Lorenzo Vittorio Rindi, Drieda Zaçe, Mirko Compagno, Luna Colagrossi, Maria Mercedes Santoro, Massimo Andreoni, Carlo Federico Perno, Loredana Sarmati
{"title":"Management of low-level HIV viremia during antiretroviral therapy: Delphi consensus statement and appraisal of the evidence","authors":"Lorenzo Vittorio Rindi, Drieda Zaçe, Mirko Compagno, Luna Colagrossi, Maria Mercedes Santoro, Massimo Andreoni, Carlo Federico Perno, Loredana Sarmati","doi":"10.1136/sextrans-2024-056199","DOIUrl":null,"url":null,"abstract":"Objective While antiretroviral therapy (ART) is highly effective, detection of low levels of HIV-1 RNA in plasma is common in treated individuals. Given the uncertainties on the topic, we convened a panel of experts to consider different clinical scenarios, producing a Delphi consensus to help guide clinical practice. Methods A panel of 17 experts in infectious diseases, virology and immunology rated 32 statements related to four distinct scenarios: (1) low-level viremia during stable (≥6 months) first-line ART (≥2 consecutive HIV-1 RNA measurements 50–500 copies/mL); (2) a viral blip during otherwise suppressive ART (a HIV-1 RNA measurement 50–1000 copies/mL with adjacent measurements <50 copies/mL); (3) low-level viral rebound during previously suppressive ART (≥2 consecutive HIV-1 RNA measurements 50–500 copies/mL); (4) residual viremia during suppressive ART (persistent HIV-1 RNA quantification below 50 copies/mL). A systematic review, conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement, informed the 32 statements. The Delphi procedure was modified to include two voting rounds separated by a moderated group discussion. Grading of Recommendations, Assessment, Development, and Evaluations-based recommendations were developed. Results Overall, 18/32 statements (56.2%) achieved a strong consensus, 3/32 (9.4%) achieved a moderate consensus and 11/32 (34.4%) did not achieve a consensus. Across the four scenarios, the panel unanimously emphasised the importance of implementing specific interventions prior to considering therapy changes, including assessing adherence, testing for genotypic drug resistance and scheduling more frequent follow-up visits. Strategies indicated in selected circumstances included therapeutic drug monitoring, quantifying total HIV-1 DNA and evaluating concomitant chronic infections. Conclusions While acknowledging the many uncertainties about source, significance and optimal management of low-level viremia during ART, the findings provide insights to help harmonise clinical practice. There is a need for well-designed randomised studies assessing different interventions to manage low-level viremia and future research regarding its definition. Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.","PeriodicalId":21624,"journal":{"name":"Sexually Transmitted Infections","volume":null,"pages":null},"PeriodicalIF":3.6000,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Sexually Transmitted Infections","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1136/sextrans-2024-056199","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"INFECTIOUS DISEASES","Score":null,"Total":0}
引用次数: 0
Abstract
Objective While antiretroviral therapy (ART) is highly effective, detection of low levels of HIV-1 RNA in plasma is common in treated individuals. Given the uncertainties on the topic, we convened a panel of experts to consider different clinical scenarios, producing a Delphi consensus to help guide clinical practice. Methods A panel of 17 experts in infectious diseases, virology and immunology rated 32 statements related to four distinct scenarios: (1) low-level viremia during stable (≥6 months) first-line ART (≥2 consecutive HIV-1 RNA measurements 50–500 copies/mL); (2) a viral blip during otherwise suppressive ART (a HIV-1 RNA measurement 50–1000 copies/mL with adjacent measurements <50 copies/mL); (3) low-level viral rebound during previously suppressive ART (≥2 consecutive HIV-1 RNA measurements 50–500 copies/mL); (4) residual viremia during suppressive ART (persistent HIV-1 RNA quantification below 50 copies/mL). A systematic review, conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement, informed the 32 statements. The Delphi procedure was modified to include two voting rounds separated by a moderated group discussion. Grading of Recommendations, Assessment, Development, and Evaluations-based recommendations were developed. Results Overall, 18/32 statements (56.2%) achieved a strong consensus, 3/32 (9.4%) achieved a moderate consensus and 11/32 (34.4%) did not achieve a consensus. Across the four scenarios, the panel unanimously emphasised the importance of implementing specific interventions prior to considering therapy changes, including assessing adherence, testing for genotypic drug resistance and scheduling more frequent follow-up visits. Strategies indicated in selected circumstances included therapeutic drug monitoring, quantifying total HIV-1 DNA and evaluating concomitant chronic infections. Conclusions While acknowledging the many uncertainties about source, significance and optimal management of low-level viremia during ART, the findings provide insights to help harmonise clinical practice. There is a need for well-designed randomised studies assessing different interventions to manage low-level viremia and future research regarding its definition. Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
期刊介绍:
Sexually Transmitted Infections is the world’s longest running international journal on sexual health. It aims to keep practitioners, trainees and researchers up to date in the prevention, diagnosis and treatment of all STIs and HIV. The journal publishes original research, descriptive epidemiology, evidence-based reviews and comment on the clinical, public health, sociological and laboratory aspects of sexual health from around the world. We also publish educational articles, letters and other material of interest to readers, along with podcasts and other online material. STI provides a high quality editorial service from submission to publication.