Clinical predictors and correlates of viral suppression among people living with HIV accessing care at the Federal Medical Center HIV clinic in Ogun State, Nigeria

doi:10.21203/rs.3.rs-4314565/v1

Background

Globally, Human Immune-deficiency Virus (HIV) continues to be one of the world’s most significant public health issues. At the end of 2022, 39.0 million people were living with HIV (PLHIV) worldwide with 9% resident in Nigeria. Viral suppression is associated with a reduction in HIV disease progression. However, Nigeria is yet to achieve the 95-95-95 declaration of UNAIDS 2020 to eliminate the global HIV epidemic. This study assessed the clinical predictors and correlates of viral suppression among people living with HIV accessing care at Antiretroviral Therapy clinic in Federal Medical Center Abeokuta, Ogun State, Nigeria.

Methods

The study design was a facility-based retrospective cohort study that was conducted among patients on antiretroviral therapy (ART) at HIV clinic from May 2016 to October 22, 2021, Federal Medical Center of Abeokuta (FMCA), Ogun State Nigeria. Secondary data was exported from Microsoft Excel into Stata MP 17 for data cleaning and recoding, and analysis. Stepwise model selection was done for factors associated with viral suppression and binary logistic regression was used to investigate the predictors of viral suppression among participants at p-value < 0.05.

Results

Majority of the patients were females 1116(73.4%) and 241(15.9%) were aged 25–34 years. One thousand three hundred and eighty-six (90%) of the clients achieved viral suppression. Predictors of viral suppression were older age group of 25–34 years (OR: 2.62, 95% CI: 1.19–5.78, p < 0.017) and > 45 years (OR: 2.42, 95% CI: 1.11–5.28, p < 0.026), and active on ART (OR: 6.05, 95% CI: 4.10–8.91, p < 0.000).

Conclusion

Viral suppression was significant among patients who were older and ART active. Improving drug adherence is a significant factor to enhance viral suppression among PLHIV. It is important to promote clinic attendance and strengthen support groups so as to encourage drug adherence among PLHIV.

Viral suppression

HIV

clinical predictors

drug adherence

Globally, Human Immune-deficiency Virus (HIV) continues to be one of the world’s most significant public health issues. At the end of 2022, 39 million people were living with HIV worldwide. The WHO African Region remains most severely affected, with nearly 1 in every 25 adults (3.2%) living with HIV and accounting for more than two-thirds (66%) of the people living with HIV worldwide [1]. The 2018 Nigeria AIDS indicator and Impact Survey (NAIIS) reported that nine percent of all people living with HIV (PLHIV) globally live in Nigeria, with adult HIV prevalence estimated at 1.4% among people aged 15–49 years [2]. The survival of seropositive PLHIV has been increased by access to life-saving antiretroviral therapy (ART), the annual number of HIV-related deaths as well as new HIV infections have also been reduced in Nigeria [3].

Viral suppression is associated with a reduction in HIV disease progression, morbidity, and mortality among PLHIV. It also helps in minimizing the likelihood of HIV transmission to uninfected sexual partners [4]. In 2014, the 90-90-90 declaration by joint United Nations Programme on HIV/AIDS (UNAIDS) affirmed that 90% of people who are infected should know their status through testing, of whom 90% positive individuals be put on antiretroviral medication and of those on medication, 90% should achieve viral load suppression by the year 2020 [5]. However, in Nigeria, the progress on the 90–90–90 treatment targets in Nigeria at the end of year 2020, was 73–89–78, which means, 73% of people living with HIV had been diagnosed, 89% of those diagnosed were accessing treatment and 78% of those accessing treatment were virally suppressed [6].

In 2020, the Joint United Nations Programme on HIV/AIDS (UNAIDS) released a new set of targets which are major components of eliminating the global HIV epidemic, called the 95-95-95 [7]. The declaration expects 95% of all people living with HIV (PLWH) to be identified through testing, provide antiretroviral therapy (ART) for 95% of those who are diagnosed, and achieve viral suppression of 95% of those in treatment by 2030. Nigeria with some other 12 countries such as Namibia, Kenya, Zimbabwe, Botswana, Burundi, Lesotho, Rwanda, Estwani, Ethiopia, Malawi, Zambia have achieved 73% population viral load suppression [8].

