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The Impact of Alcohol use during Seemingly Suppressive Antiretroviral Therapy: Risk of Blips and Rebounds

María José Míguez-Burbano, Mario Stevenson, Clery Quiros, Luis Espinoza and Wenyaw Chan

Background: After achieving “clinically undetectable levels”, many HIV positive individuals remain in a phase called residual viremia. Some of these patients have viral blips, while others have viral rebounds, but little is known about their causes. Our objective was to identify the rate and determinants of viral load dynamics, particularly the effect of hazardous alcohol use. Methods: We evaluated 400 cohort participants starting ART and comprehensively assessed alcohol intakes using validated instruments. Viral load (VL) was measured at four time points (baseline, 6 12 and 18 months), along with potential covariates, such as demographics, CD4, CD8, platelets, alcohol use profiles, and medication adherence. VL suppression was assessed at 6 months and then based on prior published work, viral trajectories were censored according to the following categories: reference Group 1 (very low viremia<50), viral blips Group 2 (50-399), and the viral rebound Group 3 (400-1000 copies/mL). Factors associated with VLV, blips, and rebounds were identified using logistic regression models. Results: Among the 320 subjects who achieved undetectable viral loads, during the subsequent 12 months of therapy, 20% exhibited viral blips, and 43% had viral rebounds. Despite similar medication adherence (95% vs. 85%), hazardous alcohol users were twice more likely to have a viral rebound, compared with non-users (95% CI, 1.8-2.5; p=0. 000). Alcohol users were also more likely to have blips. After adjustment for potential confounders, regression analyses indicated that CD4 counts at the time of therapy initiation, alcohol use, and age were independently associated with blips and rebounds. Conclusions: In this cohort, hazardous alcohol use was associated with an increased risk of viral blips, and thus will likely play an important role in the development of effective strategies to eliminate HIV, and prevent transmission and disease progression. These findings have implications for clinicians, researchers and policy makers, as they highlight the detrimental effects of alcohol use while on ART therapy.