Vol. 12(2), pp. 9-16, July-December 2020
DOI: 10.5897/JAHR2020.0510
Article Number: AC6281864471
ISSN 2141-2359
Copyright © 2020
Author(s) retain the copyright of this article
http://www.academicjournals.org/JAHR
Journal of AIDS and HIV Research
Full Length Research Paper
Viral suppression and predictors among adolescents
receiving care for HIV/AIDS in a tertiary health centre in
Uyo, South-South, Nigeria
Dixon-Umo Ofonime Tony
Department of Biochemistry, University of Allahabad, India.
Received 16 January 2020; Accepted 17 July, 2020
Viral suppression assesses the success of HIV/AIDS treatment and can avert or reduce transmission of
infection. Several factors contribute to viral suppression and may vary in different settings and age
groups, hence the need to study the associated factors in different populations. The aim of the research
was to study the level of viral suppression and its predictors among adolescents living with HIV
(ALHIV), who knew their status, at the paediatric infectious diseases unit of a tertiary hospital in Nigeria.
This was a descriptive cross-sectional study of 50 consecutive ALHIV who had full disclosure of their
HIV diagnosis. There were 29 females with a female to male ratio of 1.38:1. Age range was 10 to 19
years. Mean age was 15.06 ± 2.26 years. A pretested questionnaire was used together with information
retrieved from case notes. Socio-demographic data and responses to possible factors affecting viral
suppression were obtained and recorded in a proforma. Viral load ranged from <40 to 522,244 HIV RNA
copies/ml of blood. Viral suppression rate was 82.00 with 22.00% in those aged 10 to 14 years and
60.00% in those between 15 and 19 years. Factors significantly associated with viral suppression were:
Parents being alive (p=0.035), caregivers being on routine medications (p=0.003), missing medications
(p=0.0001), number of missed doses of antiretroviral medications (p=0.001), and the current regimen of
antiretroviral therapy (p=0.034). In conclusion, viral suppression is approaching UNAIDS target for 2020
and factors related to good adherence to antiretroviral regimens were significant associations.
Key words: Viral suppression, disclosed adolescents, HIV, antiretroviral therapy.
INTRODUCTION
There are many potential benefits to maintaining
undetected or in the least, low viral load in people living
with HIV (PLHIV). Those with undetected viral load,
which is the ultimate goal of treatment, are generally
more likely to be healthier than those with high viral load
and are less likely to transmit the infection to their sexual
partners (and in the case of females to their babies). Viral
suppression which results from good adherence to
combined antiretroviral therapy (cART) is a principle that
drives the prevention of transmission of human
immunodeficiency virus (HIV). ALHIV constitute about 5%
of all HIV global infections and those between 15 and 19
years account for 16% of new adult global infections
(UNAIDS, 2018). Sub-Saharan Africa and south Asia
account for the highest number of ALHIV with about 1.6
million cases (89%) of global adolescent infections
(Global HIV and AIDS Statistics, 2019; UNAIDS, 2017).
Nigeria, the second largest HIV prevalence after South
*Corresponding author. E-mail: ofonuuth@yahoo.com.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
10 J. AIDS HIV Res.
Africa, with only 26% of infected children receiving cART
as at 2017 and only 24% viral suppression in 2016
(Global HIV and AIDS statistics, 2019; UNAIDS, 2017).
Ekweme et al. (2018) reported viral suppression rates of
69.1 and 64.8% among 10-14 and 15-19 years old ALHIV
respectively (P<0.001), in a study involving 10 states in
Nigeria. World Bank (2017) reported that Nigeria has the
largest population of youths in the world. It is also the
only country with rising mortality of HIV infected
adolescents between the ages of 10 and 14 years (NBS
and UNICEF, 2017).
After the introduction of highly active antiretroviral
therapy (HAART), potential barriers to optimal adherence
must be eliminated or at worst reduced to maximise the
likelihood of achieving sustained viral suppression
(Zanoni, 2019). Irrespective of disease duration and
mode of transmission, efforts need be made towards
retaining adolescents in care to improve and maintain
their health for the long term.
