Factors associated with knowledge about ‘Undetectable HIV viral load is Untransmittable’ among Zambian adults on antiretroviral therapy: a mixed method approach

  • Fredrick Ngwenya Department of Population Studies, School of Public Health, University of Zambia, Lusaka, Zambia
  • Mpundu Makasa Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
Keywords: human immunodeficiency virus, knowledge, antiretroviral therapy, viral load, sustained virologic response, transmission, Zambia


Background: Knowledge of ‘Undetectable HIV viral load (VL) is Untransmittable’ (U=U) motivates optimal adherence to antiretroviral therapy (ART).

Objective: This study assessed factors associated with knowledge about U=U among Zambian people living with HIV on ART.

Design: The study used questionnaires and in-depth interviews (IDIs) concurrently between December 2018 and January 2019. Three high volume health facilities, Chilenje, Chipata, and Kalingalinga, were selected. A single proportion of 63.4% of HIV VL suppression (VLS) in Lusaka Province was used to calculate a sample size of 362 respondents. Probability proportional to size procedure was used to apportion the sample to the study sites while a simple random technique was employed in selecting respondents aged 18–59 years and on ART for over 9 months. Stata 14 was used to run descriptive and chi-square statistical analyses. Fifty-five respondents were drawn from 362 respondents for IDIs. The selection was based on varied VL levels. Interviews were audio-recorded, transcribed and analysed thematically, and the findings merged in the discussion.

Results: Approximately, 34.5% of the 362 respondents (n = 125) had knowledge about U=U. The VLS status was significantly associated with U=U knowledge (P = 0.01).

Discussion: Diverse information sources, symbiotic understanding of VL, and treatment-as-prevention benefits were enablers of acquiring more knowledge about U=U, while inadequate health discussion about VL and congestion and waiting time were barriers.

Conclusions: The findings suggest that increased information sharing on the implication of suppressed VL being able to prevent HIV transmission could motivate people living with HIV to adhere to ART, thus sustaining VLS.


Download data is not yet available.


Labhardt ND, Ringera I, Lejone TI, et al. When patients fail UNAIDS’ last 90 – the “ failure cascade ” beyond 90-90-90 in rural Lesotho, Southern Africa: A prospective cohort study. J Int AIDS Soc. Published online 2017; 20(1): 1–10. doi: 10.7448/IAS.20.1.21803

Assefa Y, Gilks CF. Ending the epidemic of HIV/AIDS by 2030: Will there be an endgame to HIV, or an endemic HIV requiring an integrated health systems response in many countries? Int J Infect Dis. 2020; 100: 273–277. doi: 10.1016/j.ijid.2020.09.011

Horter S, Wringe A, Thabede Z, et al. “Is it making any difference?” A qualitative study examining the treatment-taking experiences of asymptomatic people living with HIV in the context of Ttreat-all in Eswatini. J Int AIDS Soc. 2019; 22(1): e25220. doi: 10.1002/jia2.25220

Haberer JE, Sabin L, Amico KR, et al. Improving antiretroviral therapy adherence in resource-limited settings at scale: A discussion of interventions and recommendations. J Int AIDS Soc. 2017; 20(1): 11–15. doi: 10.7448/IAS.20.1.21371

Cohen MS, Holmes C, Padian N, Wolf M, Hirnschall, G, Lo YR, Goosby E. HIV treatment as prevention: How scientific discovery occurred and translated rapidly into policy for the global response. Health Aff. 2012; 31(7): 1439–1449. doi: 10.1377/hlthaff.2012.0250

Hosseinipour MC, Kumarasamy N, Hakim JG, et al. Prevention of HIV-1 infection with early antiretroviral therapy. J New Engl J Med. 2011; 365(6): 493–505. doi: 10.1056/NEJMoa1105243

World Health Organiszation. Treatment and care: HIV treatment and care what’s new in treatment monitoring: Viral load and CD4 testing; 2017. Available from: www.who.int/hiv [cited 23 December 2019].

