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[00:00:00] Welcome to the Decera Clinical Insights podcast, HIV Viral Blips: Interpretation and Clinical Management in the Era of Modern Antiretroviral Therapy. Our guests today are Dr. Anu Hazra, associate professor, Section of Infectious Diseases and Global Health at the University of Chicago, Chicago, Illinois, and Dr. Bohuma K. Tatonji, Assistant Professor, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia

Hey, BK. How's it going? Going great. Uh, I'm excited to spend sort of the next few minutes, uh, sort of talking about, um, something that a lot of us in HIV care kind of struggle with, uh, these blips and, and sort of increases in, in viral load that drive both our, us and our patients kind of crazy sometimes.

Yeah. It's a, a huge source of anxiety for [00:01:00] patients and also sometimes for clinicians that are not deeply steeped in HIV care management, so. Yeah. We can help hopefully clear some of the, the issues around this particular question. Yeah. I'm excited about, um, sort of, uh, s- going through some of the pathophys behind this and hopefully offer, maybe offering some reassurance, but most importantly, some sort of clinical tips of, of, of what to do when we come across this scenario.

Maybe it'll be nice to maybe start with a, a clinical case that we can work through and, and go from there. So I'm gonna ... This is actually a, a patient of mine, um, so, uh, this is very real to me. Um, and so let's start with a 46-year-old male, uh, living with HIV, who presents for routine follow-up in your clinic.

Um, he's been taking dolutegravir/lamivudine fixed-dose combination for the past two years, and has maintained consistent undetectable viral loads, uh, per your assay, which detects below 50 copies per ML. Um, he reports excellent adherence, uh, rarely misses any doses, and has, uh, no recent [00:02:00] changes to either his HIV medications or any other medications on his, uh, on his record.

At today's visit, he feels well, has no new concerns. It's just a routine sort of visit. His CD4 count is 680 cells, um, uh, which is sort of his, uh, his, his normal amount. Um, eh, but when his laboratory results return, his viral load is at 113 copies, uh, per ML. Uh, before even we are able to contact him about these results, he checks his portal and sees sort of a red flag, um, and, uh, immediately messages you and says, you know, "I've been undetectable for years.

Does this new value mean my medications are failing? Do I need resistance testing or a completely brand-new regimen?" Um, so obviously, you know, anxious and, and concerned. Um, so BK, does this, um, sound familiar to you at all? Is this a, a case that resonates with you at all? Absolutely. Um, I've had the exact same scenario happen to a bunch of patients of mine, and I think when we're dealing with, [00:03:00] uh, the fact that sometimes patients are now able to see their results even before their clinician- Yeah

notified of them, then you deal with instances where you have a patient maybe panicking over a result that may not warrant that level of anxiety. So I think, you know, a really good place for us to get started is just to lay out the definitions of- What is a blip and, you know, when should patients panic?

Yeah, yeah. Uh, yeah, I think definitions are important to sort of level set so we're all on the same page. And I think also im- important to not only sort of educate providers about these definitions, but also patients, so then they also have this information as well. So, so let's go through some of these definitions and terminologies as we talk about sort of blips and viremia.

So, you know, a viral blip by definition is a single detectable HIV RNA. Typically, um, a blip is under 200 copies per ml. Um, and the, the point of a blip is exactly that. It goes up and comes right back down. And so you have just an isolated increased amount, [00:04:00] uh, uh, of your, uh, of your viral load and comes back down to undetectable without doing anything else.

So it just goes up and comes back down by itself. And we'll talk maybe a little bit about why blips happen. Uh, but that's what a blip is. Now, what is, um, you know, what is persistent low-level viremia? So if someone doesn't have, just have a blip, goes up and then remains at, at sort of that level for a while.

So we consider low-level viremia as anything under 200 copies per ml. Remember, like, you know, our assays for, for PCR testing has become so, so sensitive. Um, uh, but we consider sort of low-level viremia as anything under 200 copies per ml that remains, um, you know, it's not a blip that comes back down to undetectable, but remains at this sort of persistent low-level, uh, viremia, sometimes abbreviated as LLV.

