Magnitude and characteristics of unsuppressed HIV viral load in children and adolescents on antiretroviral therapy in sub-Saharan Africa: a systematic review and meta-analysis

Abstract

Background: HIV/AIDS remains a major health issue in sub-Saharan Africa, especially among children and adolescents, with a substantial proportion of people with HIV having unsuppressed viral loads despite the availability of antiretroviral therapy (ART), complicating efforts to manage and control the epidemic. We aimed to estimate the prevalence of unsuppressed viral load and identify the factors contributing to this issue among children and adolescents living with HIV on ART in sub-Saharan Africa.

Methods: In this systematic review and meta-analysis, we assessed data from Web of Science, Google Scholar, Scopus, PsycINFO, Embase, PubMed (MEDLINE), EBSCOhost Research Databases, and Wiley Online Library, as well as grey literature searches. We included studies published between Jan 1, 2010, and Nov 30, 2024 that focused on children and adolescents (aged <20 years) on ART in sub-Saharan Africa and reported on factors related to viral load suppression, defined by a viral load of less than 1000 copies per mL. Eligible studies included observational and interventional designs. Data appraisal and extraction were conducted by two independent reviewers from the author group, with summary data extracted from published reports. The primary outcome assessed was the prevalence of unsuppressed viral loads, with meta-analysis performed using STATA software to calculate prevalence and associated factors. The study is registered with PROSPERO (CRD42023451212).

Findings: From an initial 13 121 identified articles, 52 studies involving 169 949 children and adolescents on ART met the inclusion criteria. Prevalence of unsuppressed viral load among children and adolescents in sub-Saharan Africa was 26·47% (95% CI 23·06-29·87); specifically, 26·01% (20·51-31·52) for studies in children (<15 years), 24·76% (17·36-32·16) for studies in adolescents (10-19 years), and 28·52% (23·33-33·72) for studies in a combined group of children and adolescents. Factors associated with unsuppressed viral load included younger age (<5 years), male sex, rural residence, orphan status, attendance at a level 1 or 2 health-care facility, HIV status not disclosed, poor ART adherence, advanced WHO clinical stage of HIV, low CD4 cell counts, history of opportunistic infections, nevirapine-based treatment regimen, drug substitution history, and not receiving co-trimoxazole prophylaxis. This meta-analysis showed a significant heterogeneity across the included studies, as evidenced by I²=99·66% and p<0·0001.

Interpretation: Unsuppressed viral load among children and adolescents is a key concern in sub-Saharan Africa, and is influenced by sociodemographic, clinical, immunological, and treatment-related factors. Addressing these issues through targeted interventions and improved ART adherence strategies is crucial for better health outcomes.

Funding: HEARD PhD Scholarship, Swedish International Development Agency.