Testing and treatment are documented to be essential factors in achieving viral suppression. However, Nigeria is yet to achieve the 2020 declaration for viral suppression. This study was conducted to assess the clinical predictors and correlates of viral suppression among people living with HIV accessing care at the Federal Medical Center HIV clinic in Ogun State, Nigeria.

Study setting and design

A facility-based retrospective cohort study was conducted among patients on antiretroviral therapy (ART) at HIV clinic from May 2016 to October 22, 2021, Federal Medical Center of Abeokuta (FMCA), Ogun State Nigeria. This clinic was established in 2006 and managed by the Department of Community Medicine and Primary Care, which is currently being supported by the AIDS Prevention Initiative in Nigeria (APIN). Federal Medical Center is a 500- bedded regional specialist hospital and houses one of the centres for the management of HIV in Nigeria. The goal of the hospital is to provide excellent medical services to the people of Ogun and other neighbouring states. The prevalence of HIV prevalence in Ogun State as at 2023 was 1.6% [9].

Study population, sample size and sampling technique

This comprised of all HIV patients aged 18 years and above receiving ART care at FMCA Ogun State. A total of 2176 patients’ case records were available within the study period: May 2016 to October 22, 2021, however, only 1520 with complete required information were included in the secondary data analysis. The information of all HIV patients aged 18 years and above that received ART care at the clinic and fulfilled inclusion criteria such as record of viral load, were included in this study. Participants' information utilized for this study was extracted from the clinic record book which contained the patient’s socio-demographic characteristics (such as age, sex among others), past medical history, pharmacy record and laboratory characteristics.

Study variables

The outcome variable for this study was HIV viral suppression. Viral suppression was measured using the laboratory result of < 1000 copies/ml for patients that were ‘suppressed’ and ≥ 1000 copies/ml for patients that were ‘not suppressed’ [10, 11]. The explanatory variables in this study were patients’ socio-demographic and clinical characteristics, which were age grouped into (≤ 24, 25–34, 35–44, ≥ 45 years), sex (male and female), marital status (never married, married and divorced), current ART regimen line (adult 1st line, adult 2nd line and child 1st line), current ART status (active and LTFU), WHO Hypertension stage (stage 1,2,3 and 4), pharmaceutical benefits scheme (yes or no), respondents with at least one of any of cough, fever, weight loss and night sweats is categorized to as having a clinical symptom.

Data analysis

Data collected was exported from Microsoft Excel into Stata MP 17 for data cleaning and re-coding. For analysis, ‘viral suppression’ was coded one, and ‘non-viral suppression’ was coded zero. Categorical variables were presented using frequencies and percentages while mean and standard deviation were used to present continuous variables. The association between the outcome and explanatory variables were tested using Chi-square and Fisher’s exact test, and variables that were significant at a 10% level of significance were pulled for stepwise model selection which was used in the selection of variables in models one and two. A binary logistic regression was used to investigate the predictors of viral suppression among participants at p-value < 0.05.

One thousand and five hundred and twenty patients record were utilized for this study. Majority of the patients were females 1116(73.4%) and 241(15.9%) were aged 25 – 34 years. One thousand and ten (66.4%) had secondary and above while 1204(79.2%) were married. Three hundred and ninety-eight (26.2%) had job employment. Table1

One thousand four hundred and thirty-four (94.3%) were currently on TDF-3TC-DTG, which was the adult 1st line and 1473(96.9%) were currently on it. One thousand four hundred and eleven (92.8) patients were in WHO disease stage 1, 1323(87%) were currently active on ART while 197 (13%) had been lost to follow-up. Table 2

One thousand three hundred and eighty-six (90.0%) achieved viral suppression while 152(10%) did not achieve viral suppression. Table 2.

Table 3 shows that patients older than 24 years old achieved viral suppression compared to those younger than 24 years (p<0.05). In addition, female respondents who had secondary education and above, unemployed/unknown job/retired/student attained viral suppression, this was however not statistically significant (p> 0.05).

