Background Studies have demonstrated that persons with HIV (PWH) maintaining viral suppression do not transmit HIV to HIV-negative partners through condom-less sex, leading to the “Undetectable = Untransmittable” (U=U) prevention campaign. However, few studies have examined the durability of suppression in the era of U=U. Methods This retrospective cohort study was conducted in Providence, RI. PWH age ≥18 years with documented viral suppression [defined as at least 1 viral load (VL) <200 copies/mL and no VL ≥200 copies/mL] in 2015 were included in the baseline cohort. Primary outcomes were viral suppression, viral rebound (at least 1 VL ≥200 copies/mL), or gap in VL monitoring assessed annually from 2016-2019. Those with viral rebound were assessed for re-suppression within six months. Demographic and clinical characteristics associated with viral rebound or gaps in VL monitoring were investigated by bivariate analysis and logistic regression. Results 1242 patients with viral suppression were included in the baseline cohort. In each follow-up year, 85-90% maintained viral suppression, 2-5% experienced viral rebound, and 8-10% had a gap in VL monitoring. Among those with viral rebound, approximately one-half were suppressed again within 6 months. In the logistic regression models, retention-in-care was significantly associated with viral suppression, while younger age, black race, high school or equivalent education, non-MSM, and history of incarceration were significantly associated with viral rebound. Conclusions In the U=U era, most patients with viral suppression who are retained in care are likely to maintain viral suppression over time. Some patients require additional support for regular VL monitoring.

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Justice-involved (JI) populations bear a disproportionate burden of HIV infection and are at risk of poor treatment outcomes. Drug resistance prevalence and emergence, and phylogenetic inference of transmission networks, understudied in vulnerable JI populations, can inform care and prevention interventions, particularly around the critical community re-entry period. We analyzed banked blood specimens from CARE+ Corrections Study participants in Washington, D.C. (DC) across three time points and conducted HIV drug resistance testing using next-generation sequencing (NGS) at 20% and 5% thresholds to identify prevalent and evolving resistance during community re-entry. Phylogenetic analysis was used to identify molecular clusters within participants, and in an extended analysis between participants and publicly-available DC sequences. HIV sequence data from 54 participants (99 specimens) were analyzed. The prevalence of transmitted drug resistance was 14% at both thresholds, and acquired drug resistance was 47% at 20%, and 57% at 5% NGS thresholds, respectively. The overall prevalence of drug resistance was 43% at 20%, and 52% at 5% NGS thresholds, respectively. Among 34 participants sampled longitudinally, 21-35% accumulated 10-17 new resistance mutations during a mean 4.3 months. In phylogenetic analysis within the JI population, 11% were found in three molecular clusters. The extended phylogenetic analysis identified 46% of participants in 22 clusters, of which 21 also included publicly-available DC sequences, and one JI-only unique dyad. This is the first study to identify a high prevalence of HIV drug resistance and its accumulation in a JI population during community re-entry and suggests phylogenetic integration of this population into the non-JI DC HIV community. These data support the need for new, effective and timely interventions to improve HIV treatment during this vulnerable period, and for JI populations to be included in broader surveillance and prevention efforts.