|Year : 2020 | Volume
| Issue : 2 | Page : 133-140
Clinical profile and viral load suppression among HIV positive adolescents attending a tertiary hospital in North Central Nigeria
Esther S Yiltok, Cordelia Y Agada, Ruth Zoakah, Aweng G Malau, Dooh A Tanyishi, Emeka U Ejeliogu, Augustine O Ebonyi
Department of Paediatrics, College of Health Sciences, University of Jos, Jos, Nigeria
|Date of Submission||04-Apr-2020|
|Date of Decision||13-May-2020|
|Date of Acceptance||18-May-2020|
|Date of Web Publication||11-Sep-2020|
Dr. Esther S Yiltok
Department of Paediatrics, College of Health Sciences, University of Jos, Jos
Source of Support: None, Conflict of Interest: None
Background: The use of combination antiretroviral therapy (cART) helps in HIV viral load suppression and has improved survival of children into adolescence. The aim of the study was to look at the clinical profile and identify factors associated with HIV-viral load suppression among adolescents on long-term cART. Methods: Consenting adolescents aged 10–19 years attending the pediatric and adult antiretroviral therapy (ART) program of Jos University Teaching Hospital (JUTH) were enrolled into the study. A semi-structured interviewer administered questionnaire was used to collect the necessary information like the biodata, educational background, orphan and vulnerable children (OVC) status, and ART use. Self-reported adherence and viral load results were retrieved and data was analyzed using SPSS version 23. Results: A total of 143 were recruited into the study with 87(60.8%) females and 56(39.1%) males. Eighty-one (56.6%) had viral load suppression while 62 (43.4%) had unsuppressed viral load. Forty-three (55.1%) out of the 78 orphaned children had viral suppression and the single orphan type had a better viral load suppression compared to the double orphan type and this was statistically significant (P < 0.05). Adherence to medication, where adolescents lived, if felt like stopping medication or ever stopped medication were significantly associated with viral load suppression (P < 0.05). Conclusion: Virologic suppression was mainly related to adherence, being double orphan, and whom the child lives with. Therefore, additional interventions should be instituted to address adolescent-specific services to enhance virologic suppression among them.
Keywords: Adolescence, adherence, clinical profile, viral suppression
|How to cite this article:|
Yiltok ES, Agada CY, Zoakah R, Malau AG, Tanyishi DA, Ejeliogu EU, Ebonyi AO. Clinical profile and viral load suppression among HIV positive adolescents attending a tertiary hospital in North Central Nigeria. J Med Trop 2020;22:133-40
|How to cite this URL:|
Yiltok ES, Agada CY, Zoakah R, Malau AG, Tanyishi DA, Ejeliogu EU, Ebonyi AO. Clinical profile and viral load suppression among HIV positive adolescents attending a tertiary hospital in North Central Nigeria. J Med Trop [serial online] 2020 [cited 2021 Apr 20];22:133-40. Available from: https://www.jmedtropics.org/text.asp?2020/22/2/133/294813
| Introduction|| |
The World Health Organization (WHO) has reported that the number of adolescents on antiretroviral therapy (ART) continues to increase. This increase is as a result of the success in the treatment of perinatally infected children, infections during early adolescence as well as the expansion of the access to ART worldwide. Progress has been made so far in the treatment of people living with HIV/AIDS (PLWHA) with increased access to ART.
Currently, HIV has no cure and therefore, lifelong ART is required. The ART helps to suppress viral replication and this helps to facilitate the restoration of the immune function and thereby reducing the risk of HIV transmission. The goal of the combinations of ART is to sustain the suppression of HIV replication and increase the barrier for drug resistance. This means that the person taking the drugs has to adhere to the treatment schedule. Adherence has been defined as a patient’s ability to follow a treatment plan, take medications at prescribed times and frequencies, and follow restrictions regarding food and other medications. Adherence therefore is key to viral suppression and because of the unique characteristics of adolescents they may have worse adherence to the ART regimen., This has the potential of increasing the risk of drug resistance and consequently morbidity and mortality.
