ZIMBABWE INSTITUTE OF HIV & AIDS TRUST

RESEARCH PROJECT

FACTORS ASSOCIATED WITH high VIRAL LOAD AMONG ADOLESCENCE AGED

14 to 24 YEARS AT RAFFINGORA RURAL HOSPITAL

BY

MAGORONGA ANOPA C

Z0410321

SUPERVISOR: DR R MAKURUMIDZE

A RESEARCH PROPOSAL SUBMITTED TO ZIMBABWE INSTITUTE OF HIV &

AIDS IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DIPLOMA
IN HIV & AIDS COUNSELLING CARE & SUPPORT
Abstract

Across the entire globe, 75% of people are aware of their HIV Status, at the same time 79% of
the people living with HIV are now accessing anti-retroviral therapy while 81% of those people
are at the same time accessing the treatment and have suppressed viral loads. Zimbabwe County
viral suppression stands at 88.3 % (30,407) below the UNAIDS target and National target
(2020). The purpose of the study was to determine the factors influencing viral suppression
among adolesents on ART at Raffingora Rural Hospital .

A descriptive cross-sectional study was carried out at Raffingora Rural Hospital .A Sample size
of 18 clients was selected using systematic random sampling. Data was collected using interview
guide for patients who managed HIV to meet the selection Criteria at Raffingora Rural Hospital .

The study found the following factors to be critical predictor challenges leading to high viral load
suppression; distance to facility, occupation, adherence, and co-morbidity, leadership of facility
and ARV regimen.

The study made the following recommendations; there is need of policy makers at County Level
to develop policies that focus on client’s centred management of viral load suppression. The
county level should advocate to the facilities on proper use of guidelines and come up with new
innovations of patient’s management through evidence based approach on the existing policies.
There should be improved coordination and programs ownership at facility and County level that
will foster continuity of services and facilities should develop protocols on drugs sensitivity
testing before changing regimen especially clients with high viral load.
 Table of Contents

CHAPTER 1

1.1 Introduction............................................................................................................................8

1.2 Background............................................................................................................................9

1.3 Problem Statement.................................................................................................................9

1.4 Justification of Study.............................................................................................................9

1.5 Research Question...............................................................................................................10

1.6 Objectives of Study..............................................................................................................10

1.7 Delimitation of the Study.....................................................................................................11

1.8 Definitions of Terms............................................................................................................11

CHAPTER 2 LITERATURE REVIEWS

2.0 Introduction.............................................................................................................................12

2.1 HIV Virological Failure...........................................................................................................12

2.2 Adherence to Anti- Retro Viral Drugs......................................................................................13

2.3 ARV Regime-Related Factors .................................................................................................13

2.4 Patient Adherence-Related Factors.........................................................................................14

2.5 HIV-Related Factors................................................................................................................14

CHAPTER 3 RESEARCH METHODOLOGY

3.0 Introduction.............................................................................................................................17

3.1 Study Setting........................................................................................................................17

3.2 Study Design........................................................................................................................17

3.3 Study Participants................................................................................................................18

3.4 Inclusion/ Exclusion Criteria...............................................................................................18

3.5 Sampling..............................................................................................................................18

3.6 Sample Size..........................................................................................................................19

 3.7 Sampling Techniques...........................................................................................................19

3.8 Study Variables....................................................................................................................19

3.9 Data Collection Procedures..................................................................................................19

3.12 Data Analysis.....................................................................................................................20

3.13 Permission and Ethical Considerations..............................................................................20

3.14 Conclusion.........................................................................................................................21

CHAPTER 4 RESULTS

4.1 Introduction...........................................................................................................................22

4.1 Demographic characteristics of the respondents ..................................................................22

4.2 Change of Treatment after Treatment Failure........................................................................23

4.3 Reasons for Failed Viral Load Suppression............................................................................24

4.4 Unsuppressed Viral Load due to Treatment Failure...............................................................24

CHAPTER 5 DISCUSSION

5.1 Discussion................................................................................................................................28

5.2 Conclusion...............................................................................................................................31

5.3 Recommendation.....................................................................................................................31

References.....................................................................................................................................32

Appendices....................................................................................................................................32
List Of Abbreviation

