Trends in Human Immunodeficiency Virus Care Outcomes among Key Populations: Evidence from High-Burden States

INTRODUCTION WITH OBJECTIVES

Human immunodeficiency virus (HIV) remains a formidable global health challenge, with approximately 39.9 million people living with HIV (PLHIV) worldwide as of 2023.^1,2 Despite decades of progress, the epidemic continues to demand robust responses, particularly in regions disproportionately affected. Advances in prevention, treatment, and care have been significant; 85% of PLHIV are now aware of their status, and over 29 million individuals are accessing life-saving antiretroviral therapy (ART) globally. These achievements reflect the global commitment to achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) (UNAIDS) 95-95-95 targets of 95% diagnosis of all PLHIV, 95% ART coverage among diagnosed individuals, and 95% viral suppression among those receiving treatment.^3,4

However, despite this progress, substantial challenges persist. Disparities in healthcare access, stigma, and systemic gaps in the HIV care continuum hinder equitable progress across regions and populations. Globally, the epidemic has claimed an estimated 42.3 million lives, with approximately 630,000 deaths from HIV-related causes in 2023 alone.^5,6 These figures underscore the persistent public health, economic, and social challenges posed by HIV, even in the face of advanced medical interventions and prevention strategies.¹

Sub-Saharan Africa remains the epicenter of the HIV epidemic, accounting for 67% of the global PLHIV population. Nigeria, as the most populous country in the region, plays a pivotal role in the global HIV response.^7,8 With an estimated 2 million PLHIV and a national prevalence rate of 1.4%, Nigeria’s HIV epidemic is a significant public health concern.^9,10 Despite progress in expanding ART coverage and increasing awareness, Nigeria remains a high-burden country, grappling with numerous challenges. Stigma, inconsistent ART coverage, and inadequate healthcare infrastructure continue to impede the country’s response efforts.^11,12

Among Nigeria’s 36 states, Akwa Ibom, Cross River, and Lagos are particularly notable for their high HIV burden. Akwa Ibom has the highest prevalence rate in the country at 5.5%, followed by Cross River at 3.1% and Lagos at 1.3%.^13,14These concentrated epidemics are driven by a confluence of factors, including urbanization, socio-economic disparities, and high population density. While efforts such as ART expansion and community awareness programs have yielded measurable progress, barriers such as healthcare access in rural areas and inadequate linkage to care systems continue to undermine sustained improvements.^12,15

The HIV care continuum, spanning diagnosis, linkage to care, retention in care, and viral suppression, provides a crucial framework for assessing progress toward global targets. It enables stakeholders to identify gaps, improve service delivery, and tailor evidence-based interventions to address specific needs.³ Monitoring the continuum is especially critical in high-burden regions such as Akwa Ibom, Cross River, and Lagos, where disparities in care outcomes require targeted, state-specific strategies.¹⁶ For example, while progress has been observed in ART coverage and viral suppression at the national level, retention rates and linkage to care remain inconsistent, particularly among vulnerable populations such as adolescents and key populations (KPs).¹⁷

Understanding state-specific trends in HIV care outcomes is essential for addressing disparities and accelerating progress in Nigeria’s HIV response. In regions like Akwa Ibom, evidence shows that tailored, community-based models significantly improve care engagement and retention among PLHIV.^15,18 However, the lack of disaggregated data at the subnational level limits the development of nuanced interventions capable of addressing these challenges. This study aims to provide a comprehensive analysis of trends in HIV care outcomes across these states, highlighting progress toward the UNAIDS 95-95-95 targets. By identifying factors influencing these outcomes, this research seeks to inform targeted interventions and contribute to the global and national agenda of ending the HIV epidemic by 2030.^3,16,17,19

