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The Open Public Health Journal, 2018, 11, 135-146 135

The Open Public Health Journal

Content list available at: www.benthamopen.com/TOPHJ/

DOI: 10.2174/1874944501811010135

RESEARCH ARTICLE
The Prevalence of HIV Load Suppression and Related Factors Among
Patients on ART at Phedisong 4 Clinic, Pretoria, South Africa
N.J. Mogosetsi, L.H. Mabuza* and G.A. Ogunbanjo
Sefako Makgatho Health Sciences University, Pretoria, South Africa

Received: December 28, 2017 Revised: April 5, 2018 Accepted: April 9, 2018
Abstract:
Background:
Globally, the benefits of viral load suppression in improving the lives of people living with HIV/AIDS have been established. In
2010, the South African Government decentralised ART to the primary care level. This study intended to determine the effect of this
decentralisation in achieving viral load suppression among patients.

Objective:
To determine the prevalence of HIV viral load suppression and factors related to the suppression among patients initiated on ART at
Pedisong 4 clinic, Tshwane District in Pretoria.

Methods:
A prospective cohort study was conducted on 98 patients initiated on ART between 01 November 2012 and 30 April 2013. Based on
the viral load results, they were divided into those who achieved Viral Load Suppression (VLS), and those who did not (NVLS).
Analyses were done using SAS® (version 9.2) for Microsoft software. A p < 0.05 was considered significant.

Results:
Ninety patients (91.8%; 95%CI, 84.7% – 95.8%) achieved viral load suppression while eight (8.2%; 95%CI, 4.2% – 15.3%), did not.
Of the 98 patients, 63 (64%) were female. In the NVLS group, the female to male ratio was 7:1 (p = 0.038). There was no
relationship between viral load suppression and patients’ baseline characteristics, behavioural characteristics and clinical
characteristics (p > 0.05). ART adherence reported in both patient groups was ≥ 87.0%.

Conclusion:
There was good viral load suppression in patients initiated on ART at Pedisong 4 clinic. Patients’ baseline, behavioural and clinical
characteristics were not related to viral load suppression, necessitating further large sample size studies in various health facilities.

Keywords: Viral load suppression, Anti-retroviral treatment, Adherence, CD4 count, Pedisong 4 clinic, Prospective cohort study.

1. BACKGROUND
Globally, the benefits of Human Immunodeficiency Viral (HIV) load suppression in prolonging and improving the
lives of People Living With HIV/AIDS (PLWHA) have been demonstrated [1, 2]. The link between inadequate
adherence to treatment regimens and lack of viral load suppression has been shown in literature whereby inadequate
adherence negatively influenced viral load suppression, resulting in poor patient clinical outcomes [3, 4].From various
studies, there are other factors that impact on viral load suppression, namely patients’ socio-demographic, behavioural,
* Address correspondence this author at the Sefako Makgatho Health Sciences University, Pretoria, South Africa; Tel: 0125213607;
Fax: 0125214172; E-mail: [email protected]

