Case 32. Nonsuppressible Viremia: When Undetectable Is Unachievable
Download MP3A 45-year-old male patient with HIV and a history of sustained viral suppression suddenly has detectable viremia that persists for more than 12 months (range 80 to 250 copies/mL). The patient has been taking bictegravir/emtricitabine/tenofovir alafenamide for more than 6 years, and assessment indicates high adherence and no drug-drug interactions. Listen as Eileen Scully and guest Francesco Simonetti of Johns Hopkins discuss nonsuppressible viremia (NSV), including the mechanisms underlying it, the potential clinical impact, and how to address it with patients.
References:
References:
- Box JR, Camilo-Contreras A, Dragoni F, et al. 5' leader defects drive persistent HIV-1 viremia on long-term ART. Nat Commun 2026 Jun 8;17(1):4725. PMID: 42259781
- Halvas EK, Joseph KW, Brandt LD, et al. HIV-1 viremia not suppressible by antiretroviral therapy can originate from large T cell clones producing infectious virus. J Clin Invest 2020 Nov 2;130(11):5847-5857. PMID: 33016926
- Mohammadi A, Etemad B, Zhang X, et al. Viral and host mediators of non-suppressible HIV-1 viremia. Nat Med 2023 Dec;29(12):3212-3223. PMID: 37957382
- White JA, Wu F, Yasin S, et al. Clonally expanded HIV-1 proviruses with 5'-leader defects can give rise to nonsuppressible residual viremia. J Clin Invest 2023 Mar 15;133(6):e165245. PMID: 36602866
Resource:
- Clemente T, Stam A, Elvstam O, et al. Guidance on the clinical management of HIV-1 persistent low-level viraemia on antiretroviral treatment: a scoping review and an international Delphi consensus. The Lancet HIV 2026;13: e502-e514. PMID: 42276093
