Prevalence of Virologic Failure and Determinants Among Adults on First-Line Antiretroviral Therapy at Debre Tabor Comprehensive Specialized Hospital in Northwest Ethiopia

: Introduction: Even though first-line antiretroviral therapy (ART) has led to a profound reduction in the incidence of opportunistic infections (OIs) and AIDS related deaths, it is challenged by virologic failure, which predisposes patients to a new or recurrent clinical condition and, as a result, affects their quality of life and increases HIV-associated mortality. Therefore, understanding the burden of virologic failure and its determinants helps with early prevention and improvement of the quality of life. However, the prevalence of virologic failure and its associated factors among adult patients on first-line ART at Debre Tabor Comprehensive Specialized Hospital is not well understood. Objective: This study was aimed at determining the prevalence of virologic failure and identifying its contributing factors among HIV-positive adults receiving first-line ART at Debre Tabor Comprehensive Specialized Hospital in Northwest Ethiopia. Methods: An institutional-based cross-sectional study was conducted on 376 adults who had started ART from February 8, 2017, to February 7, 2022. After selecting a computer-generated simple random sampling technique, data on patients' socio-demographic, behavioral, clinical, and ART-related factors were collected through a review of medical charts. A binary logistic regression model was used to identify associated factors with virologic failure, and an AOR with a 95% CI at P less than or equal to 0.05 was used to declare the association. Results: The prevalence of virologic failure was 13.6% (95% CI: 10.4%- 17.2%). Significant associated factors for virological failure were smoking cigarettes (AOR 4.76, 95% CI: 1.06-21.38), HIV non-disclosure (AOR 4.56, 95% CI: 1.6-2.46), presence of stigma and discrimination (AOR 2.91, 95% CI: 1.14-7.39), having baseline OIs (AOR 6.66, 95% CI: 1.94-22.90), not taking CPT (AOR 3.21, 95% CI: 1.12-9.18), treatment interruption (AOR 2.97, 95% CI: 1.11-7.94), loss to follow-up (AOR 9.03, 95% CI: 3.08-26.47), fair or poor adherence status for ART (AOR 3.409, 95% CI: 1.26-9.24). Conclusion and recommendation: The prevalence of virologic failure was in line with the national prevalence. Smoking cigarettes, HIV non-disclosure, baseline OIs, suboptimal adherence, loss to follow-up, treatment interruption, not taking CPT, and taking additional medication were significantly associated with virological failure. Therefore, special attention should be given to those individuals who have the above factors to minimize and prevent virologic failure.


