The HIV care cascade for adolescents initiated on antiretroviral therapy in a health district of South Africa: a retrospective cohort study

Trend and factors associated with non-suppression of viral load among adolescents on ART in Tanzania: 2018-2021

Background

Tanzania is one of the countries with a high burden of HIV. It has an estimated 1.4 million people living with HIV in 2021. Adolescents living with HIV on antiretroviral therapy (ART) have worse treatment adherence, viral suppression, and mortality rates compared to adults. This study aim was to determine the trend of non-suppression among adolescents on ART in Tanzania from 2018 to 2021 and latest associated predictors.

Methodology

The study utilized data of adolescents (10-19 years) receiving ART in Tanzania mainland for the period of 2018-2021 from the National Care and Treatment Centers database. The primary outcome of interest was non-suppression of viral load, defined as a VL above 1,000 copies/ml. The study employed multivariable logistic regression models to identify factors associated with non-suppression of VL. STATA 15 statistical software was used to analyze the data.

Results

Records of 65,942 adolescents present in the CTC database Tanzania were analyzed. Approximately more than half were female 38,544 (58.5%). The proportion of non-suppression was 34.5%, 23.3%, 12.1%, and 9.7% for the years 2018-2021, respectively. After adjusting for other factors, adolescents with a history of poor adherence to ART in the last six months had higher odds of non-suppression (OR = 1.95, 95% CI = 1.64, 2.31). Adolescents on second or third line ART regimens were almost two times more likely to be non-suppressed compared to those on first-line regimens (OR = 2.85, 95% CI = 2.52, 3.23). Girls had lower odds of non-suppression compared to boys (OR = 0.91, 95% CI = 0.84, 0.98), and similarly, patients attending hospitals had lower odds compared to those attending dispensaries (OR = 0.79, 95% CI = 0.72, 0.87).

Conclusion

Being female, having good history of adherence over the last six months, and attending hospital level was significantly associated with lower levels of non-suppression, while being on second line ART or attending lower health facilities increased the odds of non-suppression. Efforts to enhance the quality and capacity of health services at lower-level facilities (dispensaries and health centers) should be prioritized, as well as promoting gender-sensitive approaches that take into account the unique needs and experiences of adolescent girls and boys are needed to improve VL suppression among this population.

Analysis of HIV drug prophylaxis services cascade in healthcare workers: a cross-sectional study in China

BACKGROUND

Human immunodeficiency virus (HIV) drug prophylaxis, including post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), has not yet been generally recognized and accepted by the whole society in China, and the utilization coverage among high-risk populations is low. Healthcare workers (HCWs) are important to the promotion and implementation of HIV drug prophylaxis strategy. This study analyzed the HIV drug prophylaxis services cascade (knowledge, attitude, and service) in HCWs, and explored the correlations between PEP and PrEP.

METHODS

A cross-sectional study was conducted among 1066 HCWs in 20 designated hospitals for HIV antiretroviral therapy in 20 cities in China. We collected information on participants' essential characteristics, HIV drug prophylaxis services cascade (knowledge, attitude, and service) and so on. The Chi-square test was used to analyse whether the differences and correlations between categorical variables were statistically significant, and Pearson contingency coefficient was used to analyse the strength of correlations. Multivariable logistic regression was used to analyse associated factors.

RESULTS

Among three stages of HIV drug prophylaxis services cascade, a high percentage of 1066 participants had knowledge of HIV drug prophylaxis (PEP: 78.2%, PrEP: 80.0%). Of them, almost all had supportive attitudes towards HIV drug prophylaxis (PEP: 99.6%, PrEP: 98.6%). Only about half of them would provide HIV drug prophylaxis services (PEP: 53.5%, PrEP: 48.5%). There were positive correlations between knowledge of PEP and PrEP (r = 0.292), between attitudes toward PEP and PrEP (r = 0.325), and between provision of PEP services and PrEP services (r = 0.555) in HCWs.

CONCLUSIONS

There was a positive correlation between PEP and PrEP in HCWs. At the stage of providing HIV drug prophylaxis services, training, advocacy and education for HCWs, should be targeted and also combine PEP and PrEP to maximize the effects, so as to improve the enthusiasm of HCWs to provide HIV drug prophylaxis services.

A youth-centred approach to improving engagement in HIV services: human-centred design methods and outcomes in a research trial in Kisumu County, Kenya

IntroductionInnovative interventions are needed to improve HIV outcomes among adolescents and young adults (AYAs) living with HIV. Engaging AYAs in intervention development could increase effectiveness and youth acceptance, yet research is limited. We applied human-centred design (HCD) to refine adherence-support interventions pretrial and assessed HCD workshop acceptability.