Saito S, Duong YT, Metz M, et al. Returning HIV-1 viral load results to participant-selected health facilities in national Population-based HIV Impact Assessment (PHIA) household surveys in three sub-Saharan African Countries, 2015 to 2016. J Int AIDS Soc. 2017; 20(June): e25004. doi: 10.1002/jia2.25004

Ministry of Health Z. Zambia Population-Based HIV Impact Assessment (ZAMPHIA) 2016: First report, Zambia, Ministry of Health, Lusaka.

Ngwenya F. Knowledge level on treatment -as-prevention among HIV sero positive adults on antiretroviral therapy in three health facilities of Lusaka District in Zambia. University of Univ Zambia Institutional Repository; Published online 2020. Available from: http://dspace.unza.zm/bitstream/handle/123456789/6909/MainDocument.pdf?sequence=1&isAllowed=y [cited 17 January 2023].

Hanrahan CF, Schwartz SR, Mudavanhu M, et al. The impact of community-versus clinic-based adherence clubs on loss from care and viral suppression for antiretroviral therapy patients: Findings from a pragmatic randomized controlled trial in South Africa. PLoS Med. 2019; 16(5): e1002808. doi: 10.1371/journal.pmed.1002808

Campbell C, Scott K, Skovdal M, Madanhire C, Nyamukapa C, Gregson S. A good patient? How notions of ‘a good patient’ affect patient-nurse relationships and ART adherence in Zimbabwe. BMC Infect Dis. Published online 2015; 15: 404. doi: 10.1186/s12879-015-1139-x

Schaefer R, Gregson S, Fearon E, Hensen B, Hallett TB, Hargreaves JR. HIV prevention cascades: a unifying framework to replicate the successes of treatment cascades. Lancet HIV. 2019; 6(1): e60–e66. doi: 10.1016/S2352-3018(18)30327-8

Hayes R, Sabapathy K, Fidler S. Universal testing and treatment as an HIV prevention strategy : research questions and methods. Curr HIV Res. 2011; 2011: 429–445. doi: 10.2174/157016211798038515

Hollingdrake O, Lui C, Mutch A, Dean J, Howard C, Fitzgerald L. Factors affecting the decision to initiate antiretroviral therapy in the era of treatment-as-prevention: synthesis of evidence from qualitative research in high-income settings. AIDS Care. 2019; 31(4): 397–402. doi: 10.1080/09540121.2018.1533235

Bavinton BR, Holt M, Grulich AE, Brown G. Willingness to act upon beliefs about ‘Ttreatment as Pprevention’ among Australian gay and bisexual men. PLoS One. 2016 Jan 7; 11(1): e0145847. 2016;(January). doi: 10.1371/journal.pone.0145847

Killingo BM, Taro TB, Mosime WN. Community-driven demand creation for the use of routine viral load testing: aA model to scale up routine viral load testing. J Int AIDS Soc. 2017; 20: 4–8. doi: 10.1002/jia2.25009

United Nations Joint Programme on HIV/AIDS (UNAIDS). Undetectable = untransmisable public health and HIV viral load supression explained. Published online 2018. Available from: http://www.unaids.org/sites/default/files/media_asset/undetectable-untransmittable_en.pdf%0AUNAIDS.org [cited 2 February 2019].

Bond V, Hoddinott G, Viljoen L, Simuyaba M, Musheke M, Seeley J. gGood health and moral responsibility: Key concepts underlying the interpretation of treatment as prevention in South Africa and Zambia before rolling out universal HIV testing and treatment. AIDS Patient Care STDS. 2016; 30(9): 425–434. doi: 10.1089/apc.2016.0114

Seeley J, Bond V, Yang B, et al. Understanding the time needed to link to care and start ART in seven HPTN 071 (PopART) study communities in Zambia and South Africa. AIDS Behav. 20189; 23(4): 929–46071(0123456789). doi: 10.1007/s10461-018-2335-7

Orne-Gliemann J, Larmarange J, Boyer S, et al. Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal. BMC Public Health. Published online 2015; 15: 209. doi: 10.1186/s12889-015-1344-y

