Level of viral load suppression in Rwinkwavu District Hospital: A cross-sectional study

Metuschelah Habimana^1,2,&, Rachel Niyogushimwa³, Vedaste Ndahindwa¹, Theoneste Ntakirutimana⁴

 

¹Department of Epidemiology and Biostatistics, University of Rwanda, Kigali, Rwanda, ²Pharmacy Department, Rwinkwavu District Hospital, Kayonza, Rwanda, ³Neonatology Department, Rwinkwavu District Hospital, Kayonza, Rwanda, ⁴Department of Environmental Health, University of Rwanda, Kigali, Rwanda

 

 

^&Corresponding author
Metuschelah Habimana, Rwinkwavu District Hospital, Kayonza, Rwanda.

 

 

 

 

Globally, human immunodeficiency virus (HIV) is a major public health problem where 37.7 million cases of HIV infections; around 1.5 million new HIV infections, and around 680 000 deaths related to acquired immunodeficiency syndrome (AIDS) were observed in 2020 [1]. Moreover, approximately 650,000 people died in 2021 from AIDS-related causes, while 28.7 million people with HIV got antiretroviral (ART) medications, making up 75% of the total number of persons living with HIV worldwide. The susceptibility of adolescent girls and young women was apparent, with one being newly infected every two minutes, and about 160,000 youngsters were also newly infected with HIV throughout the year [2], in 2020, the global impact of HIV was profound, with approximately 680,000 people losing their lives to HIV-related causes, while 1.5 million individuals acquired HIV infections, including 150,000 children [3]. Moreover, in 2019 there were 690,000 deaths related to HIV and 1.7 million new HIV infections worldwide [4], and 54% of all HIV patients live in eastern and southern Africa [2].

 

In 2014 the Joint United Nations Program on HIV/AIDS (UNAIDS) set 90-90-90 and 95-95-95 targets to be achieved by 2020 and by 2025 respectively aiming at ending HIV epidemics by 2030 [5-7]. According to UNAIDS in 2022, Eastern and Southern Africa remains the region most severely affected by HIV. However, it's noteworthy that this region has made remarkable progress, surpassing other areas, and by 2020, at least six countries in Eastern and Southern Africa had successfully achieved the 90-90-90 targets for HIV testing and treatment. These countries include Botswana, Eswatini, Malawi, Rwanda, Zambia, and Zimbabwe. Moreover, an additional four nations, namely Kenya, Namibia, South Africa, and Uganda, achieved a commendable 73% VL suppression rate among their HIV-positive populations by the end of 2020 [2]. However, a study conducted in East and South Africa found that one out of every three children who had a VL test had not achieved VL suppression [8].

 

In Rwanda, according to Rwanda population-based HIV impact assessment (RPHIA), 2018-2019 revealed that VL suppression was at 90.1% in the general population. The highest prevalence of VL suppression in HIV -positive women was among those aged 35-44 years (85.2%) and the lowest in those aged 15-24 years (62.3%). The highest prevalence of VL suppression in HIV-positive men was found among those aged 55-64 years (84.9%) and the lowest in those aged 25-34 years (45.9%) [9].

 

The proportion of morbidity and mortality among children infected with HIV is higher compared to adults because during childhood the immune system is immature and is not strong enough to fight against HIV, this implies that the virus will replicate at a high rate and result in high VL and high rates of cluster of differentiation 4 (CD4) destruction, accumulation of mutations in the viral population and faster rates of disease progression [10].In addition, medication adherence is often a challenge for adolescents with HIV, and dose adjustment based on their weight is difficult, contributing to virological failure [11]. Low level of adherence to antiretroviral (ARV) drugs in children and adolescents living with HIV is thought to be associated with various factors like medication formulation, frequency of dosing, drug toxicities, and side effects, child´s age and developmental stage, as well as psychosocial, behavioral, and sociodemographic characteristics of children and caregivers [12]. According to the World Health Organization (WHO), various factors are known to influence VL suppression, and those factors are ART regimen, past exposure to nevirapine, gender, age, adherence, disclosure of HIV status, having an active opportunistic infection and the quality of clinical care at the health facility [13].

 

In the Rwinkwavu district hospital catchment area, their efforts to improve the clinical outcome of HIV patients receiving ART are hampered by patients´ HIV VL suppression rates which are poorly understood. To gain insights into patient monitoring, we assessed the rates of HIV VL suppression and the factors associated with it in this catchment area. This evaluation was conducted by analyzing HIV patients´ data stored in a web-based electronic medical record system (EMRS). To our knowledge, this research was the inaugural attempt to analyze data from HIV patients within the Rwinkwavu hospital catchment area, focusing on the assessment of VL suppression rates and their related factors.

 

 

Research Design and Target Population

 

This study utilized a cross-sectional design, and the targeted population was every patient who had been part of the HIV program in the Rwinkwavu district hospital catchment area between 2005 and 2018. Initially, there were 1,348 individuals in the dataset before data cleaning. The study included all patients who had complete identification and clinical information. Patients with incomplete identification and clinical information were excluded from the study. Therefore, following the data-cleaning process, only 314 patients were considered for analysis.