METHODS

We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants.

RESULTS

Twenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants.

CONCLUSIONS

Research employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions.

Exploring Self-reported Adherence Measures to Screen for Elevated HIV Viral Load in Adolescents: A South African Cohort Study

The timely identification of ART non-adherence among adolescents living with HIV presents a significant challenge, particularly in resource-limited settings where virologic monitoring is suboptimal. Using South African adolescent cohort data (N = 933, mean age 13.6 ± 2.89 years, 55.1% female, follow-up = 2014-2018), we examined the association between elevated viral load (VL ≥ 1000 copies/mL) and seven self-reported adherence measures on missed doses, and clinic appointments -with varying recall timeframes. The best performing measures, which were significantly associated with elevated viral load in covariate-adjusted models are: any missed dose -past 3 days (sensitivity = 91.6% [95%CI: 90.3-92.8], positive predictive value (PPV) = 78.8% [95%CI: 77.2-80.4]), -past week (sensitivity = 87% [95%CI: 85.4-88.6], PPV = 78.2% [95%CI: 76.5-79.9]), -past month (sensitivity = 79.5% [95%CI: 77.5-81.4], PPV = 78.2% [95%CI: 76.4-79.9]), any past-month days missed (sensitivity = 86.7% [95%CI: 85.1-88.3], PPV = 77.9% [95%CI:76.2-79.6]), and any missed clinic appointment (sensitivity = 88.3% [95%CI: 86.8-89.8], PPV = 78.4% [95%CI: 76.8-79.9]). Combining the three best performing measures missed dose -past 3 days, -past week, and any past-year missed clinic appointment increased sensitivity to 96.4% while maintaining a PPV of about 78%. The discriminatory power of simple and easy-to-administer self-reported adherence measures in detecting elevated viral load warrants consideration in resource-limited settings and may contribute to the aims of the new Global Alliance to End AIDS in children and adolescents by 2030.

"If they had a place to live, they would be taking medication": a qualitative study identifying strategies for engaging street-connected young people in the HIV prevention-care continuum in Kenya

INTRODUCTION

Street-connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention-care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention-care continuum from healthcare providers, policymakers, community members and SCY in Kenya.

METHODS

This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in-depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men.

RESULTS

Our analysis resulted in four major themes corresponding to stages in the HIV prevention-care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient-centred and responsive to the diversity of their circumstances. The use of pre-exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer-based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer-based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence.

CONCLUSIONS

This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti-poverty strategies as cash transfers and provision of food. Peer-based interventions are a clear option but require SCY-specific adaptation to be implemented effectively.

Mode of HIV acquisition among adolescents living with HIV in resource-limited settings: A data-driven approach from South Africa

Adolescents living with HIV (ALHIV) face unique treatment and care challenges which may differ by how they acquired HIV, whether vertically (in-utero, perinatal or postnatal exposure during breastfeeding) or sexually (sexual exposure). Distinguishing and documenting the mode of HIV acquisition (MOHA) is crucial to further research on the different needs and outcomes for ALHIV and to tailor HIV services to their needs. Age-based cut-offs have been used to attribute MOHA but have not been validated. We analysed data from a three-wave cohort of n = 1107 ALHIV part of a longitudinal study in South Africa. Age-based MOHA was allocated using age at ART initiation, validated against a logic-tree model based on literature-hypothesised factors: self-reported HIV, sexual, and family history. After testing six ART initiation age cut-offs (10 to 15 years old), we determined the optimal MOHA cut-off age by calculating the sensitivity and specificity for each cut-off, measured against the final logic-tree allocation. Following validation using this longitudinal study, the methodology is extended to 214 additional third-wave participants-adolescent girls and young women living with HIV who became mothers before the age of 20. Finally, descriptive statistics of the final allocations are presented. Among the 1,063 (96.0%) cohort study participants classified, 68.7% acquired HIV vertically, following validation. ART initiation before cut-off age 10 had the highest sensitivity (58.9%) but cut-off age 12 had the largest area under the curve (AUC) (0.712). Among the additional young mothers living with HIV, 95.3% were estimated to have acquired it sexually, following the same algorithm. For this group, while cut-off ages 10 to 12 had the highest sensitivity (92.2%), age 14 had the highest AUC (0.703). ART initiation before 10 years old is strongly associated with vertical HIV acquisition. Therefore, a cut-off age of 10 would remain the recommendation in LMIC regions with similar epidemiology as South Africa for determining MOHA in research and clinic settings.