The gold standard for monitoring of the effectiveness of ART treatment that was introduced by the WHO is the checking of the viral load monitoring. Through this investigation there will be an objective way to ascertain the effectiveness of treatment. The global target for HIV viral suppression following treatment is 90% based on an ambitious target set to end HIV/AIDS epidemic by the UN by 2020. The increase in the access to ART has not shown a concomitant increase in viral suppression especially in low-resource settings. This is more so in adolescents where they tend to experience worse outcomes in immunological and viral suppression.,, Studies have shown that children and adolescents from different parts of world have worse viral load suppression compared to adults.,, The main reason for the poor rate of viral load suppression has been the non-adherence to treatment.,, In addition to adherence, several other factors have been found to influence the outcome of treatment., Although adherence to ART is an important factor in viral load suppression some studies have shown that viral load remains high in some children and adolescents despite sufficient adherence to treatment with ART while others have suppressed viral load despite their poor adherence to their treatment.,,
The Jos University Teaching Hospital (JUTH) Pediatric ART program has been following up a cohort of children who mostly acquired HIV perinatally and these children have now reached their adolescent years. These adolescents are transiting into adult care and their virologic suppression has not been determined. Therefore, this study aims to look at the clinical profile and identify factors associated with HIV-viral suppression among adolescents on long-term cART attending the Pediatric ART program of APIN JUTH.
| Materials and methods|| |
The study was conducted in the Pediatric/Adult Infectious Disease Clinic, Department of JUTH which is located in Jos, North Central Nigeria.
HIV positive adolescents aged 10 years to 19 years that are attending the Pediatric and adult ART program of JUTH who had documented viral load results within a period of 6 months from the time of the study were recruited for the study over a period of 6 months.
This was a descriptive cross-sectional study of adolescents on routine regular follow up at the pediatric and adult HIV clinic who are on antiretroviral therapy.
Subject selection and methods
Consenting adolescents aged 10–19 years attending the Pediatric and adult ART program of JUTH and who had viral load results were enrolled into the study. All of them were on cART for ≥ 1 year. A semi-structured interviewer administered questionnaire was used to collect the necessary information such as the socio-demographic data like age group (years), sex, residence, highest educational attainment, whether in boarding school, orphan, orphan type, who the individual lives with, whether the individual felt like stopping ART and has stopped ART before, adherence to ART, whether he/she hides ART from certain groups of people, who assist them to take their ART, suicidal thought, alcohol abuse, and taking alternative treatment. We also established the individual’s knowledge of their HIV retroviral status. Other relevant data were obtained from the data unit of AIDS prevention initiative in Nigeria (APIN) JUTH with regards to their HIV viral load levels to categorize as virologically suppressed or unsuppressed. Participants with viral load < 1000 copies/ml and ≥ 1000 copies/ml where considered virologically suppressed and unsuppressed respectively according to the national adult and pediatric treatment guideline of 2016. Self-reported adherence 6 months before the viral load result was reviewed from patients’ folders (> 95% drug ingestion = good ART adherence while < 95% drug ingestion = poor ART adherence). The participants viral load results conducted within 6 months from the time of enrolment were retrieved from the computer database.
All eligible adolescents attending ART program at JUTH that gave consent/assent were recruited into the study within the study period of 6 months.
Ethical approval was obtained from Health Research Ethical Committee (HREC) of JUTH (Reference − JUTH/DCS/ADM/127/XIX/6645) and obtained permission to carry out the study from AIDS Prevention Initiative in Nigeria (APIN) authorities.
A written informed consent/assent was obtained from adolescents ≥ 18yrs or the parents/guardians of the adolescent aged < 18 years. Participation in the study was voluntary and those who declined participation in the study were not denied any form of treatment, care, and support entitled to them. The participants were also allowed to withdraw voluntarily at any stage of the study. Confidentiality was kept during the research including all findings.