ADR Adverse Drug Reactions

AIDS Acquired Immune Deficiency Syndrome

ART Anti Retro Viral Treatment

ARV Anti Retro Viral

CD4 Cluster of Differentiation

CDC Center of Disease Control

DOT Directly Observed Therapy

HAART Highly Active Antiretroviral Therapy

HAART Highly Active Antiretroviral Treatment

HCT HIV Counseling and Testing

HIV Human Immunodeficiency Virus

HIVDR HIV Drug Resistance

MSM Male sex with male

NARHS National HIV and Reproductive Health Survey

PLWHIV People Living with HIV

UN United Nations

WHO World Health Organization

 CHAPTER 1

1.1 Introduction

Access to antiretroviral therapy has increased tremendously in Sub-Saharan Africa with the
World Health Organization (WHO) estimates pointing to an increase from 100,000 people
receiving treatment at the end of 2003 to over two million in December 2007 representing a 20-
fold increase. This has changed the clinical course of Human Immunodeficiency Virus (HIV)
with significant decline in morbidity and mortality. Now the challenge has shifted from access to
adherence since with increased access to antiretroviral therapy(ART), HIV has become a chronic
disease where patients have to take antiretroviral drugs for a long time with substantial side
effects and sometimes with complex regimens (WHO 2003a:5; WHO 2008b:16).

In one study, a 95% level of adherence to antiretroviral therapy was reported as the minimum
level necessary to maintain viral load suppression and improve immune status. Unfortunately
taking more than 95% of the prescribed regimen is a difficult goal to achieve and maintain.

Therefore the long term success of treatment programs in resource-limited settings requires
establishing the levels and long term determinants of adherence to antiretroviral therapy among
HIV patients (Paterson, Swindells, Mohr, Brester, Vergis, Squier, Wagener & Singh 2000:27-
28).

This study therefore described factors associated with high viral load in adolescents on ART at
Raffingora Rural Hospital .

1.2 Background

The sub-Saharan African region in Africa is only home to only 14% of the global population
(Federal Reserve Bank, 2019), yet it carries the highest burden of HIV among pregnant women,
2019 reports indicated that about 1.5 million [1.0 million–2.1 million] (88%) HIV-infected
adolescents live in sub-Saharan Africa, which is 88% of the total number of adolescents HIV
infections (UNICEF, 2020).

Within the sub-Saharan region, South Africa accounts for a third of all new HIV infections in
southern Africa and has the highest profile of HIV epidemic in the world (Avert, 2019). In the
sub-Saharan region, South Africa is considered as the largest ART programme in Africa and the
world (UNAIDS, 2020a).

The key goal of ART is to suppress the replication of the virus. Suppressed viral replication
facilitates restoration of the immune function and significantly reduces the risk of onward HIV
transmission from mother to child (National Institute of Health, 2021). The South African
National Department of Health (NDOH) guidelines use viral load monitoring as a gold standard
to follow up the treatment effectiveness (NDOH, 2019), as recommended by WHO (2013a).

1.3 Problem Statement

Zimbabwe has adopted the UNAIDS 95-95-95 treatment targets ,there is still a
challenge with attaining the last 95 which states that 95 % of living with HIV should be
virally suppressed .Viral load registers ,green books ,patient booklets and viral load
return forms at Raffingora Rural Hospital show that 2 in 10 adolescence who are on
ART are having high viral load. Amongst the causes of high viral load not adhering to
medication is one of the major causes of high viral load .Adhering to medication may
contribute in the improvement of the last 95 of UNAIDS target and the vise versa is true
.This threatens life of adolescence ,therefore l request to carry out a research on the
factors causing high viral load in adolescence .

1.4 Justification of the Study

This study will provide knowledge on the level of adherence and viral load of HIV positive
adolescents and understand the potential barriers to optimal adherence in Zimbabwean context.
Moreover, it will provide important information with regard to aspects of adherence and viral
load and forwarded recommendations to health care providers, health facilities and policy
makers in enhancing the implementation of ART program and development of evidence_based
interventions to improve adherence to antiretroviral therapy.

This study will benefit the clients directly or indirectly through provision of appropriate and
relevant information to the adolescents and their health care providers about the pervasiveness
of poor adherence and contribute to help them understand the need for patients to play active
role in achieving the maximum required adherence level with due emphasis on the focus areas of
improving adherence.

