Mukuku Olivier, Govender Kaymarlin, Wembonyama Stanislas Okitotsho, Kiakuvue Yannick Nkiambi
Department of Maternal and Child Health, Institut Supérieur des Techniques Médicales de Lubumbashi, Lubumbashi, Democratic Republic of the Congo.
Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa.
Lancet HIV. 2025 Jul;12(7):e506-e521. doi: 10.1016/S2352-3018(25)00039-6. Epub 2025 Jun 2.
BACKGROUND: HIV/AIDS remains a major health issue in sub-Saharan Africa, especially among children and adolescents, with a substantial proportion of people with HIV having unsuppressed viral loads despite the availability of antiretroviral therapy (ART), complicating efforts to manage and control the epidemic. We aimed to estimate the prevalence of unsuppressed viral load and identify the factors contributing to this issue among children and adolescents living with HIV on ART in sub-Saharan Africa. METHODS: In this systematic review and meta-analysis, we assessed data from Web of Science, Google Scholar, Scopus, PsycINFO, Embase, PubMed (MEDLINE), EBSCOhost Research Databases, and Wiley Online Library, as well as grey literature searches. We included studies published between Jan 1, 2010, and Nov 30, 2024 that focused on children and adolescents (aged <20 years) on ART in sub-Saharan Africa and reported on factors related to viral load suppression, defined by a viral load of less than 1000 copies per mL. Eligible studies included observational and interventional designs. Data appraisal and extraction were conducted by two independent reviewers from the author group, with summary data extracted from published reports. The primary outcome assessed was the prevalence of unsuppressed viral loads, with meta-analysis performed using STATA software to calculate prevalence and associated factors. The study is registered with PROSPERO (CRD42023451212). FINDINGS: From an initial 13 121 identified articles, 52 studies involving 169 949 children and adolescents on ART met the inclusion criteria. Prevalence of unsuppressed viral load among children and adolescents in sub-Saharan Africa was 26·47% (95% CI 23·06-29·87); specifically, 26·01% (20·51-31·52) for studies in children (<15 years), 24·76% (17·36-32·16) for studies in adolescents (10-19 years), and 28·52% (23·33-33·72) for studies in a combined group of children and adolescents. Factors associated with unsuppressed viral load included younger age (<5 years), male sex, rural residence, orphan status, attendance at a level 1 or 2 health-care facility, HIV status not disclosed, poor ART adherence, advanced WHO clinical stage of HIV, low CD4 cell counts, history of opportunistic infections, nevirapine-based treatment regimen, drug substitution history, and not receiving co-trimoxazole prophylaxis. This meta-analysis showed a significant heterogeneity across the included studies, as evidenced by I=99·66% and p<0·0001. INTERPRETATION: Unsuppressed viral load among children and adolescents is a key concern in sub-Saharan Africa, and is influenced by sociodemographic, clinical, immunological, and treatment-related factors. Addressing these issues through targeted interventions and improved ART adherence strategies is crucial for better health outcomes. FUNDING: HEARD PhD Scholarship, Swedish International Development Agency.
背景：在撒哈拉以南非洲地区，艾滋病毒/艾滋病仍然是一个重大的健康问题，尤其是在儿童和青少年中。尽管有抗逆转录病毒疗法（ART），但仍有相当一部分艾滋病毒感染者的病毒载量未得到抑制，这使得控制该流行病的努力变得复杂。我们旨在估计未抑制病毒载量的患病率，并确定撒哈拉以南非洲地区接受抗逆转录病毒治疗的艾滋病毒感染儿童和青少年中导致这一问题的因素。 方法：在这项系统评价和荟萃分析中，我们评估了来自科学网、谷歌学术、Scopus、PsycINFO、Embase、PubMed（MEDLINE）、EBSCOhost研究数据库和Wiley在线图书馆的数据，以及灰色文献检索。我们纳入了2010年1月1日至2024年11月30日期间发表的研究，这些研究关注撒哈拉以南非洲地区接受抗逆转录病毒治疗的儿童和青少年（年龄<20岁），并报告了与病毒载量抑制相关的因素，病毒载量抑制定义为病毒载量低于每毫升1000拷贝。符合条件的研究包括观察性和干预性设计。数据评估和提取由作者团队的两名独立评审员进行，汇总数据从已发表的报告中提取。评估的主要结果是未抑制病毒载量的患病率，使用STATA软件进行荟萃分析以计算患病率和相关因素。该研究已在PROSPERO注册（CRD42023451212）。 结果：从最初识别出的13121篇文章中，52项涉及169949名接受抗逆转录病毒治疗的儿童和青少年的研究符合纳入标准。撒哈拉以南非洲地区儿童和青少年中未抑制病毒载量的患病率为26.47%（95%置信区间23.06 - 29.87）；具体而言，15岁以下儿童的研究患病率为26.01%（20.51 - 31.52），10 - 19岁青少年的研究患病率为24.76%（17.36 - 32.16），儿童和青少年合并组的研究患病率为28.52%（23.33 - 33.72）。与未抑制病毒载量相关的因素包括年龄较小（<5岁）、男性、农村居住、孤儿身份、在一级或二级医疗机构就诊、未披露艾滋病毒感染状况、抗逆转录病毒治疗依从性差、世界卫生组织艾滋病毒临床分期较晚、CD4细胞计数低、机会性感染史、基于奈韦拉平的治疗方案、药物替代史以及未接受复方新诺明预防。这项荟萃分析显示纳入的研究之间存在显著异质性，I = 99.66%且p < 0.0001证明了这一点。 解读：儿童和青少年中未抑制的病毒载量是撒哈拉以南非洲地区的一个关键问题，并且受到社会人口统计学、临床、免疫学和治疗相关因素的影响。通过有针对性的干预措施和改进抗逆转录病毒治疗依从性策略来解决这些问题对于改善健康结果至关重要。 资金来源：HEARD博士奖学金，瑞典国际开发署。
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