1874-9445/18 2018 Bentham Open

136 The Open Public Health Journal, 2018, Volume 11 Mogosetsi et al.

psychosocial and clinical characteristics [5 - 8]. At the study site, Phedisong 4 clinic it was observed that some patients
did not achieve adequate viral load suppression following review at six months post-ART initiation.
Baseline socio-demographic characteristics have been shown to influence viral load suppression in patients [5, 9,
10]. In terms of age, a multi-centre observational study conducted in 13 American clinical sites reported that age was
independently linked with viral load suppression, where the median age of people who did not attain viral load
suppression was 41.1 years versus 47.1 years for those who did [5]. A survey conducted in Kenya, Malawi, Zimbabwe
and South Africa investigated the association between age and viral load suppression in patients initiated on
antiretroviral treatment and reported that viral load suppression improved with increasing age [9].
A Brazilian study showed that married patients or those in committed relationships exhibited higher rates of HIV
viral load suppression as compared to those who were in unstable relationships, single or widowed [10]. Regarding the
level of education and employment, a study conducted in eight United Kingdom clinics between 2011 and 2012, found
that education below university level, unemployment and having an increased financial hardship were associated with
virological non-suppression in patients on ART [11]. However, contradictory results were observed in the study by
Wiewel et al., where poverty, unemployment and education level were not associated with viral load suppression [12].
A number of behavioural factors associated with viral load suppression among People Living With HIV/AIDS
(PLWHA) have been identified [6, 13]. In a South African study, fifty percent of patients who engaged in risky sexual
behaviour (unprotected vaginal or anal sex during which a condom was not used or used inconsistently) did not achieve
viral load suppression [6]. The ASTRA study from the United Kingdom confirmed that viral load suppression was
better amongst patients who did not engage in risky sexual behaviour [13]. Since patients with HIV/AIDS are still
stigmatized in many societies, the viral infection poses a major barrier to disclosure [14]. Disclosure has been found to
be the first step in gaining support from families and significant others [15]. However, limited data exist about the
association of disclosure with viral load suppression, but lack of family support has been reported to have a negative
association with viral load suppression [16].
Jordan et al. studied the clinical correlates of viral load suppression among 100 HIV positive patients who received
ART and used substances like cigarettes. Although cigarette smoking was the most prevalent (84%) substance used in
their cohort, the study showed no correlation between cigarette smoking and viral load suppression [7]. In another
study, patients on ART who admitted to daily alcohol use had an almost four-fold rise in the odds of detectable HIV
viral load as compared to patients on ART who did not use alcohol (OR=3.81, p=0.01, 95%CI = [1.42-11.48]) [8]
Depression in patients on ART was associated with decreased amounts of natural killer cells, resulting in increase in the
activated CD8 T lymphocytes and viral loads [17].
From the aforementioned, a number of factors associated with viral load suppression among PLWHA have been
identified at various settings. The studies did not produce the same findings. This study was aimed at determining the
extent to which these factors were related to viral load suppression among patients initiated on ART at our setting. It is
hoped that the findings of this study will guide health care professionals and policy makers to identify and closely
monitor patients on ART who are at risk of poor or suboptimal viral load suppression, in the interest of optimum
treatment outcome.

2. METHODS

2.1. Study Area and Period

The study was conducted at Phedisong 4 clinic, which offers various primary health care services to patients,
including ART. It is located in the Ga-Rankuwa Township of the Gauteng Province, about 37 km north of Pretoria, the
capital city of South Africa. At the time of the study, it served an estimated population of 2 921 488 [18]. Odi District
Hospital (23 km away) and a tertiary hospital, Dr George Mukhari Academic Hospital (5km away) served as the referral
centres for this clinic.

2.2. Study Design

We conducted a prospective cohort study among patients down referred primarily from the aforementioned referral
centres for ART initiation.
The Prevalence of HIV Load Suppression and Related The Open Public Health Journal, 2018, Volume 11 137

2.3. Study Population

At the time of the study, the clinic managed an average of seven patients per week who were referred from other
health care centres for ART initiation. That amounted to 28 patients per month. To obtain a sample size with 95%
confidence level and 10% error margin, the Epi Info (version 7.0) software was used yielding a sample size of 93
patients. To account for possible drop-outs over-sampling was done over a period of six months (1st November 2012 up
to and including 31st March 2013) which yielded 155.

2.4. Sampling Procedure

The inclusion criteria were the age ≥ 18 years, patients initiating ART, patients who were ART naïve and patients
who had undergone the mandatory three adherence counselling classes recommended by the South African Department
of Health [19].
Of the 155 eligible patients for ART, 20 did not meet the inclusion criteria and 13 declined participation. We,
therefore, enrolled 122 patients for the study (79% response rate of eligible patients). In addition, another 24 patients
did not attend the follow up viral load measurements at six months after ART initiation as follows: Defaulters (9),
deceased (3), transferred to another health facility (3) and discontinued participation (9). Fig. (1) VLS was defined as a
viral load of < 40 copies/millilitre and NVLS was a viral load >1000 copies/millilitre, based on. viral load
measurements by the South African National Health Laboratory Services (NHLS) using the m2000 Real Time HIV-1
Viral Load System® supplied by Abbott [20].

Eligibility for study (n = 155)

Excluded (n = 33):
 Not meeting inclusion criteria (n = 20)
 Declined participation (n = 13)

Enrolled (n = 122)

Follow-up x 6/12
Lost to follow up (n = 24):
 Defaulters (n = 9)
6  Deceased (n = 3)
 Transfer out (n = 3)
 Discontinued participation (n = 9)
Sample size (n = 98)

Viral load suppression (n = 90) No viral load suppression (n = 8)

Fig. (1). Participants flow chart.

