Viral blips, where HIV RNA plasma viral load (pVL) intermittently increases above the lower limit of assay detection, are a cause for concern. We investigated a number of hypotheses for their cause. We assessed HIV RNA, and total and episomal HIV DNA from 16 individuals commencing antiretroviral therapy (ART) consisting of raltegravir and tenofovir/emtricitabine for 3 years, using two assays: a single-copy assay [SCA; lower limit of quantification (LLOQ), < 1 copy/ml] and the Amplicor assay (LLOQ of 50 copies/ml). Two individuals exhibited viral blips. From week 20 onward, the period where ART had achieved its final suppressive levels, pVL ranged from < 1 to 330 copies/ml, except for one individual at the final time. Both assays were 98% consistent (108/110) in assessing pVL < 50 copies/ml, but the Amplicor assay registered 56% of samples (19/34) as below the LLOQ that were in the 50 to 1000 copy/ml range as quantified by SCA. pVL changes between successive time points did not correlate with changes in cellular infection as measured through either total or episomal HIV DNA. Changes in pVL were correlated (negatively) with changes in total CD4+ T cell numbersPatients receiving stable, seemingly suppressive ART can have pVL near the 50 copy LLOQ at multiple time points. The high Amplicor assay error rate around this level implies that viral blips underrepresent pVL being more consistently above the LLOQ. Activation of latently infected cells is less likely to contribute to this phenomenon. S uppression of HIV plasma viral load (pVL) to as low levels as possible and for as long as possible is the primary goal of antiretroviral therapy (ART). Sudden rises of pVL in a patient after extended periods in the undetectable range ( < 50 copies/ml for many assays) can be a cause for concern for both physician and patient. A consistent increase in pVL is often a sign of ART failure, most likely due to noncompliance, low plasma drug levels, or the outgrowth of a drug-resistant viral quasispecies. The clinical implications of viral "blips," where seemingly random detectable pVL levels occur amongst undetectable ones, are less clear.A number of theories have been advanced to explain viral blips, but there are essentially two hypotheses: (1) differences in detection of pVL at or around the lower limits of assay quantification (LLOQ) occur through errors in the reproducibility of the assays and fluctuations of pVL around mean HIV RNA levels below the LLOQ 1-3 ; and (2) new rounds of viral replication arise through a variety of mechanisms resulting in rapid increases in pVL above the LLOQ from previously low levels. [4][5][6] An underlying assumption with the second hypothesis is that successful ART suppresses pVL much lower than 50 copies/ml and a blip represents a large change in pVL.We investigated these questions using data from 16 HIVinfected, therapy-naive patients [eight primary (PHI) and eight chronic (CHI)] commencing raltegravir and Truvada (tenofovir/emtricitabine) who were followed for 3 years (the PINT Study 7...