Nigeria continues to face persistent challenges in achieving optimal HIV care outcomes, particularly in high-burden states such as Akwa Ibom, Cross River, and Lagos. Despite the availability of national-level data, state-specific insights are often lacking, limiting the ability to design tailored interventions.^15-17 This study addresses these gaps by analyzing longitudinal trends in HIV care outcomes, assessing progress toward achieving the UNAIDS 95-95-95 targets in these states, identifying factors associated with observed trends and disparities in care outcomes, and providing recommendations for improving HIV care outcomes in these high-burden regions. It contributes to the understanding of HIV care outcomes at the subnational level in Nigeria, addressing critical data gaps and informing targeted public health interventions. It offers valuable insights for policymakers, healthcare providers, and program managers to optimize HIV care and aligns with global and national strategies to end the HIV epidemic by 2030.

MATERIAL AND METHODS

RESULTS

Kind of ART treatment received by the KPs

Figure 1 presents the types of ART regimens received by the KPs. The majority of the KPs (98.4%), 61,132, are on the TDF (300 mg) + 3TC (300 mg) + DTG (50 mg) regimen. A smaller proportion (1.5%), 961, are receiving the TDF (300 mg) + 3TC (300 mg) + EFV (600 mg) regimen. Only a very small fraction (0.1%, 56) of the participants are on other combined regimens, such as AZT (Zidovudine, also known as azidothymidine), ATV/r (Atazanavir/ritonavir. The “r” indicates the addition of a low dose of ritonavir to “boost” the levels of the primary protease inhibitor (atazanavir) in the blood), EFV (Efavirenz), LPV/r (Lopinavir/ritonavir), and ACB (Abacavir).

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Figure 1: Kind of antiretroviral therapy treatment received. AZT: known as azidothymidine, ATV/r: Atazanavir/ritonavir, EFV: Efavirenz, LPV/r: Lopinavir/ritonavir, ACB: Abacavir, TDF: Tenofovir disoproxil fumarate, 3TC: Lamivudine and DTG: Dolutegravir. ART: Antiretroviral therapy

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State Level Number of OSS for ART treatment received among KPs

Figure 2 shows the distribution of the number of OSS for ART treatment received across three states among KPs. Lagos and Cross River each account for 35.7% of the total OSS, with 5 OSS reported in each state. Akwa Ibom has 4 OSS, representing 28.6% of the total 14 OSS.

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Figure 2: State-level number of one-stop-shops for antiretroviral therapy treatment received. OSS: One stop shop

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ART treatment status among KPs

Figure 3 illustrates the ART treatment status among KPs. The majority, 57,753 (92.9%), are actively receiving treatment. Smaller proportions include those who have transferred out 1,734 (>2.8%), actively restarted treatment 1,060 (1.7%), or stopped treatment, 645 (1.0%). In addition, 595 (1.0%) are classified as intentionally interrupted treatment, while 362 (0.6%) have died.

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Figure 3: Antiretroviral therapy treatment status among key populations. ITT: Interruption in treatment, ART: Antiretroviral therapy.

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HIV treatment outcomes among KPs

Figure 4 presents the HIV treatment outcomes among KPs. The vast majority, 57,937 (98.4%), have achieved suppressed viral loads. A small proportion, 960 (1.6%), have unsuppressed viral loads.

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Figure 4: Human immunodeficiency virus (HIV) treatment outcomes among key populations.

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State-level trend of viral load suppression from HIV treatment among KPs 2019–2024

Figure 5 illustrates the state-level trends of viral load suppression among KPs in Akwa Ibom, Lagos, and Cross River from 2019 to 2024. Over the years, the trend of viral load suppression in Akwa Ibom showed suppression rates rising from 72.2% in 2019 to 99.3% in 2023. There was a slight dip in 2024 to 98.7%. While in Lagos, the viral load suppression rate was consistently high, starting at 87.5% in 2019 and reaching 100% in 2020, where it remained until 2023. In 2023, there was a slight decrease to 99.5%, and the rate further dropped to 98.4% in 2024. Furthermore, in Cross River, the viral load suppression rate improved significantly from 73.5% in 2019 to 93.2% in 2020 and continued to rise, reaching 99.7% by 2023. However, in 2024, there was a slight decrease to 97.8%.