Introduction
At the end of 2021, the human immunodeficiency virus (HIV) was still a major global public health problem, with an estimated 38.4 million people living with HIV (PLHIV) worldwide [1], with more than two-thirds (25.4 million) in the WHO African Region [2], and 20.6 million in eastern and southern Africa [1].HIV is a viral infection that has no cure and targets cells of the immune system and replicates, damages, and destroys the cells [1].However, the effective use of highly active antiretroviral treatment (HAART) achieves long-term durable suppression of HIV replication, which gives immunologic and clinical benefits and, in turn, leads to a reduction in HIV-associated morbidity and mortality, ultimately improving the quality of life and minimizing the risk of HIV transmission through heterosexual relationships [2].However, the effective goals of first-line HAART are affected by drug resistance and treatment failure, which are major bottlenecks for effective viral suppression in resourcelimited countries like Ethiopia [3].
Antiretroviral treatment failure continues to be a major global public health issue.Of the total PLHI, more than 46% failed for first-line drugs [4].According to the World Health Organization (WHO) recommendation, viral load is the preferred monitoring approach to diagnose and confirm treatment failure [5,6].Viral load monitoring was affected by the COVID 19 pandemic mainly because laboratory skilled staff members were shifted from molecular testing for HIV to testing for SARS-CoV-2, using the same equipment for SARS-CoV-2 and HIV viral load testing and treatment follow-up restriction [7].Virological failure is the overgrowing levels of detectable HIV, which is associated with multiple nucleoside or nucleotide resistance mutations [8].Of the three 90 targets by the UNAIDS for 2020 goals, only an estimated, 28.7 million (75%) PLHIV had accessed ART and only 68% were being virally suppressed, globally at the end of 2021 [9] and drug resistance and subsequent ART failure [10] could be one of the factors for under-achievement of the third "90%" (viral suppression) [11].Several developments have occurred for HIV globally since 2016; these include the introduction of a treat all strategy, the introduction of a new drug (dolutegravir), self-testing, scaling up of viral load, infant testing, and new options for TB preventive therapy (TPT) and post-exposure prophylaxis [5,12].However, antiretroviral therapy failure has been recognized as a persistent challenge in the world.
Despite the improved utilization of ART, the issue of drug resistance and subsequent treatment failure is a continuous and challenging public health problem in middle-income and low-income countries [13][14][15].The Sub-Saharan region has the world's highest HIV prevalence, with 60% of new infections [16] that is being challenged by high ART drug resistance and treatment failure [17].The prevalence of tenofovir resistance was highest (57%); 83% had cytosine analog resistance; 78% had major NNRTI resistance; and 65% had both [4].The identification of drug resistance and management of first-line ART failure is a key challenge for HIV programs in resource-limited settings like Ethiopia.
In Ethiopia, even though the country has a high scale-up of ART coverage currently, the three 90 goals were not achieved and it was mainly affected by the COVID-19 pandemic and major conflict across the country [18].This was mainly because of a limited number of viral load machines for monitoring in the country.Amhara regional state contributed 30% of the national PLHIV at the end of 2020 [18] that was challenged by viral load monitoring and patient retention in care due to the COVID-19 pandemic and the current neighborhood conflict which, could impact patient adherence and facilitate treatment failure.Patients who developed first-line antiretroviral treatment had many health and health-related complications.Patients who had failed for first-line ART were 46% more likely to fail again for the second-line drugs, which are attributed to the higher number of side effects and have a greater likelihood of experiencing drug resistance and treatment fatigue as a result of being on treatment longer [19,20].Staying on a failing first-line therapy is associated with an increased risk of developing HIV/AIDS-related morbidity and mortality.Delayed detection of treatment failure may increase drug toxicity and the accumulation of drug resistance-associated mutations and may result in increased HIV-associated morbidity and mortality [21].
According to previous studies, age groups, being divorced, having no formal education and primary education, low baseline CD4 count, prolonged ART usage, having drug toxicities, poor adherence, recent CD4 count of less than 200 cells/mm3, presence of OIs, and ART discontinuation were associated with virological ART failure.
An early understanding of the burden and determinants of virologic failure helps for prevention and control as well as for an early switch to second-line ART.Anti-retroviral treatment failure can be prevented through the implementation of globally recommended strategies including improving ART adherence, taking medication based on the appropriate prescription, preventing drug-drug interactions, increasing knowledge and attitudes of patients towards HAART, timely initiation of ART, prevention and control of opportunistic infections, and implementation of effective food and nutrition policies [19,22,23].The joint United Nations Program on HIV/AIDS has set the three 95 (95-95-95) targets to control HIV infection by 2030.However, antiretroviral drug resistance and virological failure are the main problems in achieving viral suppression.
Therefore, understanding the burden and the mechanism of virologic failure helps with health care planning and prevention as well as supports achieving the third 95 target.Despite improved ART coverage in Debre Tabor Comprehensive Specialized Hospital, ART failure has not been studied after the introduction of the treat all strategy and DTG as well as after the COVID-19 pandemic.Therefore, this study was intended to determine the prevalence of virologic failure and its associated factors among HIVinfected adults on first-line ART at Debre Tabor Comprehensive Specialized Hospital in Northwest Ethiopia from February 8, 2017 to February 7, 2022.

Study Setting
This study was conducted at Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia.The hospital is located in Debre Tabor town, which is the capital of South Gondar Zone, in the Amhara regional state, about 100 kilometers from Bahir Dar and 666 kilometers from Addis Ababa, Ethiopia.It is also located at 11°51′N 38°1′E, with an elevation of 2,706 meters above sea level.
The hospital serves both outpatient and inpatient services to more than five million people.In the hospital, the ART Clinic was established in 2005, and since then, a total of 2,430 HIV-infected clients have started ART.Currently, there are 2,149 active patients on ART.Of the total, there were about 1,127 total HIV-infected adults enrolled for ART between February 2017 and February 2022 in the clinic.