2.5. Data Collection

A research assistant assisted the patients to complete a standardised, structured questionnaire provided in either
English or Setswana, the predominant local language. The principal researcher trained the research assistant in
recruitment and data collection procedures for this study. The baseline characteristics questionnaire contained questions
on age, gender, marital status, highest educational level attained and employment status. At the inception of the study,
we collected these variables from all 122 patients who initiated ART at the clinic.
138 The Open Public Health Journal, 2018, Volume 11 Mogosetsi et al.

At six months’ evaluation, data on behavioural and clinical characteristics were available from 98 patients who
remained in the study. Behavioural characteristics entailed reported use of condoms, presence or absence of life-time
sexual partners, cigarette smoking, use of alcohol, HIV status disclosure, an expression of the level of satisfaction about
family support, as well as admission to feeling sad in the previous two weeks. Clinical characteristics were based on
patient’s clinical condition according to the World Health Organization (WHO) HIV staging, the Antiretroviral
Treatment (ART) combination the patient had been receiving since treatment initiation and the presence of any co-
morbid illnesses.
Patients who admitted to alcohol use completed the CAGE test questionnaire to establish harmful alcohol use.
CAGE stands for “need to Cut down on alcohol”, Annoyed by being criticised for taking alcohol”, feeling Guilty about
one’s drinking” and “needing alcohol first thing in the morning to steady one’s nerves (Eye opener)”. Each variable
when present is allocated “1” point. A score of 0-2 indicates non-harmful alcohol use; 2-3 indicates harmful alcohol use
and 4 - alcohol dependence [21]. Therefore, a total score ≥ 2 was considered clinically significant as it indicated
harmful alcohol use, with a sensitivity of 93% and a specificity of 76% 21].
Patients who answered “Yes” to the question “Have you been feeling sad in the past week” were further requested
to complete an internationally validated tool, namely the Centre for Epidemiological Studies Depression Scale (CES-
DS) to screen them for clinical depression. The CES-DS questionnaire consists of 20 questions with a total possible
score of 0 to 60. A total score ≥ 16 is considered as pointing towards depression [22].
We allocated a special code to each patient for identification at six months review when s/he came for routine
measurement of HIV viral load as per the South African National Department of Health guideline protocol [19]. The
adherence of each patient was assessed by means of the Morisky Medication Adherence Scale (MMAS-4) [23]. This
scale is a generic self -reporting measurement of patient behaviour in taking medication. It consists of four questions
with a scoring of 0 for “Yes” and 1 for “No”, with a total range of 0-4 points. A score of 0 indicates high adherence, 1-2
medium adherence and 3-4, low adherence [23].

2.6. Data Analysis

We compared percentage outcomes in the two groups (VLS versus NVLS). All the categorical variables mentioned
under “data collection” were compared by the use of Fisher’s exact test which was appropriate for the sample size
below 100 respondents [24]. Statistical tests were two-sided and a p-value < 0.05 was considered statistically
significant. The SAS® (version 9.2) for Microsoft statistical software was used for all analyses.

2.7. Ethical Considerations

The Medunsa Research and Ethics Committee (MREC) approved the study with the clearance certificate number
MREC/M/265/2012: PG. The Facility Manager at Phedisong 4 clinic gave permission to conduct the study at the clinic.
All respondents gave consent for the study. Participation was voluntary, patients were informed that they were free to
discontinue from the study after enrolment and their discontinuation would not compromise their clinical care at the
health facility. The researchers assured them of anonymity and confidentiality of collected data.

3. RESULTS
The profiles of the two groups of patients (90 versus 8) are reflected in the following tables and graphs, with
significance tested by the Fisher Exact test appropriate for small samples. Because of the imbalance in the size of the
two groups (90 versus 8), the power of the Fisher Exact test to verify the difference between the two groups was low in
relation to the different variables. However, these results should be regarded as descriptive and not as conclusive.
A total of 90 out of 98 patients (91.8%; 95% CI: 84.7% – 95.8%) of the patients who formed the sample size
achieved viral load suppression which reflected the prevalence of HIV load suppression in this setting. This proportion
was significantly different to those who did not (p < 0.001). Table 1 outlines the distribution of the baseline
characteristics between the group that achieved Viral Load Suppression (VLS) and the group that did Not achieve Viral
Load Suppression (NVLS). When considered according to age-groups, there was no significant difference between the
two groups (p = 0.483). The mean age was also comparable between the two groups. There were more females than
males in both groups albeit with no statistical difference between them (p = 0.253). In both the VLS and NVLS groups
the female to male ratio was statistically significant [(56; 62%), p = 0.003] versus [(7; 88%), p = 0.001], respectively.
The most frequent level of education among the patients was high school in both the VLS and NVLS groups: 66 (73.4)
The Prevalence of HIV Load Suppression and Related The Open Public Health Journal, 2018, Volume 11 139

