Factors Associated With HIV Viral Suppression Failure in Children, Adolescents

child's hands holding red ribbon
Close up horizontal image of child’s hands holding red ribbon on white background, HIV awareness concept, world AIDS day. Flat lay, top view, copy space
Investigators conducted a study to determine the factors associated with viral suppression failure among children and adolescents with HIV infection

Challenges unique to children and adolescents with HIV infection living in Kenya, including poor antiretroviral therapy (ART) adherence and unsuppressed maternal viral load were found to be inversely correlated with viral suppression (VS), according to results of a randomized cross-sectional study published in Clinical Infectious Diseases.

Between December 2018 and March 2020, investigators enrolled children and adolescents (age range, 1-19 years) with HIV infection. Eligible participants included those who were started on first- or second-line ART within the past 6 months and had attended at least 1 follow-up ART visit within the past 6 months. Participants with HIV RNA viral load counts greater than or equal to 1000 copies/mL were tested for major mutations that conferred resistance to HIV medications. The medications included nucleoside reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), and protease inhibitors (PI). Wilson score method was used to estimate (VS) prevalence, with VS defined according to criteria established by the World Health Organization (WHO) as an HIV viral load greater than 1000 copies/mL. They used Poisson regression models and prevalence ratios to determine associations between potential predictors of VS.

There were a total of 969 participants enrolled in the study, of whom 935 has complete case data and were included in further analyses. Among the total cohort, the median age was 12 (IQR, 8-15) years and 51.6% were women. In regard to the duration of ART among the included participants, 2.1% had been taking ART for less than 1 year, 6.0% for 1 to 2 years, and 91.9% for more than 2 years, with a median duration of 2.3 (IQR, 0.7-4.5) years. Referrals for other services, such as nutrition support, were common, with a median of 10 (IQR, 4-23) referrals for other services and a median of 7 (IQR, 2-13) referrals for adherence counseling.

Among all participants included in the final analysis, the prevalence of VS was 0.80 (95% CI, 0.78-0.83). The prevalence of VS was decreased among participants on second-line ART (0.75; 95% CI, 0.70-0.79) compared with those on first-line ART (0.83; 95% CI, 0.80 to 0.86). In addition, the investigators noted that the prevalence of VS decreased among participants aged between 10 and 14 years compared with those between 1 and 9 years, as well as those between 15 and 19 years.

The investigators found that treatment with ART for more than 24 months was independently associated with VS (adjusted prevalence ratio [aPR], 1.22; 95% CI, 1.06-1.41). Other factors independently associated with VS included treatment with an INSTI (aPR, 1.13; 95% CI, 1.02-1.26) and admission to a level 3 health facility (aPR, 1.23; 95% CI, 1.11-1.36).

Factors found to be inversely associated with VS included missing 3 or more ART doses in the past month (aPR, 0.73; 95% CI, 0.58-0.92), unknown malnutrition status (aPR, 0.79; 95% CI, 0.66 to 0.95), and an unsuppressed maternal HIV RNA viral load (aPR, 0.72; 95% CI, 0.53 to 0.98). The number of referrals for adherence counseling was also found to be inversely associated with VS: 3 to 7 referrals (aPR, 0.90; 95% CI, 0.83-0.97), 8 to 13 referrals (aPR, 0.89; 95% CI, 0.82-0.97), and 14 referrals or more (aPR, 0.84; 95% CI, 0.77-0.92).

The investigators found evidence of major mutations that conferred resistance to HIV medications among a total of 119 (81.5%) participants.

This study was limited by its cross-sectional design, the lack of assessment for weight-based dosing and integrase resistance, and that measurements of ART adherence were self-reported.

“Results from this study stress the importance of optimizing regimens to include INSTIs and evaluating the effectiveness of adherence counseling programs across all levels of health care settings,” the investigators concluded.


Tsikhutsu I, Bii M, Dear N, et al. Prevalence and correlates of viral load suppression and HIV drug resistance among children and adolescents in South Rift Valley and Kisumu, Kenya. Clin Infect Dis. Published online January 29, 2022. doi:10.1093/cid/ciac059/6517349