Impact of Enhanced Adherence Counselling on PLHIV with Unsuppressed Viral Load and Prevalence of Virological Failure in Osogbo, Nigeria: A Quasi-experimental Study

Impact of Enhanced Adherence Counselling on PLHIV with Unsuppressed Viral Load and Prevalence of Virological Failure in Osogbo, Nigeria: A Quasi-experimental Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Enhanced Adherence Counselling on PLHIV with Unsuppressed Viral Load and Prevalence of Virological Failure in Osogbo, Nigeria: A Quasi-experimental Study Funso Abidemi OLAGUNJU, Samuel Olorunyomi ONINLA, Efeturi AGELEBE, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7990487/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Enhanced adherence counselling (EAC) is an important strategic intervention to prevent virological failure among people living with HIV (PLHIV) with unsuppressed viral loads. However, inconsistencies exist as regards EAC efficacy. Therefore, this study set out to determine the impact of EAC on PLHIV with unsuppressed viral loads, and the prevalence of virological failure in Osogbo, Nigeria. Methods One hundred twenty-nine PLHIV with unsuppressed viral load ≥ 1000 copies per millilitre from three hospitals had three sessions of EAC on monthly basis. The barriers to optimal adherence to antiretroviral therapy were identified and strategic actions were deployed. After EAC sessions, participants’ HIV viral loads were assayed. EAC impact was determined by the percentage of participants with suppressed viral load < 1000 copies per millilitre, and comparison of the participants’ mean viral load before and after EAC. Results One hundred four (80.6%) participants had viral suppression after EAC while 25 (19.4%) still had unsuppressed viral load (virological failure). The impact of EAC in this study was 80.6% (104/129) favourable outcome and significantly lower mean viral load after EAC (p = 0.001). The major barriers identified were forgetfulness, far distance to the treatment centre and stigma, and the most impactful strategic actions instituted were peer support and extended drug pick-up. Conclusion EAC is impactful with over 80% success rate and significantly lower mean viral load of the participants. Peer support and extended drug pick-up were most impactful strategic actions. It is therefore recommended that all stakeholders in HIV/AIDS care should be wholly committed EAC. HIV Enhanced Adherence Counselling Impact Virological Failure Figures Figure 1 INTRODUCTION Human Immunodeficiency Virus (HIV) infection is still regarded as a disease to reckon with as far as public health is concerned going by the fact that about 42.3 million deaths have been documented globally since the onset of the disease. 1 About 39.9 million people were living with HIV at the end of 2023, with 1.3 million new infections recorded in the same year. 1 Available data revealed that approximately two million people lived with the virus in Nigeria in 2023 with a prevalence of 2.1 percent. 2 Adherence is the behaviour of a patient towards taking the right drugs, at the right dose, at the right dosing interval, and at the appropriate time based on mutual agreement between the patient and the healthcare provider at a clinical session. 4 It is fundamental to the care of people living with HIV (PLHIV) and good management outcome. Adherence is described as “good” when is ≥ 95%, while the percentage below is described as “poor”. 5 Good adherence to antiretroviral therapy (ART) is a predictor of good clinical outcomes while poor adherence depicts the opposite. 4 Factors associated with poor adherence to ART include stigma, forgetfulness, lack of social support, and lack of education. 4 Enhanced adherence counselling (EAC) is an ongoing, dynamic, and repetitive action that deals with a detailed evaluation of the present state of individual’s adherence to ART. It identifies the impediments hindering good adherence, assisting the individual in recognizing solutions, and addressing the impediments based on individual peculiarities, which are geared towards obtaining virological suppression. 6 It is an important intervention in HIV care as recommended by World Health Organization (WHO) for the care of PLHIV on ART with unsuppressed viral load. 6 It provides basic knowledge on HIV and its manifestation, information on antiretroviral drugs, including; dosing, frequency, timing, duration, and adverse effects of the medications, and what to do in case of missed dose. 6 For every ten PLHIV with unsuppressed viral load, EAC is targeted at turning the tide of events for good for at least seven, that is, making them to have viral suppression. 7 , 8 Furthermore, EAC emphasizes the importance of 100% adherence, which means not missing any of the prescribed medications and reinforces the fact that non-adherence remains the single most important factor that can lead to the development of treatment failure and drug resistance later. 4 EAC sessions are usually carried out every month for a period of 3 or 6 months and upon successful completion, the affected individual is re-evaluated by assessing the viral load. 4 , 7 Those with suppressed viral load after EAC will continue their initial ART while those who failed to have their viral load suppressed despite EAC are judged to have treatment failure (virological failure). Antiretroviral treatment failure is the sub-optimal treatment outcome that is seen following the initiation of antiretroviral therapy, which could be clinical, immunological or virological. Virological failure is a persistent detectable viral load exceeding 1000 copies per millilitre (cp/ml) in 2 consecutive viral load measurements within 3 months intervals, with adherence support between measurements after at least 6 months of using HAART. 3 It prepares a conducive environment for ART drug resistance and diminishes future treatment options. 4 , 5 Virological failure prevalence of 55.5% 9 and 29% 10 have been reported in Nigeria and Ethiopia respectively. Positive impact of EAC has been reported in Southern Nigeria with the efficacy being 73.8% 11 and in another study in Uganda, a 56% efficacy (though falling short of the 70% target of WHO) has been reported as well. 12 Contrary to the foregoing, a few studies have reported low HIV viral load suppression rates of 2.8%, 13 9%, 14 23%, 15 following EAC. The reports from these studies , 13 , 14 , 15 question the cost-effectiveness and importance of this intervention, especially in a resource-limited environment like Nigeria. This inconsistency underscores the need to thoroughly investigate the impact of EAC on our environment. This study sets out to provide answers to the following research questions: What impact does EAC have on PLHIV with unsuppressed viral load? What are the strategic actions in EAC deployed in combating unsuppressed viral load and their efficacy? What is the prevalence of virological failure among PLHIV during the period of this study? The aim of this study therefore is to assess the impact of EAC on PLHIV with unsuppressed viral load and determine the prevalence of virological failure in Osogbo, Nigeria. METHODOLOGY Study Location The study was carried out at the ART clinics, Osun State University (UNIOSUN) Teaching Hospital, State Specialist Hospital, Asubiaro (SSHA) and Our Lady of Fatima Catholic Hospital (OLFCH). These hospitals offer HIV care services for PLHIV, and as well as other curative and preventive healthcare services to all and sundry within Osogbo and her environment. Osogbo is the capital city of Osun State in South-West Nigeria and inhabited majorly by the Yoruba ethnic group. It is situated along the Osun River and is home to the Osun-Osogbo Sacred Groove which was designated as UNESCO World Heritage site in the year 2005. 16 Study Population The study population was people living with HIV (PLHIV) who had had first-line ART regimen for at least 6-month period, with unsuppressed HIV viral load ≥ 1000 copies per millilitre and had attended the ART clinics of the three chosen hospitals during the study period. Inclusion and Exclusion criteria Inclusion criteria PLHIV (adults; >18 years) who had first-line ART regimen for at least 6-month period and with unsuppressed viral load who gave informed consent. PLHIV (children; < 18 years) who had first-line ART regimen for at least 6-month period and with unsuppressed viral load who gave assents followed by informed consent given by their parents or caregivers. Exclusion Criterion All critically ill PLHIV. Study Duration The study was conducted in 6 months. Study Design The study design was quasi-experimental without concurrent control which evaluated the impact of enhanced adherence counselling as an intervention. Study participants recruitment The study participants were recruited from the second phase / continuation of the previously published research article: Predictors of virological outcomes among patients with HIV on antiretroviral therapy in Osogbo, Nigeria: a cross-sectional study. 17 In the study, virological outcomes of 830 PLHIVs were reported. Seven hundred one, 701, (84.5%) had viral suppression while 129 (15.5%) had unsuppressed viral load. 17 These 129 subjects were studied and became the sample size for this study. Study Instruments The instruments included: semi-structured questionnaire, plain universal bottles, 21 and 23 French gauge needles and syringes, Amplicor HIV-1 monitor TM test version 1.5 machine (Roche diagnostic systems Inc., USA), and sterile gloves. Operational Definitions Virological treatment failure: A participant whose HIV viral load quantity was ≥ 1000 copies per millilitre (Unsuppressed HIV viral load) despite undergoing 3 EAC sessions monthly. No virological treatment failure: A participant whose HIV viral load quantity was < 1000 copies per millilitre (Suppressed HIV viral load) after undergoing 3 EAC sessions monthly. 3 Data Collection and Clinical Evaluation An informed consent form which explained the purpose of the study was given to all the participants above 18 years of age, while an assent form was given to those between 7 and 18 years. The consent of parents / caregivers of those less than 18 years were further sought. The purpose of the study was emphasized and other details regarding the study were explained to them. After the study participants/caregivers demonstrated good understanding of the research details, a written informed consent / assent was then obtained from them. Each participant was identified by a serial number, which was coded but known only by the researchers. The serial number was written on the questionnaire of each participant and investigation items. All information obtained from each participant and the results of the laboratory investigations were kept on a computer with a password known to the researchers only. A questionnaire designed specifically for the study was used to obtain information from the participants by the researchers and research assistants using the interview method. The research assistants (doctors) were trained in how to obtain the information needed prior to the commencement of data collection. Socio-demographic and socio-economic classes of the participants were determined using the revised scoring scheme for the classification of socio-economic status in Nigeria. 