia, and fever — and Kaposi’s Sarcoma (KS), a type of cancer that manifests itself as grayish-purple skin lesions, lesions on several internal organs, night sweats, and weight loss. Other symptoms associated with the various opportunistic diseases and conditions are chronic headaches, chronic and persistent diarrhea and vomiting, blindness, memory loss, rashes, sores, assorted aches and pains, neurological dysfunction and other manifestations.



Get the facts about how HIV is transmitted. Become more aware of how you might be putting yourself at risk.

Body Fluids

HIV can live only in certain fluids of the human body. These fluids are blood, semen, vaginal secretions and breast milk. Saliva, sweat, urine and tears do not spread the virus because they do not have enough white blood cells for the virus to grow and survive.

Risk Behaviors

HIV can be transmitted by any type of sexual contact (anal, penis-to-rectum; vaginal, penis-to-vagina; or oral, mouth-to-penis, -vagina, or -rectum), by blood-to-blood contact, including injecting drugs and sharing needles, or by a woman to her baby either before or during birth or through breastfeeding. HIV is not transmitted through any type of casual contact, nor by insects or animals. People are at risk of HIV infection when they participate in behaviors in which the exchange of bodily fluids is possible. Two examples of risky behaviors are having unprotected sex with an infected person and sharing needles.

Unprotected sex

Unprotected sex, or sex without latex or polyurethane condoms, can let HIV enter the blood. Vaginal, anal and oral sex each can transmit HIV. In an infected man, the semen (male sexual fluid) has a high amount of HIV. Semen can pass HIV from one person to another during unprotected vaginal, anal or oral sex. The virus can go through the lining of the vagina, anus or mouth into a person’s bloodstream. In women, vaginal fluids and menstrual blood can pass the virus to another person.


The most efficient means of HIV transmission is blood-to-blood transmission and injecting drugs and sharing needles is the behavior that accounts for the second highest number of reported AIDS cases (behind sexual contact) in the United States. If sufficient amounts of HIV-infected blood get into the body, infection may occur. It may take as little as a few drops for infection to occur. History has shown exposure of infected blood to intact skin (no open sores or lesions) does not transmit the virus.

If a person injects drugs either intravenously (into the vein) or intramuscularly (into the muscle) and shares needles, they are engaging in a behavior that puts them at great risk of transmitting or acquiring HIV.

Any type of needle sharing may transmit HIV. If an infected body builder injects anabolic steroids and shares the needle with someone else, the virus may be transmitted. Sharing tattoo needles or sharing needles for ear or body piercing could be a means of transmitting HIV. Intravenous infection could occur among seniors who are diabetic and share insulin needles.

Breast Feeding

The risk of transmission from mother to child through breastfeeding is present due to the high concentration of HIV in breast milk. Without treatment, an estimated one in every seven infants breast-fed by an HIV-positive mother becomes infected through breast milk.

Blood Transfusions

Since 1985, all donated blood and blood products are screened for HIV. The risk of HIV infection through a blood transfusion is almost zero. Donating blood poses no risk because blood is drawn using sterile needles that have never been used.

Substance Use

The use of drugs and alcohol continues to be prevalent in many communities and is linked to risk factors for HIV infection and other STDs. Substance use can increase the risk for HIV transmission through the tendency toward risky sexual behaviors while under the influence and through sharing needles or other injection equipment.



HIV risk factors are the same for everyone, but some populations are more affected than others (see the data here):

Racial/Ethnic Groups

In Florida, African American and Hispanic populations are disproportionately affected. Social and economic factors including racism, poverty, lack of access to health care, and geographic region are barriers to receiving HIV prevention services. African American and Hispanic men are more likely than white men to be given a diagnosis of HIV infection in the late stages of infection, often when they already have AIDS, suggesting that they are not accessing testing or health care services through which HIV infection could be diagnosed at an earlier stage.

Men Who Have Sex With Men (MSM)

MSM are members of all communities, all races and ethnicities, and all strata of society. Social and economic factors, including racism, homophobia, poverty, geographic region and lack of access to health care, are barriers to receiving HIV prevention services, particularly for MSM of minority races or ethnicities. Sexual risk factors account for most HIV infections in MSM. Not using a condom during anal sex continues to be a significant threat to the health of MSM.