Adolescent HIV/AIDS is regarded as a separate
epidemic in terms of the distinctive requirements for
managing them as it differs from the adult counterpart
(Naswa et al., 2010). One of the issues in managing
adolescent HIV cases is the disclosure of their sero-
status, which has been reported to improve adherence
(Montalto et al., 2017; Phiri et al., 2015; Mburu et al.,
2014; Midtbø et al., 2012). Viral suppression, which is
achievable through the provisions of HAART by donor
agencies, because the government is yet to take over the
programme, need to be studied in different localities to
know the gaps that must be filled towards achieving the
ambitious target of ending the global HIV/AIDS epidemic
in 2030. There is paucity of data on viral suppression
among Nigerian adolescents living with HIV, especially
those who are aware of their HIV diagnosis. Many
adolescents started treatment in infancy and their care-
givers still do not accept disclosure, opting for disclosure
when they are older than 15 years. Newly enrolled
adolescents have disclosure done before introduction of
HAART. Available data (Ekweme et al., 2018) shows that
adolescent viral suppression rates are still lower than the
Sustainable Development Goals of vision 90-90-90 by
2020: UNAIDS, 2017) which demands that 90% of those
on treatment should achieve viral suppression. This has
to be achieved before moving to the latest target of 95-
95-95 (Avert, 2019)
This study seeks to document the viral suppression
rates of disclosed ALHVI at the University Teaching
Hospital, Uyo and to find out any factors that may be
associated with the viral suppression in our environment.
METHODS
This cross-sectional study was done at the Paediatrics’ Infectious
Diseases Unit of University of Uyo Teaching Hospital, Uyo, Nigeria.
The unit caters for 206 paediatric HIV patients of which 140 are
adolescents aged between 10 and 19 years. All eligible and
consenting subjects were recruited consecutively. Inclusion criteria
were: Adolescents who have had full disclosure of their HIV
diagnosis for about 6 months and have been on HAART for same
duration or longer, have had at least one viral load result, and
whose parent(s) or legal guardians gave informed consent and
themselves assented to participate. Fifty adolescents met these
criteria and were recruited consecutively into the study. A pretested
semi-structured self-administered questionnaire was used to obtain
the biodata, information on schooling, parentage, clinic appointment
visits, adherence to HAART, treatment partner, observation and
monitoring of medications, any missed doses and reasons, whether
or not the caregivers were on routine medications. The treatment
regimens, duration on HAART, viral load results, confirmation on
keeping clinic appointments were obtained from the case notes.
The social class of each participant was determined using
Oyedeji’s social class scoring system (Oyedeji, 1985) which uses
the educational level and occupation of parents/caregivers of the
adolescent. The educational level is scored on a scale of five, with
1 being the most educated, degree holders and equivalent and 5
being those without formal education or those who can just read
and write. Occupation is also on a scale of five with category 1
being senior civil servants, chief executive officer and contractors,
while 5 consist of the unemployed, full time house-wives or
students. The sum of the educational and occupation scores of
each parent is divided by 4 and the answer to the nearest whole
number represents the social class which is also from 1 to 5. Social
class 1 is the highest.
Viral suppression was taken as less than 1000 RNA copies/ml of
blood based on the World Health Organisation (WHO) consolidated
guidelines (WHO, 2015) and those who were stable on HAART as
having less than 40 copies/ml of blood. Viral load of 1,000
copies/ml of blood or more constituted the virally unsuppressed
group.
Data obtained were inputted and analysed using the Statistical
Package for Social Sciences (SPSS), version 25. Simple
frequencies were obtained and proportions compared using Chi-
Square test with significance established at P<0.005.