And then virological failure is sustained viral loads that are above 200 copies per ml. Uh, important to note, this is the United States threshold. The WHO has a separate threshold for what they consider to be virological failure. But here in the United States where we practice, um, you know, a, [00:05:00] a viral failure would be a, an elevated viral load above 200 copies per mL.

Now undetectable, um, is something that is, um, important for us to pin down, specifically as it pertains to U equals U and how that's a huge part of our messaging to, to patients and how we th- think about undetectable equals untransmittable. Now undetectable on your assay may depend on the type of assay you have.

Some assays go down to 13 copies per mL now. Majority of the assays are, are at least at 15 copies per mL. So you could have an assay that's undetectable, but what d- what does it mean for U equals U or, or to be functionally undetectable, uh, meaning that you're able to harness the power of U equals U that re- eliminates the transmission, um, we define as under 200 copies per mL.

So anything that's under 200 copies mL, you know, we are using this terminology called functionally undetectable and maybe, you know, you can preserve your undetectable to be sort of equivalent to what your assay, um, shows in, in, in general. [00:06:00] Um, and you know, y- you know, we have sort of guidelines to think about.

So in the United States when we think about suppression or sort of sustained biological suppression, we really use that 200 copies per mL as our sort of threshold. The WHO uses 1,000 copies per mL as their threshold. Um, and there is, you know, obviously a growing body of evidence that U equals U can likely be pushed to 1,000 copies and anything under 1,000 copies to be undetectable, uh, for untransmittable.

But we continue to really, uh, preserve the 200 copies here, uh, in the US. Um, and again, uh, you know, thinking about sort of functional undetectable becau- versus what your assay says to be undetectable, um, it not all detectable virus means it's a treatment failure and hopefully our conversation can go through that.

A- and again, it's more than just a single value and this is in medicine in general. We're not chasing a number. Uh, we're chasing a pattern or a concern that we have or a trajectory of where things are going. Um, but yeah, w- with sort of level setting sort of these definitions, uh, BK, I'd love to hear sort of your take on, you know, why [00:07:00] blips happen, when do we see them, um, and sort of what might be some of the biology behind this?

Yeah, I, I think that that's usually the immediate question when you've had the conversation with a patient about what the levels of detection are and what the thresholds and the definitions are. They want to know, "Why do I have a blip, and why does this happen?" You already went over one of the main drivers, which is the assay variability.

So a blip in my clinic that when we use an assay that has a detection level of less than 200 copies may be different from a blip in a clinic where they're using an assay that has a detection level of less than 13 copies. So, you know, in my clinic, someone who shows up with 67 copies, for example, will not be considered a blip because on my report they will be marked as undetectable.

Whereas in another scenario using a more sensitive assay, that clinic may, you know, [00:08:00] flag a blip. So the assay variability is one of the drivers of these, uh, differences that patients can sometimes see in their report. But there are true biological drivers of these, uh, detectable viremias that can be seen in, in patients.

One of them is anything that activates the immune system, and I'm particularly thinking about things like viral infections. You may have a cold, and you're someone living with HIV who has been undetectable for years and years and quite stable on your treatment. But having an acute infection, be it a viral infection or a bacterial infection, can activate the immune system.

And when you have, um, an activated immune system, those resting CD4 T cells that are the viral reservoir can be activated to become cells that are capable of churning out virus, and that can cause a blip And we oftentimes see these types of blips, for example, when patients are acutely ill and then someone [00:09:00] checks a viral load on them Right, right, right.

So one of the, that's one of the drivers, is anything that leads to an, an pro-inflamed state. So an acute illness or even a stress situation, like if you're undergoing a period of stress and your immune system is, is activated by that, that could result in a transient, um, detection of your viremia. There's also the whole idea of clonal expansion.

Again, that viral reservoir is your CD4 T cells that are resting. And because you see the pool of CD4 cells that everybody has is maintained by those cells replicating themselves, in your CD4 cells that are the reservoir, they can replicate themselves to maintain your pool of CD4 T cells. But when they do that, they are, they copy exactly also the proviral, uh, DNA that was existing in the mother, the mother T cell.