Substance Users

Behaviors that may accompany drug use can put people at risk for HIV. For example, trading sex for drugs or for money to buy drugs increases the number of sexual partners and the risk of infection. Similarly, heavy alcohol consumption may cause a person to lose inhibitions and engage in unprotected sexual contact with an infected person and transmission could occur. Judgment is often impaired during inebriation and any measures to prevent the transmission of HIV by the individual may be compromised.



Protect yourself from HIV infection. Find out how you can make changes in your lifestyle to reduce your risk.


Abstinence from sexual activity is the only sure way to not become infected through sexual contact. If a person is not sexually active (through oral, anal or vaginal contact), there is virtually no chance of contracting HIV or any STD through sexual activity.


Having sex with only one uninfected partner is a way to be sexually active and not risk infection with HIV. Mutual monogamy means that both partners in a relationship are only having sex with each other.


Condoms are an important tool in preventing the spread of HIV. When used properly, condoms create a barrier that prevents the virus from spreading from an infected individual to someone else. Latex condoms are approximately 90 percent effective at preventing pregnancy and the passage of almost all STDs, including HIV. Most often, human error causes condoms to fail. This figure would be about 98-99 percent if everyone who used condoms used them correctly. Polyurethane condoms and female condoms are also highly effective.

Condoms may be obtained free of charge at any county health department in the state of Florida. Local AIDS services organizations and other community-based organizations also distribute free condoms. To find the nearest location where free condoms are available, call the Florida HIV/AIDS Hotline.

Clean Needles

If an injecting drug user is sharing needles, needles and syringes must be cleaned. Ordinary household bleach drawn into the needle and syringe will inactivate HIV. The bleach must be drawn into the syringe, shaken, and squirted out. This process must be completed three times. Then, water must be drawn in, shaken, and squirted to thoroughly rinse out the bleach. This process should also be completed three times since injecting bleach into the veins can be more deadly than HIV.

PrEP and PEP

PrEP (Pre-Exposure Prophylaxis) is a comprehensive HIV prevention strategy that involves the daily use of antiretroviral medications to reduce the risk of HIV infection in HIV-negative individuals. In July 2012, the US Food and Drug Administration approved the use of Truvada (TDF/FTC) for use as PrEP in HIV prevention in sexually active HIV–negative individuals.  PrEP is used in conjunction with other prevention methods to reduce the risk of infection. Learn more about PrEP by clicking here.

Post Exposure Prophylaxis (PEP) involves taking antiretroviral medications as soon as possible after a potential exposure to HIV to reduce the likelihood of HIV infection. There are two types of PEP: 1) occupational PEP, or an exposure that happens in the workplace (such as a needle stick in a healthcare setting), and 2) non-occupational PEP (nPEP), or when someone is potentially exposed to HIV through sexual intercourse or injection drug use.

To be effective, PEP must begin with 72 hours of exposure and consists of 2-3 antiretroviral medications that must be taken for 28 days. A physician must determine what treatment is appropriate based on the nature of the exposure. Starting PEP after a potential exposure does not guarantee that someone exposed to HIV will not become infected.

Avoid Breast Feeding

Because there are documented cases showing that HIV can be transmitted from mother to infant through breastfeeding, HIV-positive women are counseled to avoid breastfeeding. If the mother does not want to feed her baby formula, another option is locating a milk bank (an organization that collects donated breast milk and distributes it). For more information on this option, look for the Human Milk Banking Association of North America, Inc.

Universal Precautions

The observation of universal precautions involves the assumption that any patient could be infected with HIV and/or hepatitis and the responsibility to take appropriate precautions. Universal precautions include such practices as hand washing, the use of protective barriers, proper disposal of needles, and cleaning and disinfecting spills. Health care workers must take precautions when working with the body fluids of others. Hands should be washed properly and frequently.

Latex or plastic gloves, goggles, masks, and protective aprons should be worn during appropriate times and procedures to reduce the risk of exposure of skin and mucous membranes. Needles used for the injection of medicines or the drawing of blood should never be recapped or manipulated by hand in any way.

All needles should be disposed of properly in puncture-proof containers. Some healthcare workers have reported contracting HIV through accidental needle sticks from recapping used needles. When cleaning and disinfecting spills, visible material should be removed with disposable towels and the area decontaminated with a 1:10 solution of bleach and water. If universal precautions are followed at all times, infections are not likely to be transmitted in the health care setting.

Avoid Substance Use

Substance use does not necessarily put people at risk for HIV directly; however, judgment is often impaired during inebriation and any measures to prevent the transmission of HIV by the individual may be compromised.