Traditional and biomedical health practices of adolescent boys and young men living with perinatally-acquired HIV in the Eastern Cape Province of South Africa

Men are less vulnerable to HIV acquisition than women, but have poorer HIV-related health outcomes. They access HIV services less, and are more likely to die on antiretroviral therapy. The adolescent epidemic presents further challenges, and AIDS-related illness is the leading cause of death among adolescents in sub-Saharan Africa. We explored the health practices of adolescent boys and young men (aged 13-22) living with perinatally-acquired HIV and the processes through which these practices are formed and sustained. We engaged health-focused life history narratives (n = 35), semi-structured interviews (n = 32) and analysis of health facility files (n = 41), alongside semi-structured interviews with traditional and biomedical health practitioners (n = 14) in the Eastern Cape, South Africa. Participants did not access traditional products and services for HIV, a finding that deviates from much of the literature. Findings suggest that health practices are mediated not only by gender and culture, but also childhood experiences of growing up deeply embedded in the biomedical health system.

Contextual Factors Influencing Self-Management of Adolescents and Youth Living with HIV: A Cross-Sectional Survey in Lesotho

Background: HIV treatment outcomes of adolescents and youth living with HIV (AYLWH) are lagging. One way to improve outcomes is through supporting AYLWH to acquire self-management skills. Although self-management is associated with improved health outcomes, condition-specific, individual/family, and social/environmental contextual factors influence self-management. We aimed to describe factors influencing the self-management of AYLWH in Lesotho. Methods: A cross-sectional survey design was used. AYLWH (n = 183) aged 15−24 were conveniently sampled from two HIV treatment sites in Lesotho. Participants completed self-report questionnaires in English or Sesotho. Results: Participants (89.1% female) had high HIV self-management scores (mean 92.7%, SD 5.3%) that corresponded with treatment outcomes (98.9% adherent and 100% viral load < 1000 copies/mL). This might be attributed to condition-specific factors, including once-daily doses (100%) and longer duration of treatment (81.4% on ART for more than 10 years). Participants were older (median age 22), and the majority (61.7%) had stable living conditions. Individual strengths were associated with higher self-management scores (p < 0.01) and mental health problems with lower self-management scores (p < 0.05). Most (97.9%) were satisfied with their health care services. Conclusions: Uncomplicated treatment regimens, longer duration of treatment, stable living conditions, individual strengths, good mental health, and satisfaction with healthcare services have a positive influence on self-management.

Viral suppression among adolescents on HIV treatment in the Sedibeng District, Gauteng province

Background

Progress has been made to increase access to antiretroviral therapy (ART) for adolescents living with HIV (ALHIV) to improve their survival, but ALHIV still have worse treatment adherence and viral suppression compared to adults and children.

Objective

To determine the prevalence of viral suppression and the associated factors among adolescents aged 10–19 years on ART at an urban public primary healthcare facility in the Sedibeng district, Gauteng.

Method

A cross-sectional survey was conducted among 192 adolescents who were on ART for at least six months between 2015 and 2018. A self-developed data extraction tool was used to collect data from the Tier.Net electronic database and clinical folders. Data were captured on Microsoft Excel, and descriptive and inferential analyses were performed using SPSS 27 statistical software.

Results

The median age at ART initiation of adolescents was 9.0 years (interquartile range [IQR]: 5.0–12.0), and the median duration on ART was 70.5 (IQR: 30.25–105.5) months. The prevalence of viral suppression (< 1000 copies/mL) among adolescents on ART was 74%, with 41% achieving full suppression (< 50 copies/mL). Those adolescents who reported optimal ART adherence were more likely to be virally suppressed compared to those who reported poor adherence (98.1% vs 25.0%; p ≤ 0.001).

Conclusion

Adolescent viral suppression of 74% is higher than in comparable sites, but still way too short of the UNAIDS target of 90%. We recommend adherence support for adolescents to achieve viral suppression.

Contribution

The study highlights the urgent need for targeted adherence support interventions for adolescents living with HIV on antiretroviral therapy to improve rates of viral suppression to meet UNAIDS target of 95%.

Viral load monitoring for people living with HIV in the era of test and treat: progress made and challenges ahead - a systematic review

Background

In 2016, we conducted a systematic review to assess the feasibility of treatment monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in low and middle-income countries (LMICs), in line with the 90-90-90 treatment target. By 2020, global estimates suggest the 90-90-90 target, particularly the last 90, remains unattainable in many LMICs. This study aims to review the progress and identify needs for public health interventions to improve viral load monitoring and viral suppression for PLHIV in LMICs.