The data collected were analyzed using IBM SPSS Statistics for Windows, version 23. Descriptive statistics were used to summarize and display the characteristics of the participants and to determine the frequencies of the children. Student t-test was used for continuous variable (age) where applicable. Chi-square was used to test for associations of independent variables (participants’ clinical profile) and dependent variable (viral load suppression). Binary logistic regression was done to determine the variable that was independent predictor of virologic suppression.
| Results|| |
One hundred and forty-three adolescents on HAART were recruited into the study with 87 (60.8%) females and 56 (39.1%) males with a male: female ratio of 1:1.6. Nearly all (99.3%) of them are single with only one married and 78 (54.6%) of them are orphans. The socio-demographic characteristic of the adolescents on ART are as shown in [Table 1]. Nearly half (49%) of them are in the mid adolescent period (14–16). Majority (88.1%) of the adolescents that were studied live in an urban area. Out of the 78 of those that are orphaned 50 (64.1%) are single orphans and 28 (35.9%) are double orphans. Most (78.3%) of them have had at least a secondary school education as well as adherent (76.9%) to their medication and only seven (4.9%) live in an orphanage. One hundred and ten (76.9%) of the adolescents studied were adherent to their medication, out of which 76 (69.1%) had viral suppression. Out of the 33 that were non-adherent only five (15.2%) of them had viral suppression. In all a total of 81 (56.6%) of the adolescents had viral suppression.
|Table 1: Socio-demographic characteristics of HIV positive adolescents on ART (n = 143)|
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Different variables were analyzed to demonstrate if there was any relationship to viral suppression amongst the adolescents studied as shown in [Table 2]. Eighty-one (56.6%) of the study population had viral suppression while 62 (43.4%) had no viral suppression. Those who were adherent to their medication had a better viral suppression (69.1%) and this was statistically significant (P < 0.05). Forty-three (55.1%) out of the 78 orphaned children had viral suppression and the single orphan type had a better viral suppression compared to the double orphan type and this was statistically significant (P < 0.05). Living with husband, parents, or orphanage instead of relatives gives a better chance of viral suppression (P <0.05), while having felt like stopping medication or have ever stopped medication before, decreases the possibility of viral suppression (P < 0.05). Knowing their status, the level of education, discrimination, type of assistance in taking medication, thoughts of suicide, and hiding medication had no statistical significance in viral suppression. A great majority (87.4%) of them usually hide their medications from others and almost an equal number (86.7%) of them are assisted by relatives, parents, siblings, and caregivers to take their medications and only 18 (12.6%) experienced discrimination. Only few of them attend boarding school (2.8%), abuse alcohol (1.4%), and take alternative treatment (8.4%) and these too had no statistical significance in viral suppression.
|Table 2: Relationship between characteristics and viral suppression of HIV positive adolescents (n = 143)|
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[Table 3] shows that the odds of virologic suppression among those who had good adherence level was 0.2 times the odds of those with poor adherence having adjusted for all other factors in the model such as orphan type, ever stopped ART, felt like stopping ART before and living with parents or not. This means that good adherence is an independent predictor of virologic suppression.
|Table 3: Binary logistic regression of variables and viral load suppression|
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| Discussion|| |
The rate of viral suppression in this study is 56.6%. This rate is low compared to some studies within and outside Africa.,,,,,. but was better than the report from some other studies., It was however, comparable to the report by Bain et al., Ryscavage et al. and Hall et al. In this study, adolescents’ virologic suppression was significantly affected when the adolescents felt like stopping ART before, have stopped ART before, whom they are living with, and when they are double orphan. The common pathway to these variables is poor or lack of adherence to long-term ART as demonstrated in this study and adherence was the independent predictor of virologic suppression. Adherence in our study was better than that by Ernesto et al. using their pharmacy dispensing records (PDR), where they recorded non-adherence of 45.4%. The ART adherence in this study was determined by self-reporting, which is subject to recall bias. Our adherence assessment method was different from that by Ernesto et al. and that could have accounted for the differences in adherence rates. However, prevalence of adherence has been shown to vary from 49% to 100% with most studies reporting above 75%. Therefore, maintaining high level of adherence is a key factor to viral suppression, the development of drug resistance and disease progression, and adherence acts as an early warning indicator of drug resistance. A study has shown that a decrease of 10% adherence can lead to doubling of the HIV viral level and disclosure and educational status of the adolescents did not show any statistical association with viral load suppression in this study. This implies that disclosure of HIV status and educational level of the individual are not enough to lead to viral suppression but this will require the patient having adequate adherence to ART.