Study Design and Period
An institutional based cross-sectional study was conducted to determine virological failure and its associated factors among adult HIV patients on first-line ART at Debre Tabor Compressive Specialized Hospital in Northwest Ethiopia between February 8, 2017 and February 7, 2022.

Population
The source population for this study were all HIV positive adults aged 18 years and above who were living in the South Gondar zone, Northwest Ethiopia between February 8, 2017 and February 7, 2022, while all adult HIV-positive patients whose age was 18 years or more at the time of ART initiation and who had started ART between February 8, 2017 and February 7, 2022 in the hospital and who had been taking ART for more than 6 months in the facilities were the study population.

Eligibility Criteria
All records of adult HIV-positive patients whose age was 18 years or older at the time of ART initiation and who had started ART in the hospital and had been taking ART for more than 6 months in the facilities were included in this study, whereas death, TO, LTFU, and incomplete charts with a major variable (viral load) were excluded from this study.

Sample Size Determination
The sample size was determined by using a single population proportion formula based on the following assumptions: the proportion (P) (33.42%) from the previous study [24], 95% CI, and margin of error (d) (5%).Therefore, the sample size calculated was 342 by using single population proportion formula, and after adding 10% for incomplete charts, the total sample size was 376.
Sample Size for Associated Factors Was Considered and It Was Described as Follow:

Sampling Techniques
About 1,127 HIV-infected adults aged 18 years and above on first-line ART were enrolled between February 8, 2017 and February 7, 2022 in Debre Tabor Comprehensive Specialized Hospital Northwest Ethiopia.Those participants who had taken first-line ART for less than 6 months were not part of this study.First, we exclude TO, loss to follow-up, and death from study population.Then, among 1076 eligible participants, we used computer-generated SRS to select a sample size of 376.Of these, 2 medical charts were excluded due to incomplete data (absence of viral load measurement).Therefore, 374 study participants were included in this analysis (Figure 1).

Study Variables
The dependent variable is first-line antiretroviral therapy virologic-failure.Virological failure is defined as a viral load greater than 1000 copies/mL based on two consecutive viral load measurements taken three months apart, with enhanced adherence support following the first viral load test, as documented by the health provider [6].Independent variables are described as follows: Sociodemographic factors (age, sex, educational status, marital status, occupation, residence, distance from health facility, religion); personal factors (smoking, alcohol abuse, stigma and discrimination, HIV disclosure status, absence of treatment supporter, and having unsafe sex during ART); clinical factors (nutritional status, baseline WHO stage, current WHO stage, TB/HIV coinfection.mental illness, initial viral load, baseline CD4 count, baseline functional status, comorbidity, base line OIs, and OIs in the past 6 months); factors related to ART (adherence status, loss to follow-up, TB preventive therapy, Baseline ART regimen, cotrimoxazole preventive therapy, duration of ART taken, taking other medications, ART interruption).Loss to follow-up (LTFU) is defined as a patient who has not been seen at the clinic for at least 90 days (three months) after the last missed appointment, but not TO or dead" [6].

Data Collection Technique and Instruments
Four trained BSc professional nurses working in an ART clinic collected socio-demographic, personal characteristics, clinical, and ART-related factors by reviewing the patient's medical charts and database.Data collection tools or checklists were adapted from the WHO standard and/or EFMOH ART intake-form.

Data Quality Control
Two days of training were given for data collectors and a supervisor to maintain data quality.A pretest was done before data collection.Each item of data was checked for its completeness by the principal investigator and a supervisor during the data collection period every day.