 

Research Setting

 

Kayonza Districtwavu Hospital, one of the two district hospitals in the Eastern province of Rwanda, in Kayonza District, serves a population of 222,379 individuals. It offers advanced medical services to those arriving from eight local health centers and is actively involved in supervising and monitoring HIV patients in these health centers. During routine healthcare visits, where HIV patients receive medications and have their VL monitored at both the hospital and the local health centers, their information is electronically recorded and stored in an efficient web-based EMRS, and the hospital has access to each patient's data. The core purpose of the EMRS is to create concise consult sheets for patients, which contain essential information such as weight, CD4 count, VL, and medication regimens, as well as a comprehensive medical history encompassing symptoms, allergies, and any noteworthy concerns.

 

The eight health centers involved in this study include Ndego, Cyarubare, Karama, Rutare, Ruramira, Nyamirama, Rwinkwavu, and Kabarondo.

 

Data Collection Procedure

 

Individual patient data was extracted from a web-based EMRS that encompasses HIV patient information from health centers within the catchment area as well as those managed at the hospital. This data was then downloaded into an Excel file. HIV patients´ data in EMRS was considered from its initial use in the Rwinkwavu district hospital catchment area from 2005 till 2018. The t baseline (at six months after ART initiation) VL, VL in 2018, baseline CD4, age, sex, past exposure to nevirapine, and length of retention in the HIV program were considered as the variables of interest in this study. In the process of cleaning the dataset, we made sure that each patient was included in the analysis once at baseline enrolment in the HIV program, and once in 2018. Any follow-up visits that occurred between the baseline enrolment and 2018 were excluded. Patients who had missing variables of interest during both their baseline enrolment and in 2018 were not included in the analysis.

 

Data Analysis

 

Data analysis was performed using Stata 15. Descriptive analysis was performed to characterize variables of interest and results were presented in terms of percentages. Bivariate analysis was performed by using chi-square tests at 95% confidence intervals (CI) to identify the relationship between dependent and independent variables. By adopting WHO guidelines for VL suppression, patients´ VL in 2018 (dependent variable) was grouped into two categories. The first category consisted of patients whose VL <1000 copies/ ml, the second category consisted of patients whose VL ≥ 1000 copies/ ml, and undetectable HIV VL was considered for VL < 20 copies/ml [14]. As individual patients´ VL data in 2018 was the dependent variable, independent variables were baseline VL, baseline CD4, age, sex, length of retention in the HIV program, and past exposure to nevirapine. Any variable that was found to be significantly associated with no VL suppression during bivariate analysis was considered for multivariate analysis to assess the strength of the association between the dependent variable and independent variables. Adjusted odds ratios at 95% CIs for the multivariate logistic regression model were taken into consideration.

 

Ethical considerations

 

Ethical clearance was obtained from the University of Rwanda, College of Medicine and Health Sciences Institutional Review Board. During this study, confidentiality was highly respected. The dataset was deidentified, patients´ names were replaced by code and every patient had only one unique identification code for different variables. The data collected were only used for research purposes. The authorization to collect data was granted by the Director General of Rwinkwavu District Hospital.

 

 

Demographic and clinical characteristics of the studied population

 

Among 314 patients who were considered in this research 203 (65%) were females. Demographic and clinical characteristics of the studied population are illustrated in Table 1. The median age was 44.8 years (IQR 10.8 -75.6 years). The median time of retention in the HIV program was 37.5 months IQR (11.2- 131.8 months), the median baseline CD4 count cell was 605 cell/mm³ interquartile range (IQR) (82-1668 cells/mm³) and the median baseline VL was 19.9 copies/ml IQR(19- 162000 copies /ml). Among 314 patients considered in this study, 115 patients (37%) were exposed to a drug regimen containing nevirapine. Among all patients, 295 (93.9%) had their VL, which was less than 1000 copies/ ml in 2018. Among 203 female patients, 194 of them (96%) had VL which was less than 1000 copies/ ml in 2018. Among 111 male patients, 101 of them (91%) had suppressed VL in 2018, and among 314 patients, 208 (66.2%) of them had undetectable viral load (<20 copies/ml) in 2018 (Table 1).

 

Factors associated with unsuppressed VL in 2018

 

Table 2 describes the results of bivariate analysis, considering unsuppressed VL in 2018VL< 1000 copies/ml as the outcome of interest. Based on bivariate analysis, being aged between 13- 19 years was found to be significantly associated with no VL suppression status. OR= 8.6, 95% CI (2.3- 31.8), p-value =0.001, and among clinical characteristics of patients, baseline VL which was greater or equal to 1000 copies/ ml was found to be significantly associated with no VL suppression OR: 9.4, 95% CI (3.4 - 26.1), p-value: 0. Other variables including baseline CD4, age, sex, past exposure to nevirapine, and length of retention in HIV program were not significantly associated with VL suppression status (Table 3).

