HIV Viral Load Suppression Rate and Predictors of Unsuppressed Viral Load among Patients Receiving Antiretroviral Therapy at a Secondary Treatment Centre in Kano State
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Study Level: BTech, BSc, BEng, BA, HND, ND or NCE
Background: Achieving and maintaining viral load suppression is a critical goal in the management of HIV infection. Understanding the prevalence of viral load suppression and identifying factors associated with unsuppressed viral load can inform targeted interventions and improve treatment outcomes.
Aim:This study aimed to determine the prevalence of viral load suppression and explore the factors independently associated with unsuppressed viral load among patients on antiretroviral therapy (ART) for at least six months.
Methods: A facility-based analytical cross-sectional study was conducted among patients aged 15 and above who were receiving ART. Systematic sampling was used to recruit a sample size of 359 participants. Data on sociodemographic, clinical and treatment characteristics were collected through interviews and medical record reviews. Blood samples were collected, processed, and tested for CD4 count and Viral Load using VISITEC CD4 Test kit and PCR methods respectively. Multivariate logistic regression analysis was performed to identify factors independently associated with unsuppressed viral load.
Results: The study found a viral suppression rate of 90.8% among the study population. Factors independently associated with unsuppressed viral load included CD4 count >350 cells/µl (AOR=0.42, 95% CI 0.2-0.9), poor adherence to treatment (AOR=5.2, 95% CI 2.3-12.0), TB-coinfection (AOR=5.1, 95% CI 1.3-19.2), and previous unsuppressed viral load (AOR=5.0, 95% CI 1.2-20.5).
Conclusion: The prevalence of viral load suppression among patients on long-term ART was high in the study population. However, certain factors were identified as independent risk factors for unsuppressed viral load, including low CD4 count, poor adherence, TB-coinfection, and previous unsuppressed viral load.
Recommendation: These findings emphasize the need for targeted interventions focusing on improving treatment adherence, managing TB-coinfection, and closely monitoring patients with a history of unsuppressed viral load to enhance viral suppression rates and improve overall treatment outcomes in HIV-infected individuals.
Keywords: HIV, viral load suppression, unsuppressed viral load, antiretroviral therapy, prevalence, associated factors, cross-sectional study.
TABLE OF CONTENT. vii
LIST OF TABLES. x
LIST OF FIGURES. xi
CHAPTER I 1
1.1 BACKGROUND.. 1
1.1 Operational Definitions. 3
1.2 Problem Statement 4
1.3 Study Justification. 5
1.4 AIMS AND OBJECTIVES. 7
1.41 General Objective. 7
1.42 Specific objectives. 7
CHAPTER II 8
LITERATURE REVIEW… 8
2.1 INTRODUCTION.. 8
2.2 HIV Viral Load Suppression Rates. 9
2.3 Socio- demographic Predictors for Unsuppressed Viral Load. 10
2.4 Clinical Factors. 11
2.4.1 CD4 Count 11
2.4.2 Adherence Level 12
2.4.3 HIV/TB coinfection. 13
2.4.4 History of Previous Unsuppressed Viral Load. 14
2.4.5 Duration on ART. 15
2.4.6 WHO Clinical Staging. 16
CHAPTER III 17
3.1 Study Area. 17
3.2 Study Design. 17
3.3 Study Population. 17
3.4 Inclusion Criteria. 18
3.5 Exclusion criteria. 18
3.6 Sample Size Determination. 18
3.61 Finite Correction. 19
3.7 Sampling Technique. 20
3.8 Study instruments. 21
3.9 Data collection methods. 21
3.91 Venous blood sample collection, processing, testing, and transportation. 21
3.92. Laboratory Procedure for the Estimation of CD4 count using VISITEC CD4 Test Kit 21
3.93 Viral Load Testing. 22
3.10. Data Management 24
3.10.1 Data Quality. 24
3.10.2 Measurement Variable. 25
3.10.3 Data Analysis. 25
3.10.4 Ethical Consideration. 25
3.10.5 Study Limitations. 26
CHAPTER IV.. 27
4.1 Socio-demographic Characteristics of Study Participants on ART at IDH.. 27
4.2 Clinical and Treatment Characteristics of Study Participants on ART at IDH.. 29
Table 2 continued. 31
4.3 Proportion of Study participants with Viral Load Suppression on ART at IDH.. 31
4.4 Factors associated with unsuppressed viral load among patients on ART attending IDH Kano. 34
Table 4 continued. 36
4.5 Independent Predictors of Unsuppressed Viral load among adult ART patients Receiving Care at IDH kano. 36
CHAPTER V.. 39
CHAPTER VI 43
CONCLUSION AND RECOMMENDATION.. 43
6.1 Conclusion. 43
6.2 Recommendations. 43
APPENDIX I 50
APPENDIX II 51
Appendix III: Data extraction tool 53
Human immunodeficiency virus (HIV) is a leading cause of global burden of disease. Globally in 2021, an estimated 84.2 million people had become infected with Human immunodeficiency virus (HIV) and 40.1 million people had died of Acquired Immunodeficiency Disease Syndrome (AIDS)-related illnesses since the start of the pandemic1,2. In 2021, an estimated 38.4 million people were living with HIV worldwide and 36.7 million of them were adults. An estimated 68% live in sub- Saharan Africa3.In 2020, there were 20.6 million people with HIV in eastern and southern Africa, and 5.0 million in western and central Africa4.Nigeria has the second largest HIV epidemic in the world and one of the highest rates of new infections in sub-Saharan Africa. Although HIV prevalence among adults is much less (1.4%) than other sub-Saharan African countries such as South Africa (19%) and Zambia (11.5%), the size of Nigeria’s population means 1.9 million people were living with HIV in 2019.Six states in Nigeria accounts for 41% of people living with HIV, including Kaduna, Akwa Ibom, Benue, Lagos, Oyo, and Kano5.