Data Management and Analysis
Data were entered into Epi-Info 7 and exported to SPSS version 22 for cleaning, recoding, and analysis.
Both descriptive and analytic methods were used for data analysis.The median value with interquartile range for continuous variables and frequencies with percentages for participant categorical variables were summarized and described using text and tables in the descriptive analysis.
Binary logistic regression was used to identify associated factors with virologic factors.A bivariable analysis was carried out for all independent variables with an outcome variable, and variables with a P-value less than 0.2 were entered into a multivariable logistic regression model to identify the independent determinants of treatment failure.We used a backward stepwise method to enter variables for multivariable analysis.Overall model fitness was done by using the Hosmer and Lemeshow goodness of fit test, and a non-significant test result indicated a good model for the study.Finally, the adjusted odds ratio and 95% CI were determined, and variables with a P-value less than 0.05 were reported as significant for virological failure.

Socio-Demographic and Personal/Behavioral Characteristics
Of a total sample size of 376, 374 study participants were included in the analysis.The participants' median age was 37 years (IQR: 30-45).More than half, 216 (58%), of the study participants were females.The majority of them, 270 (72%), came from urban areas.Of the total participants, 344 (92%) were orthodox Christians.More than half, 228 (61%), were married.One hundred thirty-eight (37%) were either government or NGO employees.More than half, 192 (51%), of the participants disclosed their HIV status to others, and half of them, 188 (50%), had treatment supporters.Eighteen percent, 69 (18%), of study participants had a history of unsafe sex after ART initiation (Table 2).
The majority, 314 (84%), had good adherence status for ART and the median duration of ART was 36 months (IQR: 25-51.00).Fort-two (11%) had a history of loss to follow-up in the past.The majority of the participants, 347 (92%), took TPT (Table 3).

The Prevalence of Virological Failure and Its Associated Factors
This study showed that the prevalence of virological failure was found to be 13.6% (95% CI: 10.4% -17.2%).The overall model goodness of fit test was done with the Hosmer and Lemeshow Test and it was reported to be a good model with a chi-square significance level of 0.518.Logistic regression assumptions of multicollinearity and outliers were checked.
In the bi-variable logistic regression, independent variables with a "P-value" of less than 0.2 were candidates for multivariable logistic regression analysis to identify the effect of confounding.
In multivariable logistic regression analysis, we used a stepwise backward selection procedure to identify associated factors at a "P-value" less than 0.05 with AORs and 95% CIs to obtain the association with virologic failure.Cigarette smokers were 4.76 times more likely than nonsmokers to develop virological failure (AOR 4.76, 95% CI: 1.06-21.38).In this study, those HIV patients who did not disclose their HIV status to somebody who may have supported them were 4.56 times higher to develop virological failure compared with those who disclosed their status (AOR, 4.56; 95% CI: 1.67-12.46).According to our study, those study participants with a history of having stigma and discrimination after ART initiation were 2.91 times more likely to develop treatment failure (AOR, 2.91; 95% CI: 1.14-7.39)(Table 4).
Participants who had a history of baseline opportunistic infection were 6.66 times more likely to develop subsequent virologic treatment failure (AOR, 6.66; 95% CI: 1.94-22.90).Similarly, those study subjects who did not take cotrimoxazole preventive therapy with ART were 3.21 times more likely to develop antiretroviral treatment failure (AOR, 3.21; 95% CI: 1.12-9.18).Those HIV clients having a history of treatment interruption for ART were 2.97 times higher for the development of virologic treatment failure compared with those consistently taking their medication (AOR, 2.97; 95% CI: 1.11-7.94).Similarly, participants with one or more episode of loss to follow-up for their antiretroviral medication were 9 times more likely to have virologic failure compared with their counter-parts (AOR, 9.03; 95% CI: 3.08-26.47).The odds of developing treatment failure among the study participants with either fair or poor adherence status to their antiretroviral medication were 3.41 times higher than those with good adherence status (AOR, 3.409; 95% CI: 1.26-9.24).The likelihood of developing antiretroviral treatment failure among HIV patients taking additional medication other than ART was 3.64 times higher compared with their counter parts (AOR, 3.64; 95% CI: 1.33-9.97)(Table 5). 1. *** = "P-value" < 0.001 2 ** = "P-value" < 0.01 3. * = "P-value" < 0.05