Okoli C, Van De Velde N, Richman B, et al. Undetectable equals untransmittable (U = U): aAwareness and associations with health outcomes among people living with HIV in 25 countries. Sex Transm Infect. 2021; 97(1): 18–26. doi: 10.1136/sextrans-2020-054551

Kim H-Y, Hanrahan CF, Dowdy DW, Martinson N, Golub J, Bridges JFP. The effect of partner HIV status on motivation to take antiretroviral and isoniazid preventive therapies: a conjoint analysis. AIDS Care. 2018; 30(10): 1298–1305. doi: 10.1080/09540121.2018.1455958

Das M, Chu PL, Santos G, Scheer S, Vittinghoff E, Colfax GN. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One. 2010; 5(6): e11068. doi: 10.1371/journal.pone.0011068

Card KG, Armstrong HL, Lachowsky NJ, et al. Belief in treatment as prevention and its relationship to HIV status and behavioral risk. J Acquir Immune Defic Syndr. 2018; 77(1): 8–16. doi: 10.1097/QAI.0000000000001557

Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. JAMA. 2019; 321(5): 451–452. doi: 10.1001/jama.2018.21167

Hayes R. HPTN 071 demonstrates community-wide HIV prevention strategy can reduce new infections. In: Conference on Retroviruses and Opportunistic Infections (CROI); 2019. Available from: doi:http://www.croiconference.org/ [cited 15 December 2019].

Bond V, Hoddinott G, Viljoen L, et al. How ‘place’ matters for addressing the HIV epidemic: evidence from the HPTN 071 (PopART) cluster-randomised controlled trial in Zambia and South Africa. Trials. 2021; 22(1): 1–13. doi: 10.1186/s13063-021-05198-5

Boyd MA, Shah M, Barradas DT, et al. Increase in Antiretroviral therapy enrollment among persons with HIV infection during the Lusaka HIV treatment surge – Lusaka Province, Zambia, January 2018–June 2019. MMWR Morb Mortal Wkly Rep. 2020; 69(31): 1039–1043. doi: 10.15585/mmwr.mm6931a4

Cochran W. Sampling techniques. 2nd ed. John Wiley & Sons; 1963. Available from: https://books.google.co.zm/books?id=Y-SxXwAACAAJ [cited 14 January 2023].

United Nations Joint Programme on HIV/AIDS (UNAIDS). Test and treat showing results in Uganda and Zambia. Published online 2018. Available from: https://www.unaids.org./en [cited 10 October 2018].

Silwamba A. Issues surrounding adoption of electronic health records in the Zambia defence force: A case study of Kalewa Urban Health Centre. Texila Int J Public Health. Published online 2019; 7: 81–87. doi: 10.21522/tijph.2013.se.19.02.art013

Mweebo K. Security of electronic health records in a resource limited setting: The case of Smart-Care electronic health record in Zambia. 3rd Aust eHealth Informatics Secur Conf. Published 2014. Available from: 10.4225/75/5798297631b47 [cited 10 January 2023].

Hayes R, Ayles H, Beyers N, et al. HPTN 071 (PopART): Rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment – a study protocol for a cluster randomised trial. Trials. 2014; 15(1): 57. doi: 10.1186/1745-6215-15-57

Agency for Co-operation and Research in Development (ACORD). ARV Ccommunity Kknowlegde, Aawareness, Aaccessibility and the Policy Eenvironment: A Ccompendium Rreport of Tanzania, Mozambique and Burkina Faso; 2007. Available from: www.acordinternational.org

Kasumu Lo BM. Knowledge and attitude towards antiretroviral therapy and adherence pattern of HIV patients in southwest Nigeria. Int J Infect Control. 2014; 10(3): 1–8. doi: 10.3396/IJIC.v10i3.024.14

