Comparing the efficacy of efavirenz and boosted lopinavir using viremia copy-years

Introduction: HIV-1 plasma viral load during treatment can be highly variable. Thus, there is the need to find a measure of cumulative viremia that can be used to assess both the short-and long-term efficacy of highly active antiretroviral therapy (HAART). Here, we validate a measure of cumulative viremia to evaluate HAART efficacy. Methods: We accessed HAART efficacy using data from a randomized clinical trial conducted in Mexico. We compared the proportion of individuals achieving a viral load < 50 and < 400 copies/mL at week 48, against the cumulative plasma viral load, estimated as the area under the plasma viral load curve (AUVLC). High AUVLC indicates high cumulative viremia. Results and discussion: There was a strong and significant association between the proportion of individuals achieving a viral load < 50 and < 400 copies/mL at week 48, with individuals suppressed having significant lower cumulative viremia. The median area was 7513 (25th-75th percentile [Q1-Q3] 6634-8180) if viral load < 50 copies/mL and 7679 (Q1-Q3 6899-9373) if viral load >= 50 copies/mL (p-value 0.0284). When the analysis was stratified by study arm, individuals on efavirenz had lower cumulative viremia than those on boosted lopinavir. Conclusions: Our findings suggest that cumulative viremia should be explored further as a tool to simultaneously evaluate the individual and public health efficacy of HAART. This is particularly relevant to the implementation and evaluation of the Treatment 2.0 strategy recently proposed by UNAIDS and the WHO, as a means to maximize the individual and public health benefit of HAART.