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Figure 5: State-level trend of viral load suppression from Human immunodeficiency virus treatment among key populations 2019– 2024. *Significant at p<0.05. VL: Viral load

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DISCUSSION

The study reveals that 98.4% of KPs are on the TDF (300 mg) + 3TC (300 mg) + DTG (50 mg) regimen. This aligns with the WHO’s recommendation for dolutegravir-based regimens as the preferred first-line treatment for HIV due to their efficacy, tolerability, and high genetic barrier to resistance.²⁰ The limited use of alternative regimens, such as Efavirenz (EFV)-based combinations (1.5%) and others (0.1%), suggests that Nigeria’s ART program has successfully transitioned to more effective regimens. A similar pattern among the general population was reported in several studies carried out where over 95% of ART patients transitioned to DTG-based regimens due to their superior outcomes in viral suppression and fewer side effects.^21-24 Possible reasons for this result may be due to the prioritization of updated ART guidelines in Nigeria, the availability of DTG, and robust training programs for healthcare workers on the efficacy of newer regimens.²⁵ Furthermore, the low use of other regimens may be attributed to contraindications or specific patient conditions, such as co-occurring tuberculosis or pregnancy.

This study result shows that Lagos and Cross River each accounted for 35.7% of the total OSS providing ART treatment services among KPs, with Akwa Ibom contributing 28.6%. This distribution may reflect programmatic priorities, population density, and HIV burden in these states. A study conducted by Davis et al.²⁶ emphasizes that the geographical distribution of ART services significantly impacts accessibility, retention, and treatment outcomes. The slightly lower number of OSS in Akwa Ibom, despite its high HIV burden, may represent a gap in service delivery that requires redress. Furthermore, the majority of KPs (92.9%) in this study were actively receiving treatment, while a small proportion had stopped treatment or transferred out. The retention rate observed is commendable and reflects robust support systems. The findings from this study align with the results of a study by Wimonsate et al.²⁷ on antiretroviral treatment initiation among HIV-positive participants in the Bangkok men who have sex with men cohort study, 2006–2016. Their result found a high retention rate of ART among MSM individuals. Furthermore, studies conducted in Canada, Spain, and South Africa reported similar high retention rates in which the majority of HIV patients were actively involved in ART regimens.^28-30 However, findings from this study also highlighted gaps, such as the 1.0% of KPs classified as “Intentionally Interrupted Treatment.” These interruptions may be attributed to stigma, mobility, or logistical barriers. For instance, studies among KPs in Nigeria and India identified stigma and fear of disclosure, discrimination, and financial challenges as significant barriers to ART retention among KPs.^31,32

This study revealed an impressive overall viral suppression rate of 98.4%, consistent with UNAIDS’ 95-95-95 targets, which advocate for 95% of individuals on ART to achieve viral suppression by 2030.³³ State-level trends showed significant improvements from 2019 to 2023, although there was a slight decline in 2024 across all states. For instance, Akwa Ibom’s suppression rates peaked at 99.3% in 2023 before decreasing marginally to 98.7%. Similar declines were noted in Lagos and Cross River. The increase in the rate of viral suppression among KPs in this study is in consonance with studies conducted by Oluwakemi and Ekejiuba among KPs in Nigeria after the completion of enhanced adherence counselling (EAC) and ART.^34,35 Also, studies conducted among the general population align with this study’s findings.^36-38 However, the slight fluctuations in the State-level trends might result from systemic challenges, such as healthcare worker shortages, drug supply inconsistencies, or data reporting gaps.

