Globally, an estimated 79.3 million people have become infected with Human immunodeficiency virus (HIV) and 36.3 million people have died of Acquired Immunodeficiency Disease Syndrome (AIDS)-related illnesses since start of the disease. In 2020, an estimated 37.7 million people were living with HIV worldwide and 36 million of them were adults. An estimated 68% are living in sub-Saharan Africa [1].
In 2018, almost two thirds (62.1%) of all PLWHIV were receiving life-saving ART, and more than half (53%) had suppressed viral load and nearly half of them had unsuppressed viral load globally. However, the number of people accessing treatment was not rising rapidly enough to reach the 2020 global target of 30 million people. Besides, more than 20% of PLW HIV was not aware of their HIV status [2].
Antiretroviral therapy is aimed to achieve and maintain viral suppression, thereby preventing disease progression and transmission. In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 global targets and for epidemic control of HIV, where by the third 90 represents a target to achieve viral suppression in at least 90% of patients initiating ART by 2020 . The program also set 95-95-95 global target aiming to end epidemic by 2030 in which the third 95 represents a target to achieve viral suppression in at least 95% of patient initiating ART [3].
In 2018, Eastern and Southern Africa accounted 54% of global total HIV infection and 67% had access to antiretroviral therapy (ART) and 46% had unsuppressed viral loads. The study conducted in South Africa also indicates that among 19% of the people admitted to hospital with advanced HIV disease, 21% of admissions were receiving ART with an unsuppressed viral load in 2015 [4, 5].
According to the systematic review of virological efficacy and drug resistance conducted in 2009 sub-Saharan Africa. among 89 studies 15% of patients showed virological failure after two consecutive viral load results of > 1000 copies/ micro litre because of lack of monitoring viral suppression due to inadequate viral load test services [6].
Study conducted in South Africa indicates only 2% of the patients taking first-line ART were switched to second-line ARV despite virology treatment failure ranges from 8 to 17% for patients on ART care in 2012. It was found that there was a delay in assessing, managing, and shifting first line ARV failures [7].
According to the current new spectrum estimate, 665,723 Ethiopians were living with HIV and of which 79.0% of HIV positive adults know their HIV status, 97.1% of them were receiving ART with regional disparities. From Adult positive with HIV receiving ART, 87.6% of them had suppressed viral loads [8].
The number of patients switched to 2nd line ART in Ethiopia remains low which is around 1.5%. This likely reflects the difficulty in determining treatment failure due to limited access of viral load test, and barriers in access to 2nd line regimens [9].
Since 2015, Ethiopian ART guidelines state that Viral load test should be performed for all patients starting from 6 months after ART initiation and then annually for early detection of treatment failure. However, treatment monitoring is still based on clinical and immunological monitoring where there is a limited resource for Viral load test for the decision of treatment failure [9, 10].
Treatment failure among population taking ART in Ethiopia is still a public health concern. According to the study conducted in Ethiopia from March 2016 to 2017, the prevalence of virological failure among population taking ART in Ethiopia is 11% [11].
According to global goal of the three 90s (90-90-90) targets in the development of the current HIV National Strategic Plan, 87% of those on ART have attained viral suppression in Ethiopia [12]. However, viral load testing service coverage which is the gold standard for the decision of treatment failure was 51%.
Systematic review and Meta analysis done in Ethiopia which included 22 published articles from the years of 2012-2018 on magnitude and cause of treatment changes indicates that 7% of the cause of treatment change was treatment failure [13].
Monitoring viral load among individuals receiving ART is important to ensure successful treatment response. Identifying adherence problems and confirmation of ART failure enable clinicians to take an appropriate course of action for patient management [14].
In the absence of viral load monitoring, unnecessary regimen switches are common resulting in increased treatment costs and loss of future options for treatment succession which puts the patient on an increased risk for drug toxicity from second-line regiment [15]. Late detection of treatment failure results in high frequencies of accumulated mutation and drug resistance.
Several studies in public hospitals of Ethiopia indicate that lower CD4, lower Body mass index, Immunological failure, duration in month on ART and adherence associated with unsuppressed viral load. Drug resistance, anti-HIV medications poorly absorbed by the body, Side effect of the medications, other illnesses or conditions are the major impact on treatment success [15,16,17]. Hence, early detection of non-suppressed viral load is vital for management of the patients and monitoring of treatment outcome.
However, few studies have comprehensively included the patients who follow ART in public and private hospitals as well as in health centers to identify predictors of unsuppressed viral load. Predictors of unsuppressed viral load may vary across different types and levels of health facilities due to the variation in quality of care and treatment. Therefore, this study is aimed to identify factors associated with unsuppressed viral load in both private and public health facilities of the study settings and provide information for implementation of preventive action against factors contributing unsuppressed viral load.