So in expanding your pool of T cells to sort of [00:10:00] maintain that pool of cells, they expand your reservoir. Right. And again, whenever these cells are activated and churn out virus, you can get a detectable viremia. But it's important to note that not all detectable viral RNA is actually viral RNA that can cause an infection.

Sometimes it's just pieces of viral RNA. But because the assays are so sensitive, they pick these things up, and that can show up as a blip And then the last thing that I wanted to talk about is also, you know, adherence, particularly of daily regimens, is not always perfect. And sometimes you might have an individual who has missed one dose per week or a couple of doses over the course of a month, and that may also lead to, um, low level of viremia if you time their viral load testing to- That's unfortunately, yeah, wrong.

Yeah ... one of those, yeah, missed doses. But I, I also want to just stress [00:11:00] that, you know, in the context of the medications that we currently have for antiretroviral therapy, these are very potent, uh, regimens, particularly with, uh, integrase inhibitors that are the backbone of a lot of these, uh, regimens.

Blips tend to occur less frequently. And we can't stress enough the importance of having a trend as opposed to fixating on just one single value. Yeah. And I... The, the same goes for long-acting antiretroviral therapy because it impacts on adherence, but it also contains medications that are very potent.

And I think it's important for those, uh, clinicians that are listening to us to take away from this conversation that the majority of blips that they would encounter are benign, and when you recheck, it usually goes back to the undetectable, uh, viral load that is expected on someone who is taking their medications as prescribed.

Yeah, yeah. This, uh, thank you for walking us through sort of a really [00:12:00] complex topic in a very straightforward way, BK, because I feel like when we experience these blips, particularly in the community, there's this urge to, like, intensify the regimen, to add another drug on or change people off of ART. And all the guidelines, DHHS and ISUSA, say no, to hold steady in the setting of just a blip, uh, to continue to monitor.

And like you said, BK, not reacting to a single value, but really trying to step back and looking for a trend, a pattern, uh, and, and whatnot. Um, thank you. Yeah, I mean, I, I think, you know, going back to our case, um, you know, so we have this, you know, otherwise healthy individual living with HIV on a two-drug regimen, which already might make some people nervous about sort of what it means in terms of virological control, and that might be a whole other podcast.

Uh, but let's say, yeah, so, you know, he's just coming in, routine follow-up, otherwise healthy, not ill right now, and he has, you know, he's been undetectable per your assay. So let's say your, our assay is under 50 copies per ML, and he's always been under 50 copies this entire time and now comes in with 113 copies.

Um, [00:13:00] what do we make of this? Is this something that we need to sort of act on? Is this something that, um, how, how would you, how would you handle this in, in, in your clinical setting, BK? You, you know, I think the, the main response to this, um, 113 copies is primarily calling the patient to reassure them. Yeah, yeah.

That this is not unusual. This is not something that should trigger panic. And then, uh, tell them to continue to take their medications and plan a recheck at their next visit. And when I have these conversations, I always go back to stressing on the U equals U threshold, because really when patients are anxious, that's usually what they're worried about.

Right. Yeah. They're worried about, "Is this going to mean that I can then pass on the, the virus to someone else?" Right. "Is it going to mean that my T cells are going to suddenly drop?" Yeah. So I really focus the conversation on these elements to reinforce the messaging that, "No, you're good, and we can recheck."

Now, another [00:14:00] question that frequently comes up is, do we need to recheck immediately? Right. Yeah. Personally, in my practice, I don't feel the need to recheck immediately. Yeah. Because by definition of a blip- I know that when I recheck- It'll come back down ... it, it should be, uh, back to where I would expect it to be.

So I don't recommend calling the patient back into the clinic and disrupting their schedule just to recheck because that you, you had one blip. I would just say at their next scheduled visit, if it's in six months or in three months- Right ... when you get labs, it's okay to recheck at that time. Exactly. And sometimes patients may themselves ask to be rechecked, you know, at a certain time, and this is very similar to how we think about sometimes, like, syphilis screening, where people wanna get checked for their RPR immediately after treatment and whatnot.