and 5 (62.5), respectively. There were no significant differences in the remaining baseline characteristics: marital status,
level of education and employment status (p > 0.05).
Table 1. Comparison of baseline characteristics between patients who achieved viral load suppression (VLS) (n=90) and those
who did not (NVLS) (n=8).

Baseline Characteristics Achieved Viral Load Suppression (VLS) Did Not Achieve Viral Load Suppression p-Values*
n (%) (NVLS)
n (%)
Viral load suppression 90 (91.8) 8 (8.2)) < 0.001
Age (Years) 0 (0) 0 (0) 0.483
≤ 20 23 (26) 2 (25)
21 – 30 38 (39) 4 (50)
31 – 40 20 (22) 2 (25)
41 – 50 8 (8) 0 (0)
51 – 60 1 (1) 0 (0)
≥ 61 37 35
Mean 9.33 8.07
Standard Deviation
Gender (%) 56 (62) 7 (88) 0.253
Female 34 (38) 1(12)
Male
Marital status (%) 65 (72.2) 5 (62.5) 0.536
Single 2 (2.2)
Divorced 15 (16.7) 1 (12.5)
Married 3 (3.3)
Separated
Widowed 2 (2.2) 1 (12.5)
Cohabiting 3 (3.3) 1 (12.5)
Question not answered
Highest Level of Education (%) 2 (2.2) 0 0.372
None 6 (6.7)
Primary 6 (6.7) 2 (25.0)
Secondary 66 (73.4) 5 (62.5)
High school 8 (8.8)
Post matric 2 (2.2) 1 (12.5)
Question not answered
Employment (%) 50 (55.6) 5 (62.5) 1.000
No 40 (44.4) 3 (37.5)
Yes
*Fisher Exact Test

Table 2 shows that the reported consistent use of condoms was similar in the VLS and NVLS groups [45(50%)
versus 4(50%)], respectively. In both the VLS and NVLS groups, the highest proportion of sexual partners ranged from
2-4 partners (50; 55.5%) versus (5; 62.5%), respectively, with no significant difference between them (p = 0.76). All the
patients in the NVLS group admitted to cigarette smoking 8 (100%) versus 78 (86.7%) in the VLS group. The use of
alcohol in the VLS group was 15 (16.7%) and none in the NVLS group.
Table 2. Comparison of behavioural characteristics between patients who achieved viral load suppression (VLS) (n=90) and
those who did not (NVLS) (n=8).

Behavioural Characteristics Achieved Viral Load Suppression Did Not Achieve Viral Load Suppression p-Value*
(VLS) (n=90) (NVLS) (n=8)
Use of condoms n (%) 45 (50.0) 4(50.0) 0.83
Always 25 (27.8) 3(37.5)
Never 6 (6.7) 0(0)
Occasionally 14 (15.5) 1(12.5)
No response
Life-time number of sexual partners n (%) 4(4.4) 0(0) 0.76
1 50(55.5) 5(62.5)
2-4 21(23.3) 1(12.5)
>5 15(16.8) 2(25.0)
No response
140 The Open Public Health Journal, 2018, Volume 11 Mogosetsi et al.

(Table 2) contd.....
Behavioural Characteristics Achieved Viral Load Suppression Did Not Achieve Viral Load Suppression p-Value*
(VLS) (n=90) (NVLS) (n=8)
Cigarette smoking n (%) 11 (12.2) 0(0) 0.59
Yes 78 (86.7) 8(100.0)
No 1 (1.1) 0(0)
No response
Use of alcohol n (%) 15(16.7) 0(0) 0.35
Yes 75(83.3) 8(100.0)
No 14 (94.3) 0(0)
CAGE score (14/15) ≥ 2
*Fisher Exact Test

Table 3 demonstrates that among the 15 patients who used alcohol in the VLS group, 14 had a CAGE score ≥ 2
(implying harmful alcohol use).
Table 3. CAGE score21 among patients who answered “Yes” to alcohol use (n=15).