18 Execution of the EAC Each participant was taken through EAC sessions monthly for three months by the researchers and adherence counsellors at the clinics as scheduled. The EAC dwelt in identifying the potential issues that led to unsuppressed viral load, and the provision of possible solutions to the identified issues. All the participants were offered health education on each visit at their respective clinics. The strategic actions instituted during EAC sessions included ways and means of adhering to ART (peer support, extended drug pick-up, directly observed therapy (DOT), use of mobile messages and calls, and the use of alarm clock), and psychotherapy. Strategic action given to each participant depended on the barrier identified in each of them. Post-intervention Evaluation At the end of the three-monthly sessions of EAC, the participants were evaluated by assaying their blood for HIV viral load. The samples were analyzed by a medical laboratory scientist. Those with viral load copies < 1000 per millilitre, were considered to have had viral suppression and as a result their ART was not changed. However, those that still had viral load copies persistently ≥ 1000 per millilitre, were considered to have had virological failure and consequently had their ART regimen switched to the 2nd-line in accordance with the standard treatment guidelines. Evaluation of the Impact of Intervention (EAC) The impact of EAC was measured by determining the ratio of PLHIV with suppressed viral load after EAC to total number of PLHIV who started the study with unsuppressed viral load (before EAC) expressed as percentage. The impact was also measured by comparing the mean of the participants’ HIV viral load before and after EAC to see if there existed a statistically significant difference between them. Data Management and Analysis Proformas were manually sorted out for errors and omissions at the end of the data collection. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS Chicago Inc, IL, USA). Categorical variables were summarized using proportions and percentages. Continuous variables were summarized using mean ± standard deviation (± SD) for normally distributed variables. The difference in the means of the continuous variables was determined using T-test. Statistical significance was set at p-value < 0.05. RESULTS Socio-demographic Characteristics of the Participants All 129 participants completed the study giving a response rate of 100%. More than a quarter (34, 26.4%) of the participants were within the age range of 31 and 40 years. Majority, 87, (67.4%) were female. Fifty-two (40.3%) of the participants lived within Osogbo while 77 (59.7%) lived outside Osogbo, and approximately three-quarters, 97, (75.2) of the participants were of the low socioeconomic class. Other details are as shown in Table 1. Table 1: Socio-demographic Characteristics of the Participants Variables Frequency n (%) Age Groups (Years) 1 – 10 8 (6.2) 11 – 20 14 (10.9) 21 – 30 15 (11.6) 31 – 40 34 (26.4) 41 – 50 31 (24.0) 51 and above 27 (20.9) Total 129 (100.0) Sex Male 42 (32.6) Female 87 (67.4) Total 129 (100.0) Socio-economic Class Low 97 (75.2) Middle 20 (15.5) Upper 12 (9.3) Total 129 (100.0) Legend: This Table 1 shows the pattern of distribution of the study participants in relation to age, gender and socioeconomic background. Ages 31-40 bracket recorded highest participants closely followed 41-50 bracket (most productive years). Female and low socio-economic status participants predominated this study Clinical Characteristics of the Participants One hundred twenty-two (94.6%) participants had Tenofovir-Lamivudine-Dolutegravir (TDF/3TC/DTG) ART regimen while seven (5.4%) were on Abacavir-Lamivudine-Dolutegravir (ABC/3TC/DTG). Majority, 109, (84.5%) had used the ART for ≤ 10 years and only 20 (15.5%) participants had utilized it > 10 years. More than three quarters, 113 (87.6%) of the participants had poor adherence while only 16 (12.4%) demonstrated good adherence to ART. Barriers to ART Adherence and Strategic Actions Instituted During EAC The barriers identified during EAC included forgetfulness, treatment fatigue, stigma and discrimination, and long distance to healthcare facility. Forgetfulness, which is most common of the barriers to ART adherence, accounted for 39.5% (51/129), and Figure 1 shows the pattern. The frequency of the various strategic actions deployed, and their outcomes are as shown in Tables 2 and 3. Table 2: Strategic Action Instituted During EAC Strategic Actions Frequency (N = 129) n (%) Peer Support 36 (27.9) Extended Drug Pick-up 34 (26.4) Direct Observed Therapy 5 (3.9) Phone Calls 15 (11.6) Mobile Messages 20 (15.5) Alarm Clock 16 (12.4) Psychotherapy 3 (2.3) Legend: Tabe 2 displays the various strategic actions deployed enhanced adherence counselling to mitigate unsuppressed HIV viral load. Peer support was most used followed by extended drug pick, while psychotherapy was least used. Table 3: Outcomes of the Strategic Actions Instituted During EAC Strategic Actions Outcomes n (%) Favourable (Suppressed Viral Load) Unfavourable (Unsuppressed Viral Load) Total Peer Support 35 (97.2) 1 (2.8%) 36 (100.0) Extended Drug Pick-up 32 (94.1) 2 (5.9%) 34 (100.0) Direct Observed Therapy 2 (40.0) 3 (60.0) 5 (100.0) Phone Calls 10 (66.7) 5 (33.3) 15 (100.0) Mobile Messages 10 (50.0) 10 (50.0) 20 (100.0) Alarm Clock 13 (81.2) 3 (18.8) 16 (100.0) Psychotherapy 2 (66.7) 1 (33.3) 3 (100.0) Total 104 (80.6) 25 (19.4) 129 (100.0) Legend: Effectiveness or otherwise of these various strategic actions are shown in this Table 3. The most effective action was peer support and closely followed by extended drug pick-up, and the least effect strategic action was direct observed therapy and followed by mobile message. Impact of EAC and Prevalence of Virological Failure among the Participants The mean ± SD HIV viral load copies of the participants before and after the EAC were 49927.1 ± 1244.2 copies per millilitres and 5569.9 ± 150.9 copies per millilitres, respectively [t (128) = 4.524, 95% CI = 24857.6 – 63756.9, (p = 0.001)]. In addition, 104 (80.6%) out of the 129 study participants had viral suppression and their ART regimens were continued. On the other hand, 25 (19.4%) participants still had unsuppressed viral load (Table 3), and they represented the proportion of participants with virological failure and as a result their ART regimen was considered for a switch to second-line regimen. Therefore, the impact of EAC in this study was 80.6% favourable outcome with significant reduction in the mean viral load of the participants after EAC. DISCUSSION This study sets out to determine the impact of EAC as an intervention in the management of PLHIV with unsuppressed viral load, the efficacy of various strategic actions deployed during the execution of EAC and the prevalence of virological failure among the participants studied. The impact of EAC in this study is 80.6% favourable outcome, which was greater than 23% and 54% reported by Nasuuna et al., 15 and Awolude et al., 19 respectively. The efficacy of EAC in the present study was also better than 2.8% reported by Ukwueze et al, 13 in a study in Delta State, Nigeria. The improvement noted in the present study could be attributed to the multidisciplinary approach to the management of study participants. The involvement of professional adherence counsellors, clinical psychologists, ART champions and behavioural and mental health specialists helped to harness the skills of these professionals to emphasize the import and benefits of good adherence to HIV care instructions. During the EAC, forgetfulness was the commonest reason given by the participants for the non-adherence to ART. This assertion has been corroborated by similar studies across Nigeria. 20, 21 It has been reported that cognitive impairment could occur among PLHIV, especially those with advanced diseases, and this could manifest with decline in memory functions, which may be short or long term. 21 Consequently, the use of mobile calls, mobile messages and alarm clock were deployed to combat forgetfulness during the study. Out of the three strategic actions used against forgetfulness, the use alarm clocks had the best outcome (81.2%), while those who used mobile calls and messages only did slightly above average. The outcomes seen with mobile calls and messages were not a surprise because mobile network availability remains a challenge in Nigeria with internet penetration rate of 45.4%. 22 Thus, this situation had negative impact on effective communication and hindered to some extent its use to remind the participants to ensure optimal ART adherence. The strategic action with the best performance overall was peer support. Peer support refers to a set of assistance given by a person or group of individuals to another person or group of persons based on common or shared experiences. 23 It is an important strategy in which the modus operandi is targeted at providing emotional support, social identity formation, motivational reinforcement, and practical information sharing. It can combat fears, treatment fatigue, stigma and discrimination, and loneliness. 23 The outstanding performance from peer support obtained in the present study is in tandem with reports from other studies. 24,25 Extended drug picks as a strategic action in EAC offered another remarkable outcome. It provided some respite for some of the participants because they lived far from the location of the ART centre. This strategy reduced the cost of transportation to the clinic and improved routine clinic attendance, antiretroviral drugs pick-ups, and ultimately adherence to ART. This finding is consistent with report by Keene et al. in a South African study. 