Virological Non-Suppression and Associated Factors Among Adolescents and Youth Living with HIV in Ethiopia: A Facility-Based Case-Control Study

Abstract Background: Virological non-suppression remains the major cause of treatment failure and mortality among adolescents and youth living with HIV in low- and middle-income countries (LMICs). Behavioral and mental health disorders affect adherence to antiretroviral therapy (ART) and the underlying virological suppression, but evidence from LMICs is relatively limited. We aimed to assess HIV virological non-suppression and associated factors among adolescents and youth attending ART in Ethiopia. Methods: A 1:2 matched facility-based case-control study was conducted at ALERT Hospital, Addis Ababa, Ethiopia, among patients with HIVaged 12-24 years who were on ART and with a viral load > (case) or < (control) than 1000 copies/ml after at least six months on ART. The primary outcome was viral load non-suppression: a plasma viral load > 1000 copies/ ml based on two consecutive viral load measurements every three months. The primary exposure was depressive symptoms as measured using the PHQ-9 (Patient Health Questionnaire, 9-item version). Other variables include adherence to ART and sociodemographic characteristics of participants. Data were collected using structured, blinded lay interviewer-administered questionnaires, and data extraction forms. Conditional multivariable logistic regression was conducted using STATA version 14.2 to test the main hypotheses. Results: The study enrolled 192 participants, with a median age of 18 years and 52.1% males. None of the participants reported smoking or chewing Khat (a leaf that stimulates mood). With the PHQ-9 tool, 47%, 28%, and 25% had minimal or no, probable to mild and moderate to severe depression symptoms, respectively. Having depressive symptoms is associated with a higher conditional likelihood of virological failure (odds ratio [OR] = 1.8, p < 0.001) and the association was stronger among those who have moderate or severe depressive symptoms (adjusted OR = 5, 95% CI [1.7-14.6] )and unadjusted OR = 6.8, 95% CI [3.1-14.8]). Having moderate and severe depression is associated with non-adherence to ART (adjusted OR = 10.5). Conclusion: Non-adherence to ART medications, depressive symptoms, advanced WHO stage on ART initiation, poor social support and orphan status were independently associated with virological failure among HIV-infected adolescents and youths on ART. Having moderate and severe depression has higher odds of non-adherence and virological failure. We recommend integration and task-sharing of mental health and HIV care services to reduce virological failure in this group of people.