Alcohol Use CAGE Score Number of Respondents Number of Respondents Total Number of Respondents
(CAGE < 2) (CAGE ≥ 2)
Non-harmful alcohol use 0 1
(< 2) 1 0
Harmful alcohol use 2 8
(≥ 2) 3 6
4 0
Total 1 14 15

Table 4 shows the level of satisfaction with family support as reported by 83 (92.2%) in the VLS group and 8
(100.0%) in the NVLS group. The level of disclosure of the HIV status to family members was equally high in both
groups, 81 (90.0%) in the VLS group and 8 (100.0%) in the NVLS group. Patients who admitted feeling sad in the
previous week in the NVLS group were 2 (25.0%) versus 7 (7.8%) in the VLS group. However, the difference between
these two groups was not statistically significant (p = 0.41). Using the Centre for Epidemiologic Studies Depression
Scale (CES-DS), only three of the nine patients scored ≥ 16 at baseline as depicted in Table 4. The depression rate in
this cohort was 3/98 (3.1%). One of these three patients did not achieve viral load suppression and answered “No” to
the same question at six months review.

Table 4. Comparison of family support, disclosure and depression between patients who achieved viral load suppression
(VLS) (n=90) and those who did not (NVLS) (n=8).

Family Support and Disclosure Achieved Viral Load Suppression Did Not Achieve Viral Load Suppression p-Value*
(VLS) (NVLS)
(n=90) (n=8)
Satisfied about family support n (%) 83(92.2) 8(100) 1.00
Yes 3(3.3) 0(0)
No 4(4.4) 0(0)
No response
Disclosure of HIV status n (%) 81(90) 8(100) 1.00
Yes 9(10) 0(0)
No
Depression
‘YES’ to feeling sad in the past week 7(7.8) 2(25) 0.41
Yes 83(92.2) 6(75)
No
Screened for depression n=7 n=2 0.57
CES-DS score > 16 2 (28.6) 1 (50)
CES-DS score < 16 5 (71.4) 1 (50)
*Fisher’s Exact Test

Table 5 shows that the majority of the patients were within World Health Organization (WHO) stages II and III, and
the percentages were comparable between the two groups 40 (44.4%) versus 4 (50%) and 42 (42.2%) versus 4 (50%)
respectively (p > 0.05).
The Prevalence of HIV Load Suppression and Related The Open Public Health Journal, 2018, Volume 11 141

Table 5. Comparison of WHO clinical staging between patients who achieved viral load suppression (VLS) (n=90) and those
who did not (NVLS) (n=8).

WHO Clinical Staging Achieved Viral Load Suppression Did Not Achieve Viral Load Suppression (NVLS) (n=8) P-Value*
(VLS) (n=90)
Stage I 3(3.3) 0(0) 0.60
II 40(44.4) 4(50) 0.76
III 42(46.7) 4(50) 0.85
IV 5(5.6) 0(0) 0.50
*Fisher’s Exact Test

The Fig. (2) below shows the self-reported levels of adherence to ART by the patients. There was no significant
difference (p = 0.98) between the VLS and NVLS patients. The majority of patients in the VLS and NVLS group had a
high MMAS-4 score of zero in 87.0% and 88.7%, followed by a low medium MMAS-4 score of 1-2 in 12.2% and
11.3%, respectively. None of the patients fell in the low MMAS-4 score of 3-4 in both groups.

p = 0.98
Key:
MMAS -4 Score:
0: High adherence
1-2: Medium adherence
3-4: Low adherence

p = 0.98

Fig. (2). Level of adherence to medication using the Morisky Medication Adherence Scale at six months evaluation.

4. DISCUSSION
This preliminary study has shown a viral load suppression success rate of 92% six months after ART initiation. This
was possibly linked to the generally high self-reported level of adherence to medication (≥ 87%). There was no
relationship between viral load suppression and patients’ baseline characteristics, behavioural characteristics, reported
family support, disclosure of HIV status to family, a positive screening for depression and WHO clinical staging.
Ninety-eight patients were retained on ART at six months evaluation. A study with a comparable sample size of 71
patients reported virological failure to be associated with depression, young age and low adherence to HIV therapy in
contrast to our study findings where this association was not found. The researchers attribute this difference to the 29
months follow up period in their study versus six months in the current study [25].
142 The Open Public Health Journal, 2018, Volume 11 Mogosetsi et al.