1.5 Research Question

What are the causes associated with high viral load among adolescence from the age of
14 to 24 years at Raffingora Rural Hospital

1.6 Objectives of Study

(a) Broad Objective

To determine factors associated with high viral load in adolescents on ART at Raffingora Rural
Hospital

(b)Specific Objectives

 To assess demographic associated with high viral load among adolescence aged
14 to 24 years at Raffingora Rural Hospital
 To identify economic associated with high viral load among adolescence aged 14
to 24 years at Raffingora Rural Hospital
  To determine cultural associated with high viral load among adolescence aged
14 to 24 years at Raffingora Rural Hospital
 To establish religious and social factors associated with high viral load among
adolescence aged 14 to 24 years at Raffingora Rural Hospital

1.7 . Delimitation of the Study

This study will only cover male and female adolescents receiving ART at Raffingora Rural
Hospital .

1.8 Definitions of the Terms

I. Adherence: Describes the degree to which a patient correctly follows medical advice in
terms of correct drug dosage, frequency and duration.

II. Clinical failure: New or recurrent clinical event indicating severe immunodeficiency
(WHO clinical stage 4 condition) after 6 months of effective treatment.

III.Disclosure: Defined as a process of revealing a person’s HIV status whether positive or

negative.

IV. Immunological failure: CD4 count falls to the baseline (or below) OR Persistent CD4
levels below 100 cells/mm3.

V. Unsuppressed viral loads: This is when the viral load is >1000copies/ml of plasma
despite a person being on ART for a minimum of 6 months

VI. Virological failure: Plasma viral load above 1000 copies/ml based on two consecutive
viral load measurements after three months with adherence support.
 CHAPTER 2 - REVIEW OF LITERATURE

2.0 Introduction

This chapter contains literature review about virological failure, Adherence to Anti- Retro Viral
Drugs, ARV Regime-Related Factors, Patient Adherence-Related Factors and HIV-Related
Factors.

2.1 HIV Virological Failure

This is defined as a type of treatment failure which occurs when antiretroviral therapy (ART)
fails to suppress and sustain a person’s viral load to less than 200 copies/ml. Virological failure
can occur because of many reasons. Data from patient cohorts in the earlier era of combination
ART suggested that young age, male gender, active TB, suboptimal adherence and drug
intolerance / toxicity are key contributors to virological failure and regime discontinuations
(Kerrissey, 2008). The presence of existing (transmitted) drug resistance may lead to virological
failure. Virological failure may be different in various patients and is highly associated with
adherence, HIV and ART regime related factors as below:

2.2 Adherence to Anti- Retro Viral Drugs

Adherence means taking medicine consistently and as prescribed by a health care provider for at
least 95% of the time. Non- adherence refers to the failure to take medication consistently and
correctly, and it can include missing one or multiple doses and not observing dietary instructions.

The consequences of non- adherence to ARVs are serious and sometimes fatal. These include
incomplete viral suppression, continued destruction of the immune system, disease progression,
increased side effects and development of resistant restrains of HIV. In this sense, non-adherence
to ARVs represents a hazard to the individual health of the person living with HIV as well as the
health of the general public (Friedland, 1997).Some of the reasons of non-adherence to ARVs are
lack of transport to reach the facility for resupply, waiting long time at the facility, lack of
enough food, stigma associated with HIV infection, lack of social support, difficult drug
regimens, treatment fatigue and poor service delivery by health workers (Nakiyemba, 2005).

2.3 ARV Regime-Related Factors

 Prescription errors that may result in low serum ART regimen resulting into resistance.

 Suboptimal pharmacokinetics of the drugs (variable absorption, distribution, metabolism,

or possible penetration into reservoirs).

 Suboptimal virologic potency of the ART regimen.

 The patient’s low genetic barrier to resistance.

 Reduced efficacy due to prior exposure to suboptimal regimes (e.g., mono therapy, dual
nucleoside therapy, or the sequential introduction of drugs).

 The excessive demand for food during treatment.

 Adverse drug-drug interactions with concomitant medications.

2.4 Patient Adherence-Related Factors

 Comorbidities that may affect adherence (e.g., active substance abuse, mental health
disorders, neurocognitive impairment).

 Unstable housing and other psychosocial factors.