Um, and I try, you know, I, I, I think it's a patient-centered discussion, right? So it's shared decision-making in terms of what's important. If a patient is really anxious and really wants to see that number back down, certainly you can, you know, recheck or, or, or whatnot. [00:15:00] But, um, I think, you know, to your point, Bke, it's like, uh, a blip is exactly that, so you would expect it come back down.

So there's no clear indication that they need to come back, um, uh, uh, uh, uh, for a second sort of viral load earlier than when you have wanted to recheck, um, uh, subsequently. And yeah, I, I think this patient education is really important in the, in the era of open records and portals and, and, and whatnot, um, uh, it causes a lot of anxiety for patients, and that anxiety is contagious to, like, your clinic staff and, and the people answering those messages.

And so I think really having clear definitions that you're able to provide to patients and then this idea that you are functionally undetectable, that the function of U=U remains even if your viral load is now somewhere, you know, between, you know, 50 and 200 or 20 and 200. And in fact, as our assays are getting even better, there's this, like, ultra-low viremia, which is between 20 or now 13, likely, and 50.

Uh, and really, is this a clinically meaningful number? And, you know, many of us would argue that no, I [00:16:00] don't think there's any clinical meaningfulness between someone having a viral load of 24 and then having a viral load of 45. Um, and to Bke's point, um, like we've seen with COVID and a lot of other PCR tests, that just because a PCR is positive doesn't mean there's, you know, active pathogen, um, that, that can cause disease or, or, or, or issue, um, uh, based on that.

Let's change our, let, let's change our scenario up. So, so what if, BK, this is someone, uh, the same patient who is hospitalized, uh, for, let's say, co- acute cholecystitis, and the surgeons are about to take him out for a lap choly and decide to, you know, you know, check his viral load before the OR. And, um, like before, he's on lamivudine, dolutegravir, has been undetectable.

And now, you know, let's say his viral load is, you know, 163 copies per ML. You get a call from the hospitalist who's panicking and saying, "Hey, we need to get his viral load undetectable before they can go into the OR." Um, do we need to change a regimen? Do we need to get a resistance assay? How, how would you handle that type of sort of inpatient scenario?

Yeah. These [00:17:00] inpatient scenarios are not infrequent because, um, unfortunately, when, uh, our patients or people living with, with HIV come into the clinic, one of the few tests that, uh, clinicians were not necessarily familiar with HIV care remember to order is the CD4 count and the viral load. Yeah. And I don't, I think that they don't always process the, the component of the information that this is someone who's acutely ill- Right

and translate that into the fact that they might have a detectable viremia that they then have to have a conversation about. So the conversations I have in this type of scenario, u- I usually take this as an opportunity to provide that education for our colleagues, um, that are more likely to be seeing these patients who are stable and coming in for something else that's not related to their HIV status.

And I provide reassurance that it's not unexpected that they have a blip, and that it's entirely safe for them to proceed with whatever treatment is, [00:18:00] um, determined to be appropriate for their acute, um, condition. And I think in the case of this particular scenario, where again, you're talking about the surgical team maybe being nervous because someone has a detectable viremia, I go back to that U and, U equals- Yeah

two threshold. Yeah. Saying, you know, "This is a blip. This person is going to continue taking their HIV medication while they're inpatient, and the risk of, um, transmitting it to someone else, even in the context of a needlestick injury- Right ... will be quite low." Yeah. And we know that our surgical colleagues are taking all precautions- Right

anyways when they have these, uh, procedures, and thankfully, needlestick injuries remain a rare occurrence in the hospital as opposed to something that happens on the daily. Right. And nosocomial acquisition of, of HIV, uh, from health, uh, from patient to healthcare providers is sort of a completely rarefied event now in 2026 and, and not something that, that we are concerning ourselves as much with.

But [00:19:00] obviously, you know, uh, for folks who are not as involved with the, you know, caring for people living with HIV, it, it remains a concern. So there's like, you know, multiple layers of education that you're doing in this setting to the patient, uh, to the care teams, uh, to the surgical teams, um, a- a- a- as well.