RESULTS
Fifty-eight of the 206 paediatric clients on follow-up care
for HIV/AIDS in the unit have had full disclosure of their
HIV diagnosis. There are a total of 140 clients aged 10-
19 years but 82 are yet to have full disclosure as many
parents/caregivers still insist that disclosure should not be
made to perinatally infected children who are now
adolescents till after 15 years of age, and their opinion
has to be respected while educating them on the need for
disclosure and its benefits. Fifty out of 58 disclosed
adolescents participated in the study for having at least
one viral load test result on record. Forty-one (82%) of
the 50 participants had achieved viral suppression based
on the WHO recommendation of less than 1,000 HIV
RNA copies/ml of blood (WHO, 2015). Viral suppression
rates were 11(22%) for 10 to 14 years and 30(60%) for
15 to 19 years age bracket respectively, p=0.254
(Fisher’s Exact Test). There were 29 (58.00%) females
and the female to male ratio was 1.38:1. Mean age was
15.06 ± 2.26 years while the median was 15.00 years.
The mean duration on HAART was 9.10 ± 4.03 years
with the minimum being 7 months and the maximum
16.00 years. The viral load ranged from <20 to 522,244
Dixon-Umo 11
Table 1. Characteristics of study population.
Parameter
Frequency
Percentage
Age (years)
10-14
15
30.00
15-19
35
70.00
Gender
Male
21
42.00
Female
29
58.00
Level of education
Primary
3
6.00
Secondary
36
72.00
Post- secondary
5
10.00
Out of school
6
12.00
Social class
I
11
22.00
II
8
16.00
III
14
28.00
IV
13
26.00
V
4
8.00
Parentage
Father only
22
44.00
Mother only
6
12.00
Both parents
26
52.00
Complete orphan
7
14.00
Duration on HAART
>7-11months
1
2.00
1 -5years
13
26.00
6-10years
16
32.00
11-15 years
19
38.00
>15 years
1
2.00
Treatment partner
Parent(s)
27
54.00
Sibling(s)
3
6.00
Others
11
22.00
No treatment partner
9
18.00
Total
50
100.00
HIV RNA copies/ml of blood.
Table 1 shows the characteristics of the study
population: There were 29(58.00%) females and
21(42.00%) males, 36(72.00%) of the participants were in
secondary school, the largest social class was class III
with 14 (28.00%) participants, 36 (52.00%) of the
adolescents had both parents alive but 7(14.00%) were
complete orphans. Nineteen (38.00%) of the participants
had been on HAART for 11 to 15 years and only 1
(2.00%) had antiretroviral therapy for less than a year.
Parents were treatment partners for 27 (54.00%) of the
respondents but 9 (18.00%) had no treatment partner.
Figure 1 shows that 28(56.00%) of the participants had
achieved viral suppression at the level of <40 HIV RNA
copies/ml of blood and another 13(26.00%) at 40 to
<1000 HIV RNA copies/ml of blood. However 9(18.00%)
were yet to achieve viral suppression. The figure shows
the proportion of viral suppression: 28 (56%) respondents
had <40 HIV RNA copies/ml of blood, and 13 (26%) had
40≤1,000 HIV RNA copies/ml of blood but 9 (18%) had
over 1,000 HIV RNA copies/ml of blood.
From Table 2, the Chi square test analysis of factors
associated with viral suppression in 50 ALHIV shows that
viral suppression was significantly associated with
parentage, p=0.035, as adolescents with both parents
alive were more likely to achieve viral suppression;
caregivers being on routine medications was also a
positive factor (p=0.003), not missing medications in the
past month (p=0.0001), and no missed doses of
medications in the past month (p=0.001). Also the
adolescents who were currently taking the fixed dose
medication of Tenofovir, Lamivudine and Abacavir
regimen of medications were more likely to achieve viral
suppression (p=0.034). There was no significant
association with the age (p=0.254), gender (0.577), level
of education (p=0.234) and social class (p=0.298) of the
12 J. AIDS HIV Res.
Figure 1. Proportions of ALHIV participants and their levels of viral suppression.
respondents. Having a treatment partner, the duration on
HAART, missing clinic appointment, and the number of
adherence counselling received were also of no statistical
significance (p=0.757, p=0.157, p=0.113 and p=0.854,
respectively). Membership of the adolescent support
group was also not a statistically significant factor
(p=0.321).