Barradas DT, Gupta S, Moyo C, et al. Williams, D.B., Patel, H., Dobbs, T., Nakazwe, C and Kasongo W. Oral abstracts of the 21st International AIDS Conference. J Int AIDS Soc. 2017; 20(0): 30–36. doi: 10.7448/ias.20.6.22188

Ellman TM, Alemayehu B, Abrams EJ, Arpadi S, Howard AA, El-Sadr WM. Selecting a viral load threshold for routine monitoring in resource-limited settings: Ooptimizing individual health and population impact. J Int AIDS Soc. 2017; 20: 16–18. doi: 10.1002/jia2.25007

El-sadr WM, Rabkin M, Nkengasong J, Birx DL. Realizing the potential of routine viral load testing in sub-Saharan Africa. J Int AIDS Soc. 2017; 20: 1–3. doi: 10.1002/jia2.25010

Grimsrud A, Lesosky M, Kalombo C, Bekker LG, Myer L. Community-based adherence clubs for the management of stable antiretroviral therapy patients in Cape Town, South Africa: A cohort study. J Acquir Immune Defic Syndr. 2016; 71(1). doi: 10.10.1097/QAI.0000000000000863

Mukumbang FC, Van Wyk B, Van Belle S, Marchal B. Unravelling how and why the Aantiretroviral Aadherence Cclub Iintervention works (or not) in a public health facility: A realist explanatory theory-building case study. PLoS One. 2019; 14(1): e0210565. doi: 10.1371/journal.pone.0210565

Schwartz SR, Kavanagh MM, Sugarman J, et al. HIV viral load monitoring among key populations in low- and middle-income countries: Challenges and opportunities. J Int AIDS Soc. 2017; 20(Suppl. 7): e25003. doi: 10.1002/jia2.25003

Tsondai PR, Wilkinson LS, Grimsrud A, Mdlalo PT, Ullauri A, Boulle A. High rates of retention and viral suppression in the scale-up of antiretroviral therapy adherence clubs in Cape Town, South Africa. J Int AIDS Soc. 2017; 20(Suppl. 4): 21649. doi: 10.7448/IAS.20.5.21649

Levesque J, Harris MF, Russell G. Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013; 12(1): 1. doi: 10.1186/1475-9276-12-18

Renju J, Moshabela M, McLean E, et al. ‘Side effects’ are ‘central effects’ that challenge retention in HIV treatment programmes in six sub-Saharan African countries: A multicountry qualitative study. Sex Transm Infect. 2017; 93(Suppl. 3): e052971. doi: 10.1136/sextrans-2016-052971

Bond V, Ngwenya F, Thomas A, et al. Spinning plates: livelihood mobility, household responsibility and anti-retroviral treatment in an urban Zambian community during the HPTN 071 (PopART) study. J Int AIDS Soc 2018 Jul; 21 Suppl 4: e25117. doi: 10.1002/jia2.25117

Thomas R, Friebel R, Barker K, et al. Work and home productivity of people living with HIV in Zambia and South Africa. AIDS. 2019; 33(June 2018): 1063–1071. doi: 10.1097/QAD.0000000000002160

Prust M, Banda C, Nyirenda R, et al. Multi-month prescriptions, fast-track refills, and community ART groups: Results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals. J Int AIDS Soc. 2017; 20(Suppl. 4): 2165041-50. doi: 10.7448/IAS.20.5.21650

Warrier R, Pry JJ, Elish P, Kaumba P, Smith H, Sikazwe I, Bolton C, Herce M. The" Failure Cascade" for patients with unsuppressed viral load in Zambia: Results from a large HIV treatment cohort. In Journal Of The International Aids Society 2019 Jul 1 (Vol. 22, pp. 71-71). The Atrium, Southern Gate, Chichester, W Sussex, England: John Wiley & Sons Ltd.

How to Cite
Ngwenya, F., & Makasa, M. (2023). Factors associated with knowledge about ‘Undetectable HIV viral load is Untransmittable’ among Zambian adults on antiretroviral therapy: a mixed method approach. International Journal of Infection Control, 19. https://doi.org/10.3396/ijic.v19.20588
Original Articles