Furthermore, among KPs, MSM participants were more likely to achieve viral load suppression compared to other groups, with an AOR of 0.775 (95% CI: 0.589–1.020, p = 0.049). This indicates that MSM had higher adherence to ART, potentially due to targeted interventions such as outreach programs and education campaigns meant for this group. In comparison, FSW showed an AOR of 0.775 (95% CI: 0.589–1.020, p = 0.049), suggesting a moderate likelihood of achieving viral suppression. These findings align with prior research suggesting that targeted interventions for FSWs and MSM, such as enhanced adherence counseling and pre-exposure prophylaxis, improve treatment outcomes.³⁹ However, the lack of statistical significance for transgender people and PWIDs indicates potential disparities in care delivery for these groups, which warrants further investigation.

Residents in Lagos were 2.854 times more likely to achieve viral load suppression compared to Cross River residents (AOR: 2.854, 95% CI: 2.292–3.553, p < 0.001). This regional advantage could stem from improved healthcare infrastructure and better access to ART in Lagos.^40,41 Participants aged 26–33 years were significantly more likely to achieve viral load suppression compared to those aged 18–25 years (AOR: 1.337, 95% CI: 1.059–1.688, p = 0.015). This might be attributed to greater maturity, better health literacy, and improved adherence in older cohorts. Similar findings have been reported in other studies in which older HIV participants had higher odds of being virally suppressed compared to younger female participants.^42-44

The duration of ART treatment was a strong predictor of viral suppression. Individuals on ART for 6 years or more were significantly more likely to achieve suppression compared to those on treatment for <1 year (AOR: 354.781; 95% CI: 162.949–772.447, p < 0.001). This finding underscores the importance of sustained ART adherence and long-term care engagement in achieving optimal outcomes. Similarly, several studies support these findings, highlighting the significance of long-term retention in care.^45,46 In addition, patients on TDF (300 mg)/3TC (300 mg)/DTG (50 mg) ART regimens showed a significantly higher likelihood of viral suppression compared to those on other regimens (AOR: 25.929; 95% CI: 9.866–68.140, p < 0.001). This is consistent with studies where DTG-based regimens showed a better treatment outcome and viral suppression rates.^21-23 Dolutegravir-based regimens are known for their potency, high barrier to resistance, and lower side effect profile, making them the preferred first-line option in global HIV guidelines.²⁰

Longer ARV refill intervals (5–6 months) were associated with better viral suppression compared to shorter intervals (1–2 months). This may indicate that stable patients benefit from differentiated service delivery models, which reduce the burden of frequent clinic visits and improve patient satisfaction and retention. Furthermore, KPs presenting at clinical stage 1 were significantly more likely to achieve viral suppression (AOR: 0.148, 95% CI: 0.034–0.632, p < 0.001) than those presenting at stage III and IV. Advanced HIV disease at the time of ART initiation is a known predictor of poor outcomes.⁴⁷ Early diagnosis and linkage to care remain essential to mitigate this trend. Active ART patients were significantly more likely to achieve suppression compared to inactive patients (AOR: 3.850, 95% CI: 2.643–4.123, p< 0.001). This shows the importance of consistent monitoring and follow-up. The findings are consistent with the research evidence by Ogbanufe, which emphasizes that treatment continuity is a key determinant of viral suppression.⁴⁸

CONCLUSION

This study underscores the remarkable progress in HIV care outcomes among KPs in the high-burden states of Akwa Ibom, Cross River, and Lagos, Nigeria. The findings demonstrate significant viral load suppression rates, predominantly driven by the widespread adoption of the TDF/3TC/DTG regimen. State-level trends reveal that Lagos achieved the most consistent outcomes, while Akwa Ibom and Cross River showed substantial improvements over time. Factors such as ART regimen type, treatment duration, age, and state of residence were key predictors of treatment success. Despite these successes, disparities remain among specific subgroups, including younger populations and those in advanced clinical stages. These results emphasize the importance of sustaining investments in ART programs, scaling up tailored interventions for vulnerable groups, and strengthening state-level operational frameworks to ensure equitable and comprehensive care. This evidence serves as a critical resource for policymakers and stakeholders aiming to optimize HIV care outcomes and achieve epidemic control in Nigeria.