Determinants of Unfavourable Viral Load Suppression among Pregnant and Breastfeeding Women on Antiretroviral Therapy in Lesotho: A Case–control Study

Lesotho is making strides toward 95-95-95 targets for the population living with HIV and improved antenatal care coverage. However, challenges persist in new HIV infections, including vertical HIV infection. There is a paucity of evidence on the determinants of Viral Load (VL) suppression among pregnant and breastfeeding women living with HIV in Lesotho. The objective of the study was to determine VL suppression among pregnant and breastfeeding women living with HIV on ART in the Maseru district of Lesotho.

A case‒control study employing 420 pregnant and breastfeeding women living with HIV was performed; 140 cases with VL > 1000 copies/ml and 280 in the control group with VL ≤ 1000 copies/ml were included. Bivariate and multivariate analyses were carried out to identify determinants of VL unsuppression via Adjusted Odds Ratios (AORs) with 95% Confidence Intervals (CIs).

A total of 420 (140 cases and 280 controls), 263 (86.4%) were breastfeeding, and 57 (13.7%) were pregnant. The mean age was 29.21 ± 5.33 years (SD), two-thirds (66%) of women’s partners' HIV status was positive, and 21% of partners' HIV status was unknown. Two-thirds (64.3%) of women received ART from urban facilities. More than one-fifth (21.2%) of the women did not adhere to ART. The majority (60%) knew their HIV status during pregnancy. The partner's unknown HIV status, knowledge of HIV before pregnancy, transfer from other facilities, and adherence status were identified as independent predictors of VL suppression (AOR: 95% CI; P < 0.05). An unknown HIV status was 3 times more likely to indicate an unsuppressed VL: AOR = 3.08 (95% CI: 1.15–8.21, P < 0.05), and an HIV status before pregnancy was 4.6 times more likely to indicate an unsuppressed VL: AOR = 4.62 (95% CI: 2.50–8.48, P < 0.001). Transferring from facilities was 12.4 times more likely to have unsuppressed VL; AOR = 12.45 (95% CI: 5.04--30.75). Women who did not adhere to ART were 24.7 times more likely, AOR = 24.7 (95% CI: 12.3--60.9).

Despite national progress toward the 95-95-95 targets, gaps remain that increase the risk of mother-to-child transmission. Poor ART adherence, unknown partner HIV status, transfers between facilities, and knowing HIV status before pregnancy were major predictors of VL unsuppression. Addressing these factors is essential for sustaining maternal health gains and accelerating the elimination of vertical HIV transmission in Lesotho.

This study identified modifiable determinants of VL suppression among pregnant and breastfeeding women with HIV. The study highlights the need for improved partner involvement in the HIV care continuum, encouraging their status to be known by their partners, posttest counseling strategies, and continuing psychosocial support for young and single women, ensuring that women know their HIV status and VL suppression before conception and ART adherence.