In the current study, the majority of patients were in their late 30’s with the mean ages of 37 and 35 years in the
group that achieved viral load suppression and the group that did not, respectively. Studies have shown that the older
age group (> 40 years) is associated with better viral load suppression among patients on ART [5, 9, 26] which, as
already mentioned above, was not the case in this study. A high proportion of patients accessing ART were female
(64%) which was comparable to the systematic review study by Muula et al. [27]. In their study, the reason advanced
for the sex difference was that women displayed a high health seeking behaviour than males, which may also be the
same explanation in our study.
Seven of the eight patients who did not achieve viral load suppression were females. This was consistent with
another study on the interplay of baseline characteristics factors on virological suppression among out-patients who
attended an HIV clinic in the USA, where failure of viral load suppression was observed mostly among women [28].
The higher viral load suppression among men was also observed in a multi-center cohort study in Canada that found the
male sex as one of the predictors of the likelihood of viral load suppression [29]. The failure of viral load suppression in
8/98 (8%) was comparable to the cross-sectional study from Papua New Guinea by Gare et al. where evidence of
virological failure was shown in 12/95 (12%) of their patients [30].
In our study, patient behaviour entailed reported use of condoms, life-time number of sexual partners, cigarette
smoking and use of alcohol. The effect of proper and consistent condom usage in reducing HIV transmission has been
demonstrated in many studies [31, 32]. In this study, an equal percentage (50%) of patients in the VLS and NVLS
groups respectively reported that they used condoms consistently, while almost a third in each category reported that
they never used condoms. However, the two categories did not differ significantly with respect to condom use. The
most frequent number of life-time sexual partners indicated by both patient groups was two to four. The study did not
inquire about condom usage in this regard. The study conducted in North Carolina (USA) by Peters et al. [33], although
focussing on men who have sex with men (MSM), demonstrated the need for tracing and treatment of infected patient
partners to break the cycle of infection with the virus.
A study has demonstrated that cigarette smoking in patients with HIV is associated with the development of
opportunistic infections (oral candidiasis and community acquired pneumonia), lung cancer and obstructive lung
disorders [34]. In the current study, all patients in the NVLS group indicated that they did not smoke cigarettes, but one
in ten in the VLS group admitted to cigarette smoking. There was therefore no association between cigarette smoking
and viral load suppression, in keeping with Kabali et al., who investigated cigarette smoking and HIV disease
progression and found no association between the two [35].
Harmful alcohol use among PLWHA has been associated with unprotected sexual behaviour [36], and poor ART
adherence [37], leading to failure of viral load suppression [38]. In our study, over 90% of patients who admitted to use
of alcohol reported harmful alcohol use (CAGE score ≥ 2). However, since they were in the group of patients who
achieved viral load suppression, alcohol use could not be directly linked to the failure of viral load suppression.
Syed et al. reported disease non-disclosure to be associated with fear of stigma and family emotions [39].
HIV/AIDS stigma, in particular, poses a major barrier to disclosure [40]. However, the disclosure is identified as the
first step in gaining support from family and significant others [41]. Family support and care are vital in ensuring
patient ART adherence, as reported by Afolabi et al. in Osogbo, Nigeria [42]. The South African HIV Clinicians
Society encourages disclosure as a vital component of HIV/AIDS management as it facilitates patient directed support
[43]. In our study, we found that over 90% of the patients who achieved viral load suppression, and 100% the patients
who had not achieved viral load suppression indicated that they had disclosed their status to their families. These
patients also indicated that they were satisfied with the family support they were receiving. Consequently, in this study,
the failure of viral load suppression among the 8% cannot be explained by lack of HIV status disclosure or lack of
family support.
The effect of depression on HIV viral load has been demonstrated in a few studies linking symptoms of depression
with detectable viral loads and virological non-suppression [44, 45]. In the current study, the majority (≥ 75%) of the
patients in both groups indicated that they did not feel sad in the previous week. Among the seven in the VLS group,
only two had a CES-DS score above 16, while among the two in the NVLS group, only one had a CES-DS score above
16. The results in the current study did not link depression with viral load suppression.
There was no relationship between the WHO HIV clinical staging of patients and their viral load suppression in our
study. We recorded five (5%) patients who had HIV WHO clinical stage IV among the patients who had achieve viral
load suppression, and none among the patients who had not achieved viral load suppression. The fact that the five
The Prevalence of HIV Load Suppression and Related The Open Public Health Journal, 2018, Volume 11 143

