Unsuppressed viral load after intensive adherence counselling in rural eastern Uganda; a case of Kamuli district, Uganda

Abstract

Background The East Central (EC) region of Uganda has the least viral suppression rate despite having a relatively low prevalence of human immunodeficiency virus (HIV). Although the viral suppression rate in Kamuli district is higher than that observed in some of the districts in the region, the district has one of the largest populations of people living with HIV (PLHIV). We sought to examine the factors associated with viral suppression after the provision of intensive adherence counselling (IAC) among PLHIV in the district. Methods We reviewed records of PLHIV and used them to construct a retrospective cohort of patients that started and completed IAC during January – December 2019 at three high volume HIV treatment facilities in Kamuli district. We also conducted key informant interviews of focal persons at the study sites. We summarized the data descriptively, tested differences in the outcome (viral suppression after IAC) using chi-square and t-tests, and established independently associated factors using log-binomial regression analysis with robust standard errors at 5% statistical significance level using STATA version 15. Results We reviewed 283 records of PLHIV. The mean age of the participants was 35.06 (SD 18.36) years. The majority of the participants were female (56.89%, 161/283). The viral suppression rate after IAC was 74.20% (210/283). The most frequent barriers to ART adherence reported were forgetfulness 166 (58.66%) and changes in the daily routine 130 (45.94). At multivariable analysis, participants that had a pre-IAC viral load that was greater than 2000 copies/ml [adjusted Prevalence Risk Ratio (aPRR)= 0.81 (0.70 - 0.93), p=0.002] and those that had a previous history of viral load un-suppression [aPRR= 0.79 (0.66 - 0.94), p=0.007] were less likely to achieve a suppressed viral load after IAC. ART drug shortages were rare, ART clinic working hours were convenient for clients and ART clinic staff received training in IAC. Conclusion Despite the consistency in drug availability, counselling training, flexible and frequent ART clinic days, the viral suppression rate after IAC did not meet recommended targets. A high viral load before IAC and a viral rebound were independently associated with having an unsuppressed viral load after IAC. IAC alone may not be enough to achieve viral suppression among PLHIV. To improve viral suppression rates after IAC, other complementary services should be paired with IAC.

Factors Associated with HIV Virological Non-Suppression Among Adults Receiving Anti-Retroviral Therapy at Lira Regional Referral Hospital, Northern Uganda

“…This is similar to other studies in South Africa where the nonsuppression rate was found at 15% (Lisa et al, 2014) This could be based on the fact that adults living with HIV were taking their medication, health workers were conducting adherence counseling, and drug side effects were properly managed as recommended, as statistics show that up to 85% of patients receiving care from Lira Regional Referral Hospital had a high level of adherence. This finding is in congruence with another study that revealed that barriers to VL non-suppression included forgetfulness, changes in the daily routine, side effects, and pill burden, among others (Ndikabona et al, 2021). Another study's findings also show that more than half of patients (66%) had viral suppression as of 2020 (Tomescu et al, 2022).…”

Barriers and Facilitators to Successful Intensive Adherence Counseling in Rural Northern Uganda: An Exploratory Interview with HIV-Positive Clients Using the COM-B Framework

“…[6][7][8] Conversely, evidence from other contexts indicates that there are sub-optimal HIV-1 viral load suppression rates following the IAC program. [9][10][11][12] Informal interactions with HIV healthcare providers in the context of rural northern Uganda also indicated that some HIV-positive clients remain virally non-suppressed even after IAC. This could be attributed to the weak healthcare systems in such contexts which undermines harnessing the benefits of IAC.…”

Virological failure and its predictors among human immunodeficiency virus infected individuals on second line antiretroviral treatment in North‐East Ethiopia, 2021

“…A study in West Ethiopia, Northern Ethiopia, South Africa, and Nigeria also showed that viral re‐suppression rate after EAC was low 29,66–68 indicating that EAC alone may not be effective in viral load suppression without drug resistance tests. Research evidence showed that the rate of EAC sessions among individuals who had VF was not complete yielding a lower viral re‐suppression rate 65,69,70 . Enhanced adherence counseling was not effective in reversing virologically defined treatment failure for patients on long‐term ART who had no genotype tests because of the probability of having genetic mutations of the virus 63 …”

“…Research evidence showed that the rate of EAC sessions among individuals who had VF was not complete yielding a lower viral re-suppression rate. 65,69,70 Enhanced adherence counseling was not effective in reversing virologically defined treatment failure for patients on long-term ART who had no genotype tests because of the probability of having genetic mutations of the virus. 63…”