Skip to main content
HHS Author Manuscripts logoLink to HHS Author Manuscripts
. Author manuscript; available in PMC: 2022 Nov 16.
Published in final edited form as: Ann Intern Med. 2017 Aug 8;167(6):446–447. doi: 10.7326/L17-0278

Viral Suppression Patterns Among Persons in the United States With Diagnosed HIV infection in 2014

Nicole Crepaz 1, Tian Tang 1, Gary Marks 1, H Irene Hall 1
PMCID: PMC9668246  NIHMSID: NIHMS1838920  PMID: 28785761

Background:

The most common measure of HIV suppression in clinical and surveillance studies is whether a patient’s most recent viral load was less than 200 copies/mL during the preceding 12 months. This single-value measure provides only a snapshot of suppression status and does not capture changes in viral load over time (1, 2). Persons who are suppressed according to their most recent viral load measurement may still transmit HIV if their suppression status changes.

Objective:

To determine the usefulness of a single measure of viral load for understanding long-term suppression and examine the extent of cumulative HIV burden for understanding the potential risk for transmission.

Methods and Findings:

We used data reported to the National HIV Surveillance System through June 2016 from 33jurisdictions with complete reporting of tests for CD4+cellcount and viral load. We included persons aged 13 years or older who were diagnosed with HIV infection through 2013, most recently resided in 1 of the 33 jurisdictions, and were alive through 2014. We used information about sex, age, transmission category, and race/ethnicity (2) to calculate the percentage of persons with HIV infection whose last viral load in 2014 was less than 200 copies/mL. In addition, we calculated 3 longitudinal measures: the percentage of persons in whom all viral loads in 2014 were less than 200 copies/mL(durable viral suppression) and 200 copies/mL or greater (viral suppression never achieved) (3) and a measure of viremia known as the “copy-year.” Copy-years measure a person’s exposure to HIV over time the way that pack-years measure a person’s exposure to tobacco smoke over time. For example, 10 000 copy-years could indicate that a person had 1000 copies of the virus every day for 10 years, 10 000 copies every day for 1 year, or 5000 copies every day for the first half of the year and 15,000 copies every day for the second half (4). We used the geometric mean to calculate viremia over time.

A total of 630,965 persons were diagnosed with HIV infection through 2013, with 4.2% of infections diagnosed that year. The median time between diagnosis and the end of 2013 was 11 years (interquartile range, 5 to 17 years), and viral load was measured a median of 2 times in 2014. Of all persons with HIV infection, 57.3% had a suppressed viral load on their most recent test in 2014, a total of 47.6% had durable viral suppression throughout 2014, and 8.1% never achieved viral suppression during 2014 (Table). Those more likely not to have viral suppression on their most recent viral load test or durable viral suppression were women, Black persons/African Americans, younger persons, and persons with HIV infection from causes other than male-to-male sexual contact. The 51,114 persons who never achieved viral suppression in 2014 had an average of 17,530 copy-years of viremia; of these, 28,765 (56.3%) had at least 2 tests for viral load in 2014, which indicates that they probably received regular care for their infection. These persons had an average of 21,387 copy-years of viremia.

Table.

Viral load status among persons aged 13 years or older with HIV infection diagnosed through 2013 and alive through 2014 in 33 U.S. jurisdictionsa

