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ObjectivesIdentify factors (demographic and clinical) associated with a non-suppressed viral load (VL) of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Nigeria.DesignCross-sectional study.SettingSixteen US Agency for International Development supported states in Nigeria.Participants585 632 PLHIV on ART.Primary outcome measuresVL non-suppression (defined as having a VL of at least 1000 HIV RNA copies per mL of plasma). χ2testing and multivariable modified Poisson regression with robust variance estimates were conducted on routinely collected ART programme data.ResultsSixty-six per cent of the study population were females. The largest age groups were 25–34 and 35–44, accounting for 32.1% and 31.1%, respectively. Males had a 9% greater likelihood (adjusted prevalence ratio, APR=1.09) of being non-suppressed. The age groups below 60+ (APR=0.67) had a higher likelihood of a non-suppressed VL, with the highest in the 0–14 age group (APR=2.38). Clients enrolled at tertiary and secondary level facilities had the greatest likelihood of a non-suppressed VL. Clients who started ART between 2010 and 2015 had the greatest likelihood of viral non-suppression (APR=6.19). A shorter time on ART (ConclusionsTargeting males, clients of younger age, those on treatment for less than 3 years, clients at tertiary and secondary health facilities, small and medium facilities, and clients in the Edo, Niger and Borno states for interventions could lead to improvements in VL suppression in Nigeria. The independent factors associated with a non-suppressed VL can guide improvements in ART programme development and VL suppression of PLHIV on ART in Nigeria.

We identified combinations of modifiable factors that HIV programs supporting orphans, vulnerable children, and their families may be able to act on to increase the proportion of beneficiaries who know their HIV status., Key Findings Using fuzzy-set qualitative comparative analysis, we identified combinations of modifiable factors that HIV programs that support orphans, vulnerable children, and their families may be able to act on to increase the proportion of beneficiaries who know their HIV status. Key Implications To improve HIV status knowledge, programs should consider implementing a formal process to: Assign cases considering case complexity and caseload to reduce overworkProvide activistas with supervision supportHire experienced activistasTrain activistas to address challenging casesReimburse activistas for work-related expenses, In Mozambique, more than a million children are living with HIV or are otherwise vulnerable due to HIV. In response to this crisis, the US President’s Emergency Plan for AIDS Relief funds programs that serve orphans and vulnerable children affected by HIV and their families. These programs retain case workers, known as activistas, who provide and refer beneficiaries to services to increase beneficiaries’ knowledge of their HIV status and to improve retention in care among those living with HIV. To improve program effectiveness, implementing organizations need to understand how different case management attributes affect beneficiary outcomes. We applied fuzzy-set qualitative comparative analysis (QCA), based on 119 interviews, to identify the combinations of case management attributes that led to (1) increased knowledge of HIV status, and (2) high percentages of beneficiaries with known HIV status. We identified 6 pathways for the first outcome and 5 pathways for the second outcome. Each pathway demonstrates an alternative combination of conditions that positively influences the outcome and is equally sufficient in achieving the outcome. To improve knowledge of HIV status, programs in a similar context as this study may select any of the identified pathways based on their existing resources and work on ensuring the presence of each of the conditions in the pathway. Overall, based on the presence of some of the factors in multiple pathways, we conclude that to improve knowledge of HIV status it is important that programs implement a formal process to assign cases considering case complexity and existing caseload to reduce overwork; provide activistas with external support such as weekly care team meetings, weekly supervisor meetings, and/or low supervision ratios; hire experienced activistas; provide all activistas with follow-up trainings so they have the tools to address challenging cases; expand the financial resources offered to activistas; and reimburse activistas for work-related expenses.

Background Human immunodeficiency virus (HIV) is untransmissible when the viral load (VL) is undetectable, underscoring the importance of achieving VL suppression for HIV epidemic control. It is estimated that 78% of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Nigeria are virally suppressed. The need to improve VL suppression rates raises questions about the factors associated with an unsuppressed VL, which this study explored using a large cross-sectional database of clients who received ART over a period of 20 years. Methods Data from 517,012 clients with a documented VL were analyzed using univariate and adjusted multivariate logistic regression. The independent variables investigated were sex, age group, facility type, time on ART until last VL test, multi-month dispensing (MMD), and geopolitical zone. To verify model improvement by variable, we performed backward elimination for the logistic regression model. Results Sixty-six percent of the study population were females. The largest age groups were 35–44 and 25–34, accounting for 32% and 31%, respectively. The greatest adjusted odds for an unsuppressed VL were associated with shorter duration MMD prescriptions of 1–2 months (adjusted odds ratio [AOR]=14.05) and 3 months (AOR=3.13). Males had 8% greater odds (AOR=1.08) of being unsuppressed. The age groups below the 45–59 age group (AOR=0.84) had higher odds of having an unsuppressed VL, with the highest odds in the 0–14 age group (AOR=1.87). Clients enrolled at tertiary and secondary level facilities had the greatest odds of having an unsuppressed VL. A shorter time on ART until the last VL (1–3 years [AOR=1.14]) was associated with a higher risk of an unsuppressed VL. Clients in the North-Central (AOR=1.83) and North-East (AOR=1.49) zones had the greatest odds of viral non-suppression. Conclusions Enabling the provision of 3+ months of MMD to PLHIV and targeting younger age groups, tertiary and secondary health facilities, small and medium facilities, and the North-Central and North-East zones for interventions could lead to improvements in VL suppression in Nigeria. The independent factors associated with an unsuppressed VL can guide improvements in ART program development and VL suppression of PLHIV in Nigeria.