Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is a leading cause of death worldwide. The fight against HIV/AIDS is hinged on initiation and adherence to an effective Antiretroviral Therapy (ART), and this has increased the attainment of viral suppression and reduction in HIV/AIDS-related death. Unfortunately, some people who achieve viral suppression are unable to maintain it and experience viral rebound, increasing their risk of treatment failure and the potential for transmission.
The United Nation's principal goal for eradicating HIV/AIDS by 2030 involves expanding access to and coverage of ART across the globe and viral suppression [24–26]. However, global assessment has shown that only around half of the world's HIV patients on ART are currently virally suppressed [25, 27]. In the present study, the proportion of patients who attained viral suppression was 76.1%. Consistent but quite higher than our study finding, Lebelonyane et al.  and Koss et al. , reported viral suppression among 82% of PLWH in Botswana and 80.7% among those in Uganda [28, 29]. Our study finding is higher compared to studies by Lokpo et al.  and Maina et al. , who reported 69% and 59% viral suppression rate among patients in the Volta region of Ghana and Kenya respectively [11, 30]. Again, viral suppression rate observed in our study is much higher compared to 24% in Sierra Leone and 41% in Senegal . Although the 90% UNAIDS target for viral suppression is much higher than what was found in this study, our results provide a glimpse into the country’s progression towards the UNAIDS 90-90-90 agenda.
We explored the factors associated with viral suppression among patients on ART. We observed that being diagnosed with WHO stage I, having good adherence to ART, being on a Nevirapine-based regimen and increasing duration of treatment with ARV were independently associated with higher chances of viral suppression. However, stopping or changing ARVs was associated with lower chances of viral suppression. Our findings are comparable to those observed by Maina et al. , who reported WHO stage I of HIV infection and good adherence to ART were associated with an increased likelihood of viral suppression . Moreover, a study by O’Connor et al. , who found good ART adherence, and being diagnosed in WHO stage I were associated with viral suppression. The findings for WHO stage I being associated with high chances of viral suppression could be attributed to the initial infection stage of the virus and less downregulation of the immune system at this stage, making the body’s natural immune system still responsive to infection.
In our study, increasing duration of treatment was associated with higher chances of viral suppression, consistent with a study by Kiselinova et al.  in the United Kingdom. This supports evidence from clinical studies that suggests prolonged cART use can reduce viral load below the limit of detection for a long-term period . Moreover, stopping or changing ARVs was associated with lower chances of viral suppression. A similar finding was reported by Martínez et al.  and Maman et al. , who observed that switching HIV patients from a protease inhibitor to nevirapine, efavirenz, or abacavir resulted in a higher rate of virologic failure [34, 35]. Hence, the type of cARV regimen may influence viral suppression and the risk of viral rebound.
Viral rebound increases vulnerability to illness, treatment failure, ART resistance, and the potential for HIV transmission [36, 37]. In the current study, viral rebound occurred in 21.0% of our patients. Our study finding is comparable but much higher than findings of Craw et al. , who reported 7.5% viral rebound rate among American HIV patients who had achieved viral suppression . In Kenya, among PLWH, viral rebound was 41% . This implies that a considerable number of HIV patients who achieve viral suppression are unable to remain suppressed and therefore experience rebound episodes. This may contribute to some of the reasons why Ghana could not achieve the UNAIDS agenda 90–90–90 target in 2020.
We evaluated a number of putative factors associated with viral rebound. In the current study, we observed that patients diagnosed at WHO stage II and stage III had higher chances of viral rebound compared to those diagnosed at WHO stage I. Our study finding is in harmony with a study by Maina et al. , who reported that being diagnosed at WHO stage II is associated with higher viral rebound . These findings suggests that patients at WHO stage II and above have downregulated immune system with associated opportunistic infections and comorbidities, increasing their venerability to viral rebound .
Notably, we observed that poor adherence was associated with higher viral rebound. Consistent with our study findings, Bulage et al.  reported higher viral rebound among HIV patients who experience rebound episodes. Among Kenyan HIV patients, Maina et al. , reported that poor ART adherence is associated with viral rebound . The agreement between the current and previous studies may explain why majority of non-adherent HIV patients are vulnerable to illness, experience treatment failure and ART resistance [36, 37]. Furthermore, we observed that patients who recorded a baseline viral suppression value of 20-49 copies/mL had higher chances of viral rebound compared to those who had target not detected. Consistent with our study finding, Palmer et al., reported that baseline suppression count is associated with viral rebound . Among Chinese HIV patients, Li et al. , reported similar association of baseline suppression value and viral rebound . This finding is suggestive that patients with the lowest levels of viral load to the target not detected are more stable and unlikely to experience viral rebound.
Moreover, we observed that patients on Zidovudine based-regimen (AZT/3TC/EFV and AZT/3TC/NVP) had higher chances of viral rebound compared to patients on Tenofovir based-regimen (TDF/3TC/EFV). This is in line with a study by Mania et al. , who observed that AZT/ 3TC/NVP regimen was associated with high viral rebound. NNRTI- and NRTI-based regimens have increased risk of resistance within the first six months of treatment .
Our study provides useful findings to guide HIV clinicians and policy makers in the fight against the infection. However, it is limited by the fact that it was a retrospective study and single-centered. We relied on available hospital data, especially patients’ viral load results, which posed a challenge to completeness of data.