Table 4 shows that patients who were on adult 1st line ARV (TDF-3TC-DTG), active ART status, and in WHO stage 1 attained viral suppression compared to those on other ART (p<0.05).

Modelling factors associated with viral suppression

Table 5 shows the result of model selection using the stepwise model selection method. In the model I, age group (coef = 0.014, p = 0.116), current regimen line (coef = 0.014, p = 0.116), WHO stage (coef = -0.327 p = 0.073) and current ART (coef = 0.266, p = 0.000) were assumed to be statistically significant. In model II WHO stage (coef = -0.038 p = 0.049) and current ART (coef = -0.232, p = 0.000) were statistically significant at p-value<0.05.

Table 6 shows that patients between the age group of 25-34 years (OR: 2.62, 95% CI: 1.19-5.78, p < 0.017) and >45 years (OR: 2.42, 95% CI: 1.11-5.28, p < 0.026) were more likely to achieve viral suppression compared to patients younger age ≤24 years. Patients who were active on ART were four times more likely to achieve viral suppression (OR: 6.05, 95% CI: 4.10-8.91, p< 0.000) compared to those who were loss to follow-up.

This study assessed the clinical predictors and correlates of viral suppression among PLHIV accessing care at a tertiary health facility HIV clinic in Ogun state, Nigeria. This study is crucial as it adds to the body of evidence on the Nigeria’s milestone in achieving the global target of 95% viral suppression among PLHIV by 2030. Several factors were correlated with viral suppression in this study, but importantly is the age of the respondents and current ART status.

Compared with other studies in sub-Sahara Africa [12, 13], the proportion of respondents with viral suppression is similar in the range of 90%. This proportion still falls below the 95% target for viral suppression among PLHIV on ART treatment [6]. However, the proportion of patients with viral suppression in our study is higher than the 51.7% reported by [14], 65% by [15] and [16], and the 77% by [17] and in Ethiopia, Kenya, Ghana and Nigeria, respectively. The level of viral suppression recorded in this study could be attributed to the fact that our study was conducted among PLHIV accessing care at a tertiary health facility which has comprehensive HIV clinic and follow-up system. A structure that could improve drug adherence and reduce loss to follow-up among patients.

Unlike in the study of Nakazea [15] and Atnafu and colleagues [14], the proportion of our respondents with TB co-infection was minimal. Perhaps, this could be due to the larger proportion of our respondent with viral suppression (90%), compared to the 65% in the study of Nakazea [15]. Similarly, our study was conducted in an ART clinic which also has a TB DOTS clinic that runs alongside with it. Importantly, PLHIV are often exposed to TB and other co-infections that further reduce their immunity and viral suppression. Thus, early detection and treatment of co-infections among PLHIV will contribute significantly to viral suppression.

In contrast to the study of [15] in Kenya and [12] in Katsina, Nigeria, viral suppression was correlated with age in our study. We found that viral suppression increased by increasing age of the respondents, with respondents older than 35 years having better viral suppression than younger patients. Our finding is similar to that of Mogosetsi and colleagues [13] in South Africa and Isaac et al., 2021 in Nigeria. Age is an important socio-demographic factor associated with many health conditions. It is likely that people in older age group understand the gravity of HIV, are more likely to be adherent with ART regimen and lifestyle modification that improve viral suppression. Significant correlation has been established to exist between drug adherence and viral suppression [10, 18].

Although not significant in our study and other studies [13, 15, 16], viral suppression was better among females than males. Although, a study in Ethiopia [14] reported a significant association between viral suppression among female than males. Their study reported early commencement of counselling among females which contributed to better drug adherence among them. Secondly, they reported higher CD4 + among their female respondents at baseline. Similarly, global estimate has documented that antiretroviral coverage is higher among females than males [19]. Although, we cannot draw a conclusion from this study on the reason for sex difference in viral suppression. This result should be interpreted with caution and the observed gender difference needs to be further explored.

Like in other studies [12, 14, 20], viral suppression reduced with increasing WHO clinical staging, and this was significant in our studies. Respondents on clinical stages I and II achieved better viral suppression than stages III and IV. In contrast, Mogosetsi et al., (2018) reported lower viral suppression among patients on clinical stage I compared to other stages. For better understanding of this association, a comparative study is recommended.