26 In addition, EAC rooted in psychotherapy also yielded an impressive outcome. It offers answers to what to do in cases of feelings of isolation, rejection, and other emotional-related concerns of PLHIV. There has been good testament to the role of psychotherapy, especially counselling and cognitive behavioural therapy in ensuring adherence to ART, and indeed total well-being of all PLHIV. 27 On the contrary, participants whose EAC were based on directly observed therapy (DOT) could not deliver optimal outcomes in the present study. This finding is in line with the results from a systematic review and meta-analysis which concluded that there was no statistically significant difference in viral load suppression obtained among participants who had directly observed therapy and those who practiced self-administered therapy. 28 Reason for the low performance of DOT in the present study is not known, however, there have been instances where children and some adolescents play pranks by pretending to have swallowed the pills in front of un-noticed healthcare workers or their caregivers only to go elsewhere and spit it out. It has been documented that ensuring consistency of long-term adherence to ART is quite challenging and difficult, especially among children and adolescents. 28 The prevalence of virological failure (19.4%) in the present study was lower compared to 29%, 10 51.6%, 29 and 69.6% 30 obtained in studies from Ethiopia, Togo and Peru, respectively. The prevalence was however higher than 3.9%, 31 4.1%, 32 and 6% 33 from India, Northern Ethiopia and Kenya, respectively. The reasons for these observed variations might be due to differences in study design. Strength and Limitation of the Study The multidisciplinary approach to the execution of EAC which yielded an impressive outcome in this study, is regarded as a strength. The weakness, however, lies in the relatively smaller number of participants. Consequently, there would be need to exercise caution generalizing the outcomes from this study. CONCLUSION With 80.6% of the study participants achieving viral suppression after EAC, this study has demonstrated that EAC remains a quintessential intervention to solving adherence problems among PLHIV. Forgetfulness was the leading barrier to optimal adherence to ART, other barriers identified in this study included long distance participants had to cover to reach treatment facility, stigma, and treatment fatigue. It has also been revealed that EAC is rooted in peer support, extended drug picks, use of alarm clock, psychotherapy, mobile calling, and mobile messaging can deliver good outcomes as far as HIV viral suppression is concerned. Furthermore, the prevalence of virological failure obtained from this study was 19.4% despite the EAC. In terms of implication for policy decision making, EAC is recommended to be taken seriously by all stakeholders involved in the management of HIV. Peer support and extended drug pick are strongly advocated in combating adherence problems among PLHIV while DOT should be implemented with caution especially among children and adolescents. There is a need to look deeply beyond adherence to ART to unravel other reasons (virus-related and drug-related) why PLHIV has virological failure despite EAC through research into the dynamics of HIV pathophysiology and ART. Abbreviations ABC Abacavir AIDS Acquired Immune Deficiency Virus ART Anti-retroviral therapy CI Confidence Interval DOT Directly Observed Therapy DTG Dolutegravir EAC Enhanced Adherence Counselling HIV Human Immunodeficiency Virus OLFCH Our Lady of Fatima Catholic Hospital PLHIV People Living Human Immunodeficiency Virus SD Standard Deviation SSHA State Specialists Hospital Asubiaro TDF Tenofovir 3TC Lamivudine UNIOSUN Osun State University Teaching Hospital WHO World Health Organization Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Research Ethics Committee of Osun State University Teaching Hospital, Osogbo and the State Specialist Hospital Osogbo Research Ethics Committee, with the approval numbers UTH/REC/2023/02/745 and HREC/27/04/2015/SSHO/782, respectively. Informed consents to participate were obtained from all the adults’ participants and assents from the old enough (>7years) minors and the consents of the parents/caregivers of all the minors. The confidentiality of the information provided by the participants was ensured throughout the study by identifying the participants by serial numbers only, their names and other details pointing to their identity were excluded. The study adhered to the Helsinki Declaration. Consent for publication Not applicable Availability of the data The data used is available from the first author or corresponding author upon reasonable request. Competing interest The authors declare that there are no competing interests. Funding No individual or organization funding for this research work. Author’s Contributions Concept and design: FAO, SOO, OAO Acquisition of data: TOA, CAA, AOO 1 Analysis and interpretation of data: FAO, EA, TOA, AOO 1 , Drafting of the manuscript: FAO, KA, AOO 6 , EDW Critical review of the manuscript for important intellectual content: SOO, CAA, EA, AOO 6 Supervision: SOO, OAO, KA, EDW All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work. Acknowledgement We sincerely appreciate the staff of the ART clinics of the 3 health facilities used for their assistance with data collection. Authors’ information (optional) Clinical trial number declarations Not applicable References World Health Organization. Global Health Observatory: Data on the size of the HIV epidemic. Available at: https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/data-on-the-size-of-the-hiv-aids-epidemic?lang=en accessed, 25th April 2025. Onovo AA, Adedayo A, Onime D, Kalnoky M, Kagniniwa B, Dessie M, et al. Estimation of HIV prevalence and burden in Nigeria: a Bayesian predictive modelling study. eClin Med. 2023;62:102098. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, 2nd ed. 2016. Available at: https://www.who.int/publications/i/item/9789241549684 accessed. on 25th April 2025. Federal Ministry of Health, Nigeria, National AIDS, and STI’s Control Programme. : National guidelines for HIV prevention treatmentcare. 2020 Available at: https://www.differentiatedservicedelivery.org/wp-content/uploads/National-guidelines-Nigeria-2020.pdf accessed 25th April2025. Kim J, Lee E, Lee JY, Park BJ, Bang JH. Adherence to antiretroviral therapy and factors affecting low medication adherence among incident HIV-infected individuals during 2009–2016: a nationwide study. Sci Rep. 2018;8:31–3. Diress G, Dagne S, Alemnew B, Adane S, Addisu A. Viral load suppression after enhanced adherence counseling and its predictors among high viral load HIV seropositive people in North Wollo Zone Public Hospitals, Northeast Ethiopia, 2019: Retrospective Cohort Study. AIDS Res Treat. 2020;8909232. https://doi.org/10.1155/2020/8909232 . Bakari HM, Alo O, Mbwana MS, Salim SM, Ally ZM, Musoke E, et al. Enhanced adherence counselling completion rates, viral load suppression in people with HIV in Africa: systematic review and meta-analysis. Discov Pub Health. 2025;22:12. https://doi.org/10.1186/s12982-025-00386-z . Atnafu GT, Moges NA, Wubie M, Gedif G. Incidence and Predictors of Viral Load Suppression After Enhanced Adherence Counseling Among HIV-Positive Adults in West Gojjam Zone, Amhara Region, Ethiopia. Infect Drug Resist. 2022;15:261–74. 10.2147/IDR.S341392 . Orji ML, Onyire NB, Ojukwu JO, Oyim-Elechi CO. The outcome of intervention, characteristics and determinants of treatment failure in HIV-infected adolescents on first-line antiretroviral therapy at a tertiary institution in South –East Nigeria. Niger J Med. 2021;30:586–91. Bereda G, Berede G. Prevalence of, and factors influencing first line antiretroviral treatment clinic of Mettu Karl Referral Hospital, Southwestern Ethiopia: A prospective cross-sectional study. Int J Virol AIDS. 2021;8:075. Akpan U, Nwanja E, Ukpong K, Toyo O, Nwaokoro P, Sanwo O. Reaching viral suppression with HIV with suspected treatment failure who received enhanced adherence counseling in Southern Nigeria: a retrospective analysis. Open Forum Infect Dis. 2022;9:12. 10.1093/ofid/ofac651 . Kikaire B, Ssemanda M, Asiimwe A, Nakanwagi M, Rwegyema T, Seruwagi G. HIV viral load suppression following intensive adherence counseling among people living with HIV on treatment at military-managed health facilities in Uganda. Int J Infect Dis. 2021;112:45–51. Ukwueze LN, Ifeanyi CIC, Iroegbu GA, Aribike J, Ikeneche NF. Evaluation of Enhanced Adherence Counselling among Virally Unsuppressed HIV-Infected Adults on Antiretroviral Therapy in Suburban and Metropolitan parts of Delta State, Nigeria. J Community Med Public Health 2021; 5: 224. DOI: https://doi.org/10.29011/2577-2228.100224 . Birungi J, Cui Z, Okoboi S, Kapaata A, Munderi P, Mukanjjanga, et al. Lack of effectiveness of adherence counselling in reversing virological failure among patients on long-term antiretroviral therapy in rural Uganda. HIV Med. 2020;21(1):21–9. 10.1111/hiv.12790 . Nasuuna E, Kigozi J, Babirye L, Muganzi A, Sewankambo NK, Nakanjako D. Low HIV viral suppression rates following the intensive adherence counseling (IAC) program for children and adolescents with viral failure in public health facilities in Uganda. BMC Pub Health. 2018;18(1):1048. 10.1186/s12889-018-5964-x . Murphy JM, Sanford MM. Reviewed Work(s): Osun across the Waters: A Yoruba Goddess in Africa and the Americas. Int J Afr Histo Stud. 2001;34:3. Olagunju FA, Oninla SO, Adeyemo SC, Fadahunsi KP, Odeyemi AO, Olabode ED, et al. Predictors of virological outcomes in patients with HIV on antiretroviral therapy in Osogbo, Nigeria: a cross-sectional study. BMC Infect Dis. 2025;25:746. https://doi.org/10.1186/s12879-025-11084-1 . Ibadin MO, Akpede GO. A revised scoring scheme for the classification of socio-economic status in Nigeria. Niger J Paediatr. 2021;48:26–33. Awolude OA, Olaniyi O, Moradeyo M, Abiolu J. Virologic Outcomes Following Enhanced Adherence Counselling among Treatment Experienced HIV Positive Patients at University College Hospital, Ibadan, Nigeria. Int. STD Res. Rev. [Internet]. 2021 Mar. 2 [cited 2025 Aug. 13];10(1):53–65. Available from: https://journali-srr.com/index.php/I-SRR/article/view/131 Usman SA, Shehu A, Ajumobi O, Gidado S, Dalhatu I, Balogun M, et al. Predictors of non-adherence to antiretroviral therapy among HIV patients in secondary health care facilities in Kano State- Nigeria, a case-control study. Pan Afr Med J. 2019;32(1):3. 10.11604/pamj.supp.2019.32.1.13746 . Okuku MO, Dan-Jumbo A. Forgetfulness and Non-Adherence to Antiretroviral Therapy in Nigeria: A Review. Asian J Med Principles Clin Pract. 