Factors Associated with HIV Viral Load suppression Among Adults at HIV Care and Treatment Centers in Dodoma, Mtwara and Lindi Region, July 2018-June 2019

Ona Machangu^*
*Correspondence: Ona Machangu, Ministry of Health, Community Development for Gender, Elderly and Children, NACP, Tanzania, Tel: +255754437009, Email:

Keywords

Human immune deficiency virus • Stigma level • Viral load suppression

Abbreviations

HIV: Human Immunodeficiency Virus • AIDS: Acquired Immunodeficiency Syndrome • HVL: HIV Viral Load • HC: Health center • THIS: Tanzania Health Impact survey • WHO: World Health Organization • UNAIDS: United Nation for Aids • ARVs: Anti-Retroviral Drugs • VLS: Viral Load Suppression • ART: Antiretroviral Treatment

Introduction

Globally, it was estimated that by 2018 there would be 37.9 million people living with HIV of which 21.7 million would be receiving antiretroviral treatment. In Tanzania however, by the end of 2017 it was estimated that 1.5 million people were living with HIV and about 1.1 million have access to antiretroviral treatment [1]. In 2013 WHO recommended that viral load suppression to be one of the treatment outcome to all people living with HIV worldwide who are on antiretroviral treatment and they must achieve viral suppression of 90% [2].

Viral load refers to the number of viral particles found in the blood of an individual infected by the HIV. The more viral particles in the blood the more HIV in the blood, and the faster the CD⁴⁺ T-cells are likely to be destroyed and the faster the progression towards AIDS and the easier the transmission of the virus [3]. In 2016 the World Health Organization (WHO) introduced viral load monitoring as a gold standard for the follow up on treatment effectiveness [4]. Therefore, a WHO consolidated guidelines was produced on the use of antiretroviral drugs for treating and prevention of HIV infection, and this guideline defines a viral load threshold of less than 1000 copies per milliliter as a treatment success.

And in 2016, Tanzania through the Ministry of health at programmatic level adopted and developed the national guidelines that recommended that viral load testing be performed 6 months after the initiation of ART and repeated routinely once a year, as a key indicator of treatment success in HIV-positive individuals on ARVs in the effort to meet the third 90 of the UNAIDS 90-90- 90 strategy which is 90% achievement of Viral Load Suppression [5]. Recent survey data on viral load suppression showed that about 87% of adults on ARVs aged 15 years and above are virally suppressed, However in adolescent and children viral load suppression remains a challenge as it has remained high [6].

There is a need for sustainable coverage of HIV testing, linkage, and retention in care and treatment. This requires strengthening the public health workforce to better collect, analyze, and report data on factors associated with each of the ‘90’ targets. Thus the aim of this study was therefore to determine factors associated with HIV viral load suppression among HIV-positive adults on ARVs at HIV care facilities in order to inform decision maker on improvements in service delivery [6].

Materials and Methods

Study design and study area

This was a facility based cross-sectional analytical study conducted in three regions.

Dodoma

• Dodoma MC (Makole H/C, Dodoma Regional Referral Hospital and Mirembe Hospital).

Mtwara

• Mtwara MC ( Ligula Regional referral Hospital)

• Masasi DC ( Ndanda Referral Hospital)

• Newala TC (Newala District Hospital)

• Nanyamba DC ( Nanyamba H/C)

Lindi

• Lindi MC (Lindi Town Health Center)

• Lindi DC (Nyangao Council Designated Hospital)

• Kilwa DC (Tingi Health Center)

• Ruangwa DC (Ruangwa Hospital)

• Nachingwea DC (Nachingwea District hospital)

Study population

The study population was HIV positive adults aged 18 years and older who have been enrolled in care and treatment attending CTC at respective facilities in the specified councils mentioned above for a period of not less than six months before the start of this study.

Sampling and sample size

Review of appointment register at CTC in each facility to identify eligible study participants who will attend clinic on the months of august 2019, and 30 eligible adults were identified by simple random sampling from each of the 15 facilities that were selected for the study.

Eligibility criteria

Inclusion and exclusion criteria

To be included in this study the participant must have met the following criteria:

• Aged 18 years and older

• Has been enrolled in care for at least 6 months by the start of recruitment (8^th July 2019), and is not classified as defaulter, lost to follow up, or transferred to another facility

• Has at least one viral load test in the last 6 months

• Has at least one CD4 result test in the last 6 months, if no viral load result is available

• Able and willing to provide informed consent (at time of recruitment)

Outcome variables

Primary outcome variable was viral load suppression (viral load count of less than 1000 copies/mL.

Exposure variables

Exposure variables were Socio-demographic information, travel time, costs of travel, waiting time at the clinic, Satisfaction with care, HIV status disclosure, HIV stigma, Reasons for missed visits, Self-rated ART and adherence in the last month.