The patient’s current ART status was significantly correlated with viral suppression. ART active patients have better viral suppression compared to those loss to follow-up. This is not unexpected because drug adherence improves disease outcome and reduce the chance of drug resistance. The same observation was reported by other studies [13, 14]. Thus, PLHIV should be encouraged to adhere to their drug regimen. Measures such as group support, extensive follow-up, and involvement of family members in treatment will encourage adherence.

This study shows a significant viral suppression among PLHIV who were aged 35 years and above, and ART active. Improving drug adherence is a significant factor to enhance viral suppression among PLHIV. There is a need to promote clinic attendance, and strengthen support groups, to encourage drug adherence among PLHIV.

Ethical approval and consent to participate

Ethics approval was obtained from the Federal Medical Center, Abeokuta Health Research Ethics Committee (HREC). At the ART clinic, the healthcare worker usually seeks written informed consents from PLHIVs about use of their data for research purposes while receiving treatment and when they no longer attend the clinic. Our study was a secondary data analysis of the patients ART records. Hence, the need for consent to participate was waived by the FMCA-HREC before the commencement of the data retrieval (protocol number- FMCA/470/HREC/01/2023/23).

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

Authors declare that there is no conflict of interest.

Funding

Authors have received no funding for the study.

Authors' contributions

The study was conceived by MMS, YAO and GBI. Data analysis and interpretation was done by YAO and MMS. The manuscript was drafted by MMS, YAO, OOO and GBI. Manuscript was revised by all authors. All the authors have read and agreed to the final manuscript.

Acknowledgments

We acknowledge the nurses, doctors, and medical record officers at the HIV clinic in FMC, Abeokuta, Ogun State, Nigeria for their assistance in compilation of the study data.

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Table 1: Socio-demographic characteristics of patients

Variables	N	%
Sex
Female	1116	73.4
Male	404	26.6
Age (years)
≤24	45	3
25-34	241	15.9
35-44	562	37
>45	672	44.2
Mean±SD (years)	43.8±11
Education
Less than secondary	510	33.6
Secondary and above	1010	66.4
Marital status
Never married	268	17.6
Married	1204	79.2
Divorced/Separated/Widowed	48	3.2
Employment status
Employed	398	26.2
Unemployed/unapplicable/unknown/retired/student	1122	73.8

Table 2: Antiretroviral regimen and clinical correlates of patients

Variables	N	%
Current ART Regimen
ABC-3TC-DTG	47	3.2
ABC-3TC-ATV/r	12	0.8
TDF-3TC-DTG	1434	94.3
TDF-3TC-ATV/r	22	1.4
TDF-3TC-LPV/r	5	0.3
Current Regimen Line
Adult 1st line ARV	1473	96.9
Adult 2nd line ARV	40	2.6
Child 1st line ARV	5	0.3
TDF-3TC-EFV	2	0.1
Current ART status
Active	1323	87
LTFU	197	13
TI
Yes	16	1.1
No	1504	98.9
Clinical symptoms
Yes	61	4
No	1459	96
TB status
Present	27	1.8
Absent	1493	98.2
Blood pressure
<140/90	1418	93.3
≥140/90	102	6.7
PBS
Yes	1402	92.2
No	118	7.8
WHO stages
Stage 1	1411	92.8
Stage 2	80	5.3
Stage 3	20	1.3
Stage 4	9	0.6
Viral suppression
Yes	1368	90.0
No	152	10.0

Table 3: Association between patients’ sociodemographic characteristics and viral suppression

Variable	Viral suppression		ᵪ²	P-value
Variable	Yes (%)	No (%)	ᵪ²	P-value
Sex
Female	1009(90.4)	107(9.6	0.79	0.373
Male	359(88.9)	45(11.1)
Age (years)
≤24	35(77.8)	10(22.2)	8.42	0.038*
25-34	215(89.2)	26(10.8)
35-44	512(91.1)	50(8.9)
>45	606(90.2)	66(9.8)
Education
Less than secondary	457(89.6)	53(10.4)	0.13	0.718
Secondary and above	911(90.2)	99(9.8)
Marital status
Never married	43(89.6)	5(10.4)	0.54	0.763
Married	1087(90.3)	117(9.7)
Divorced/Separated/Widowed	238(88.8)	30(11.2)
Employment status
Employed	354(88.9)	44(11.1)	0.67	0.437
Unemployed/unapplicable/unknown /retired/student	1014(90.4)	108(9.6)