2021;4:34–41. We Are Social & Meltwater. (2023), Digital 2025 Nigeria, retrieved from https://datareportal.com/reports/digital-2025-nigeria . Accessed: 13 August 2025. Kibibi Muthoni L. Effect of Peer Support Groups on ART Adherence Among Young Adults With HIV: A Narrative Review. Res Output J Public Health Med. 2025;5(3):50–3. https://doi.org/10.59298/ROJPHM/2025/535053 . Pugh LE, Roberts JS, Viswasam N, Hahn E, Ryan S, Turpin G, et al. Systematic review of interventions aimed at improving HIV adherence to care in low- and middle-income countries Sub-Saharan Africa. J Infect Pub Health. 2022;15:1053–60. Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A clinical trial. PLoS ONE. 2017;12:e0177698. https://doi.org/10.1371/JOURNAL.PONE.0177698 . Keene CM, Zokufa N, Venables EC. Only twice a year’: a qualitative exploration of 6-month antiretroviral treatment refills in adherence clubs for people living with HIV in Khayelitsha, South Africa. BMJ Open. 2020;10:e037545. 10.1136/bmjopen-2020-037545 . Okonji EF, Mukumbang FC, Orth Z, Vickerman-Delport SA, Van Wyk B. Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10–24 years): a scoping review. BMC Public Health. 2020;20(1):1841. 10.1186/s12889-020-09717-y . Gaur AH, Belzer M, Britto P. Directly observed therapy (DOT) for nonadherent HIV-infected youth: lessons learned, challenges ahead. AIDS Res Hum Retroviruses. 2010;26(9):947–53. 10.1089/aid.2010.0008 . Salou M, Dagnra AY, Butel C, Vidal N, Serrano L, Takassi E. High rates of virological failure and drug resistance in perinatally HIV-1-infected children and adolescents receiving lifelong antiretroviral therapy in routine clinics in Togo. J Inter AIDS Soc. 2016;19:120683. https://doi.org/10.7448/IAS.19.1.20683 . Alave J, Paz J, González E, Campos M, Rodríguez M, Willig J, Echevarría J. Risk factors associated with virologic failure in HIV- infected patients receiving antiretroviral therapy at a public hospital in Peru. Revista Chil de Infectologia. 2013;30:42–8. https://doi.org/10.4067/S0716-10182013000100006 . Rajasekarana S, Jeyaseelanb L, Vijilaa S, Gomathia C, Raja K. Predictors of failure of first-line antiretroviral therapy in HIV-infected adults: Indian experience. AIDS. 2007;21:S47–53. 10.1097/01.aids.0000279706.24428.78 . Ayalew MB, Kumilachew D, Belay A. First-line antiretroviral treatment failure and associated factors in HIV patients at the University of Gondar Teaching Hospital, Gondar, Northwest Ethiopia. HIV AIDS (Auckl). 2016;8:141–6. 10.2147/HIV.S112048 . Ferreyra C, Yun O, Eisenberg N. Evaluation of clinical and immunological markers for predicting virological failure in a HIV/AIDS treatment cohort in Busia, Kenya. PLoS ONE. 2012;7(11):e49834. 10.1371/journal.pone.0049834 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7990487","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":539527773,"identity":"53907701-7d56-481a-b845-030d8f947d14","order_by":0,"name":"Funso Abidemi OLAGUNJU","email":"","orcid":"","institution":"Osun State University","correspondingAuthor":false,"prefix":"","firstName":"Funso","middleName":"Abidemi","lastName":"OLAGUNJU","suffix":""},{"id":539527774,"identity":"022176b4-5199-47c8-9264-c15b3e7631b3","order_by":1,"name":"Samuel Olorunyomi 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16:33:38","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67575,"visible":true,"origin":"","legend":"","description":"","filename":"ImpactofEAConPLHIVArticle.docx","url":"https://assets-eu.researchsquare.com/files/rs-7990487/v1/f11d0d801e7f0fd0e4f60a83.docx"},{"id":95173611,"identity":"5925e3f2-6989-4c45-8134-0369dfbfe76b","added_by":"auto","created_at":"2025-11-05 06:44:26","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10969,"visible":true,"origin":"","legend":"","description":"","filename":"db0805d5e59a414e8027aa7549a5c370.json","url":"https://assets-eu.researchsquare.com/files/rs-7990487/v1/bbbc986ef279e89cdc6e52d5.json"},{"id":95173615,"identity":"a2cf1863-e768-4a71-ba32-47c205d9772e","added_by":"auto","created_at":"2025-11-05 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06:44:26","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117637,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7990487/v1/7b82aef16be9d85d023773f8.html"},{"id":95173613,"identity":"0a44d6ed-efc6-4848-9d96-58f8fe790944","added_by":"auto","created_at":"2025-11-05 06:44:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26796,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIdentified Barriers to ART Adherence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend: \u003c/strong\u003eFigure 1 presents various barriers hindering good adherence to ART and the proportions of the study participants that faced each barrier.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7990487/v1/7e986c9a6030a22e35471453.png"},{"id":95312252,"identity":"14d8b48e-bebd-4ae9-b5e9-fbe393958de7","added_by":"auto","created_at":"2025-11-06 15:48:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1052079,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7990487/v1/b031f344-52a7-482a-adc2-016d2a76689a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Enhanced Adherence Counselling on PLHIV with Unsuppressed Viral Load and Prevalence of Virological Failure in Osogbo, Nigeria: A Quasi-experimental Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHuman Immunodeficiency Virus (HIV) infection is still regarded as a disease to reckon with as far as public health is concerned going by the fact that about 42.3\u0026nbsp;million deaths have been documented globally since the onset of the disease.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e About 39.9\u0026nbsp;million people were living with HIV at the end of 2023, with 1.3\u0026nbsp;million new infections recorded in the same year. \u003csup\u003e1\u003c/sup\u003e Available data revealed that approximately two million people lived with the virus in Nigeria in 2023 with a prevalence of 2.1 percent.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAdherence is the behaviour of a patient towards taking the right drugs, at the right dose, at the right dosing interval, and at the appropriate time based on mutual agreement between the patient and the healthcare provider at a clinical session.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e It is fundamental to the care of people living with HIV (PLHIV) and good management outcome. Adherence is described as \u0026ldquo;good\u0026rdquo; when is \u0026ge;\u0026thinsp;95%, while the percentage below is described as \u0026ldquo;poor\u0026rdquo;. \u003csup\u003e5\u003c/sup\u003e Good adherence to antiretroviral therapy (ART) is a predictor of good clinical outcomes while poor adherence depicts the opposite.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Factors associated with poor adherence to ART include stigma, forgetfulness, lack of social support, and lack of education. \u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEnhanced adherence counselling (EAC) is an ongoing, dynamic, and repetitive action that deals with a detailed evaluation of the present state of individual\u0026rsquo;s adherence to ART. It identifies the impediments hindering good adherence, assisting the individual in recognizing solutions, and addressing the impediments based on individual peculiarities, which are geared towards obtaining virological suppression.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e It is an important intervention in HIV care as recommended by World Health Organization (WHO) for the care of PLHIV on ART with unsuppressed viral load.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e It provides basic knowledge on HIV and its manifestation, information on antiretroviral drugs, including; dosing, frequency, timing, duration, and adverse effects of the medications, and what to do in case of missed dose.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e For every ten PLHIV with unsuppressed viral load, EAC is targeted at turning the tide of events for good for at least seven, that is, making them to have viral suppression.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFurthermore, EAC emphasizes the importance of 100% adherence, which means not missing any of the prescribed medications and reinforces the fact that non-adherence remains the single most important factor that can lead to the development of treatment failure and drug resistance later.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e EAC sessions are usually carried out every month for a period of 3 or 6 months and upon successful completion, the affected individual is re-evaluated by assessing the viral load.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Those with suppressed viral load after EAC will continue their initial ART while those who failed to have their viral load suppressed despite EAC are judged to have treatment failure (virological failure).\u003c/p\u003e\u003cp\u003eAntiretroviral treatment failure is the sub-optimal treatment outcome that is seen following the initiation of antiretroviral therapy, which could be clinical, immunological or virological. Virological failure is a persistent detectable viral load exceeding 1000 copies per millilitre (cp/ml) in 2 consecutive viral load measurements within 3 months intervals, with adherence support between measurements after at least 6 months of using HAART.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e It prepares a conducive environment for ART drug resistance and diminishes future treatment options.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Virological failure prevalence of 55.5% \u003csup\u003e9\u003c/sup\u003e and 29% \u003csup\u003e10\u003c/sup\u003e have been reported in Nigeria and Ethiopia respectively.\u003c/p\u003e\u003cp\u003ePositive impact of EAC has been reported in Southern Nigeria with the efficacy being 73.8% \u003csup\u003e11\u003c/sup\u003e and in another study in Uganda, a 56% efficacy (though falling short of the 70% target of WHO) has been reported as well. \u003csup\u003e12\u003c/sup\u003e Contrary to the foregoing, a few studies have reported low HIV viral load suppression rates of 2.8%,\u003csup\u003e13\u003c/sup\u003e 9%,\u003csup\u003e14\u003c/sup\u003e 23%,\u003csup\u003e15\u003c/sup\u003e following EAC. The reports from these studies\u003csup\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e question the cost-effectiveness and importance of this intervention, especially in a resource-limited environment like Nigeria. This inconsistency underscores the need to thoroughly investigate the impact of EAC on our environment.