Strategies for Improving Viral Suppression among Children Living with HIV Considered to be Failing First-Line Antiretroviral Therapy in Akwa Ibom, Nigeria: A before - after Study

The EPIC project collaborated with the state pediatric task force supporting pediatric ART management to address viral suppression. Quality improvement activities involved assessment of each child's needs by the pediatric task team, implementation of an individualized package of care together with enhanced adherence counseling (EAC), situation-room meetings to monitor overall implementation, and follow-up viral load testing to determine suppression. The study was conducted in the 21 SIDHAS-supported local government areas (LGAs) in Akwa Ibom State in southern Nigeria. Routine program data was collected and analyzed for a cohort of virally unsuppressed (viral load ≥ 1,000 copies/mL) children (0-14 years) living with HIV who were on a first-line antiretroviral (ARV) regimen as of December 2020 in 49 SIDHAS-supported comprehensive HIV treatment centers (29 primary, 19 secondary, 1 tertiary) in Akwa Ibom that participated in the quality improvement activity. Data were reviewed at baseline (January 2021) and 6 months post-intervention (July 2021). The assess-implement-evaluate approach focuses on systematic collection and assessment of data to provide useful feedback for informed decision-making. In the assessment phase, health needs are considered and a package of care is developed to address the needs. Potential barriers and challenges are also identified and a detailed plan is developed to address each one. In the implementation phase, the plan is activated and may be adjusted based on changing needs. In the evaluation phase, the outcomes of the intervention for each child are discussed for shared learning and feedback to inform decisions for childcare and treatment support. The study found that overall, 312 children were evaluated. The median age was 7 years (interquartile range: 4-10), 50.6% were males, and median duration on ART was 19 months. After 6 months of quality improvement implementation, 98.1%, 94.9%, and 92.3% had completed 1, 2, and 3 EAC sessions, respectively. Significant improvements from baseline were observed in the uptake of prophylaxis for TB opportunistic infection (p < 0.001), enrollment in age-appropriate adherence model groups (p < 0.001), HIV status disclosure (p = 0.002), multimonth drug dispensing (p < 0.001), and transition to the optimal regimen (p < 0.001). Post-EAC viral load testing uptake was 84.6%, and viral suppression was 77.2%. Males and children on ART for longer than 12 months were more likely to have persistently high viral load (p = 0.009 and p = 0.044, respectively). The study concluded that the quality improvement intervention was associated with improved viral suppression in this cohort of children. Additional measures are needed to address the needs of males and children who have been on ART for longer periods. The study highlights the importance of targeted interventions to improve health outcomes among children living with HIV. The results of this study can inform the development of quality improvement programs to address viral suppression among children living with HIV in other settings.