Assessing the association between compliance to intensive adherence counselling and viral suppression among children and adolescents living with HIV in Karamoja sub region, Uganda

Abstract

Viral load suppression (VLS) among children and adolescents living with HIV (CALHIV) remains below the 95% target in many settings; in Uganda, only about 60% of CALHIV on antiretroviral therapy (ART) are suppressed. Intensive adherence counselling (IAC) is recommended for non-suppressed patients, but evidence on its effectiveness in pastoralist, resource-limited settings such as Karamoja is limited. This study had two complementary objectives. The quantitative objective was to assess the association between compliance to IAC and viral load suppression among CALHIV at ART-accredited health facilities in Karamoja sub region, Uganda. The qualitative objective was to explore the perceived barriers and facilitators to completing IAC in the same setting. This mixed-methods cohort study combined retrospective chart review with key informant interviews (KIIs) and focus group discussions (FGDs), conducted across 36 ART-accredited Karamoja facilities (January–December 2023; data abstracted January–March 2024). All eligible CALHIV aged 0–19 years with a documented high viral load (> 200 copies/mL plasma; >400 copies/mL dried blood spot, DBS) who were initiated on IAC were enrolled. Compliance to IAC was defined, using session-attendance records, as receipt of three or more consecutive monthly sessions. Modified Poisson regression was used to estimate the association between IAC compliance and viral load suppression, reported as crude and adjusted prevalence risk ratios (PRRs) with 95% confidence intervals (CIs). Thematic analysis of the KIIs and FGDs was used to explore perceived barriers and facilitators to completing IAC. Of the CALHIV assessed for eligibility, 154 met the inclusion criteria and were analysed. Participants’ mean age was 12.0 years (SD 4.2); 53.2% were female; mean ART duration was 12.3 months. Most (83.8%, n  = 129) received three or more sessions. Suppression reached 41.1% ( n  = 53) among compliant versus 8.0% ( n  = 2) of non-compliant participants (crude PRR 5.14, 95% CI 1.34–19.72, p  = 0.0016). After adjustment for facility level, age, ART duration, and HIV disclosure status, compliance to IAC remained independently associated with suppression (adjusted PRR 4.78, 95% CI 1.26–18.10, p  = 0.021); the hospital-level association attenuated and was no longer significant (adjusted PRR 3.30, 95% CI 0.91–12.04, p  = 0.071). Both confidence intervals were wide, reflecting the small non-compliant group, so the magnitude of the effect should be interpreted with caution. Qualitative analysis identified perceived barriers (food insecurity, caregiver alcohol use, boarding-school attendance) and facilitators (caregiver meetings, peer support) to completing IAC, alongside perceptions of IAC effectiveness, health-system readiness for delivery, and improved quality of life. Compliant CALHIV were more likely to achieve suppression than non-compliant CALHIV, although the wide confidence interval means the size of this association is uncertain; 58.9% of compliant participants nonetheless remained non-suppressed. IAC is necessary but insufficient; complementary interventions addressing structural barriers and clinical factors including drug resistance screening are required.