patients who had HIV WHO clinical stage IV achieved viral load suppression tallied with the findings of Cescon et al.,
where the WHO clinical stage IV at baseline was found to be a predictor of the likelihood of viral load suppression [29].
Regarding adherence, both the patients in the VLS and NVLS groups reported high adherence rates, with no
difference between the two groups at six months evaluation. However, other studies have demonstrated a direct
correlation between adherence and viral load suppression [46, 47]. Nilsson et al. had a relatively larger sample size than
our study (144 patients) [39], while Li et al. followed their patients beyond 18 months [40]. We think our different
study findings can be ascribed to the methodological differences in the length of patient follow-up between the cited
studies and the current study.

5. STRENGTHS AND LIMITATIONS

As far as the authors are aware, this study on viral load suppression is the first to be conducted in the Tshwane
health district of Pretoria, South Africa. It can be used as a reference for studies investigating another aspect of the same
phenomenon. However, since the sample size was small, the study findings could not be generalised to other districts in
South Africa. A large variety of possible factors related to viral load suppression from the literature were taken into
consideration. The MMAS-4 score used to assess adherence to treatment is a self-reported screening tool, therefore
inaccurate reporting by patients in both groups cannot be excluded. The patient review time of six months was relatively
shorter compared to other studies, where the cohorts were followed for a minimum of a year [48, 49]. Furthermore, an
expression of satisfaction about family support could have been measured more objectively rather than being quantified
it as either “Yes” or “No”.

6. RECOMMENDATIONS
This study demonstrated that there was a significantly higher proportion of female patients who did not achieve viral
load suppression among the patients in the NVLS group. Further enquiry is needed to establish possible explanations
for this. None of the patient characteristics identified through literature search were related to viral load suppression in
the current study. We recommend that qualitative studies be conducted in our setting so as to explore the phenomenon
with the hope of identify any unidentified local peculiarities.

CONCLUSION
The high prevalence of HIV load suppression six months after ART initiation demonstrated in this study was
possibly linked to the generally high self-reported level of adherence to medication. There was no relationship between
viral load suppression and patients’ baseline characteristics, behavioural characteristics, reported family support,
disclosure of HIV status, depression, ART regimen and WHO clinical staging. However, among the patients who did
not achieve viral load suppression, there was a significantly higher percentage of female compared to male patients, and
a significantly higher percentage of single compared to other marital status categories.

AUTHORS’ CONTRIBUTION
M.N.J. conceptualised the research idea, L.H.M. supervised the Master of Medicine (Family Medicine) registrar and
drafted the manuscript. M.N.J. and G.A.O. reviewed the draft manuscript and G.A.O. edited the final draft. All authors
approved the final manuscript for publication in TOPHJ.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The Medunsa Research and Ethics Committee (MREC) approved the study with the clearance certificate number
MREC/M/265/2012: PG. The Facility Manager at Phedisong 4 clinic gave permission to conduct the study at the clinic.

HUMAN AND ANIMAL RIGHTS

No Animals were used in this research. All human research procedures followed were in accordance with the ethical
standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki
Declaration of 1975, as revised in 2008.

CONSENT FOR PUBLICATION

All respondents gave consent for the study. Participation was voluntary, patients were informed that they were free
to discontinue from the study after enrolment and their discontinuation would not compromise their clinical care at the
144 The Open Public Health Journal, 2018, Volume 11 Mogosetsi et al.

health facility. The researchers assured them of anonymity and confidentiality of collected data.

CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS
This study was conducted in partial fulfilment of the requirements for the award of the Master of Medicine (Family
Medicine) degree for the first author at the University of Limpopo, Medunsa Campus, Pretoria, South Africa [now
known as Sefako Makgatho Health Sciences University (SMU)]. The researchers acknowledge the immense
contributions of Professor HS Schoeman for the data analyses.
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