Discussion
First-line ART failure is the continued challenge for HIV programs in low-and middle-income countries.Understanding the magnitude of first-line ART failure is crucial for early prevention as well as for planning and monitoring services in resource-limited countries.This study was aimed at determining the prevalence of first-line ART virologic failure and its associated factors among HIVinfected adults on ART in Debre Tabor Comprehensive Specialized Hospital in Northwest Ethiopia.
However, this study was lower than studies conducted in Southwest Ethiopia (29.3%) [30] and Southwest Shewa, central Ethiopia (33.42%) [24].This variation could be since there might variations in sociodemographic factors like age greater or equal to18 years vs age greater or equal to 15 years, male to female ratio, female 58% vs 41%) and also relatively using a larger sample size in this study.Moreover, there might be variations in personal or behavioral activities and the quality of the healthcare delivery system.This study was also higher than the systematic review and meta-analysis in Ethiopia (5.8%) [31], the studies from Northern Ethiopia (4.70%) [32], and the studies done in Eastern African countries and Nigeria (9%) [33], and Bangkok, Thailand (5.34%) [34].The possible explanation for this difference could be a difference in improved care and being closely monitored.It might also be the sample size variation, because these studies used relatively larger sample sizes, and the variation within the study population could be another reason.
Virologic failure was influenced by a variety of sociodemographic, clinical, and therapeutic-related factors.In this study, sociodemographic factors were not associated with virologic failure (VF); however, in similar previous studies, some of these factors were associated with VF.Accordingly, different scholars reported that participants aged older than 35 years in northern Ethiopia [22], age greater than 42 years in Southwestern Ethiopia [30], and 45-54 years in Eastern Ethiopia were significantly associated with virological failure (VF).In contrast to the above, similar studies showed that age less than 35 years in northeast Ethiopia [35] and 15-24 years in central Ethiopia [8] were significantly associated factors with VF.Similarly, being an adolescent was associated with VF in Myanmar [21].From previous studies, being male [19], being rural resident [26,30,32], being divorced [4,27,30], having no formal education or primary education [2] and distance from health facilities [24] were significantly associated with virological factors.The possible justification for why these factors were not associated in the current study might be because of differences in personal and behavioral activities in society and variations in clinical conditions.
In this study, participants who smoked cigarettes were 4.76 times more likely to develop virological failure compared with non-smokers.This might be due to the fact that cigarette smoking lowers the immune system and facilitates the occurrence of different OIs.Moreover, being abducted increases the possibility of poor adherence and being lost from care and treatment.Previous research in Ethiopia [26,36] supported it.
This study also identified that HIV patients who did not disclose their status were 4.56 times more likely to have antiretroviral treatment failure compared with those who disclosed themselves.This may be because of some Known HIV patients do not volunteer to disclose their status to anyone who helps them because they fear stigma and disclosure.Therefore, they might interrupt their medication and close follow-up.A systematic review and meta-analysis in Ethiopia [31], and a study in central Ethiopia [36] backed it up.
The findings of this study also stated that participants who had a history of stigma and discrimination in their lives were 2.91 times higher than their counterparts to have a virologic failure.This to the fact that the presence of stigma and discrimination affects their adherence, and they may be unable to follow-up on care and treatment.This increases subsequent drug resistance and the possibility of VF.
In the current study, the odds of having virologic failure were 6.66 times higher among HIV patients with baseline opportunistic infections (OIs) compared with those without OIs.This may be due to the fact that the presence of different OIs not only lowers their immunity but also increases viral replication in thousands of copies, which results in mutant virions and may cause long-term development of drug resistance and treatment failure.On the other hand, patients with OIs took many drugs other than ART, and it could have drug-drug interactions and possible adverse drug effects that affected their adherence status.This study was supported by Mulisa et al. in 2019 and 2020 in central Ethiopia [24,37].
This study showed that adult HIV clients with sub-optimal adherence (fair/poor) to their antiretroviral medication were 3.41 times higher than those with good adherence status to develop virological treatment failure.This is because sub-optimal adherence to their antiretroviral treatment leads to the gradual occurrence of possible drug resistance due to low serum levels for exposed drugs.Additionally, they may have an increased number of viral replication and, as a result, they have a low CD4 count to fight different OIs.This was supported by a systematic review and meta-analysis in Ethiopia [31], and various studies in Ethiopia [22,25,32,35,36,38].
Similarly, this study showed that those HIV patients with a history of having ART interruptions in the past were 2.97 times more likely to develop virological failure than those who regularly took their medications.This might be justified by the presence of ART interruption, which might facilitate viral replication and gradual increment of drug-resistant mutants.It was supported by Bezabih et al., 2019 and D. G. Demsie et al., 2020 [32, 39].
In this study, HIV patients with a history of one or more episodes of loss to follow-up for their care and treatment were 9 times more likely to have virologic failure compared with those who were retained in care.This might be due to the fact that when HIV patients are lost from taking antiretroviral medication for prolonged periods, there is a possibility of increasing HIV viral replication, including drug-resistant mutants.This may finally cause virologic This was supported by a study done in Myanmar [21].
From the current study, those study participants who did not take cotrimoxazole preventive therapy as indicated were 3.21 times more likely to develop antiretroviral treatment failure compared with their counterparts.This is because taking cotrimoxazole prophylaxis may help HIV clients prevent different OIs and, as a result, improve their immune status and subsequent reduction.This study was supported by Age nehu et al., 2020, which sated that cotrimoxazole preventive therapy decreases the incidence of virologic failure by 45% [38].
The findings of this study also showed that the odds of developing antiretroviral treatment failure among HIV patients taking additional medication other than ART were 3.64 times higher compared with their counterparts.This might be because of having drug-drug interactions which decrease serum levels of antiretroviral drugs; taking many drugs may result in the development of adverse drug reactions (ADRs); and pill burden that affects adherence and, as a result, leads to loss to follow-up.
Strength and limitation of the study: This study provides an important input which could be helpful in HIV programs for health managers and different stakeholders.Since it is a cross-sectional study based on secondary data, a prospective multicenter analytical design with mixed research is recommended to identify the incidence and associated risk factors for first-line virologic failure.

