Ethiopia’s HIV Progress Has a Co-Infection Blind Spot

Ethiopia has made significant progress in expanding antiretroviral therapy, but a new study from Northwest Ethiopia shows why the final stretch of HIV control may be the hardest: patients living with both HIV and hepatitis B are being left dangerously short of viral suppression.

The study, conducted across four referral hospitals, found that only about one-third of adults with HIV-HBV co-infection achieved HIV viral suppression. For a country aligned with global HIV targets, that is more than a clinical statistic. It is a warning that treatment access alone is not enough when patients face co-infection, advanced illness, missed appointments and gaps in adherence support.

HIV viral suppression is the key measure of successful treatment. It protects patients, reduces illness and mortality, supports immune recovery and prevents onward transmission. But among people also living with hepatitis B, the risk is significant. HBV co-infection can accelerate liver disease, raise the risk of cirrhosis and liver cancer, and make treatment management more complex.

Titled "Magnitude and Factors Associated with HIV Viral Suppression Among Adult People Living with HIV-HBV Co-Infection in Northwest Ethiopia," the study is published in the journal Tropical Medicine and Infectious Disease.

The suppression gap is too large to ignore

Among 402 adults with HIV-HBV co-infection, only 138 achieved viral suppression, while 264 had unsuppressed viral load. That means roughly two-thirds of this high-risk group were not reaching the treatment outcome that HIV programs depend on. Antiretroviral therapy may be available, but if patients remain unsuppressed, they face higher risk of poor health outcomes and continued transmission. For co-infected patients, poor suppression can also sit alongside HBV-related liver risks, making integrated care even more urgent.

The finding also raises a broader health-system question: are HIV programs sufficiently equipped to manage complex patients? Co-infection is not simply a biological complication. It requires reliable diagnostics, effective regimens, adherence counselling, follow-up systems, liver monitoring and timely clinical response.

The low suppression rate suggests that Ethiopia's HIV response may need a sharper focus on people who are clinically vulnerable, hard to retain in care, or managing more than one chronic infection.

Adherence remains the strongest line of defence

The study found that good medication adherence was the strongest predictor of viral suppression. Patients with good adherence were far more likely to achieve suppression than those with poor adherence. In real-world health systems, adherence is shaped by far more than individual discipline. Transport costs, stigma, side effects, work schedules, food insecurity, depression, family support, clinic waiting times and drug availability can all affect whether a patient takes medicine consistently and returns for refills.

For HIV-HBV co-infected patients, adherence becomes even more critical because the treatment strategy must support control of HIV while also addressing HBV-related risks. Interruptions can undermine viral control, increase the risk of treatment failure and delay clinical intervention.

Adherence support must move beyond generic counselling. Programs should identify patients with poor adherence early and offer targeted support, including peer counselling, reminder systems, community-based follow-up, differentiated refill models and stronger patient education on the risks of missed doses.

The study shows that adherence, which is often framed as a patient responsibility, is also a service-delivery responsibility.

Missed appointments are early warning signals

Missed clinic appointments were linked to lower odds of viral suppression. A missed appointment should not be treated as an administrative lapse. It may signal deeper barriers: distance from health facilities, unaffordable transport, stigma, fear of disclosure, work conflicts, poor health, medicine stock concerns or dissatisfaction with services. For patients with co-infection, missing visits also means missed opportunities for viral load checks, regimen review, adherence support and early detection of treatment failure.

The finding shifts the focus from blaming patients to redesigning care systems. Stronger appointment tracking, patient reminders, community health worker follow-up and flexible service models could help keep people in care.

Bedridden patients were much less likely to achieve viral suppression than working patients. This points to another vulnerable group that needs more intensive support. Patients with poor functional status may face advanced disease, opportunistic infections, poor nutrition, reduced mobility and dependence on caregivers. Standard clinic-based models may not be enough for them.

For these patients, viral suppression depends not only on prescribing drugs, but on ensuring that care reaches people whose health status makes regular attendance difficult.

Integrated HIV-HBV care is now the real test

HIV programs have been built around scale: testing, treatment initiation, ART distribution and viral load monitoring. But co-infection demands a more integrated model. For HIV-HBV patients, clinicians need to consider ART regimen choice, HBV-active drugs, liver function, treatment duration, adherence and retention together. The study found that longer time on ART and use of a specific TDF-3TC-LPV/r regimen were associated with higher odds of suppression, reinforcing the importance of regimen optimization and sustained treatment engagement.

Notably, the study also has limitations that should guide how its findings are interpreted. Its cross-sectional design cannot prove cause and effect. It relied partly on routine clinical records, which may contain missing or incomplete information. Adherence was self-reported, which can introduce recall or social desirability bias. The study was limited to selected referral hospitals in Northwest Ethiopia, so its findings may not apply to all settings. It also lacked HBV-DNA and HBeAg data because these tests were not routinely available, limiting assessment of HBV activity and treatment response.

Despite the limitations, the study delivers clear policy lessons. Ethiopia and other countries with overlapping HIV and HBV burdens need stronger co-infection screening, better viral load and liver monitoring, patient-centred adherence services, appointment tracking systems, and differentiated care for high-risk patients. Development partners can support this through investment in laboratory capacity, digital follow-up tools, community-based retention models and health-worker training.

For the wider Global South, the study offers a larger lesson. The next phase of HIV progress will not be won by treatment availability alone. It will depend on whether health systems can deliver continuous, integrated and responsive care to patients with complex needs.