 Missed clinical appointments and interruption of intermittent access to ART.Cost and

affordability of ARVs (i.e., may affect ability to access or continue therapy)

 High pill burden and/or dosing frequency coupled with drug adverse effects.

 Confidentiality about HIV status.

2.5 HIV-Related Factors

These include:

 Presence of transmitted or acquired drug-resistant virus strains as documented by current

or past resistance testing.

 Prior HIV treatment failure.

 Innate resistance to ARVs based on tropism or the presence of HIV-2 infection/co

infection in the patient.

 Higher pretreatment HIV RNA level (some regimes may be less effective).

CHAPTER 3 - RESEARCH METHODOLOGY

3.0 Methodology

This chapter describes the methodology that was used to conduct the study. These include the
study setting, study design, area of study, study participants, inclusion / Exclusion criteria,
sampling ,sample size, sampling techniques,study variables, data collection procedures, data
analysis and ethical considerations of the study.

3.1 Study Setting

The study will be carried at Raffingora Rural Hospital in Zimbabwe.

3.2 Study Design

Cross-sectional designs involve the collection of data at one point in time: the phenomena under
study are captured during one period of data collection. They are appropriate for describing the
status of phenomena or for describing relationships among phenomena at a fixed point in time.
They are relatively easy and economical to conduct (Joubert & Ehrlich 2007:87; Polit & Beck
2012:184). In this study the researcher will use a cross-sectional design to describe the factors
associated with high viral load among adolescents on antiretroviral therapy and explore factors
that affect viral load during the specified data collection period.

3.3 Study Participants

This participants will include of HIV positive adolescents seeking ART at Raffingora Rural
Hospital

3.4 Inclusion/Exclusion Criteria

The study sample will include all adolescents according to the set criteria indicated below:

Inclusion criteria

 Adolescents on ART for at least 6 months.

 Those who have at least one documented VL in the last 12 months.

Exclusion criteria

 Those who are on ART for less than 6 months.

 Those with no VL documented in their record

3.5 Sampling

A sample is referred to as a subset of participants elements (Polit and Beck, 2012). The sample
of this study will be chosen from the sampling frame of HIV positive adolescents seeking
antiretroviral therapy who met the inclusion criteria.

3.6 Sample Size

The sample size will be 18 HIV positive adolescents seeking ART a Raffingora Rural
Hospital . This will be due to time and financial limitations.

3.7 Sampling Techniques

Purposive sampling will be used to select 18 participants from the total eligible adolescents
enrolled on ART at Raffingora Rural Hospital. A sampling frame (list of all eligible
adolescents) will be obtained from the in data officer at the ART clinic who generated a list of
eligible adolescents from the electronic system.

3.8 Study Variables

The study variables included the following;

Dependent variables Viral load suppression among adolescents clients who have been on
treatment for 6 months or more using the current MoH viral load monitoring guideline with a cut
off of <1000copies/mL.

Independent variables include;

- Socio-demographic factors (Age, Sex/Gender, Family members, Religion, and Education level)
for the study subjects.
- ART Regimen related factors (Age at initiation of regimen, Type of regimen at initiation,
Change of regimen and Duration on current regimen)

- Client related factors (Perceived confidentiality, Convenience in scheduled appointments, and

pregnant women overall satisfaction)

3.9 Data Collection Procedures

A data abstraction guide will be developed based on the variables of the study. The abstraction
tool will be aligned to HIV care client cards to collect data that is captured in the routine health
information management system and records. The tool will be validated before being used in the
study.

3.12 Data Analysis

Data from study tools will be coded, entered into a predestined excel spreadsheet and cleaned.
Results from the study will be mainly presented in tables and figures with narratives for each.

3.13 Permission And Ethical Consideration

The research protocol will be approved by the Zimbabwe Institute of HIV and AIDS Trust and
permission to conduct the research will be acquired from the in- Charge of Raffingora Rural
Hospital .

The main ethical issues in this study included informed consenting, privacy, confidentiality, and
anonymity.

Informed Consent - it implies informing the respondents about the procedures of the study in
which they will be participating. The respondents will be provided with information on the
purpose of the research, expected duration of participation, the procedure to be followed,
unforeseen discomforts, as well as, the extent of privacy and confidentiality. Once this will be
done, the respondents will be expected to voluntarily participate in the exercise.

