Virological failure and treatment interruption among people with unsuppressed viral load on antiretroviral therapy: a cross-sectional analysis of Population-based HIV Impact Assessment surveys in seven sub-Saharan African countries.

Authors

Mansoor Farahani, Suzue Saito, Shannon M Farley, Theodore F Smart, Felix Ndagije, Eduardo Samo Gudo, Wilford L Kirungi, Rose Kolola Nyirenda, Owen Mugurungi, Wolfgang Hladik, Hetal K Patel, Samuel Sendagala, Talent Maphosa, Munyaradzi Pasipamire, Alexander Kailembo, Fred Asiimwe, Andrew C Voetsch, Wafaa M El-Sadr

Published in

The lancet. HIV. Oct 06, 2026. Epub Oct 06, 2026.

Abstract

Viral load suppression among people with HIV on antiretroviral therapy (ART) remains a priority in sub-Saharan Africa. We aimed to quantify virological failure versus interruption in treatment among people aged 15 years or older with unsuppressed viral load.
In this cross-sectional analysis of nationally representative Population-based HIV Impact Assessment (PHIA) household surveys conducted in Eswatini, Lesotho, Malawi, Mozambique, Tanzania, Uganda, and Zimbabwe during 2019-23, we included participants aged 15 years or older with HIV who met the harmonised PHIA analytical criterion for ART use for at least 4 months. HIV RNA viral load was measured by quantitative laboratory assay, and antiretrovirals were detected in dried blood spots by liquid chromatography-tandem mass spectrometry. We classified virological failure (viral load ≥1000 copies per mL with detectable antiretrovirals) and interruption in treatment (≥1000 copies per mL without detectable antiretrovirals) and estimated survey-weighted prevalences and adjusted prevalence ratios (aPRs) using Poisson regression.
We included 14 834 participants: 10 418 were female (survey-weighted 66·2%), 4416 were male (33·8%), and 6423 were aged 30-44 years (43·6%). Overall viral load suppression was 92·4% (95% CI 91·6-93·0). Virological failure (4·7% [4·2-5·2]) was more common than interruption in treatment (3·0% [2·5-3·5]). Younger adults (aged 15-29 years) had a higher prevalence of both virological failure and interruption, strongest for interruption in treatment (aPR 7·61 [4·47-12·97] vs age ≥45 years). Men had higher virological failure than women (aPR 1·62 [1·20-2·18]). Compared with dolutegravir, efavirenz-based (aPR 3·64 [2·16-6·13]) and nevirapine-based, atazanavir-based, and lopinavir-based regimens (aPR 3·64 [1·90-6·96]) were associated with virological failure. Suboptimal adherence was associated with virological failure (aPR 2·06 [1·48-2·86]) and interruption in treatment (aPR 1·78 [1·16-2·75]).
Despite high overall viral load suppression and broad ART availability, both virological failure and interruption in treatment contribute to unsuppressed viral load among people on ART. Improving suppression requires optimising ART regimens and adherence support, particularly for men, and preventing or rapidly reversing treatment interruptions, particularly among younger adults.
President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

PMID:
42838064
Bibliographic data and abstract were imported from PubMed on 07 Oct 2026.

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