Incidence of High Viral Load and Associated Factors Among Adults Receiving Antiretroviral Therapy Under the HIV Test-and-Treat Program in West Hararghe Zone, Eastern Ethiopia: A Retrospective Cohort Study

For decades, the global fight against HIV has relied on a powerful strategy: finding the virus early and starting medication immediately. This approach, known as "test and treat," works by giving antiretroviral therapy to anyone diagnosed with HIV, regardless of how sick they are. The goal is simple but profound: keep the amount of virus in a person's blood so low that it becomes undetectable. When the virus is suppressed, the person stays healthy, and the virus cannot spread to others. However, even with free medication and a clear plan, the virus sometimes finds a way to grow again. When the viral load—the measure of how many virus particles are floating in the blood—rises above a safe level, it signals that the treatment is not working as it should. This is a critical moment in care, as it puts the patient at risk of falling ill again and allows the virus to potentially jump to new hosts. Understanding why this happens, and who is most likely to experience it, is essential for keeping the promise of the "test and treat" program alive.

In the West Hararghe Zone of eastern Ethiopia, researchers set out to investigate exactly this problem. They looked back at the medical records of 517 adults who had started HIV treatment between 2018 and 2022 under the new "test and treat" policy. The team wanted to know how often these patients developed a high viral load and what factors might be pushing them toward that outcome. By reviewing files from five different health facilities, including hospitals and health centers, they tracked the journey of each patient from the moment they began taking their medicine. They examined everything from where the patients lived and their education levels to their physical health, such as whether they had other infections or how well they were able to move around. The researchers used a method that allowed them to see not just who had high viral loads, but how long it took for those levels to rise after treatment began.

The results revealed that the challenge is real and present. Among the 517 adults studied, 68 of them, which is about 13 percent, developed a high viral load during the observation period. For those who did experience this rise in virus levels, the median time it took to happen was 18 months. This means that for a typical patient in this group, the virus began to rebound within a year and a half of starting treatment. The study also found that the risk of this happening was not the same for everyone; it depended heavily on specific circumstances. The researchers discovered that patients living in rural areas were nearly twice as likely to develop a high viral load compared to those living in towns or cities. Furthermore, patients who were already battling other infections, known as opportunistic infections, faced a much steeper climb; they were more than three times as likely to see their viral load rise compared to patients without these additional health struggles.

The study also highlighted the importance of the body's initial immune strength. Patients who started treatment with a low count of CD4 cells—a type of white blood cell that fights infection—were significantly more likely to develop a high viral load later on. In fact, those with low CD4 counts were more than five times as likely to experience this treatment failure compared to those who started with higher counts. The severity of the disease at the time of diagnosis also mattered. Patients who were in a more advanced stage of HIV illness when they began treatment were at a much higher risk of the virus rebounding. Specifically, the data showed that patients in WHO Clinical Stage 2 were significantly less likely to develop high viral loads compared to those in the most severe Stage 4, suggesting that the earlier the intervention, the better the long-term control.

These findings paint a clear picture of where the "test and treat" program faces its biggest hurdles in this region. While the policy of immediate treatment is a vital step forward, the study suggests that simply handing out medication is not enough to guarantee success for every patient. The higher risk for rural residents points to logistical barriers, such as the difficulty of traveling long distances to clinics or the lack of nearby support systems. The strong link with other infections and low immune counts suggests that the body needs extra help to keep the virus in check when it is already under stress. The researchers conclude that to improve outcomes, health programs need to look beyond just prescribing drugs. They must strengthen support for patients in remote areas, ensure that other infections are treated quickly, and provide more intensive monitoring for those who start treatment with weaker immune systems. By addressing these specific gaps, the goal of keeping the virus suppressed for everyone becomes much more achievable.