Privacy and confidentiality - To ensure privacy and confidentiality, the respondents will be
interviewed one at a time in a private room that will provided by the hospital administration.
Anonymity - for anonymity purposes, the researcher will not ask for the respondents’ names in
the questionnaires. Thus, numbers will be used to represent the respondents.

CHAPTER 4 RESULTS

4.0 Introduction

The study recruited 18 participants of whom 10 were females and 8 were males. Ten (10) fe
males were among the group of 18 participants aged 15 - 30 years while the remaining 8 were
among the group of those aged 31-49 years old. Females form the majority, around 56% whilst
males form the rest of 44% of participants. In the categories of caregivers and health care
providers.

4.1 Demographic characteristics of the respondents

The majority (68.8%) of participants were between the age of 15 -30 years, as compared to only
17 participants between the ages of 31-49 years. About 88% of participants participated in the
study live in areas 10km or more far from the clinic. Adolescents orphaned constituted the
majority of about 69% of all adults took part in the study.

Table 1. Sociodemographic Characteristics of Adolescents Participants

Demographic Characteristics Variables Frequency

Age in Years 15-30 10

31-49 8

Gender Female 10

Male 8

Home Distance from ART <10 km 3

Clinic
≥10 km 15

4.2 Change of Treatment after Treatment Failure

Of the 33% of respondents who had no viral load suppression after 3 months of Intensive
Adherence Counseling (IAC), up to 28.05% did not change treatment and only 4.95% had
changed treatment to the second line ART therap.

4.3 Reasons for Failed Viral Load Suppression

Up to 50% of the respondents had failed viral load suppression due to non-adherence to ART.
Another 30% was due to non-disclosure by the care taker and 15% did not have anyone to
remind them to take their ARVs while 5% had no care takers.

4.4 Unsuppressed Viral Load due to Treatment Failure

Among the 33% of respondents with unsuppressed viral load, 10.23% reported treatment
failure while 22.77% did not attribute to treatment failure.Figure 4: Unsuppressed Viral Load
due to Treatment Failure

CHAPTER 5 DISCUSSION, CONCLUSIONS AND RECOMENDATIONS

5.0 Introduction

This chapter presents a discussion of the study findings in relation to the problem statement
and the available literature review. The discussion is arranged into the following subsections:
viral suppression, socio-demographic factors, clinical factors, treatment factors and behavioural
factors influencing viral suppression among adolescents.
5.1 Adolescents that attained viral suppression following six or more months on ART

This study found that most participants were fully suppressed ( < 50 c/ml) or transient
suppressed (50–999 c/ml) at 9.5% and 68.7%, respectively. Our findings were low compared to
Zanoni et al. 's (2016) meta-analysis of South African adolescents and young adults on ART,
where 81% was virally suppressed. However, the findings of this study fall in the range of 28%
to 89%, as reported by Ferrand et al. (2016) in their review of adolescents in care in countries in
southern Africa, Uganda, South Africa, Rwanda, China, Brazil, Mexico, Argentina and 13 USA
cities.

However, an analysis of clinical records in the Eastern Cape facilities, which is a setting
reflecting poverty and healthcare similar to the Free State found 47.5% and 23.2% of
adolescents were virally suppressed or fully virally suppressed respectively, within the past 12
months (Haghighat et al., 2021). Another study in the Western Cape facilities reported much
lower viral load suppression (< 1000 c/ml) of adolescents at 40.0% and 25.0% after one and two
years on ART respectively (Kriel, 2017).

Findings suggest that South African adolescent progression to the final “90” of viral suppression
in the UNAIDS 90-90-90 treatment goal remains low, at 78.25% for ART-initiated adolescents
aged 10–19 years. Therefore, this study extends evidence on the need of an optimised
adolescent HIV care cascade in South Africa for the adolescent population across healthcare
facilities (Maskew et al., 2019). This low rate of viral suppression in clinical records verifies
previously published findings on the low ART adherence and ineffective adolescent adherence-
promoting interventions among adolescents (Cluver et al., 2016). These adherence promoting
interventions can be instrumental in decreasing the high numbers of adolescents that were at
transient suppression (68.74% n=3017) and converting them to fully suppressed (< 50 c/ml).
Findings suggest that critical challenges persist in adolescent attainment of consistent ART
adherence and viral suppression after treatment initiation.