Conclusion and Recommendation
The prevalence of virologic failure from this study is consistent with a national one.The findings of this study showed that smoking, non-disclosure status, having stigma and discrimination, presence of baseline opportunistic infections, not taking cotrimoxazole preventive therapy, past history of treatment interruption for ART, one or more episodes of loss to follow up, having fair or poor adherence status, and taking additional medication other than ART were significantly associated with virologic failure.
Therefore, HIV program stakeholders should give emphasis to an enhanced adherence counseling to improve HIV disclosure status, how to minimize and avoid stigma and discrimination, how to improve poor adherence, and how to reduce or minimize smoking among PLHIV.Moreover, special attention should be given to early diagnosis and management of OIs; CPT based on indication; enhanced adherence counseling and early tracing of interrupters and lost patients; and special concern should also be given for those taking additional medications (drug-drug interaction, side-effects, and pill burden).

Figure 1 .
Figure 1.Flow chart showing a selection of HIV infected adults aged ≥ 18 years on the first line ART in Debre tabor comprehensive specialized hospital between October 08, 2017 and October 07, 2022.

Table 1 .
Sample size calculation for second objectives (factors).

Table 2 .
Baseline socio-demographic and personal/behavioral characteristics of adult HIV patients on first-line ART in Debre tabor comprehensive specialized hospital, Northwest Ethiopia from February 2017 to February 2022 (N = 374).

Table 3 .
Clinical and antiretroviral medication-related factors among HIV infected adults on first-line ART in Debre tabor comprehensive specialized hospital between February 2017 and February 2022.

Table 4 .
Sociodemographic and personal factors associated with first-line ART virologic failure among HIV infected adults on ART at Debre tabor comprehensive specialized hospital, Northwest Ethiopia between February 2017 and February 2022.

Table 5 .
Clinical and antiretroviral medication-related factors associated with first-line ART virologic failure among HIV infected adults on first-line ART inDebre tabor comprehensive specialized hospital between February 2017 and February 2022.