Viral suppression amongst children living with HIV on treatment has continued to be a challenge across most HIV programs in several countries, with suboptimal viral suppression rates across the population group especially when compared to the adult population groups. A variety of factors have been identified from earlier studies to be responsible for viral non-suppression in children and adolescent patients living with HIV. The commonly identified factors are pharmacological and non-pharmacological, with the latter category comprising sociocultural factors and psychosocial factors.
Findings from this study identified that 30% of children and 57% of adolescents were virally suppressed. The suppression rates are well below program achievements for viral suppression in adults (≈ 90% − 94%), and the set target of 95% for viral suppression according to the UNAIDS framework for HIV program target milestones.
A study conducted in Uganda highlighted a poor viral suppression in children and adolescents living with HIV that ranged between 27% – 29%. Issues identified to be associated with viral non-suppression were fear of disclosure and sub-optimal disclosure of adolescents’ HIV status, exhausting medications while traveling, lack of support, feelings of loneliness, lack of perceived improvement while on medication, poor linkage to care, attrition from care and treatment, poor transition from adolescent to adult services, economic hardship and AIDS-related stigma. , , , , , .
In this study, the factors that have a positive association with viral suppression in children are those who live with their biological caregiver / parents and those who commenced ART not later than when they are at WHO clinical stage IV. For adolescents living with HIV on ART, the study revealed a positive association between good adherence, proper disclosure of HIV status and an urban residence. Patients who reside with their biological caregivers are more likely to be virally suppressed than HIV-infected children who lived with non-biological caregivers in children, but this did not appear to be so with the adolescent age group.
A biological caregiver may have a stronger emotional connection with the child and may be more motivated to promote good adherence compared with a non-biologic caregiver. Caregivers who are also on ART may draw from their own experiences to support their child's adherence. While this may be an important factor to their adherence to medication and viral suppression rate in children because of their dependence on their caregiver for administration of their medications, most adolescents living with (ALHIV) do not depend on their caregivers for the administration of their medications, and this might have provided explanation for the difference in the association between viral suppression and caregiver among ALHIV compared to the children group in our study ,
It is important to note that there are conflicting evidence on the impact of caregivers’ biological relationship to a child. While some studies agree that there are positive effects to the adherence to medications (adjudged in this study by drug pickup pattern) and viral suppression, other studies pointed otherwise. An Italian study found that younger children living with non-biologic caregivers had better adherence. Similar findings were seen in a US study; however, the association did not maintain significance when controlling for other factors. Conversely, a Romanian study of horizontally infected adolescents found that non-biologic caregivers were associated with worse adherence , , .This might reflect the impact of sociocultural backgrounds and household settings on children psychology and subsequently, drug adherence.
In this study, the WHO clinical staging of HIV disease at baseline was found to be significant in children but not significant in adolescents in affecting the attainment of viral suppression. Children with WHO clinical stage IV disease at baseline assessment were found to be about 8 times more likely to be virally unsuppressed. This finding contradicts the result from a study conducted in Pretoria, South Africa, where it was found that there was no relationship between the WHO HIV clinical staging of patients and their viral load suppression . However this finding is similar with the result of the adolescent group. The limitations in the assessment of genotypic and phenotypic drug susceptibility studies prior to ART commencement might affect the efficacy of ART in children and adolescents, especially those presenting with late-stage disease as there is the possibility of drug resistant viral strains being responsible for the primary HIV infection in the children.
The process of disclosure is an important factor in ensuring adherence to medication and subsequently a reduction in the viral load of the client, therefore efforts to increase the availability and accessibility of treatment should be accompanied by disclosure initiatives. Disclosure is the first step for children transitioning into adolescents and young adults who successfully manage their own HIV care. 
The ideal disclosure age in this study was 10 years and above, and this supports a study conducted in Northern and southern Ghana where their preferred age was 10 years  .This study also revealed that most of the ALHIV either had partial disclosure or no disclosure of their HIV status, as only one tenth of the patients had being fully disclosed to. The disclosure status was found to be significantly associated with suppressed viral load which is similar with a study in Zambia where disclosure was found to have a strong association with undetectable viral load . This is not unusual as the understanding of a disease state tends to help the patient have insight into why treatment is necessary, especially for chronic illnesses as in this case, HIV infection. Disclosure and awareness of the disease state also invariably tends to affect drug adherence.
Pertaining to the findings of associations between type of living settlements (Rural vs Urban) and viral suppression in PLHIV, patients on ART living in rural areas experience substantial barriers to HIV care, including transportation and long distances to care, provider discrimination and stigma, concerns about confidentiality, lack of health care coverage, and limited healthcare options . These barriers may contribute to delays in HIV testing among PLHIV living in rural areas and some evidence suggests that these categories of patients are less likely to be retained in care, adhere to antiretroviral medication, and reach viral suppression than patients living outside of rural areas. The former are also more likely to delay HIV testing and receive an HIV diagnosis at later disease stages than their non-rural counterparts. , , , , , 
ART regimen are usually standardised according to national treatment guidelines and protocols. Optimised regimens and dosing are especially necessary in children, based on the need to achieve a rapid and sustained viral suppression and good clinical outcomes because of the tendency for a rapid and fulminant progression of HIV disease in this age group.