DISCUSSION
The viral suppression rate of 82% which is below the
UNAIDS 2020 Fast Track Targets (UNAIDS, 2017) but
higher than 69.1 and 64.8% reported by Ekweme et al
(2018) in adolescents aged 10-14 years and 15-19 years
respectively in 10 ten states in Nigeria with a large
sample size of 8498 children and adolescents. The
suppression rate of 22% in adolescents aged 10-14 years
is however very low compared to 69.1% of the previous
study (Ekweme et al., 2018) though the sample size is
remarkably lower. The relatively lower suppression rate in
younger adolescents may not be unconnected with their
level of understanding of the importance and benefits of
good adherence towards the achievement of viral
suppression. Adolescents who have not achieved viral
suppression are receiving intensive adherence
counselling for further viral load monitoring. A
comparative study of adolescents and young adults in
South Africa reported a similar viral suppression of 80%
from the standard paediatrics clinic and 91% from
adolescent friendly clinic (p=0.028) and the participants in
that study were relatively older, between 13 and 24 years
(Zanoni, 2019).
Adolescent viral suppression is relatively lower than
that of adults in many communities. For instance,
Kapogrannis et al. (2020) reported 35% viral suppression
in adolescents and young adults aged 12 to 24 years
though it was within a short duration of 5 months.
There were slightly more females than males (female:
male ratio=1.38:1) in the study population but the reason
for this is not clear since majority of the adolescents have
been on treatment for over 10 years suggesting that they
had vertical transmission. However some female might
have had sexual transmission as was reported by Ikpeme
et al. (2016) from the same centre where some females
were told their diagnosis as part of their being managed
as cases of sexual transmission.
The mean duration on HAART of 9.00 ± 4.03 years is
comparable to 7±3.7 years reported from a Brazilian
multicentre study of children and ALHIV (Cruz et al.,
2014). This is likely because many adolescents started
treatment at an early age from early detection as
vertically infected children. Majority of the respondents
were in secondary schools and this is understandable
considering their age range.
About 56.00% viral suppression was at the level of
<40 HIV RNA copies/ml of viral suppression which is
close to the desirable undetected viral suppression that is
needed for non-transmission of HIV infection in any
population. This is slightly higher than 49% reported
among ALHIV in Brazil which is a resource-rich country
and their viral load was <50 HIV RNA copies/ml. This
shows a comparable stance as the striving towards the
UNAIDS ambitious target of ending the global HIV/AIDS
epidemic in 2030 (Avert, 2019).
Parents being alive were a significant association with
viral suppression, and this could be due to positive
parental support. Knodel et al. (2010) reported that
family members, including parents, commonly remind
patients to take their antiretroviral medications, especially
Dixon-Umo 13
Table 2. Chi square analysis of factors associated with viral suppression among 50 ALHIV.
Parameter
Viral suppression (%)
No viral suppression (%)
P value
Age (years)
10-14
11
22.0
4
8.0
0.254**
15-19
30
60.0
5
10.0
Gender
Male
17
34.0
4
8.0
0.577**
Female
24
48.0
5
10.0
Schooling
Primary
3
6.0
0
0.0
0.234
Secondary
27
34.0
9
18.0
Post-secondary
5
10.0
0
0.0
Out of school
6
12.0
0
0.0
Social class
I
7
14.0
4
8.0
0.298
II
7
14.0
1
2.0
III
13
25.0
1
2.0
IV
10
20.0
3
6.0
V
4
8.0
0
0.0
Parentage
Father only
7
14.0
4
8.0
0.035*
Mother only
6
12.0
0
0.0
Both parents
24
48.0
2
4.0
No parents
4
8.0
3
6.0
Treatment partner
Parent(s)
22
44.0
5
10.0
0.757
Sibling(s)
2
4.0
1
2.0
Others
10
20.0
1
2.0
None
7
14.0
2
4.0
Caregiver on routine
medications
Yes
22
44,0
0
0.0
0.003*
No
19
18.0
9
18.0
Duration on HAART
(years)