Data collection

At the selected care and treatment clinics, the appointment register was reviewed to identify HIV positive adults aged 18 years and older who are on ARVs and after an informed written consent, An interviewer administered structured questionnaire was used to collect information on social demographic information, travel time, travel costs, waiting time, Satisfaction with care, HIV status disclosure, HIV stigma, Self-rated ART adherence in the last 6 months. CD4 count and or viral load results obtained from medical records at clinics.

Data analysis

After data collection, data was entered, cleaned and analyzed using EPI INFO 7.2.2.16, continuous data were summarized by means and range while categorical data were summarized using frequency and proportions. In bivariate analysis, the association between viral load suppression and risk factors of interest was determined using Odds ratios, 95% Confidence Intervals and p-value of 0.05.

NB: Merged data analysis was done from the data collected in all the facilities involved in the study.

Ethical considerations

The study received a Non- Research Determination from the University of Washington with IRB ID: STUDY00000758, on December 15th 2016. In addition, Tanzania National Institute received ethical clearance for this work for Medical Research Ethical Committee, which represents the Tanzanian Ministry of Health Community Development, Gender, Elderly and Children (MOHCDGEC). There was minimal risk to the participants included in these HIV program evaluations. Patient data collected from routine HIV care records. No names were recorded and participants were assigned unique identifier number to maintain confidentiality, completed consent forms were stored in separate locked filing cabinets. All hard and soft copy files will be retained for 15 years, and then will be destroyed according to the NIMR regulations.

Results

Data collected at Makole H/C

A total of 30 adults who had been started on ART for more than 12 months were involved in this study. The mean age of the study participants was 41 years SD=11.3 among study participants 19 (63.3%) were females. With 76.7% of the study participants having primary education. All the study participants were on ART, all 30 (100%) had their viral load results and only 2 (6.6%) of the study participants had both VL and CD4 tests results available in the last 12 months.

Prevalence of viral load suppression

Among study participants with viral load results (within the last 12 month) only 17% had achieved viral load suppression of less than 1000 copies/ml. as indicated in the Figure 1 and Table 1.

Most of the study participants were 30 years or older 25 (83%). There was a higher proportion of females 19 (63%). 57% of the study participants were married, and 20 (66.7%) were Self-employed or had small business. Majority 12 (40%) reported to spend less than 30minutes to be seen by health care worker at Clinic (Figure 2).

Majority of the study participants 12 (40%) spent less than 2000Tshs to get to the clinic and back home; while another 12 (40%) spent more than 4000 Tshs. All participants 30 (100%) reported that they had disclosed their HIV status to another person beside the health staff. The median time that they had been on antiretroviral therapy (ART) was 5 years or more and majority 26 (87%) reported to be satisfied with HIV care received at the health facility (Figure 3 and Table 2).

Among the study participants those with 35 years of age and above were more likely to have viral load suppression compared to those below 35 years OR, 0.8 (95% CI: 0.70 - 8.52), however this was not statistically significant. Married individuals were more likely to have viral load suppression OR, 0.85 (95% CI: 0.12 - 5.99) than those who were not married but this was not statistically significant. There was no association between the level of education of the study participants OR, 1.0, (95% CI: 0.09 - 11.02) and viral load suppression. Those who do not travel frequently were more likely to be virally suppressed OR 1.56, (95% CI: 0.15 -16.46) compared to those who do travel frequently but this was not statistically significant. Those who spent less than an hour to get to the clinic were more likely to have high viral suppression OR, 1.18 (95% CI: 0.17, 8.33) than those who spent more than one hour to get to the clinic however this was found to be not statistically significant. Fear to disclosure lead to high viral load suppression OR, 2.67 (95% CI: 0.35, 20.51) compared to those who openly disclose their HIV status also not statistically significant (Figure 4). Majority (83%) of the study participants showed low level of stigma according to standardized stigma scale (Figure 5).

Merged data analysis

A total of 459 adults who had been started on ART for more than 12 months were involved in this study. The mean age of the study participants was 43 years SD=10.7 among study participants 315 (68.6%) were females. With 67.3% of the study participants having primary education. All the study participants were on ART, all 459 (100%) had their viral load results and only 110 (24%) of the study participants had both VL and CD4 tests results available in the last 12 months.

Prevalence of viral load suppression

Among study participants with viral load results 79.1% had achieved viral load suppression of less than 1000copies/ml.

Most of the study participants were 35 or older 25 (83%). There was a higher proportion of females 315 (68.6%). 40.3% of the study participants were married, and 280 (61.0%) were Self-employed or had small business. Majority 235 (51.2%) reported to spend less than 1 hour to reach to clinic with an average of between 30 minutes to 1 hour to be seen 181 (39.4%) by health care worker at Clinic (Table 3).