Um, so let's shift gears and, and say like, so when would we actually care? Like, when would we actually wanna delve a bit further? And I, I would argue that, you know, whenever I see a change in a viral load, I do still ask some follow-up questions, right? So like, I still ask, like you mentioned be- about adherence, right?

Ab- about, um, yeah, you know, if they're on oral ART, like, tell me, you know, you told me you didn't miss any doses. Let's think about it in the, right before, you know, we saw each other, did you miss any doses in the past week, in the past month? Try, it's easier to sometimes give a defined period of time, uh, for folks to be able to recall, uh, what that is.

If they're on long-acting injections, I, I do ask, "Did you notice like any of the recent injections feeling funny or feeling different or, or not being the usual?" But [00:20:00] sometimes it's important to ask about other drugs that that make... And while there might be n- not any changes, let's say this person, so for example, in this case, let's say that he's been having a lot of indigestion recently and have been taking a lot of Tums.

Um, that he's been taking multiple Tums on a daily, o- on a multiple-times-a-day basis, uh, in addition to his dolutegravir and, and lamivudine. Um, is this something that, you know, something that, that we would be concerned about, um, um, in the setting of, you know, a newly, uh, uh, positive viral load? Yeah. I think that you bring up a very pertinent point because, you know, sometimes when we have those conversations, we fixate on the adherence issue.

Right. And we forget that there are actually over-the-counter medications that can interact and reduce, uh, the absorption of these antiretroviral therapies. So it's always very important to do a, a thorough med rec of the stuff that we've prescribed as opposed to, and as well as the supplements that patients may have decided to get over the counter for other indications.

Because [00:21:00] in these instances, if someone, for example, uh, is taking a calcium-based supplement or is taking an antacid, uh, medication, these classes of medication which are available over the counter can really reduce the absorption levels- Yeah ... of, um, some of our antiretroviral therapies. And I usually ask patients, "How are you timing this?

Are you taking this right alongside, you know, using your Tums to swallow your TatCree pill?" Right. Right. Are you taking it down? Yeah. Or are you taking it... Exactly. Yeah. A two-hour, uh, spacing between- Right ... uh, whatever over-the-counter drug you're taking. And sometimes that would allow you to identify instances where the potential for drug interaction is real.

Yeah. And in those settings, then I worry a little bit more about that blip being something that, than just transient. Right. So I educate the patient on the importance of not taking the supplement or the drug- Yeah ... with their [00:22:00] ART and/or appropriately spacing it, and I would tend to recheck that viral load a little bit sooner.

Yeah. But I would want to do it when they are taking the ART as prescribed. Right. So that what I'm seeing is an actual reflection of, you know, taking medication as prescribed and adhering to therapy- Right ... as opposed to just rechecking on the same day where they still took the Tums and took the Exactly.

Yeah And I think this is also really important in the setting of, like, low level viremia where someone is cons- constantly floating, like, under 200 and, you know, and so this is not just a blip, but it remains as low level viremia, which could completely be clinically insignificant. But sometimes if you don't ask the right questions, maybe there have been sort of, sort of over-the-counter medications that are interacting.

And this is also when, you know, your ID pharmacist, your HIV pharmacist are incredible help- incredibly helpful. Because I've gone to my HIV pharmacist often and show them sort of this trajectory. I'm like, "Hey, this is really confusing." Like, and then they can sometimes, you know, elicit more information out of that patient, um, that [00:23:00] can actually clarify, you know, a, a, a root cause of what might be causing that low leve- low level viremia, um, uh, in, in general.

I think- And- Oh, yeah. Yeah, go. Yes. I was going to add to that, that we, you know, a couple of years ago, several years ago, I had a scenario, um, with a patient who had a surgery that, uh, essentially devel- and developed short gut syndrome. Okay. And that accelerated, you know, impacted on the absorption- Yeah ... of their medications.