\u003c/p\u003e\u003cp\u003eThis study sets out to provide answers to the following research questions: What impact does EAC have on PLHIV with unsuppressed viral load? What are the strategic actions in EAC deployed in combating unsuppressed viral load and their efficacy? What is the prevalence of virological failure among PLHIV during the period of this study? The aim of this study therefore is to assess the impact of EAC on PLHIV with unsuppressed viral load and determine the prevalence of virological failure in Osogbo, Nigeria.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Location\u003c/h2\u003e\u003cp\u003eThe study was carried out at the ART clinics, Osun State University (UNIOSUN) Teaching Hospital, State Specialist Hospital, Asubiaro (SSHA) and Our Lady of Fatima Catholic Hospital (OLFCH). These hospitals offer HIV care services for PLHIV, and as well as other curative and preventive healthcare services to all and sundry within Osogbo and her environment. Osogbo is the capital city of Osun State in South-West Nigeria and inhabited majorly by the Yoruba ethnic group. It is situated along the Osun River and is home to the Osun-Osogbo Sacred Groove which was designated as UNESCO World Heritage site in the year 2005.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population was people living with HIV (PLHIV) who had had first-line ART regimen for at least 6-month period, with unsuppressed HIV viral load\u0026thinsp;\u0026ge;\u0026thinsp;1000 copies per millilitre and had attended the ART clinics of the three chosen hospitals during the study period.\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePLHIV (adults; \u0026gt;18 years) who had first-line ART regimen for at least 6-month period and with unsuppressed viral load who gave informed consent.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePLHIV (children; \u0026lt; 18 years) who had first-line ART regimen for at least 6-month period and with unsuppressed viral load who gave assents followed by informed consent given by their parents or caregivers.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eExclusion Criterion\u003c/h3\u003e\n\u003cp\u003eAll critically ill PLHIV.\u003c/p\u003e\n\u003ch3\u003eStudy Duration\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in 6 months.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThe study design was quasi-experimental without concurrent control which evaluated the impact of enhanced adherence counselling as an intervention.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy participants recruitment\u003c/h3\u003e\n\u003cp\u003eThe study participants were recruited from the second phase / continuation of the previously published research article: Predictors of virological outcomes among patients with HIV on antiretroviral therapy in Osogbo, Nigeria: a cross-sectional study.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e In the study, virological outcomes of 830 PLHIVs were reported. Seven hundred one, 701, (84.5%) had viral suppression while 129 (15.5%) had unsuppressed viral load.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These 129 subjects were studied and became the sample size for this study.\u003c/p\u003e\n\u003ch3\u003eStudy Instruments\u003c/h3\u003e\n\u003cp\u003eThe instruments included: semi-structured questionnaire, plain universal bottles, 21 and 23 French gauge needles and syringes, Amplicor HIV-1 monitor TM test version 1.5 machine (Roche diagnostic systems Inc., USA), and sterile gloves.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOperational Definitions\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eVirological treatment failure: A participant whose HIV viral load quantity was \u0026ge;\u0026thinsp;1000 copies per millilitre (Unsuppressed HIV viral load) despite undergoing 3 EAC sessions monthly.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eNo virological treatment failure: A participant whose HIV viral load quantity was \u0026lt;\u0026thinsp;1000 copies per millilitre (Suppressed HIV viral load) after undergoing 3 EAC sessions monthly. \u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Collection and Clinical Evaluation\u003c/h2\u003e\u003cp\u003eAn informed consent form which explained the purpose of the study was given to all the participants above 18 years of age, while an assent form was given to those between 7 and 18 years. The consent of parents / caregivers of those less than 18 years were further sought. The purpose of the study was emphasized and other details regarding the study were explained to them. After the study participants/caregivers demonstrated good understanding of the research details, a written informed consent / assent was then obtained from them.\u003c/p\u003e\u003cp\u003eEach participant was identified by a serial number, which was coded but known only by the researchers. The serial number was written on the questionnaire of each participant and investigation items. All information obtained from each participant and the results of the laboratory investigations were kept on a computer with a password known to the researchers only.\u003c/p\u003e\u003cp\u003eA questionnaire designed specifically for the study was used to obtain information from the participants by the researchers and research assistants using the interview method. The research assistants (doctors) were trained in how to obtain the information needed prior to the commencement of data collection. Socio-demographic and socio-economic classes of the participants were determined using the revised scoring scheme for the classification of socio-economic status in Nigeria.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eExecution of the EAC\u003c/h2\u003e\u003cp\u003eEach participant was taken through EAC sessions monthly for three months by the researchers and adherence counsellors at the clinics as scheduled. The EAC dwelt in identifying the potential issues that led to unsuppressed viral load, and the provision of possible solutions to the identified issues. All the participants were offered health education on each visit at their respective clinics. The strategic actions instituted during EAC sessions included ways and means of adhering to ART (peer support, extended drug pick-up, directly observed therapy (DOT), use of mobile messages and calls, and the use of alarm clock), and psychotherapy. Strategic action given to each participant depended on the barrier identified in each of them.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePost-intervention Evaluation\u003c/h2\u003e\u003cp\u003eAt the end of the three-monthly sessions of EAC, the participants were evaluated by assaying their blood for HIV viral load. The samples were analyzed by a medical laboratory scientist. Those with viral load copies\u0026thinsp;\u0026lt;\u0026thinsp;1000 per millilitre, were considered to have had viral suppression and as a result their ART was not changed. However, those that still had viral load copies persistently\u0026thinsp;\u0026ge;\u0026thinsp;1000 per millilitre, were considered to have had virological failure and consequently had their ART regimen switched to the 2nd-line in accordance with the standard treatment guidelines.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eEvaluation of the Impact of Intervention (EAC)\u003c/h2\u003e\u003cp\u003eThe impact of EAC was measured by determining the ratio of PLHIV with suppressed viral load after EAC to total number of PLHIV who started the study with unsuppressed viral load (before EAC) expressed as percentage. The impact was also measured by comparing the mean of the participants\u0026rsquo; HIV viral load before and after EAC to see if there existed a statistically significant difference between them.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eData Management and Analysis\u003c/h2\u003e\u003cp\u003eProformas were manually sorted out for errors and omissions at the end of the data collection. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS Chicago Inc, IL, USA). Categorical variables were summarized using proportions and percentages. Continuous variables were summarized using mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u0026plusmn;\u0026thinsp;SD) for normally distributed variables. The difference in the means of the continuous variables was determined using T-test. Statistical significance was set at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSocio-demographic Characteristics of the Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 129 participants completed the study giving a response rate of 100%. More than a quarter (34, 26.4%) of the participants were within the age range of 31 and 40 years. Majority, 87, (67.4%) were female. Fifty-two (40.3%) of the participants lived within Osogbo while 77 (59.7%) lived outside Osogbo, and approximately three-quarters, 97, (75.2) of the participants were of the low socioeconomic class. Other details are as shown in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Socio-demographic Characteristics of the Participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Groups (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e1 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e8 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e11 \u0026ndash; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e14 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e21 \u0026ndash; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e15 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e31 \u0026ndash; 40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e34 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e41 \u0026ndash; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e31 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e51 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e27 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cem\u003e129 (100.0)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e42 (32.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e87 (67.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cem\u003e129 (100.0)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-economic Class\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e97 (75.