5.2 Socio-demographic characteristics associated with viral suppression

In this study, current age and gender were an insignificant determinant of viral suppression.
Moreover, although the duration on ART and viral suppression was statistically significant in the
bivariate analysis, results from multivariate analysis have shown that duration of ART had an
insignificant effect on viral suppression.

5.3 Current age and viral suppression

In this study, adolescents were categorised as 10–14 years and 15–19 years and the differences
in viral suppression between the two age groups was not significant. Our results were similar to
a study conducted in Kenya examining the factors associated with viral suppression among
adolescents in Hombay county which also concluded that there was no significant difference
between current age and viral suppression (Mwangi et al., 2019). On the other hand, data from
clinical records in Eastern Cape Province, South Africa facilities found that there is a significant
difference between viral suppression and current age and concluded that younger adolescents
(AOR 1.39 [95% CI 1.06–1.82]) are more likely to be virally suppressed (Haghighat et al., 2021).
Further, a study that followed adolescents initiated on ART in public health facilities in the
Metropole District Health Services of the Western Cape Province, South Africa revealed that
younger adolescents (10–14 years) had better VLS rates at months 4, 12 and 24 compared to
older adolescents (15–19 years); with significant differences at month 12 (63.4% vs 34.6%; p =
0.001) and month 24 (58.5% vs 17.3%; p < 0.001) (Van Wyk et al., 2020). Van Wyk et al. (2020)
demonstrated that better retention in care was observed in younger age groups (10–14 years)
compared to the older group resulting in better VLS rates.

In this study, the difference in the proportion of viral suppression between the two age groups
was not statistically significant (80.7% for 10–14 years vs. 77.1% for 15–19 years). Many authors
have associated viral suppression with retention in care (Adejumo et al., 2015; Van Wyk et al.
2020) and claim that younger adolescents show better retention rates because they depend on
their adult caregivers to manage their ART regimen (Van Wyk et al., 2020).

However, this was not evident in this study.

5.4 Duration on ART and viral suppression

In this study, duration of ART and viral suppression was not associated, which contrasts with
other studies. Results from Eastern Cape, South Africa revealed that adolescents on ART for ≥2
years were more likely to be fully viral suppressed (AOR 1.70 [95% CI 1.12–2.58]) (Haghighat
et al., 2021). Other studies in African countries such as Kenya found that adolescents who
initiated ART at ages 5–9 years and 10–14 years were less likely to be virally suppressed
(Mwangi et al., 2019). These findings are similar to those from a study in Thailand where
virological failure was higher among adolescents aged 10–16 years at ART initiation
(Bunupuradah et al., 2015), but contradicts Muri et al. (2017) and Makadzange et al. (2015) who
associated older age at ART initiation with higher viral suppression rates in their studies in
Tanzania and Zimbabwe, respectively.

5.5 Gender and viral suppression

In this study, gender was not associated with VLS, which contradicts Van Wyk et al. 's (2020)
study in the Western Cape Province, where adolescent males were found to be significantly more
likely to be virologically suppressed compared to females over the first two years after ART
initiation. In Malawi, 51.9% of adolescent and young adult women had virological suppression
compared to the 36.7% of males (Avert, 2016). Another retrospective crosssectional study
among adolescents and adults on ART in northern Ethiopia revealed that the likelihood of viral
non-suppression for male patients was 30% more likely compared to female patients (AOR =
1.27, 95%; CI: 1.18, 1.37) (Desta et al., 2020). Many authors suggest that males are more prone
to viral non-suppression due to poor health-seeking behaviour (Dalhatu et al., 2012; Heestermans
et al., 2016; Jobanputra et al., 2015; Penot et al., 2014).

5.6 Clinical factors associated with viral suppression

Multivariate logistic regression shows that CD4 count at baseline, baseline ART regimen, current
ART regimen and retention in care were risk factors (or determinants) of viral suppression. On
the other hand, there was no statistical association between viral suppression and the following
clinical characteristics: WHO stage, history of TB, received IPT, cotrimoxazole and pregnancy.
5.7 Conclusion

Viral suppression among adolescents on ART at Raffingora Rural Hospital is still below the
target of 90%. Adherence support for adolescents on ART is critical for viral suppression.