Yeah. And that was the only thing after extensive questioning that could be identified as what was potentially explaining the fact that they had low level viremia, because this wasn't a one-time blip. Right. But it was persistently low level viremia. And so we had to think creatively about changing that person's regimen with the support of our ID pharmac- pharm, uh, PharmD team that, you know, helped identify what medication would be better suited in- [00:24:00] Yeah

that scenario, and it did resolve the issue. So, you know- Yeah ... very important to think out of the box and- Yeah ... ask the right questions. Yeah. Um, in a situation like that for, like, low-level viremia, would you get, uh, archive resistance or, like, a proviral DNA? What, what are your thoughts on sort of thinking about more diagnostics in, in, uh, in that area?

And let's assume that this is a low-level viremia defined as under two hundred copies per mL. Well, again, it, it would come back to the sensitivity of the assays that we actually have for doing genotyping testing. Uh, for most of the available assays that we have to actually do drug resistance testing and evaluate whether there's archive resistance contributing to this, the threshold is way higher than the, the level of, um, uh, two hundred copies per ml.

Ideally, to be able to do a genotype with our commercial assays, you have to have about a thousand copies detectable. So a lot of these folks are [00:25:00] presenting at very low levels. Now, if, for example, they were to have access to, say, a research laboratory that can do genotyping for a little bit lower, um, uh, copy numbers, the question is always: What does archive resistance mean in the context of low-level viremia?

Is this actually something that we should chase and have the patient worried about? And there are studies that show that in the context of very low-level viremia, below that two hundred copy number, it doesn't matter much, even if you were to do a super sensitive research-based assay and detect archive resistance.

That doesn't mean that the treatment is failing because the patient's viral load is still below a level that, you know, places them in a safe zone where they cannot pass on the virus and where their immune system is not going to get compromised because they have that low-level viremia. Yeah. Yeah. Yeah. I mean, I think that's a, a really great point.

I think, um, you know, there was a consensus paper [00:26:00] out in Lancet ID within the last year that kind of sort of tackled this idea of archive resistance. I think a lot of folks-- I mean, I... this, um, this concern folks have about how to interpret archive resistance, I think, has been sort of reignited, uh, with the advent of long-acting ART and w- a lot of folks who wanna transition from oral ART to long-acting, uh, that don't have the opportunity to ever get a genotype because they've been suppressed for so long.

People have brought the idea, "Oh, can archive resistance sometimes help us, you know, um, figure out who would be ideal candidates?" And I think that consensus paper really pushed back hard against that kind of practice and recognizing that there are clinical limitations to archive resistance. They can be a very interesting way to know what the historical, you know, uh, mutations that someone might have accumulated over time.

But the clinical a-applicability of this, of, uh, of, of those results, um, are, are, are, are, are, are yet to really be seen. And making sort of actionable clinical decisions on archive resistance is heavily discouraged, uh, when you have other data at your disposal [00:27:00] to be, to be thinking about. Absolutely So I'm going to just re- Awesome.

Um, so you have about five more minutes. You did talk a bit about the patient communication already. I didn't know if there was anything else you wanted to further discuss on that, or if you wanna do, you know, start summarizing and, and closure. Um, is there anything you feel like you were missing? It sounded like you co- covered everything to me.

I think so because- I think, uh, yeah, I think we covered patient communication pretty well. Yeah. Yeah. So I'll let you sort of head back into the, um, sort of closing takeaways and, and sign off. Excellent. Thanks, Sarah. Thank you Um, all right, so let's, uh, let's, I guess, h- wrap this, this show up, BK. So I guess if you had to give your sort of key takeaways of how to think about, um, um, viral blips and, and low [00:28:00] level of vi- viremia, what's your sort of your, your, your top line approach to clinicians who might be listening to us right now?

I think that I always like to start by the fact that a single value should not be what clinicians use to make a decision. Trends are more important than single values where virological blips are concerned. So if you get a patient that shows up with a blip and has a detectable viremia, your first instinct should not be to think about reflexively making a clinical decision on that.

You should go through a m- a short algorithm in your head, which is what is this blip in terms of where it lies in my threshold of worry? If it's less than 200 copies, you provide reassurance to the patient, and you have a conversation about the timing of rechecking. Uh, it's always important to do, um, important clinical review on the med rec and also ask the patient if anything has changed in the way in which they're [00:29:00] taking their medication, just to make sure we're good on a- adherence as well as drug-drug interactions.