Most of the study participants 172 (37.5%) spent an average of between 2000 Tshs- 4000 Tshs to get to the clinic and back home. A great majority of the participants 407 (89.1%) reported that they had disclosed their HIV status to another person beside the health staff. The median time that they had been on antiretroviral therapy (ART) was 3 years or more 344 (74.9%) and majority 455 (99.1%) reported to be satisfied with HIV cares services provided at the health facilities.

Among the study participants those with 35 years of age and above were more likely to have viral load suppression compared to those below 35 years OR, 0.7 (95% CI: 0.41 – 1.18), however this was not statistically significant. Married individuals were more likely to have viral load suppression OR, 0.93 (95% CI: 0.59 – 1.47) than those who were not married but this was not statistically significant. There was no association between the level of education of the study participants OR, 0.47, (95% CI: 0.22 – 0.99) and viral load suppression. Those who do not travel frequently are more likely to be virally suppressed OR 0.64, (95% CI: 0.40 -1.04) compared to those who do travel frequently but this was not statistically significant. Those who spent less than an hour to get to the clinic were more likely to have attain viral suppression OR, 1.2 (95% CI: 0.8, 1.9) than those who spent more than one hour to get to the clinic however this was found to be not statistically significant. Those who openly disclose their HIV status OR, 2.5 (95% CI: 0.15, 1.01) are more likely to attain viral suppression compared to those in fear of disclosure. Those who reported to be on ART more than 12 Months OR, 0.5 (95% CI: 0.15,1.42) has shown a likelihood of achieving viral suppression compared to those who are below 12 months of treatment however not statistically significant. Satisfied with care is associated with achieving viral load suppression OR, 11.7 (CI: 1.2, 113.6) (Figure 6 and Table 4).

Discussion

In this study Viral load suppression was found to be 79% however this did not reach the desired UNAIDS 90-90-90 global goals [5] this prevalence is low compared to study done by D Colby et al. which found that the viral load suppression is at 89% to patients who had at least 12 months in ART [7]. But it is high compared to CDC report among HIV adult patient who were in treatment at least 12 months which were found to be 77% [8]. In this study all participants had been retained in treatment for at least 12 months and reported having their viral load results within 12 months period. This is universal practice according to WHO 2016 standards and guideline in providing services to the PLHIV that is set that all clients who are on ART more than 6 months there should be tested for viral load [2].

Majority of the study participants were female 69% however, gender p=0.44 was not associated with viral suppression and this similar to the study done by D Colby et al. which found that there is no significant impact of gender to viral load suppression [7]. Also Nicastri et al. reported that there is no significant difference found between genders in achieving the viral load suppression [9]. This study found out those with age > 35 years and more had viral suppression compared those<35 p=0.17, this is similar to the study which found that younger age especially adolescent is associated with unsuppressed viral load [10,11]. In this study satisfaction to care was associated with viral suppression, those who were satisfied to the health care provided at the given facility are likely to achieve viral suppression p=0.03 this is the similar to the study done by Carly E. Levitz which found that doctor to client rapport and good empathic demeanor of the health care providers are among the values that contribute to the clients satisfaction to care [12].

Conclusion

Finally those with low level of stigma were more likely to attain viral load suppression compared to those who had high stigma this is similar to the study findings by Lipira et al. [13] that suggested that HIV-related stigma is common among people living with HIV, and those who experience higher levels of stigma are less likely to be virally suppressed.

Recommendations

The study recommends the following

• Continuous Health education on the emphasis of adherence to treatment.

• HIV Programs to focus to young ages such as adolescents.

• Policy and programs that focus on reduction of Stigma to the community.

• Maintain the quality of health care service to the facilities

References

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3. WHO. Viral load testing. WHO. 2014.
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5. Fact Sheet. 2018 Global HIV Statistics. (2019):1-6.
6. Final National Guideline for HIV data management. 1996.
7. Rangarajan, Suresh, Colby Donn, Le Truong Giang, and Duc Duong Bui, et al. “Vietnam 5 Vietnam Administration for AIDS Control.” 2016. 
8. Vital Signs: HIV Prevention through Care and Treatment - United States. 2019.
9. Nicastri, Emanuele, Claudio Angeletti, Lucia Palmisano, and Loredana Sarmati, et al. “Gender differences in clinical progression of HIV-1-infected individuals during long-term highly active antiretroviral therapy.” AIDS 19 (2005): 577-583.
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11. Bulage, Lilian, Isaac Ssewanyana, Victoria Nankabirwa, and Fred Nsubuga, et al. “Factors Associated with Virological Non-suppression among HIV-Positive Patients on Antiretroviral Therapy in Uganda, August 2014-July 2015.” BMC Infect Dis 17 (2017): 1.
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