In recent years, significant progress has been made in increasing access to antiretroviral therapy (ART) for people living with HIV6.Antiretroviral therapy is aimed to achieve and maintainviral suppression, thereby preventing disease progression and transmission. In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) set the 90-90-90 global targets and for epidemic control of HIV, whereby the third 90 represents a target to achieve viral suppression in at least 90% of patients initiating ART by 20207.In December 2020, UNAIDS released a new set of ambitious targets calling for 95% of all people living with HIV to know their HIV status, 95% of all people with diagnosed HIV infection to receive sustained antiretroviral therapy, and 95% of all people receiving antiretroviral therapy to have viral suppression by 20308.HIV treatment outcomes among people living with HIV (PLWHIV) are dependent on monitoring of the response to antiretroviral therapy (ART). WHO clinical staging, immunological (CD4 T-cell count) and monitoring of routine viral load suppression are methods used to monitor treatment outcomes. Immunological and clinical monitoring has poor sensitivity and lower positive predictive value for identifying treatment failure compared to viral suppression5.
The World Health Organization (WHO) in July 2013 recommended the use of viral load testing as the gold standard to monitor patients response to ART6. Establishment of the virological suppression status among patients enrolled on ART is important for timely detection of treatment failures, identification of patients in need of more intensive adherence support and minimizes development of drug resistance and unnecessary switch to expensive and limited ART regimen options9. Maintaining VLS keeps HIV- positive patients healthy and reduces the risk of HIV transmission.A recent analysis of National HIV Surveillance System and National HIV Behavioural Surveillance data showed a rate of 0 per 100 person-years of HIV transmission for individuals on antiretroviral therapy (ART) with suppressed viral loads, but a rate of 6.1 per 100 person years for individuals in care who were not virally suppressed10. According to some studies, the median duration to suppress the viral load from the initiation of ART to suppression of the viral load below 1000 copies/ml is 1 month to 7 months4. The predictors of time to viral load suppression, identified by different studies, are: the choice of treatment regimen, initial viral load, baseline CD4 count and previous anti-retroviral (ARV) treatments used4.WHO defines viral load suppression as having a HIV-1 RNA 1000 copies/mL at least six months after initiation of ART, which indicates that viral replication is not well controlled11. WHO also recommends routine VL monitoring should be done after six months of ART initiation and then every 12 months thereafter10.
In 2015, more than 14.5 million of the 36.7 million (43%) people living with HIV did not know their status. About 54% of the people living with HIV had not yet started Antiretroviral treatment and only an estimated 38% of people living with HIV worldwide were virally suppressed4. In 2016, however, only 44% of the people living with HIV who were on treatment had viral suppression globally11.Recently, VL monitoring has been scaled up in resource-limited settings; however, in most sub-Saharan African countries, access remains limited. The proportion of patients who had received at least one VL test by mid-2016 was 19% in Malawi, 11% in Cote d’Ivoire, 49% in Kenya, 43% in Namibia, 9% in Tanzania and 22% in Uganda12.
Nigeria has shown steady progress on increasing access to treatment for people living with HIV, with the adoption of a test and treat policy in 201613. This measure has further accelerated referrals to treatment facilities for people who test positive for the virus. From 2010 to 2017, the country almost tripled the number of people living with HIV who had access to antiretroviral therapy, up from 360 000 people in 2010 to more than one million people in 201814. However, it is estimated that more than half of the people living with HIV still do not have suppressed viral loads.At the national level, viral suppression among people living with HIV aged 15–49 years stands at 42.3% (45.3% among women and 34.5% among men)14.This study aimed to determine the viral suppression rate and predictors of non-suppressed viral load among patients on ART in Kano state.
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