Viral suppression in Shashemene falls short of global HIV targets
Among adolescents and adults living with HIV in Shashemene City, Ethiopia, viral suppression remained well below the level needed to reach the UNAIDS third 95 target. In a retrospective cohort of 414 people aged 15 years and older who started antiretroviral therapy between January 2018 and December 2021, 290 patients, or 70.05%, achieved suppression by the end of follow-up in December 2022. The median time to suppression was 9.33 months, a reminder that starting treatment quickly does not always translate into equally rapid virologic control in routine care.
The cohort’s suppression rate was 6.68 per 100 person-months. For a public health program built around rapid treatment initiation and long-term control, that figure is not trivial. It signals that the gap between diagnosis, treatment start, and durable viral control remains open in everyday clinical practice, especially in settings where nutrition, baseline functional status, and adherence can shape response as much as the drug regimen itself.
Rapid ART initiation improved early control
Rapid treatment start mattered. Patients who began ART quickly had about twice the likelihood of early suppression compared with those whose treatment was delayed, with an adjusted hazard ratio of 2.05. In biological terms, earlier suppression likely limits the period of unchecked viral replication, reduces immune injury, and shortens the window in which inflammation and opportunistic complications can interfere with recovery. The clinical logic is straightforward: the less time the virus spends expanding before therapy begins, the more likely the immune system is to rebound before advanced disease takes hold.
The finding also fits the programmatic intent of the test-and-treat era. Ethiopia introduced immediate ART initiation in 2016 and same-day initiation in 2017, but evidence from routine care has remained mixed. In this cohort, faster treatment clearly tracked with better virologic outcomes, even though suppression still fell short of the 95% benchmark.
Nutritional status and baseline function shaped the odds of suppression
Undernutrition and poor baseline functional status carried a heavy penalty. Patients who were undernourished had a 46% lower chance of early suppression than those without undernutrition, with an adjusted hazard ratio of 0.54. Those who were ambulatory or bedridden at baseline had an 87% lower chance of suppression than working patients, with an adjusted hazard ratio of 0.13. Poor adherence also reduced the chance of suppression by 36%, with an adjusted hazard ratio of 0.64.
These are not isolated statistical signals. They point to a familiar clinical pattern in HIV care: virologic response depends on more than prescribing potent therapy. Malnutrition can weaken immune recovery and may reflect advanced disease, food insecurity, or both. Reduced functional status often marks a heavier burden of comorbidity, opportunistic infection, or late presentation, all of which can complicate medication taking and clinic attendance. Adherence, in turn, remains the most immediate determinant of whether ART can suppress replication long enough to achieve and maintain an undetectable viral load.
One result stands out for its bedside relevance. Patients who were already ambulatory or bedridden fared far worse than those who were working.
Routine HIV care still faces a difficult performance gap
The study was conducted in public health facilities in Shashemene City and followed patients for a maximum of two years using Kaplan-Meier methods and Cox proportional hazards regression. Participants were selected by proportional stratified random sampling, and the study included all patients who initiated ART during the study period regardless of enhanced adherence counseling status. That design matters because it reflects routine service delivery rather than a tightly controlled trial environment.
The suppression rate remained below Ethiopia’s reported 2022 national viral load suppression figure of 91% and far below the UNAIDS target of 95%. It also sits in a context of discordant prior evidence. Earlier Ethiopian observational studies reported lower retention, higher loss to follow-up, lower adherence, and lower viral suppression in the test-and-treat era, even as some work has shown reduced morbidity and mortality with early ART. The Shashemene data add a more focused message: rapid initiation helps, but the benefits are blunted when patients start treatment while undernourished, functionally compromised, or unable to adhere consistently.
The median time to suppression, just over nine months, is also clinically important. Viral load control is not instantaneous, and the delay has implications for transmission risk, clinical monitoring, and patient counseling. In a setting where U = U messaging depends on durable undetectability, prolonged time to suppression represents both an individual and public health problem.
Adherence support and nutritional care remain central to treatment success
The investigators conclude that strengthening rapid ART initiation, adherence support, and nutritional assistance is essential. That recommendation follows directly from the pattern of predictors observed in the cohort. Fast treatment start alone is not enough if the patient’s clinical condition, food security, or daily ability to take medication is poor.
For clinicians and HIV programs, the practical implication is to look beyond the prescription pad. Screening for undernutrition, assessing functional status at treatment initiation, and reinforcing adherence support may identify patients least likely to suppress quickly. Those steps may be especially important in ambulatory or bedridden patients, whose markedly lower odds of suppression suggest a subgroup with more complex needs and potentially greater risk of delayed treatment response.
The study has clear value because it examines routine care during the test-and-treat era, but it also leaves a familiar question in place: how much of the suppression gap can be closed by clinical support alone, and how much reflects broader social and health-system constraints that reach beyond the clinic visit?