{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:16:11Z","timestamp":1790615771902,"version":"4.1.0"},"reference-count":57,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,5,7]],"date-time":"2025-05-07T00:00:00Z","timestamp":1746576000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>The Joint United Nations Programme on HIV\/AIDS set ambitious-but-reachable targets to have 95% of HIV-positive people diagnosed, 95% on ART, and 95% virally suppressed by 2030. To address the latter, post-2016, South Africa\u2019s HIV treatment guidelines aimed to deliver maximal and durable viral load (VL) suppression through extensive antiretroviral therapy (ART) scale-up. Yet, standard suppression one-off measurement conceals viral response trajectories with high onward transmission potential for HIV patients on lifelong treatment. We investigated the dynamics of periodic VL patterns and associated socio-demographic factors in rural north-eastern South Africa using data from adults receiving HIV care in healthcare facilities within the Agincourt Health and Demographic Surveillance System (HDSS).<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We extracted two person-identified VL measurements collected 9-15 months apart per individual yearly between 2015 and 2020 from the Agincourt HDSS Hospital-Clinic-Linkage system for 7 493 HIV patients. Sankey diagrams were used to describe VL flows within and across the suppressed and unsuppressed statuses over each year. We classified temporal VL responses into four profiles: (i) Sustained suppression, (ii) achieved suppression, (iii) viral rebound, (iv) virologic failure. Additionally, mixed-effects multinomial logistic regression models were utilised to examine the odds of covariates factors for varied VL trajectories.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The proportion of individuals remaining virally suppressed increased steadily from 84% in 2015 to 86% in 2016, with the highest prevalence of 88% sustained for three consecutive years, from 2017 through 2019, and then dropped slightly in 2020 to 87%. However, 2-3% of initially virally suppressed rebounded annually, while ~5% experience treatment failure. The likelihood of achieving viral suppression was high among men, those aged 15-24 years and 25-34 years however, these groups were less likely to have sustained viral suppression and more likely to experience virologic failure and rebounding.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Temporal VL metrics are needed to effectively track progress towards reaching high and sustained HIV suppression potential in HIV hyperendemic settings. Thus, optimising the assessment of targeted interventions and identification of left-behind groups such as those younger, men, unmarried and poorer HIV patients to improve individual and population health outcomes.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fpubh.2025.1551847","type":"journal-article","created":{"date-parts":[[2025,5,7]],"date-time":"2025-05-07T04:10:28Z","timestamp":1746591028000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":7,"title":["Viral load dynamics among adults receiving HIV care in rural North-Eastern South Africa, 2015\u20132020: insights from a population-based record linkage study"],"prefix":"10.3389","volume":"13","author":[{"given":"Armstrong","family":"Dzomba","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesc Xavier","family":"Gomez-Olive","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean","family":"Bashingwa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Morelearnings","family":"Sibanda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Belinda","family":"Njiro","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathleen","family":"Kahn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Ohene-Kwofie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chodziwadziwa","family":"Kabudula","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,5,7]]},"reference":[{"key":"ref1","year":"2019"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1","DOI":"10.4102\/sajhivmed.v18i1.776","article-title":"Adult antiretroviral therapy guidelines 2017","volume":"18","author":"Meintjes","year":"2017","journal-title":"South Afr J HIV Med"},{"key":"ref3","year":"2015"},{"key":"ref4","doi-asserted-by":"publisher","DOI":"10.3390\/jcm10102074","article-title":"Virologic response to very early hiv treatment in neonates","volume":"10","author":"Shiau","year":"2021","journal-title":"J Clin Med"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1186\/s12981-022-00447-2","article-title":"Factors associated with viral suppression and rebound among adult HIV patients on treatment: a retrospective study in Ghana","volume":"19","author":"Opoku","year":"2022","journal-title":"AIDS Res Ther"},{"key":"ref6","first-page":"12","year":"2015"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1002\/jia2.25316","article-title":"Cash plus: exploring the mechanisms through which a cash transfer plus financial education programme in Tanzania reduced HIV risk for adolescent girls and young women","volume":"22","author":"Pettifor","year":"2019","journal-title":"J Int AIDS Soc"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12889-020-09457-z","article-title":"Towards achieving the 90\u201390\u201390 HIV targets: results from the south African 2017 national HIV survey","volume":"20","author":"Marinda","year":"2020","journal-title":"BMC Public Health"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"559","DOI":"10.1097\/QAD.0000000000002100","article-title":"Sociobehavioral and community predictors of unsuppressed HIV viral load: multilevel results from a hyperendemic rural south African population","volume":"33","author":"Tomita","year":"2019","journal-title":"AIDS"},{"key":"ref10","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0265488","article-title":"Increase in HIV viral suppression in KwaZulu-Natal, South Africa: community-based cross sectional surveys 2018 and 2013. What remains to be done?","volume":"17","author":"Conan","year":"2022","journal-title":"PLoS One"},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0255227","article-title":"To achieve 95-95-95 targets we must reach men and youth: high level of knowledge of HIV status, ART coverage, and viral suppression in the Botswana combination prevention project through universal test and treat approach","volume":"16","author":"Lebelonyane","year":"2021","journal-title":"PLoS One"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2011\/434375","article-title":"Long-term outcome of an HIV-treatment programme in rural Africa: viral suppression despite early mortality","volume":"2011","author":"Barth","year":"2011","journal-title":"AIDS Res Treat"},{"key":"ref13","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0190260","article-title":"Higher retention and viral suppression with adolescent-focused HIV clinic in South 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Method."},{"key":"ref30","year":"2016"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1016\/j.resconrec.2017.05.002","article-title":"Hybrid Sankey diagrams: visual analysis of multidimensional data for understanding resource use","volume":"124","author":"Lupton","year":"2017","journal-title":"Resour Conserv Recycl"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"1433","DOI":"10.1002\/sim.1522","article-title":"A mixed-effects multinomial logistic regression model","volume":"22","author":"Hedeker","year":"2003","journal-title":"Stat Med"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1371\/journal.pone.0213019","article-title":"Respective roles of migration and social deprivation for virological non-suppression in HIV-infected adults on antiretroviral therapy in France","volume":"14","author":"Raho-Moussa","year":"2019","journal-title":"PLoS 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countries","volume":"73","author":"Dear","year":"2021","journal-title":"Clin Infect Dis"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"819","DOI":"10.1097\/QAD.0000000000001761","article-title":"HIV viral suppression and geospatial patterns of HIV antiretroviral therapy treatment facility use in Rakai, Uganda","volume":"32","author":"Billioux","year":"","journal-title":"Aids"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"747","DOI":"10.1111\/tmi.13236","article-title":"Outcomes of patients lost to follow-up after antiretroviral therapy initiation in rural North-Eastern South Africa","volume":"24","author":"Ambia","year":"2019","journal-title":"Trop Med Int Health"},{"key":"ref52","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0000296","article-title":"Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: findings from a cohort study in rural north-eastern South 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