Methods

A literature search was conducted using an update of the initial search strategy developed for the 2016 review. Electronic databases (Medline and PubMed) were searched to identify relevant literature published in English between Dec 2015 and August 2021. The primary outcome was initial viral load (VL) monitoring (the proportion of PLHIV on ART and eligible for VL monitoring who received a VL test). Secondary outcomes included follow-up VL monitoring (the proportion of PLHIV who received a follow-up VL after an initial elevated VL test), confirmation of treatment failure (the proportion of PLHIV who had two consecutive elevated VL results) and switching treatment regimen rates (the proportion of PLHIV who switched treatment regimen after confirmation of treatment failure).

Results

The search strategy identified 1984 non-duplicate records, of which 34 studies were included in the review. Marked variations in initial VL monitoring coverage were reported across study settings/countries (range: 12–93% median: 74% IQR: 46–82%) and study populations (adults (range: 25–96%, median: 67% IQR: 50–84%), children, adolescents/young people (range: 2–94%, median: 72% IQR: 47–85%), and pregnant women (range: 32–82%, median: 57% IQR: 43–71%)). Community-based models reported higher VL monitoring (median: 85%, IQR: 82-88%) compared to decentralised care at primary health facility (median: 64%, IRQ: 48-82%). Suboptimal uptake of follow-up VL monitoring and low regimen switching rates were observed.

Conclusions

Substantial gaps in VL coverage across study settings and study populations were evident, with limited data availability outside of sub-Saharan Africa. Further research is needed to fill the data gaps. Development and implementation of innovative, community-based interventions are required to improve VL monitoring and address the “failure cascade” in PLHIV on ART who fail to achieve viral suppression.

Factors associated with viral suppression among adolescents on antiretroviral therapy in Free State province, South Africa

Background

In 2019, about 1.7 million adolescents between the ages of 10 and 19 years were living with HIV worldwide, of which 170 000 were newly infected with HIV in 2019. South Africa has the highest number of persons living with HIV. Although there has been major improvement in access to antiretroviral therapy (ART), it is still unclear what proportion of adolescents (aged 10–19 years) are virally suppressed in the provinces of South Africa.

Objectives

To determine the prevalence of and the factors associated with viral suppression among adolescents (10–19 years) on ART in the Thabo Mofutsanyane District Municipality of the Free State province of South Africa.

Method

A retrospective cross-sectional analysis of demographic, clinical and treatment-related information that were extracted from an electronic database was conducted using Statistical Package for the Social Sciences version 26.

Results

The median duration on ART was 6.58 years. Although 78% (n = 4520) of adolescents living with HIV who were on ART achieved viral suppression (< 1000 copies/mL), only 9.5% (n = 430) were fully suppressed at < 50 copies/mL. In multivariate analysis, the odds of being virally suppressed reduced with increasing age at ART initiation. Adolescents with CD4 counts greater than 500 cells/mm³ at baseline had a higher odds ratio of viral suppression (adjusted odds ratio [AOR]: 1.77; confidence interval [CI]: 1.28–2.47). The odds of viral suppression were significantly lower among those not retained in care (AOR: 0.45; CI: 0.35–0.58).

Conclusion

Tailored interventions should be developed to improve viral suppression among adolescents on ART.

Predictors and consequences of HIV status disclosure to adolescents living with HIV in Eastern Cape, South Africa: a prospective cohort study

INTRODUCTION

The World Health Organization recommends full disclosure of HIV-positive status to adolescents who acquired HIV perinatally (APHIV) by age 12. However, even among adolescents (aged 10-19) already on antiretroviral therapy (ART), disclosure rates are low. Caregivers often report the child being too young and fear of disclosure worsening adolescents' mental health as reasons for non-disclosure. We aimed to identify the predictors of disclosure and the association of disclosure with adherence, viral suppression and mental health outcomes among adolescents in sub-Saharan Africa.

METHODS

Analyses included three rounds (2014-2018) of data collected among a closed cohort of adolescents living with HIV in Eastern Cape, South Africa. We used logistic regression with respondent random-effects to identify factors associated with disclosure, and assess differences in ART adherence, viral suppression and mental health symptoms between adolescents by disclosure status. We also explored differences in the change in mental health symptoms and adherence between study rounds and disclosure groups with logistic regression.

RESULTS

Eight hundred and thirteen APHIV were interviewed at baseline, of whom 769 (94.6%) and 729 (89.7%) were interviewed at the second and third rounds, respectively. The proportion aware of their HIV-positive status increased from 63.1% at the first round to 85.5% by the third round. Older age (adjusted odds ratio [aOR]: 1.27; 1.08-1.48) and living in an urban location (aOR: 2.85; 1.72-4.73) were associated with disclosure between interviews. There was no association between awareness of HIV-positive status and ART adherence, viral suppression or mental health symptoms among all APHIV interviewed. However, among APHIV not aware of their status at baseline, adherence decreased at the second round among those who were disclosed to (N = 131) and increased among those not disclosed to (N = 151) (interaction aOR: 0.39; 0.19-0.80). There was no significant difference in the change in mental health symptoms between study rounds and disclosure groups.