Virologic suppression requires effective ART which implies that the correct dose of appropriate ART and at the right time interval between doses of drugs need to be consistently and correctly taken (adherence >95%). In this study majority of adolescents acquired HIV perinatally and some could have been on ART right from early childhood. Therefore, it is not surprising that these adolescents have started feeling like the want to stop their medications and even some have stopped their ART at some point probably because they may be tired of the medications and that could have affected their drug adherence. In addition other factors that could have led to stoppage of medications could have been due to side effects of the medications and non-disclosure of HIV status as shown in this study because only about 60% of the participants had full HIV disclosure which could have caused them to abandon their drugs and this could have significantly affected their viral load suppression. Adolescents have been found to have poor adherence to antiretroviral therapy,, and also children that are adherent to drugs later showed a decrease in adherence as children moved into adolescence. However, a study has demonstrated that having an adolescent and youth-friendly (AYF) clinic can have higher retention in care with better viral suppression compared to adolescents attending the standard pediatric clinic. This implies that having an adolescent and youth-friendly clinic can help to focus on issues that are peculiar to these individuals which can ultimately improve their adherence to their medication. This will consequently lead to suppressed viral load and prevention of treatment failure.
One of the problems affecting HIV positive children is the demise of one or both parents and this was shown in this study in which about 31.5% of them have lost their parents. These children are forced to live with their relatives, step parents, or in the orphanage homes. These children will lack the optimal support or supervision to take their medications leading to non-viral suppression. This study showed that the people who assist them take their drugs has significant influence on virologic suppression and this is a cause for concern considering the long-term antiretroviral need of these adolescents.
Despite the fact that majority of the adolescents hide their drugs from different people such as friends, pupils/students, and teachers, we observed that the virologic suppression was not statistically associated to that. This may suggest that those adolescents hiding their drugs they still adhere to taking their medications.
Our findings showed that majority of our adolescents are not in boarding school and this did not show a significant difference in virologic suppression between them and boarders. Majority of the adolescents are non-boarders because the caregivers/parents want to ensure that they adherence to medications. This might be the reason for the lack of difference in the virologic suppression between the boarders and non-boarders. Alcohol abuse, suicidal tendency, and use of alternative (traditional) treatment were not associated with virologic suppression. This may be because in our study, very few of them had those characteristics.
This study did not show that the different subclasses of adolescents were statistically associated with virologic suppression. Our cohort of patients, mostly the early and middle adolescents are usually accompanied to the clinic by parents, family members, or guardians a factor that supports adherence, and that could have responsible for the lack of statistical difference in those with viral suppression compared with the non-suppressed. Medication adherence may be particularly challenging at a time of life when adolescents do not want to be different or perceived as different from their peers most especially that they need to swallow their drugs every day. This may probably be one of the major reasons in addition to stigma and discrimination that were responsible for the adolescents hiding their drugs from different kinds of people.
This study could not establish whether the lack of viral suppression was as a result of treatment failure or the participants acquired a resistant HIV strain ab initio because HIV drug resistance testing was not conducted before the commencement of treatment. Therefore, the unsuppressed viral load in some of the participants could have been as a result of primary resistant HIV strains to the ART. Also the cross-sectional design did not allow trends in the viral load because one point test of VL is insufficient
In summary, certain clinical profile affects virologic suppression in adolescents and they were mainly related to adherence. Therefore, additional interventions should be put in place to address adolescent-specific services to enhance virologic suppression among them.
Adolescent specific corrective interventions should be implemented such as ensuring that adolescents begin to own up to their treatment to ensure sustained lifelong viral suppression.
Adolescent-friendly service should be in cooperated in over HIV clinics compared to standard pediatric clinic for better retention in care of our adolescents to enhance viral suppression.
This work was funded in part by the US Department of Health and Human Services, Health Resources and Services Administration (U51HA02522), and CDC through AIDS Prevention Initiative Nigeria − APIN (PS001058).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]