Unsuppressed viral load among HIV-positive children and adolescents on antiretroviral therapy in Lubumbashi,democratic republic of the Congo: magnitude,determinants,barriers, and facilitators.

Abstract

Despite the proven effectiveness of antiretroviral therapy, achieving and maintaining viral load suppression among children and adolescents living with HIV remains a significant challenge, particularly in resource-limited settings such as Lubumbashi, Democratic Republic of the Congo. Barriers to optimal adherence to antiretroviral therapy contribute to unsuppressed viral load, increasing the risk of disease progression and HIV transmission. Understanding the magnitude, determinants, barriers, and facilitators of viral load suppression is crucial for designing effective interventions. Objectives. This study aimed to determine the prevalence of unsuppressed viral load among children and adolescents living with HIV on antiretroviral therapy in Lubumbashi and to identify the factors associated with unsuppressed viral load. Additionally, it explored the barriers and facilitators influencing adherence to antiretroviral therapy and achieving viral load suppression from the perspectives of children and adolescents living with HIV, their caregivers, and healthcare workers. Methods. A convergent mixed-methods study was conducted from June to September 2024 in HIV care clinics in Lubumbashi. The quantitative component consisted of a multicenter cross-sectional study including 847 children and adolescents living with HIV aged 0 to 19 years on antiretroviral therapy for at least six months with available viral load results. Data were collected using an observational checklist and analyzed using STATA version 16. Bivariable and multivariable logistic regression models were used to identify factors associated with unsuppressed viral load. The qualitative component involved in-depth interviews with 39 adolescents living with HIV aged 13 to 19 years, 14 caregivers, and focus group discussions with 16 healthcare workers. Participants were purposively selected based on their roles in HIV care and treatment. Data were thematically analyzed using NVivo 14, guided by the socioecological model, to explore barriers and facilitators to adherence to antiretroviral therapy and to achieve viral load suppression. Results. The prevalence of unsuppressed viral load among children and adolescents living with HIV was 24.7% (209/847). Factors significantly associated with unsuppressed viral load included having married caregivers (AOR= 2.4; 95% CI: 1.2 to 5.0), non-perinatal HIV transmission (AOR=2.3; 95% CI: 1.2–4.5), advanced WHO clinical stages (AOR= 3.5; 95% CI: 1.0 to 13.7), poor/fair adherence to antiretroviral therapy (AOR= 107.8; 95% CI: 50.3 to 231.1), and antiretroviral therapy-induced side effects (AOR= 3.8; 95% CI: 1.9 to 7.9). The qualitative analysis identified barriers to antiretroviral therapy adherence and viral load suppression based on the socio-ecological model. Individual-level obstacles included economic constraints, forgetfulness, misconceptions about treatment necessity, and lack of food. Family-level barriers included insufficient support and stigma. Interpersonal stigma and discrimination also played a role. Facilitators, however, included strong social support, counseling, reminder tools, and positive healthcare worker-patient relationships, all of which helped improve adherence and viral load suppression. Conclusion. Reducing unsuppressed viral load among children and adolescents living with HIV in Lubumbashi requires a multifaceted approach, integrating family and community support, simplified antiretroviral therapy regimens, and enhanced healthcare worker capacity to provide comprehensive care. Targeted policy interventions and cross-sectoral collaboration are essential to improving adherence to antiretroviral therapy and achieving sustained viral load suppression in this vulnerable population.