And it's also, um, important to remind ourselves that if a patient is presenting with a cold, that may not be the best time, uh, to be checking, um- I mean, yeah ... random viral loads on them because in those scenarios, we're more likely to pick up on some of these, um, blips. Yeah. So, like, the core message here should be reassurance both for the patient and both for the HIV provider, and remembering at what threshold to do additional testing and, and to, you know, to more aggressively pursue whether you're dealing with virologic failure.

Yeah. I love it, BK. And I, again, like communication is key. In this era of open records, I think it's important to frame what a viral load means to a patient very early on to let them know that, "Hey, like, we're checking a viral load. Any number under this number, uh, under 200 copies per ML, means you [00:30:00] cannot transmit the virus at all.

Even if your number might be somewhere between zero and 200, understanding the power of U=U still holds." Um, uh, in, in general. And, um, I think, again, being able to, to continue to educate colleagues as well, that you get consulted on in the hospital or get curbsides on, um, and continuing to spread the message of equals U and understanding that the, a more nuanced approach to how to approach, how to think about viral loads is, is, is, is really important.

Um, uh, and yeah, I think this will continue to happen as, as our assays get m- even more and more sensitive, uh, down to even fewer and fewer copies. Um, but I'm, I, I'm hoping this idea of what it means to be functional and detectable kind of takes, takes hold and, and we can continue sort of uti- u- utilizing that as a, as a nice, uh, benchmark of how we think about, um, you know, uh, ongoing treatment, uh, suppression, uh, for, uh, for individuals.

Um, yeah. With that- And I'll just- Yeah ... I'll just add one more thing in terms of, like, the language that we use as [00:31:00] providers. I think that when you use language that can cause alarm, a patient is more likely to latch onto that. Yeah. So just avoiding terms like failure- Yeah. Yeah ... when discussing blips and just, you know, calling them blips.

Yeah. Yeah, yeah. Really great point. Um, well, BK, thank you so much for joining me and having- Yeah ... this awesome conversation. I learned a lot from you, and I hope, um, you know, the listeners have maybe a, a, a, a, again, a more nuanced approach of how they think about sort of viral blips and low level viremia, um, and can take into their practice.

Yeah. Thank you all for, for joining us. Same here. Thank you all. Wonderful. I have one, um, question or one thing for you. C- uh, uh, um, I know you did not define... I, I'm assuming most people know what U equal U, U, like Uh. But if you can just- It's, it is directed at... I don't know, is it, is it all the providers? It, it could be per- Yeah

yeah. It could be providers. It could be a whole slew of people. So, I [00:32:00] mean, we, we will have it in the, um, objectives, but I'm wondering if you just wanna say- Sure. Yeah ... and U, and then we'll just snip it in, put- Yeah. Sure ... put BK's face while you're saying it, and- All right. So let me, let me shut down and have you do that.

Um, yeah, and I think it's important for us to sort of all define also what U=U means. So U=U is a huge, powerful tool that we have, uh, in our efforts to end the HIV epidemic. So U=U stands for undetectable equals untransmittable. Uh, there has been a significant amount of scientific data that supports that a viral load's under 200 copies per ML.

If someone has a viral load under 200 copies per ML, they cannot transmit HIV sexually to any of their partners. Uh, there is no if, ands, or buts or fine print in that, um, that if someone's viral load is under 200 copies, they cannot transmit, uh, HIV sexually to any of their partners, and that's sort of the basis of U=U.

The WHO does go a bit further and say likely that threshold is actually up [00:33:00] to 1,000 copies per ML. Uh, but in the United States, we, we hold to, to 200 copies per ML, and I think again, U=U is a, uh, is a huge sort of tenet of how we think about both HIV treatment and, and prevention. Uh, and oftentimes, like B.K.

mentioned, is a, is a source of anxiety when people see these viral blips to make sure that they feel like they can still, uh, rely on U=U, and for the majority of these cases, uh, U=U still holds, uh, in regardless of, uh, of, of these blips.

Thank you for listening in to our podcast on HIV Viral Blitz.