Viral load suppression rate of third-line antiretroviral therapy and its association with gender among HIV patients after second-line treatment failure in Africa: a systematic review and meta-analysis

Introduction
Previous works of literatures on the viral load suppression rate of third line antiretroviral therapy in Africa has produced inconsistent and inconclusive results, with rates varying between 62% and 95%. This variability poses challenges for policymakers and healthcare providers in making informed decisions. This systematic review and meta-analysis aimed to determine the overall viral load suppression rate of third line antiretroviral therapy in Africa and to clarify the contradictory relationship between gender and viral load suppression, based on existing primary studies.

Methods
A systematic review and meta-analysis were conducted using PubMed, Medline, Cochrane Library, Henari, African Journals Online (AJOL), Web of science, and Google Scholar to access studies up to December 6, 2024. The PRISMA guideline, JBI, and Newcastle Ottawa quality assessment scale checklists were used. Heterogeneity was evaluated with Cochrane’s Q and I2 statistics. Publication bias was checked using a funnel plot, Begg’s and Egger’s test, followed by the DerSimonian and Laird random effects model. Meta-regression, subgroup and sensitivity analyses were also performed. The odds ratio with a 95% confidence interval was used to assess the association of gender with the viral load suppression rate in patients on third-line antiretroviral therapy. All analyses were conducted using Stata 18.

Results
A total of 14 primary studies with a total sample size of 1791 were included. The pooled magnitude of the viral load suppression rate was 79.82% (95%CI: 75.75%, 83.90%). Around 75% of the included studies’ heterogeneity were explained by country, study year, study settings and quality level of the study level variables. There was not statistically significant association of gender with viral load suppression rate of third line antiretroviral therapy.

Conclusion and recommendation
The pooled magnitude of the viral load suppression rate was 79.82%. There was not statistically significant association of gender with viral load suppression rate of third line antiretroviral therapy. Therefore, to maintain and further improve the strong viral load suppression rates of TLARVT in Africa, it is essential to focus on appropriate regimen selection, patient counseling and switching, adherence support, and regular viral load testing. Future studies with larger sample sizes should explore the association between gender and viral load suppression to provide conclusive findings. © The Author(s) 2025.