ART aims to suppress viral replication to reduce the patient’s viral load (VL) to undetectable levels. This reduction of viral load prevents further damage to the body’s immune system and restores and maintains the quality of life. Therefore, early enrolment into care, retention, and good adherence to ART are vital components of HIV prevention. This study investigated the factors associated with viral load non-suppression among adolescents with PLHIV on ART in care and treatment health services facilities in Tanga. The median age of the study participants was 15.2 years. The readiness of health facilities to provide viral load testing was at 54% only. The proportion of viral load suppression (VLS) among the 2547 adolescents on ART included in the study was high at 89.68%, with the observed high prevalence of VLS in DTG-related regimen users (91.09%). Furthermore, this study revealed that not using DTG-related drugs and attending care and treatment at the hospital facility level were significantly associated with viral load non-suppression.
The longitudinal nature of this study gave room to calculate the rate and factors independently associated with viral load non-suppression among adolescents in Tanga. However, this study used secondary data that limited information on important variables like pregnant status, ART adherence, support from significant others, and disclosure status, significantly predicting viral load suppression. Using secondary data presented challenges in the quality, completeness, and missing data that we mitigated by employing statistical and data management techniques to ensure data quality.
The viral load non-suppression prevalence among adolescents in this study was lower (10.32%, n = 263) than the national prevalence of 17.7% reported in 2016 [6]. This rate is lower than the studies in Uganda, Swaziland, and South Africa, at 31.4%, 16%, and 15%, respectively [8, 9, 10]. However, this observed level of viral load suppression falls short of the UNAIDS’ 95-95-95 targets. The observed lower viral load non-suppression rate in the current study may be related to the launch of the “test and treat” guidelines in October 2016 in Tanzania, which emphasised enhanced adherence counselling (EAC) and support for patients with high viral loads [6]. Additionally, the DTG ART-related drugs adopted in April 2019 for all PLHIV helped to fasten viral load suppression. The current study showed that adolescents with PLHIV who were on DTG-related drugs were highly virally suppressed (91.09%). Also, PLHIV detected with high viral loads received three sessions of EAC, after which a repeat viral load test was performed. Our findings suggest that the WHO target of 95% viral suppression by 2030 is possible for adolescents in Tanzania if the readiness of health facilities to provide viral load testing is improved. However, the VLS success observed in this study is achieved for those for viral load testing was possible; thus, it may be that this is underrepresented in this region.
The current study showed that adolescents with PLHIV on ART with no DTG combination drug increased the risk of viral load-non-suppression by 13 times compared to DTG regimen users. However, DTG-based regimens are more effective in suppressing viral load than non-DTG regimens, and their side effects are better tolerated by most clients, improving ART adherence [11, 12, 13]. In Tanzania, the use of ART with DTG combination for all PLHIV was rolled out in 2019. However, to the best of our review, limited studies looked at the association between viral load suppression and DGT use.
The adolescents with PLHIV accessing care and treatment at the hospital facility level had a higher risk of being virally non-suppressed than those who attended dispensary and health centre facilities. We found limited studies that looked for the association between facility level and viral load suppression. However, the possible reason for viral load suppression failure to PLHIV attending hospital could be fear of being seen by other patients since patients turn up to hospital level is higher than in other facilities. Meeting new people every visit possibly scares them and would end up causing a loss to follow-up and poor drug adherence that finally hampered viral load suppression.
Our study found that sex was not significantly associated with viral load suppression failure. However, from the descriptive analysis, more males were virally non-suppressed compared to females in the current study. Evidence point to a connection between sex and the suppression of viral load. For instance, one study indicated that males were more likely than females to achieve viral load suppression [14], while another study found that females were more likely than males [15]. However, our study found that females could potentially achieve viral load suppression more than males. Men are more likely than women to fail to achieve viral load suppression, which may be related to their reported lower treatment adherence rates. It is difficult to link and keep males in ART therapy [16] and have them tested for HIV since they also exhibit poor treatment-seeking behaviour [15]. This finding has been evidenced in the first studies that analysed ART treatment after five years of ART initiation in Tanzania. Excess mortality in men was rooted in poor health-seeking behaviour and non-compliance with medication [17]. Strong gender norms and behaviours, notably the concept of masculinity being superior ingrained in African civilisation, including Tanzania, have been blamed for the poor treatment outcomes recorded among males. Males are also discouraged from obtaining healthcare services due to a shortage of male-friendly services [16, 18, 19].