 

In multivariate analysis, both baseline VL ≥ 1000 copies/ ml and being aged between 13 and 19 years were statistically associated with no VL suppression. Table 3 shows the results of the multivariate analysis.

 

 

The study presented insights into the HIV program's effectiveness, highlighting a VL suppression rate of 93.9% among patients receiving ART in 2018 in the Rwinkwavu District Hospital catchment area. Additionally, the research identified a significant association between the lack of VL suppression and the age group of 13-19 years OR: 8.6, p-value: 0.001, (CI: 2.3 - 31.8). This finding aligns with previous studies indicating that younger age is indicative of poorer adherence to ART [15,16]. Poor adherence among teenagers, influenced by medication aspects, developmental stage, and psychosocial factors, contributes to virological treatment failure [12]. Several studies indicate inadequate VL suppression in adolescents, emphasizing the necessity for tailored HIV treatment optimization for this demographic [17-19].

 

Among 208 patients who had undetectable VL (< 20 copies/ml), 137(65.9%) were female and it has been found that patients whose undetectable viral load have a reduced probability of transmitting HIV sexually [20,21].

 

While this study did not find a correlation between VL suppression and baseline CD4 count, research in Ethiopia in 2018 and Vietnam in 2016 indicated that individuals with a baseline CD4 count below 200 cells/mm³ experienced inadequate VL suppression [22,23]. Since 2016, the Government of Rwanda has been dedicated to following the WHO's "Treat All" recommendation, which disregards the population´s immunological distinctions. This commitment greatly contributed to the near achievement of the 90-90-90 targets by 2020 in the general population. Specifically, 89% of HIV patients are aware of their condition, 92.3% of them receive ART, and 91% of this group successfully suppress their VL to below 1000 copies/ml [24].

 

While this study did not confirm a connection between sex and VL suppression, previous studies have indicated that sex does indeed impact VL suppression. This impact is linked to masculine behaviors involving engaging in multiple sexual partners, reluctance to use condoms, and the misuse of drugs and alcohol, which result in inadequate adherence and, consequently, the absence of VL suppression [25-27].

 

This study confirmed that a baseline VL equal to or exceeding 1000 copies/ml OR: 5.79, 95% CI: (1.38-24.28), p-value: 0.016 was linked to the continued absence of viral load suppression later in 2018, consistent with previous studies indicating that higher baseline VLs are indicative of suboptimal VL suppression baseline [28-30].

 

Adhering to ART is the most important factor for achieving VL suppression [31]. Yet, in this study, data regarding patients´ adherence to medications were not recorded in EMRS and were not considered. Furthermore, past exposure to a nevirapine-based regimen did not correlate with VL suppression, consistent with findings from a related study in Thai children comparing efavirenz-based and nevirapine-based regimens, which showed no significant difference in VL suppression between the two [32].

 

This study indicated a median retention time of 37.5 months (IQR 11.2-131.8 months) in the HIV program, with no significant association found between retention duration and VL suppression.

 

This result aligns with previous studies, demonstrating that there is no discernible difference in VL suppression between groups engaged in the HIV program for 12 months versus 24 months [33,34].

 

While studies conducted elsewhere covered the entire nation, this study exclusively analyzed data from a part of a single rural district in Rwanda. As a result, the findings should be interpreted with caution when considering their applicability to the entire country. Moreover, this research targeted 1348 patients initially enrolled in an HIV program at the Rwinkwavu District Hospital catchment area between 2005 and 2018. However, only 314 patients were considered for this analysis, as they had comprehensive records in the EMRS. Other patients, with incomplete documentation or those who discontinued the HIV program for various reasons, were not included. Consequently, the findings of this study are limited in their generalizability, and more studies are needed in other settings to make conclusions comparable to the national level.

 

 

Rwinkwavu District Hospital has demonstrated significant achievement by attaining a VL suppression rate of 93.9%. However, challenges persist for adolescents aged 13-19 and individuals with a baseline VL of ≥ 1000 copies/ml. Therefore, tailored care for adolescents, and improved counselling during patient monitoring for individuals with unsuppressed viral load are crucial as unsuppressed baseline VL correlates with continued non-suppression later in 2018.

 

 

The authors declare no competing interests.

 

 

MH, RN, VN, and TN conceptualized and designed the study; MH, RN, VN, and TN carried out a literature search, and MH and RN collected the data. Data analysis done was by MH, RN, VN, and TN. The manuscript was drafted by MH, RN, VN, and TN. MH and RN revised the manuscript. All authors read and approved the final draft.

 

 

The authors thank Prof Joseph Ntaganira; Dr Jared Omolo; Mrs. Peace Kinani; Jean D’amour Sinayobye; Rwinkwavu District Hospital; Joyeuse Uwiherekeje; Dusabe Leontine; Todd Anderson; Rwanda FETP; Rwanda CDC, and Rwanda MOH.

 

 

Table 1: Demographic and clinical characteristics of the studied population

Table 2: Factors associated with unsuppressed HIV VL (Bivariate analysis)

Table 3: Factors associated with unsuppressed HIV VL in multivariate analysis

 

 

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