Reversal of proviral latency is being pursued as a curative strategy for HIV-1 infection. Recent clinical studies of in vivo administration of the histone deacetylase inhibitor suberoylanilide hydroxamic acid (SAHA; vorinostat) show increases in unspliced cellular HIV-1 RNA levels in resting CD4 + T cells. A critical unknown, however, is the proportion of latent proviruses that can be transcriptionally reactivated by SAHA or T-cell activation. In this study, we quantified the fraction of HIV-1 proviruses in resting CD4 + T cells from patients on suppressive antiretroviral therapy that were reactivated ex vivo with SAHA or antibodies to CD3/CD28. At concentrations of SAHA achieved clinically, only 0.079% of proviruses in resting CD4 + T cells were reactivated to produce virions, compared with 1.5% of proviruses in cells treated with anti-CD3/CD28 antibodies after correcting for spontaneous virion production in the medium control. A significant positive correlation (ρ = 0.67, P < 0.001) was found between levels of virions in the supernatant and unspliced cellular HIV-1 RNA following anti-CD3/CD28 treatment, but not following SAHA treatment (ρ = 0.21, P = 0.99). These results reveal that the majority of HIV-1 proviruses are not reactivated by current therapeutic approaches and that more effective means of reversing proviral latency will likely be required to deplete HIV-1 reservoirs.HIV-1 persistence | HIV-1 eradication | HIV-1 cure | fractional provirus expression A ntiretroviral therapy (ART) for HIV-1 infection suppresses viral replication but is not curative. Assays of infectious virus recovery from quiescent CD4 + T cells isolated from patients on ART have revealed the existence of a reservoir of latent, replication competent HIV-1 with a half-life of 44 mo (1-4). In addition, low-level plasma viremia persists indefinitely on ART (5, 6), and the level of virus in plasma rebounds following cessation of ART (7,8). New therapeutic approaches are required to eliminate both persistent low-level viremia and the latent proviral reservoir. A "kick and kill" approach has been proposed in which latency reversing agents, administered in conjunction with ART, will "kick" proviruses out of latency, followed by a "kill" of the infected cells through viral cytopathic effects or immune-mediated cytotoxicity.Histone deacetylase inhibitors (HDACi) have been proposed as latency reversing agents, and single-dose or multidose administration of suberoylanilide hydroxamic acid (SAHA; vorinostat) in vivo was shown to increase expression of unspliced cellular HIV-1 RNA in resting CD4 + T (rCD4) cells in patients on suppressive ART (9, 10). Although three-to fivefold increases in cellular HIV-1 RNA were observed (9), the fraction of latent HIV-1 proviruses that were reactivated by SAHA was not quantified. It is possible that SAHA transcriptionally reactivated many latent proviruses, or alternatively reactivated only a minority of latent proviruses. These two alternatives have very different implications in terms of the impact SAHA coul...