CONCLUSIONS

Awareness of HIV-positive status was not associated with higher rates of mental health symptoms, or lower rates of viral suppression among adolescents. Disclosure was not associated with worse mental health. These findings support the recommendation for timely disclosure to APHIV; however, adherence support post-disclosure is important.

Accelerating ontological security for South African adolescents living in high HIV-prevalence areas: a longitudinal study

Ontological security is the personal need to build fundamental certainty about the continuity of life events. It is central to long-term human development, particularly among adolescents in highly vulnerable communities in South Africa. We examined the cumulative effects of eight hypothesised provisions (development accelerators) in reducing the risks of ontological insecurity outcomes aligned with Sustainable Development Goals (SDGs) targets. Three waves of survey data from adolescents living in high HIV prevalence areas in South Africa were analysed. We used standardised tools to measure twelve outcomes linked to two dimensions of ontological security: mental health and violence. Sustained receipt (at baseline and follow-ups) of eight hypothesised accelerators were examined: emotional and social support, parental/caregiver monitoring, food sufficiency, accessible health care, government cash transfers to households, basic economic security, positive parenting/caregiving, and participation in extramural activities. Associations of all accelerators with outcomes were evaluated using multivariable regressions controlling for age, sex, orphanhood and HIV status, rural/urban location, and informal housing. Cumulative effects were tested using marginal effects modelling. Of 1,519 adolescents interviewed at baseline, 1,353 (89%) completed the interviews at two follow-ups. Mean age was 13.8 at baseline; 56.6% were female. Four provisions were associated with reductions in twelve outcomes. Combinations of accelerators resulted in a percentage reduction risk in individual indicators up to 18.3%. Emotional and social support, parental/caregiver monitoring, food sufficiency and accessible health care by themselves and in combination showed cumulative reductions across twelve outcomes. These results deepen an essential understanding of the long-term effects of consistent exposure to accelerators on multi-dimensional human development. They could be directly implemented by existing evidence-based interventions such as peer-based psychosocial support, parenting programmes, adolescent-responsive healthcare and food support, providing safer and healthier environments for South African adolescents to thrive.

Determinants of viral suppression among adolescents on antiretroviral treatment in Ehlanzeni district, South Africa: a cross-sectional analysis

BACKGROUND

Achieving undetectable viral load is crucial for the reduction of HIV transmissions, AIDS-related illnesses and death. Adolescents (10 to19 years) living with HIV (ALHIV) on antiretroviral treatment (ART) have worse treatment adherence and lower viral suppression rates compared to adults. We report on the clinical factors associated with viral suppression among ALHIV in the Ehlanzeni district, Mpumalanga in South Africa.

METHODS

A cross-sectional analysis was conducted with 9386 ALHIV, aged 10 to 19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Clinical and immunological data were obtained from electronic medical records (Tier.net). ALHIV were categorised as having achieved viral suppression if their latest viral load count was < 1000 ribonucleic acid (RNA) copies/mL. Using a backward stepwise approach, a multivariate logistic regression analysis was performed to identify factors independently associated with viral suppression.

RESULTS

The mean age of the participants was 14.75 years (SD = 2.9), and 55.43% were female. Mean duration on ART was 72.26 (SD = 42.3) months. Of the 9386 adolescents with viral load results recorded, 74% had achieved viral suppression. After adjusting for other covariates, the likelihood of achieving viral suppression remained significantly higher among ALHIV who were: female (AOR = 1.21, 95% CI 1.05-1.39), and had most recent CD4 count > 200 (AOR = 2.53, 95% CI 2.06-3.11). Furthermore, the likelihood of having viral suppression was lower among adolescents with CD4 count > 200 at baseline (AOR = 0.73, 95% CI 0.61-0.87), and who were switched to second line regimen (AOR = 0.41, 95% CI 0.34-0.49).

CONCLUSIONS

Viral suppression amongst ALHIV at 74% is considerably lower than the WHO target of 95%. Of particular concern for intervention is the lower rates of viral suppression amongst male ALHIV. Greater emphasis should be placed to early enrolment of ALHIV on ART and keeping them engaged in care (beyond 6 months). Furthermore, improved and regular viral load monitoring will help to adequately identify and manage ALHIV with unsuppressed viral load and subsequently switching to second line treatment.