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Review
. 2025 Apr 10;87(6):3777-3785.
doi: 10.1097/MS9.0000000000003272. eCollection 2025 Jun.

Impact of low-level viremia on HIV non-viral load suppression in low and middle-income countries

Jackline V Mbishi  1 , Adrian Koola  2 , Haji M Ally  3 , Biruk D Ayalew  4 , Rebecca M Sileshi  4 , Muhidin I Hundisa  5 , Zarin N Rodoshi  6 , Saw W Htoo  7 , Hafidha M Bakari  8 , Zuhura M Ally  9 , Hassan F Fussi  10 , Emilie Ludeman  11 , Taylor Lascko  12 , Celestine A Buyu  12 , Habib O Ramadhani  12
Affiliations
Review

Impact of low-level viremia on HIV non-viral load suppression in low and middle-income countries

Jackline V Mbishi et al. Ann Med Surg (Lond). .

Abstract

Background: The World Health Organization (WHO) defined low-level viremia (LLV) as a viral load (VL) of 51-999 copies/mL, and LLV has been associated with an increased risk of virological failure and drug resistance. Limited information is available from low- and mid-income countries (LMICs), which predominantly use WHO guidelines in HIV program monitoring. We estimated pooled prevalence of LLV, non-viral load suppression (VLS), and association between LLV and non-VLS among people living with HIV in LMICs.

Materials and methods: In this systematic review and meta-analysis, databases were searched for articles reporting the association between LLV and non-VLS in LMICs between January 2015 and December 2023. Participants with VL ≤50 copies/mL were considered fully suppressed and those with VL ≥1000 copies/mL were non-suppressed. Using random effects models, we computed the pooled prevalence of LLV, non-VLS, and their corresponding 95% confidence intervals (CIs). We compared pooled prevalence of LLV and non-VLS between children vs adults and between studies done in Africa vs Asia.

Results: Sixteen studies with 1 159 317 people living with HIV were analyzed. Overall, pooled prevalence of LLV was 19.7% (95% CI: 15.8-23.6) and that of non-VLS was 8.6% (95% CI: 6.5-10.7). Prevalence of LLV was significantly higher among children compared to adults (25.8% vs 17.2%; P < 0.001) and higher among studies done in Africa compared to those in Asia (22.3% vs 15.6%; P < 0.001). Prevalence of non-VLS was higher among studies involving children compared to adults (17.7% vs 5.6%; P < 0.001), but lower among studies done in Africa compared to Asia 8.3% vs 9.0%; P < 0.001). Overall, LLV increased the risk of non-VLS on a subsequent VL test compared to fully suppressed (RR = 2.6; 95% CI: 2.2-3.1).

Conclusions: LLV was associated with an increased risk of non-VLS. Stakeholders should consider reviewing guidelines for the threshold of VLS given that LLV was consistently associated with increased risk of non-VLS across all groups.

Keywords: low level viremia; low-mid income countries; non-viral load suppression.

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Conflict of interest statement

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Not applicable.

Figures

Figure 1.
Figure 1.
PRISMA flow diagram of the included studies for meta-analysis of impact of low-level viremia on HIV non-viral load suppression in low and middle-income countries.
Figure 2.
Figure 2.
Overall prevalence of low-level viremia among people living with HIV in low- and mid-income countries.
Figure 3.
Figure 3.
Overall prevalence of non-viral load suppression among people living with HIV in low- and mid-income countries.
See this image and copyright information in PMC

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