< 1
0
0.0
1
2.0
0.157
1-5
10
20.0
3
6.0
6-10
15
30.0
1
2.0
11-15
15
30.0
4
8.0
>15
1
2.0
0
0.0
Missed last appointment
Yes
8
16.0
4
8.0
0.113
No
33
66.0
5
10.0
Missed medications in
past month
Yes
14
28.0
9
18,0
0.0001*
No
27
54.0
0
0.0
Number of missed doses
in past month
None
27
54
0
0.0
0.001*
1
1
2.0
1
2.0
2
6
12.0
0
0.0
3
3
6.0
3
6.0
>3
2
4.0
3
6.0
Don’t remember
2
4.0
2
4.0
Current regimen
TLD
38
76.0
6
12.0
0.034*
ALE
1
2.0
0
0.0
ALL/r
2
4.0
3
6.0
14 J. AIDS HIV Res.
Table 2. Contd.
Adherence counselling
≤3 times
8
16.0
2
4.0
0.854
Several times
33
66.0
7
14.0
Support group
membership
Yes
20
40.0
3
6.0
0.321**
No
21
42.0
6
12.0
Total
41
82,0
9
18.0
TLD = Tenofovir/ Lamivudine/Dolutegravir regimen, ALE = Abacavir/Lamivudine/Efavirenz reigemen, ALL/r= Abacavir/Lamivudine/Lopinavir/ritonavir
regimen. *Significant P value; **Fisher’s exact test.
if co-resident, also those parents often reminded the
patients to get resupplies and sometimes accompanied
them to the clinic for appointments. Also
parents/caregivers being on routine medications was
significantly associated with viral suppression (p=0.003).
While there are no previous findings to compare with, it
may be inferred that parents/caregivers on routine
medications may encourage their children/wards to
achieve good adherence leading to viral suppression. Not
missing medications expectedly had a significant
association with viral suppression (p=0.0001).
Additionally, in terms of number of missed doses, those
who self-reported missing three or more doses per month
were significantly less likely to achieve viral suppression
(p=0.001) (Table 2). Trials have traditionally considered
adherence thresholds of greater than 95% as optimal
(Paterson et al., 2000). With a once daily regimen, it
takes missing as low as two doses to fall short of this
optimal adherence.
The regimen of fixed dose combination of
Tenofovir/Lamivudine/Dolutegravir was significantly
associated with viral suppression compared to those on
Abacavir/Lamivudine/Efavirenz or Lopinovir. This could
be due to the bulk of the study population are currently on
this regimen. There was no significant association
between viral suppression and clinic attendance (Table 2)
even though ALHIV who missed clinic appointments were
less likely to be virally suppressed. The small sample size
might have affected this finding. This also contrasts with
the findings of Lokpo et al. (2020) where regular clinic
attendance was significantly associated with viral
suppression (p=0.0001). This could be due to the practice
of giving a week’s medication in excess of appointment
which makes clients miss appointment dates when they
have medications at home. Several other parameters
were also not significantly associated with viral
suppression including: clients’ age and gender, level of
education, social class, having a treatment partner,
duration of antiretroviral therapy, number of adherence
counselling sessions received or membership of the
adolescent support group.
Conclusion
Viral suppression among disclosed adolescents is close
to the UNAIDS target for 2020 and factors related to good
adherence to Tenofovir/Lamivudine/Dolutegravir regimen
are significantly associated with viral suppression of
ALHIV in our locale.
CONFLICT OF INTERESTS
The authors have not declared any conflict of interests.
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16 J. AIDS HIV Res.
APPENDIX
Table 1. Social classification using the scheme proposed by Oyedeji.
Social class
Occupation
Educational level
I
Senior public servants, professionals, managers large scale
traders, businessmen and contractors
University graduates or equivalents
II
Intermediate grade public servants and senior school
teachers
School certificate (ordinary level (GCE) holders who
have teaching or other professional training
III
Junior school teachers, drivers and artisans
School certificate holders or grade II teachers
certificate holders or equivalents
IV
Petty traders, labourers, messengers and similar grades
Modern 3 and primary 6 certificate
V
Unemployed, students, full time house-wives and
subsistence farmers
Those who can either just read and write, or are
illiterate