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e20 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e12 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cem\u003e129 (100.0)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e This Table 1 shows the pattern of distribution of the study participants in relation to age, gender and socioeconomic background. Ages 31-40 bracket recorded highest participants closely followed 41-50 bracket (most productive years). Female and low socio-economic status participants predominated this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Characteristics of the Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne hundred twenty-two (94.6%) participants had Tenofovir-Lamivudine-Dolutegravir (TDF/3TC/DTG) ART regimen while seven (5.4%) were on Abacavir-Lamivudine-Dolutegravir (ABC/3TC/DTG). Majority, 109, (84.5%) had used the ART for \u0026le; 10 years and only 20 (15.5%) participants had utilized it \u0026gt; 10 years. More than three quarters, 113 (87.6%) of the participants had poor adherence while only 16 (12.4%) demonstrated good adherence to ART.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers to ART Adherence and Strategic Actions Instituted During EAC\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe barriers identified during EAC included forgetfulness, treatment fatigue, stigma and discrimination, and long distance to healthcare facility. Forgetfulness, which is most common of the barriers to ART adherence, accounted for 39.5% (51/129), and Figure 1 shows the pattern. The frequency of the various strategic actions deployed, and their outcomes are as shown in Tables 2 and 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Strategic Action Instituted During EAC\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrategic Actions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (N = 129)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePeer Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e36 (27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eExtended Drug Pick-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e34 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eDirect Observed Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e5 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePhone Calls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e15 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eMobile Messages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e20 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAlarm Clock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e16 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePsychotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e3 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u0026nbsp;\u003c/strong\u003eTabe 2 displays the various strategic actions deployed enhanced adherence counselling to mitigate unsuppressed HIV viral load. Peer support was most used followed by extended drug pick, while psychotherapy was least used.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 3: Outcomes of the Strategic Actions Instituted During EAC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrategic Actions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 448px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eFavourable (Suppressed Viral Load)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003eUnfavourable (Unsuppressed Viral Load)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003ePeer Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e35 (97.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e1 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e36 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eExtended Drug Pick-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e32 (94.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e34 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eDirect Observed Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e5 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003ePhone Calls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e10 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e15 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eMobile Messages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e10 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e10 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e20 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eAlarm Clock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e13 (81.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e16 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003ePsychotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e1 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e3 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e104 (80.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e25 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e129 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Effectiveness or otherwise of these various strategic actions are shown in this Table 3. The most effective action was peer support and closely followed by extended drug pick-up, and the least effect strategic action was direct observed therapy and followed by mobile message.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of EAC and Prevalence of Virological Failure among the Participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean \u0026plusmn; SD HIV viral load copies of the participants before and after the EAC were 49927.1 \u0026plusmn; 1244.2 copies per millilitres and 5569.9 \u0026plusmn; 150.9 copies per millilitres, respectively [t (128) = 4.524, 95% CI = 24857.6 \u0026ndash; 63756.9, (p = 0.001)]. In addition, 104 (80.6%) out of the 129 study participants had viral suppression and their ART regimens were continued. On the other hand, 25 (19.4%) participants still had unsuppressed viral load (Table 3), and they represented the proportion of participants with virological failure and as a result their ART regimen was considered for a switch to second-line regimen. Therefore, the impact of EAC in this study was 80.6% favourable outcome with significant reduction in the mean viral load of the participants after EAC.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study sets out to determine the impact of EAC as an intervention in the management of PLHIV with unsuppressed viral load, the efficacy of various strategic actions deployed during the execution of EAC and the prevalence of virological failure among the participants studied. The impact of EAC in this study is 80.6% favourable outcome, which was greater than 23% and 54% reported by Nasuuna et al., \u003csup\u003e15\u003c/sup\u003e and Awolude et al., \u003csup\u003e19\u003c/sup\u003e respectively. The efficacy of EAC in the present study was also better than 2.8% reported by Ukwueze et al, \u003csup\u003e13\u003c/sup\u003e in a study in Delta State, Nigeria. The improvement noted in the present study could be attributed to the multidisciplinary approach to the management of study participants. The involvement of professional adherence counsellors, clinical psychologists, ART champions and behavioural and mental health specialists helped to harness the skills of these professionals to emphasize the import and benefits of good adherence to HIV care instructions.\u003c/p\u003e\u003cp\u003eDuring the EAC, forgetfulness was the commonest reason given by the participants for the non-adherence to ART. This assertion has been corroborated by similar studies across Nigeria. \u003csup\u003e20, 21\u003c/sup\u003e It has been reported that cognitive impairment could occur among PLHIV, especially those with advanced diseases, and this could manifest with decline in memory functions, which may be short or long term. \u003csup\u003e21\u003c/sup\u003e Consequently, the use of mobile calls, mobile messages and alarm clock were deployed to combat forgetfulness during the study. Out of the three strategic actions used against forgetfulness, the use alarm clocks had the best outcome (81.2%), while those who used mobile calls and messages only did slightly above average. The outcomes seen with mobile calls and messages were not a surprise because mobile network availability remains a challenge in Nigeria with internet penetration rate of 45.4%. \u003csup\u003e22\u003c/sup\u003e Thus, this situation had negative impact on effective communication and hindered to some extent its use to remind the participants to ensure optimal ART adherence.\u003c/p\u003e\u003cp\u003eThe strategic action with the best performance overall was peer support. Peer support refers to a set of assistance given by a person or group of individuals to another person or group of persons based on common or shared experiences. \u003csup\u003e23\u003c/sup\u003e It is an important strategy in which the modus operandi is targeted at providing emotional support, social identity formation, motivational reinforcement, and practical information sharing. It can combat fears, treatment fatigue, stigma and discrimination, and loneliness. \u003csup\u003e23\u003c/sup\u003e The outstanding performance from peer support obtained in the present study is in tandem with reports from other studies. \u003csup\u003e24,25\u003c/sup\u003e Extended drug picks as a strategic action in EAC offered another remarkable outcome. It provided some respite for some of the participants because they lived far from the location of the ART centre. This strategy reduced the cost of transportation to the clinic and improved routine clinic attendance, antiretroviral drugs pick-ups, and ultimately adherence to ART. This finding is consistent with report by Keene et al. in a South African study. \u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn addition, EAC rooted in psychotherapy also yielded an impressive outcome. It offers answers to what to do in cases of feelings of isolation, rejection, and other emotional-related concerns of PLHIV. There has been good testament to the role of psychotherapy, especially counselling and cognitive behavioural therapy in ensuring adherence to ART, and indeed total well-being of all PLHIV. \u003csup\u003e27\u003c/sup\u003e On the contrary, participants whose EAC were based on directly observed therapy (DOT) could not deliver optimal outcomes in the present study. This finding is in line with the results from a systematic review and meta-analysis which concluded that there was no statistically significant difference in viral load suppression obtained among participants who had directly observed therapy and those who practiced self-administered therapy. \u003csup\u003e28\u003c/sup\u003e Reason for the low performance of DOT in the present study is not known, however, there have been instances where children and some adolescents play pranks by pretending to have swallowed the pills in front of un-noticed healthcare workers or their caregivers only to go elsewhere and spit it out. It has been documented that ensuring consistency of long-term adherence to ART is quite challenging and difficult, especially among children and adolescents. \u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe prevalence of virological failure (19.4%) in the present study was lower compared to 29%, \u003csup\u003e10\u003c/sup\u003e 51.6%, \u003csup\u003e29\u003c/sup\u003e and 69.6% \u003csup\u003e30\u003c/sup\u003e obtained in studies from Ethiopia, Togo and Peru, respectively. The prevalence was however higher than 3.9%, \u003csup\u003e31\u003c/sup\u003e 4.1%, \u003csup\u003e32\u003c/sup\u003e and 6% \u003csup\u003e33\u003c/sup\u003e from India, Northern Ethiopia and Kenya, respectively. The reasons for these observed variations might be due to differences in study design.