All persons Persons with last VL suppressed Persons with durable VL suppression Persons never virally suppressed
Characteristic No. % No. % No. % No. %
Total 630965 100 361801 57.3 300477 47.6 51114 8.1
Sex
Male 484031 76.7 281769 58.2 235551 48.7 36056 7.4
Female 146934 23.3 80032 54.5 64926 44.2 15058 10.2
Race/ethnicity
Black/African American 265551 42.1 134597 50.7 106593 40.1 28914 10.9
Hispanic/Latino 135519 21.5 78140 57.7 65219 48.1 9264 6.8
White 193740 30.7 125628 64.8 109241 56.4 9688 5.0
Other races 36155 5.7 23436 64.8 19424 53.7 3248 9.0
Transmission category
Male-to-male sexual contact 346459 54.9 210486 60.8 178039 51.4 24344 7.0
Injection drug use-Men 53099 8.4 24943 47.0 20108 37.9 3833 7.2
Injection drug use-Women 34754 5.5 18075 52.0 14410 41.5 3629 10.4
Male-to-male sexual contact and injection drug use 36944 5.9 21562 58.4 17259 46.7 3690 10.0
Heterosexual contact-Men 42455 6.7 22326 52.6 18250 43.0 3517 8.3
Heterosexual contact-Women 107692 17.1 59850 55.6 48974 45.5 10664 9.9
Other§ 9561 1.5 4558 47.7 3438 36.0 1436 15.0
Age group at the end of 2013
13–24 y 27183 4.3 12994 47.8 8997 33.1 4906 18.0
25–34 y 92851 14.7 48177 51.9 37146 40.0 11945 12.9
35–44 y 139648 22.1 77717 55.7 63366 45.4 13056 9.3
45–54 y 216199 34.3 129313 59.8 109027 50.4 14677 6.8
>=55 y 155084 24.6 93600 60.4 81941 52.8 6530 4.2
Diagnosis Year
2013 26336 4.2 16011 60.8 10743 40.8 3156 12.0
Before 2013 604629 95.8 345790 57.2 289734 47.9 47958 7.9

The denominator for this analysis was all persons diagnosed with HIV infection.

Data have been statistically adjusted to account for missing transmission category

§

Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not included

Discussion:

Our results confirm those of other studies (1,2). Single measures of viral load overestimate how many persons with HIV infection have durable viral suppression (20% relative difference). In addition, some persons who seem to have received regular care for HIV infection in 2014 still had viral loads high enough to substantially increase transmission(>10 000 copies/mL) (5). These findings emphasize the importance of routine monitoring of viral suppression status and of more effective delivery of appropriate therapy in response to the results of such monitoring (5).

Funding.

This work was supported by the Division of HIV/AIDS Prevention at the U.S. Centers for Disease Control and Prevention and was not funded by any other organization.

Footnotes

Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.

Conflict of Interest. Crepaz, Tang, Marks, and Hall reported no conflicts of interest

Presented in part at the Conference on Retroviruses and Opportunistic Infections, Seattle, Washington, 13–16 February 2017.

Reference:

  • 1.Marks G, Patel U, Stirratt MJ, Mugavero MJ, Mathews WC, Giordano TP, Crepaz N, Gardner LI, Grossman C, Davila J, Sullivan M, Rose CE, OʼDaniels C, Rodriguez A, Wawrzyniak AJ, Golden MR, Dhanireddy S, Ellison J, Drainoni ML, Metsch LR, Cachay ER. Single viral load measurements overestimate stable viral suppression among HIV patients in care: clinical and public health implications. J Acquir Immune Defic Syndr. 2016;73:205–12. doi: 10.1097/QAI.0000000000001036. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Crepaz N, Tang T, Marks G, Mugavero MJ, Espinoza L, Hall HI. Durable viral suppression and transmission risk potential among persons with diagnosed HIV infection: United States, 2012–2013. Clin Infect Dis. 2016;63:976–83. doi: 10.1093/cid/ciw418. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Crepaz N, Tang T, Marks G, Hall HI. Viral load dynamics among persons with diagnosed HIV: United States, 2014. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13–16, 2017. Abstract 31. [Google Scholar]
  • 4.Mugavero MJ, Napravnik S, Cole SR, et al. Viremia copy-years predicts mortality among treatment-naive HIV-infected patients initiating antiretroviral therapy. Clin Infect Dis 2011; 53:927–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000; 342:921–9. [DOI] [PubMed] [Google Scholar]

RESOURCES