Mortality and cancer risk in HIV patients with incomplete viral suppression after antiretroviral therapy initiation

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  • March 20, 2019
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  • Lee, Jennifer
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
Abstract
  • Advances in combination antiretroviral therapy (ART) have led to prolonged survival among people infected with HIV, with clinical focus shifting from acute illnesses to chronic diseases, including malignancies. Effective ART commonly suppresses viral load levels to below the detection limit of assays used in clinical practice in the US, but not all patients on ART are able to achieve virologic suppression to undetectable levels. Detectable HIV RNA under 1,000 copies/mL has been studied as a potential risk factor for increased drug resistance, subsequent virologic failure, and mortality; however, viral load measurements in this range are of uncertain clinical significance. HIV patients with low viral load under 1,000 copies/mL may not be receiving optimal clinical management, and potential adverse consequences of low, detectable HIV RNA, such as the development of cancer and chronic disease, remain unclear. The objective of this project was to examine the clinical significance of low-level detectable HIV RNA under 1,000 copies based on the relationship between a single viral load measurement collected six months after treatment initiation and mortality, and to assess cancer risk among treated HIV patients with low, detectable viral load. We found that HIV patients with a single low-level viral load measurement between 400 to 999 copies/mL shortly after starting therapy experienced a markedly higher 10-year risk of death (20%) compared to those with viral loads under 20 copies/mL (13%). In fact, these patients faced a similar long-term risk of mortality as patients with very high viral loads (between 1,000 to 4 million copies/mL) that indicated overt treatment failure (23%). We also found that the risk of a first cancer diagnosis in the 10 years following therapy initiation was 6.9% in our study sample, and did not vary by viral load after controlling for baseline characteristics. Our overall findings highlight the importance of rapid viral load suppression after therapy initiation, and indicate that HIV patients with incomplete viral suppression shortly after starting antiretroviral therapy may require closer clinical monitoring and intervention, such as intensification or change of therapy, in order to increase the prospect of successful treatment response and improved survival.
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  • In Copyright
Advisor
  • Eron, Joseph
  • Miller, William
  • Dittmer, Dirk
  • Cole, Stephen
  • Richardson, David
Degree
  • Doctor of Philosophy
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2017
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