Targeted interventions are required to improve retention in care and VLS amongst adolescents
on ART, with specific interventions tailored for them. Routine monitoring of adherence should
be improved by formally including clinic attendance monitoring, pill-counts and client
selfreporting, as well as POC VL testing to adolescent ART services.

5.8 Limitations

The major limitation of this study was that some of the records and variables were missing.
Values that were missed were not included from each variable and the analysis conducted was
based on the totals with complete records. This may have affected the analysis of variables
associated with viral suppression.

The study also involved retrospective extraction of data from a database, restricting us to
routinely collected variables. This limited the extent to which other variables that can also be
explored such as social, cultural and economic factors that can also affect viral suppression.

The strength of this study was its large sample size (n=4 520) derived from health facilities
across Raffingora Rural Hospital , and therefore the results provide a near true reflection of viral
suppression among adolescents receiving ART at Raffingora Rural Hospita.l

5.9 Recommendation

● Adherence is imperative for viral suppression and should be assessed at every visit to identify
and address possible barriers to adherence for adolescents on ART.

● There is need for further investments in improving retention and adherence support for
adolescents on ART such as trained adherence counsellors.

● Barriers to retention in care/adherence should be identified and addressed.

● Further studies that involve qualitative studies or mixed methods could be conducted to
identify other determinants associated with viral suppression, such as cultural, economic and
social factors.

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(b) Appendices- Permission Letters

Raffingora Rural Hospital

P.O.Box 961

Raffingora

24 July 2021

Dear Madam

RE: REQUEST FOR PERMISSION TO CONDUCT A RESEARCH STUDY AT

RAFFINGORA RURAL HOSPITAL

I am Magoronga Anopa studying a Diploma in HIV and AIDS Counseling,Care and Support at
Zimbabwe Institute of HIV and AIDS Trust (ZIHAT).I am currently attached at your Hospital as
a trainee of HIV and AIDS primary care counsellor . I hereby ask a permission to carry in-depth
interviews to adolescents aged 14-24 years who have high viral load.

Your approval will be highly appreciated

Yours Sincerely
Magoronga Anopa

(c) CONCEPT NOTE

Student Name: Magoronga Anopa C

Student Number : Z0410321

Topic : Factors associated with high viral load among adolescence aged 14 to 24 years
at Raffingora Rural Hospital

Problem Statement

Zimbabwe has adopted the UNAIDS 95-95-95 treatment targets ,there is still a
challenge with attaining the last 95 which states that 95 % of living with HIV should be
virally suppressed .Viral load registers , green books ,patient booklets and viral load
return forms at Raffingora Rural Hospital show that 2 in 10 adolescence who are on
ART are having high viral load. Amongst the causes of high viral load not adhering to
medication is one of the major causes of high viral load .Adhering to medication may
contribute in the improvement of the last 95 of UNAIDS target and the vise versa is true
.This threatens life of adolescence ,therefore l request to carry out a research on the
factors causing high viral load in adolescence .

Research Question

What are the causes associated with high viral load among adolescence from the age of
14 to 24 years at Raffingora Rural Hospital ?
Broad Objectives

To determine factors associated with high viral load in adolescents on ART at

Raffingora Rural Hospital

Specific Objectives

 To assess demographic associated with high viral load among adolescence aged
14 to 24 years at Raffingora Rural Hospital
 To identify economic associated with high viral load among adolescence aged 14
to 24 years at Raffingora Rural Hospital
 To determine cultural associated with high viral load among adolescence aged
14 to 24 years at Raffingora Rural Hospital
 To establish religious and social factors associated with high viral load among
adolescence aged 14 to 24 years at Raffingora Rural Hospital

Methodology

This study will be conducted at Raffingora Rural Hospital .A quantitative cohort study
design will used ,The study shall target adolescence who are HIV positive from the age
of 14 to 24 years ,Random sampling of participants will be used for selecting the study
participants .Questioners will be used for collecting data from the study participants and
key informers (eg nurses ,primary counsellors and sister in charge ) .Data presentation
and analysis will be done using charts ,tables and graphs .Permission to conduct the
study shall be sought from the Ministry of Health and Child Care at Raffingora Rural
Hospital .