Table 4: Association between patients’ drug regimen, clinical status and viral suppression

Variable	Viral suppression		ᵪ² / F. exact	P-value
Variable	Yes (%)	No (%)	ᵪ² / F. exact	P-value
Current ART Regimen			12.43	0.014*
ABC-3TC-ATV/r	3 (25)	9 (75)
ABC-3TC-DTG	9 (19.1)	38 (80.9)
TDF-3TC-ATV/r	5 (22.7)	17 (77.3)
TDF-3TC-DTG	135 (9.4)	1299 (90.6)
TDF-3TC-LPV/r	0 (0)	5 (100)
Current Regimen Line			7.93	0.047*
Adult 1st line ARV	1331(90.4)	142(9.6)
Adult 2nd line ARV	31(77.5)	9(22.5)
Child 1st line ARV	4(80.0)	1(20.0)
TDF-3TC-EFV	2(100.0)	0(0)
Current ART status			110.53	0.000*
Active	1232(93.1)	91(6.9)
LTFU	136(69.0)	61(31.0)
Clinical symptom			0.23	0.828
Yes	56(91.8)	5(8.2)
No	1312(89.9)	147(10.1)
TB status			0.71	0.338
Present	23(85.2)	4(14.8)
Absent	1345(90.1)	148(9.9)
Blood pressure
<140/90	1281(90.3)	137(9.7)	2.69	0.121*
≥140/90	87(85.3)	15(14.7)
PBS			70.08	0.000*
Yes	1288(91.9)	114(8.1)
No	80(67.8)	38(32.2)
WHO stages			6.34	0.054*
Stage 1	1277(90.5)	134(9.5)
Stage 2	68(85.0)	12(15.0)
Stage 3	16(80.0)	4(20.0)
Stage 4	7(77.8)	2(22.2)

* statistically significant

Table 5: Stepwise model selection of factors associated with viral suppression

	Model I			Model II
Variables	Coef	Std. err	P-value	Coef	Std. err	P-value
Age (years)	0.014	0.009	0.116	0.008	0.009	0.392
Current Regimen Line	0.033	0.04	0.407	0.005	0.004	0.24
PBS	0.207	0.321	0.52	-	-	-
Blood pressure	-0.036	0.326	0.911	-	-	-
WHO stages	-0.327	0.182	0.073*	-0.038	0.019	0.049*
Current ART status	-1.618	0.875	0.000*	-0.232	0.022	0.000*

Table 6: Binary logistics regression of correlates of viral suppression among the patients

Variables	aOR	95%CI	P-value
Age (years)
≤24(ref)	1
25-34	2.1	0.90-4.87	0.085
35-44	2.62	1.19-5.78	0.017*
>45	2.42	1.11-5.28	0.026*
Current Regimen Line
ABC-3TC-ATV/r (ref)	1
ABC-3TC-DTG	3.7	0.74-18.60	0.112
TDF-3TC-DTG	1.48	0.24-8.92	0.672
TDF-3TC-ATV/r	3.83	0.93-15.75	0.063
Current ART status
LTFU (ref)	1
Active	6.05	4.10-8.91	0.000*
WHO stages
Stage 1(ref)	1
Stage 2	0.68	0.34-1.35	0.27
Stage 3	0.45	0.14-1.47	0.186
Stage 4	0.97	0.14-6.69	0.974

*Statistically significant

No competing interests reported.

Clinical predictors and correlates of viral suppression among people living with HIV accessing care at the Federal Medical Center HIV clinic in Ogun State, Nigeria

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

BACKGROUND

METHODS

Study setting and design

Study population, sample size and sampling technique

Study variables

Data analysis

RESULTS

Discussion

CONCLUSIONS

Declarations

References

Tables

Additional Declarations

Status:

Version 1