\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eStrength and Limitation of the Study\u003c/h2\u003e\u003cp\u003eThe multidisciplinary approach to the execution of EAC which yielded an impressive outcome in this study, is regarded as a strength. The weakness, however, lies in the relatively smaller number of participants. Consequently, there would be need to exercise caution generalizing the outcomes from this study.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWith 80.6% of the study participants achieving viral suppression after EAC, this study has demonstrated that EAC remains a quintessential intervention to solving adherence problems among PLHIV. Forgetfulness was the leading barrier to optimal adherence to ART, other barriers identified in this study included long distance participants had to cover to reach treatment facility, stigma, and treatment fatigue. It has also been revealed that EAC is rooted in peer support, extended drug picks, use of alarm clock, psychotherapy, mobile calling, and mobile messaging can deliver good outcomes as far as HIV viral suppression is concerned. Furthermore, the prevalence of virological failure obtained from this study was 19.4% despite the EAC.\u003c/p\u003e\u003cp\u003eIn terms of implication for policy decision making, EAC is recommended to be taken seriously by all stakeholders involved in the management of HIV. Peer support and extended drug pick are strongly advocated in combating adherence problems among PLHIV while DOT should be implemented with caution especially among children and adolescents. There is a need to look deeply beyond adherence to ART to unravel other reasons (virus-related and drug-related) why PLHIV has virological failure despite EAC through research into the dynamics of HIV pathophysiology and ART.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAbacavir\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAIDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcquired Immune Deficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eART\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnti-retroviral therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDOT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDirectly Observed Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDTG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDolutegravir\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEAC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnhanced Adherence Counselling\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOLFCH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOur Lady of Fatima Catholic Hospital\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePLHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePeople Living Human Immunodeficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSSHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eState Specialists Hospital Asubiaro\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTDF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTenofovir\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e3TC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLamivudine\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUNIOSUN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOsun State University Teaching Hospital\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Research Ethics Committee of Osun State University Teaching Hospital, Osogbo and the State Specialist Hospital Osogbo Research Ethics Committee, with the approval numbers UTH/REC/2023/02/745 and HREC/27/04/2015/SSHO/782, respectively. Informed consents to participate were obtained from all the adults\u0026rsquo; participants and assents from the old enough (\u0026gt;7years) minors and the consents of the parents/caregivers of all the minors. The confidentiality of the information provided by the participants was ensured throughout the study by identifying the participants by serial numbers only, their names and other details pointing to their identity were excluded. The study adhered to the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of the data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used is available from the first author or corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo individual or organization funding for this research work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions\u003cbr\u003e\u003c/strong\u003eConcept and design: FAO, SOO, OAO\u003cbr\u003eAcquisition of data: TOA, CAA, AOO\u003csup\u003e1\u003c/sup\u003e\u003cbr\u003eAnalysis and interpretation of data: FAO, EA, TOA, AOO\u003csup\u003e1\u003c/sup\u003e,\u0026nbsp;\u003cbr\u003eDrafting of the manuscript: FAO, KA, AOO\u003csup\u003e6\u003c/sup\u003e, EDW\u0026nbsp;\u003cbr\u003eCritical review of the manuscript for important intellectual content: SOO, CAA, EA, AOO\u003csup\u003e6\u0026nbsp;\u003c/sup\u003e\u003cbr\u003e\u0026nbsp;Supervision: SOO, OAO, KA, EDW\u003cbr\u003e\u0026nbsp;All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely appreciate the staff of the ART clinics of the 3 health facilities used for their assistance with data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number declarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Health Observatory: Data on the size of the HIV epidemic. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/themes/topics/topic-details/GHO/data-on-the-size-of-the-hiv-aids-epidemic?lang=en\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/data-on-the-size-of-the-hiv-aids-epidemic?lang=en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e accessed, 25th April 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOnovo AA, Adedayo A, Onime D, Kalnoky M, Kagniniwa B, Dessie M, et al. Estimation of HIV prevalence and burden in Nigeria: a Bayesian predictive modelling study. eClin Med. 2023;62:102098.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, 2nd ed. 2016. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789241549684\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789241549684\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e accessed. on 25th April 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFederal Ministry of Health, Nigeria, National AIDS, and STI\u0026rsquo;s Control Programme. : National guidelines for HIV prevention treatmentcare. 2020 Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.differentiatedservicedelivery.org/wp-content/uploads/National-guidelines-Nigeria-2020.pdf\u003c/span\u003e\u003cspan address=\"https://www.differentiatedservicedelivery.org/wp-content/uploads/National-guidelines-Nigeria-2020.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e accessed 25th April2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim J, Lee E, Lee JY, Park BJ, Bang JH. Adherence to antiretroviral therapy and factors affecting low medication adherence among incident HIV-infected individuals during 2009\u0026ndash;2016: a nationwide study. Sci Rep. 2018;8:31\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiress G, Dagne S, Alemnew B, Adane S, Addisu A. Viral load suppression after enhanced adherence counseling and its predictors among high viral load HIV seropositive people in North Wollo Zone Public Hospitals, Northeast Ethiopia, 2019: Retrospective Cohort Study. AIDS Res Treat. 2020;8909232. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2020/8909232\u003c/span\u003e\u003cspan address=\"10.1155/2020/8909232\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBakari HM, Alo O, Mbwana MS, Salim SM, Ally ZM, Musoke E, et al. Enhanced adherence counselling completion rates, viral load suppression in people with HIV in Africa: systematic review and meta-analysis. Discov Pub Health. 2025;22:12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12982-025-00386-z\u003c/span\u003e\u003cspan address=\"10.1186/s12982-025-00386-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtnafu GT, Moges NA, Wubie M, Gedif G. Incidence and Predictors of Viral Load Suppression After Enhanced Adherence Counseling Among HIV-Positive Adults in West Gojjam Zone, Amhara Region, Ethiopia. Infect Drug Resist. 2022;15:261\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/IDR.S341392\u003c/span\u003e\u003cspan address=\"10.2147/IDR.S341392\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrji ML, Onyire NB, Ojukwu JO, Oyim-Elechi CO. The outcome of intervention, characteristics and determinants of treatment failure in HIV-infected adolescents on first-line antiretroviral therapy at a tertiary institution in South \u0026ndash;East Nigeria. Niger J Med. 2021;30:586\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBereda G, Berede G. Prevalence of, and factors influencing first line antiretroviral treatment clinic of Mettu Karl Referral Hospital, Southwestern Ethiopia: A prospective cross-sectional study. Int J Virol AIDS. 2021;8:075.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkpan U, Nwanja E, Ukpong K, Toyo O, Nwaokoro P, Sanwo O. Reaching viral suppression with HIV with suspected treatment failure who received enhanced adherence counseling in Southern Nigeria: a retrospective analysis. Open Forum Infect Dis. 2022;9:12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ofid/ofac651\u003c/span\u003e\u003cspan address=\"10.1093/ofid/ofac651\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKikaire B, Ssemanda M, Asiimwe A, Nakanwagi M, Rwegyema T, Seruwagi G. HIV viral load suppression following intensive adherence counseling among people living with HIV on treatment at military-managed health facilities in Uganda. Int J Infect Dis. 2021;112:45\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUkwueze LN, Ifeanyi CIC, Iroegbu GA, Aribike J, Ikeneche NF. Evaluation of Enhanced Adherence Counselling among Virally Unsuppressed HIV-Infected Adults on Antiretroviral Therapy in Suburban and Metropolitan parts of Delta State, Nigeria. J Community Med Public Health 2021; 5: 224. