Are individuals with Human Immunodeficiency Virus (HIV) placed on Antiretroviral Therapy (ARV) to decrease their viral load?

Are People with HIV Placed on ARV to Decrease the Viral Load?

Yes, individuals with HIV are placed on antiretroviral therapy (ARV) primarily to achieve maximal and durable suppression of viral load, which directly reduces HIV-related morbidity and mortality, restores immune function, and improves quality of life. 1

Primary Goals of Antiretroviral Therapy

The fundamental objectives of ARV therapy extend beyond viral suppression alone and include 1:

• Maximal and durable suppression of viral load - This is the critical primary goal, as plasma viremia is the strongest prognostic indicator in HIV infection 1
• Restoration and preservation of immunologic function - Measured by CD4+ T cell count recovery 1
• Improvement of quality of life - Addressing both HIV-related symptoms and treatment tolerability 1
• Reduction of HIV-related morbidity and mortality - The adoption of these treatment strategies has resulted in substantial reductions in AIDS-related deaths 1

Why Viral Load Suppression Matters for Patient Outcomes

Reductions in plasma viremia achieved with antiretroviral therapy account for substantial clinical benefits and improved survival. 1 The evidence supporting viral suppression as a treatment goal is compelling:

• Multiple analyses among >5000 patients across approximately 18 trials demonstrated a statistically significant dose-response relationship between decreases in plasma viremia and improved clinical outcomes, including fewer new AIDS-defining diagnoses and improved survival 1
• This relationship was consistent across varying baseline characteristics, including pretreatment plasma RNA level, CD4+ T cell count, and previous drug experience 1
• Lowering plasma HIV RNA to <50 copies/mL is associated with increased duration of viral suppression compared with reducing HIV RNA to levels of 50-500 copies/mL 1

Expected Timeline for Viral Suppression

When initiating ARV therapy, clinicians should expect the following viral load response 1, 2:

• At 2-8 weeks: A substantial decrease of ≥1.0 log₁₀ (10-fold reduction) in viral load for patients with good adherence 1, 2
• By 16-24 weeks: Viral load should decrease below detectable levels (defined as <50 RNA copies/mL) for the majority of patients 1, 2
• Failure to achieve suppression by 24 weeks should prompt reassessment of adherence, consideration of malabsorption, repeat RNA testing, or regimen change 1, 2

Viral Suppression and Immune Restoration

While viral suppression is the primary goal, ARV therapy also produces important immunologic benefits 1:

• HAART typically leads to increases in CD4+ T cell count of ≥100-200 cells/mm³, though responses vary 1
• CD4+ T cell responses are usually related to the degree of viral load suppression 1
• A favorable CD4+ T cell response can occur even with incomplete viral load suppression and may not indicate an unfavorable prognosis - though the durability of immunologic responses with suboptimal viral suppression remains unknown 1, 3

Treatment as Prevention

Beyond individual health benefits, ARV therapy is recommended for all HIV-infected individuals with detectable viremia because of the reduced infectiousness of ART-treated individuals who achieve virologic suppression. 1 This "treatment as prevention" approach has demonstrated that heterosexual transmission can be prevented when the HIV-infected partner achieves viral suppression, with increasingly robust observational data suggesting similar benefits for men who have sex with men 1.

Monitoring Viral Load During Treatment

Plasma HIV RNA levels should be measured at specific intervals to guide treatment decisions 1:

• At diagnosis and every 3-4 months for untreated patients 1
• Immediately before and 2-8 weeks after initiating antiretroviral therapy to evaluate initial effectiveness 1
• Every 3-4 months after starting therapy to evaluate continuing effectiveness 1
• If HIV RNA remains detectable after 16-24 weeks of therapy, repeat testing should confirm the result and a change in therapy should be considered 1

Critical Pitfall to Avoid

Do not assume that viral load reduction is the only measure of treatment success. 1 While viral suppression is the primary goal and strongest predictor of long-term clinical outcome, clinicians should also consider sustained rises in CD4+ T cell counts and partial immune restoration, particularly when viral suppression is incomplete 1. Even patients with poor viral reduction can experience recovery of naive and memory CD4+ and CD8+ cells, which provides clinical benefit 3.