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.29011/2577-2228.100224\u003c/span\u003e\u003cspan address=\"10.29011/2577-2228.100224\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBirungi J, Cui Z, Okoboi S, Kapaata A, Munderi P, Mukanjjanga, et al. Lack of effectiveness of adherence counselling in reversing virological failure among patients on long-term antiretroviral therapy in rural Uganda. HIV Med. 2020;21(1):21\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hiv.12790\u003c/span\u003e\u003cspan address=\"10.1111/hiv.12790\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNasuuna E, Kigozi J, Babirye L, Muganzi A, Sewankambo NK, Nakanjako D. Low HIV viral suppression rates following the intensive adherence counseling (IAC) program for children and adolescents with viral failure in public health facilities in Uganda. BMC Pub Health. 2018;18(1):1048. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-018-5964-x\u003c/span\u003e\u003cspan address=\"10.1186/s12889-018-5964-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurphy JM, Sanford MM. Reviewed Work(s): Osun across the Waters: A Yoruba Goddess in Africa and the Americas. Int J Afr Histo Stud. 2001;34:3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlagunju FA, Oninla SO, Adeyemo SC, Fadahunsi KP, Odeyemi AO, Olabode ED, et al. Predictors of virological outcomes in patients with HIV on antiretroviral therapy in Osogbo, Nigeria: a cross-sectional study. BMC Infect Dis. 2025;25:746. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12879-025-11084-1\u003c/span\u003e\u003cspan address=\"10.1186/s12879-025-11084-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbadin MO, Akpede GO. A revised scoring scheme for the classification of socio-economic status in Nigeria. Niger J Paediatr. 2021;48:26\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAwolude OA, Olaniyi O, Moradeyo M, Abiolu J. Virologic Outcomes Following Enhanced Adherence Counselling among Treatment Experienced HIV Positive Patients at University College Hospital, Ibadan, Nigeria. Int. STD Res. Rev. [Internet]. 2021 Mar. 2 [cited 2025 Aug. 13];10(1):53\u0026ndash;65. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journali-srr.com/index.php/I-SRR/article/view/131\u003c/span\u003e\u003cspan address=\"https://journali-srr.com/index.php/I-SRR/article/view/131\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUsman SA, Shehu A, Ajumobi O, Gidado S, Dalhatu I, Balogun M, et al. Predictors of non-adherence to antiretroviral therapy among HIV patients in secondary health care facilities in Kano State- Nigeria, a case-control study. Pan Afr Med J. 2019;32(1):3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11604/pamj.supp.2019.32.1.13746\u003c/span\u003e\u003cspan address=\"10.11604/pamj.supp.2019.32.1.13746\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOkuku MO, Dan-Jumbo A. Forgetfulness and Non-Adherence to Antiretroviral Therapy in Nigeria: A Review. Asian J Med Principles Clin Pract. 2021;4:34\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWe Are Social \u0026amp; Meltwater. (2023), Digital 2025 Nigeria, retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://datareportal.com/reports/digital-2025-nigeria\u003c/span\u003e\u003cspan address=\"https://datareportal.com/reports/digital-2025-nigeria\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed: 13 August 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKibibi Muthoni L. Effect of Peer Support Groups on ART Adherence Among Young Adults With HIV: A Narrative Review. Res Output J Public Health Med. 2025;5(3):50\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.59298/ROJPHM/2025/535053\u003c/span\u003e\u003cspan address=\"10.59298/ROJPHM/2025/535053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePugh LE, Roberts JS, Viswasam N, Hahn E, Ryan S, Turpin G, et al. Systematic review of interventions aimed at improving HIV adherence to care in low- and middle-income countries Sub-Saharan Africa. J Infect Pub Health. 2022;15:1053\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A clinical trial. PLoS ONE. 2017;12:e0177698. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/JOURNAL.PONE.0177698\u003c/span\u003e\u003cspan address=\"10.1371/JOURNAL.PONE.0177698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKeene CM, Zokufa N, Venables EC. Only twice a year\u0026rsquo;: a qualitative exploration of 6-month antiretroviral treatment refills in adherence clubs for people living with HIV in Khayelitsha, South Africa. BMJ Open. 2020;10:e037545. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2020-037545\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2020-037545\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOkonji EF, Mukumbang FC, Orth Z, Vickerman-Delport SA, Van Wyk B. Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10\u0026ndash;24 years): a scoping review. BMC Public Health. 2020;20(1):1841. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-020-09717-y\u003c/span\u003e\u003cspan address=\"10.1186/s12889-020-09717-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaur AH, Belzer M, Britto P. Directly observed therapy (DOT) for nonadherent HIV-infected youth: lessons learned, challenges ahead. AIDS Res Hum Retroviruses. 2010;26(9):947\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/aid.2010.0008\u003c/span\u003e\u003cspan address=\"10.1089/aid.2010.0008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalou M, Dagnra AY, Butel C, Vidal N, Serrano L, Takassi E. High rates of virological failure and drug resistance in perinatally HIV-1-infected children and adolescents receiving lifelong antiretroviral therapy in routine clinics in Togo. J Inter AIDS Soc. 2016;19:120683. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7448/IAS.19.1.20683\u003c/span\u003e\u003cspan address=\"10.7448/IAS.19.1.20683\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlave J, Paz J, Gonz\u0026aacute;lez E, Campos M, Rodr\u0026iacute;guez M, Willig J, Echevarr\u0026iacute;a J. Risk factors associated with virologic failure in HIV- infected patients receiving antiretroviral therapy at a public hospital in Peru. Revista Chil de Infectologia. 2013;30:42\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4067/S0716-10182013000100006\u003c/span\u003e\u003cspan address=\"10.4067/S0716-10182013000100006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRajasekarana S, Jeyaseelanb L, Vijilaa S, Gomathia C, Raja K. Predictors of failure of first-line antiretroviral therapy in HIV-infected adults: Indian experience. AIDS. 2007;21:S47\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.aids.0000279706.24428.78\u003c/span\u003e\u003cspan address=\"10.1097/01.aids.0000279706.24428.78\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAyalew MB, Kumilachew D, Belay A. First-line antiretroviral treatment failure and associated factors in HIV patients at the University of Gondar Teaching Hospital, Gondar, Northwest Ethiopia. HIV AIDS (Auckl). 2016;8:141\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/HIV.S112048\u003c/span\u003e\u003cspan address=\"10.2147/HIV.S112048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerreyra C, Yun O, Eisenberg N. Evaluation of clinical and immunological markers for predicting virological failure in a HIV/AIDS treatment cohort in Busia, Kenya. PLoS ONE. 2012;7(11):e49834. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0049834\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0049834\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, Enhanced Adherence Counselling, Impact, Virological Failure","lastPublishedDoi":"10.21203/rs.3.rs-7990487/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7990487/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEnhanced adherence counselling (EAC) is an important strategic intervention to prevent virological failure among people living with HIV (PLHIV) with unsuppressed viral loads. However, inconsistencies exist as regards EAC efficacy. Therefore, this study set out to determine the impact of EAC on PLHIV with unsuppressed viral loads, and the prevalence of virological failure in Osogbo, Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eOne hundred twenty-nine PLHIV with unsuppressed viral load\u0026thinsp;\u0026ge;\u0026thinsp;1000 copies per millilitre from three hospitals had three sessions of EAC on monthly basis. The barriers to optimal adherence to antiretroviral therapy were identified and strategic actions were deployed. After EAC sessions, participants\u0026rsquo; HIV viral loads were assayed. EAC impact was determined by the percentage of participants with suppressed viral load\u0026thinsp;\u0026lt;\u0026thinsp;1000 copies per millilitre, and comparison of the participants\u0026rsquo; mean viral load before and after EAC.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOne hundred four (80.6%) participants had viral suppression after EAC while 25 (19.4%) still had unsuppressed viral load (virological failure). The impact of EAC in this study was 80.6% (104/129) favourable outcome and significantly lower mean viral load after EAC (p\u0026thinsp;=\u0026thinsp;0.001). The major barriers identified were forgetfulness, far distance to the treatment centre and stigma, and the most impactful strategic actions instituted were peer support and extended drug pick-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEAC is impactful with over 80% success rate and significantly lower mean viral load of the participants. Peer support and extended drug pick-up were most impactful strategic actions. It is therefore recommended that all stakeholders in HIV/AIDS care should be wholly committed EAC.\u003c/p\u003e","manuscriptTitle":"Impact of Enhanced Adherence Counselling on PLHIV with Unsuppressed Viral Load and Prevalence of Virological Failure in Osogbo, Nigeria: A Quasi-experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 06:44:21","doi":"10.21203/rs.3.rs-7990487/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8bf4bdc6-9a7e-407d-947e-8c5d90cbccdb","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T06:44:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 06:44:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7990487","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7990487","identity":"rs-7990487","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}