Clinical Science

Lack of Virological Suppression Among Young HIV-Positive Adults in Botswana

Novitsky, Vlad MD, PhD^*,†; Gaolathe, Tendani MD^*; Mmalane, Mompati MD, FRCS, MSc^*; Moyo, Sikhulile MSc, MPH, PhD^*; Chakalisa, Unoda MD^*; Yankinda, Etienne Kadima MPH^*; Marukutira, Tafireyi MPH^‡; Holme, Molly Pretorius MS^†; Sekoto, Tumalano BA^*; Gaseitsiwe, Simani PhD^*,†; Musonda, Rosemary MSc, PhD^*,†; van Widenfelt, Erik BA^*; Powis, Kathleen M. MD^*,†,§,║; Khan, Nealia MPH^†; Dryden-Peterson, Scott MD, MSc^*,†,¶; Bennett, Kara MS^#; Wirth, Kathleen E. ScD^†,**; Tchetgen, Eric Tchetgen PhD^**,††; Bachanas, Pam PhD^‡‡; Mills, Lisa A. MD, MSc^‡; Lebelonyane, Refeletswe MPH^§§; el-Halabi, Shenaaz MPH^§§; Makhema, Joseph MBBS, FRCP^*,†; Lockman, Shahin MD^*,†,║,¶; Essex, M. DVM, PhD^*,†

Author Information

^*Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana;

^†Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA;

^‡Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Gaborone, Botswana;

^§Departments of Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA;

^║Department of Medicine, Harvard Medical School, Boston, MA;

^¶Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA;

^#Bennett Statistical Consulting, Inc, Ballston Lake, NY;

Departments of ^**Epidemiology;

^††Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA;

^‡‡Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, GA; and

^§§Ministry of Health and Wellness, Republic of Botswana, Gaborone, Botswana.

Correspondence to: M. Essex, DVM, PhD, Harvard T.H. Chan School of Public Health, FXB 402, 651 Huntington Avenue, Boston, MA 02115 (e-mail: [email protected]).

Supported by the US President's Emergency Plan for AIDS Relief (PEPFAR) through CDC under the terms of cooperative agreements U01 GH000447 and U2G GH001911. The contents are solely the responsibility of the authors and do not necessarily represent the official position of the funding agencies. S.M. was supported by the Fogarty International Center and the National Institute of Mental Health, National Institutes of Health (D43 TW010543). S.M. and S.G. were partially supported by the Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE), a DELTAS Africa Initiative (DEL-15-006), which is an independent funding scheme of the African Academy of Sciences (AAS)'s Alliance for Accelerating Excellence in Science in Africa (AESA), supported by the New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (107752/Z/15/Z) and the UK government. The views expressed in this publication are those of the authors and not necessarily those of AAS, NEPAD Agency, Wellcome Trust, or the UK government.

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jaids.com).

JAIDS Journal of Acquired Immune Deficiency Syndromes 78(5):p 557-565, August 15, 2018. | DOI: 10.1097/QAI.0000000000001715

Abstract

Background:

HIV-1 RNA load is the best biological predictor of HIV transmission and treatment response. The rate of virologic suppression among key subpopulations can guide HIV prevention programs.

Methods:

The Botswana Combination Prevention Project performed a population-based household survey among adults in 30 communities in Botswana. Data collected included knowledge of HIV-positive status, antiretroviral therapy (ART) coverage, and virologic suppression (HIV-1 RNA ≤400 copies per milliliter). Individuals aged 16–29 years were considered young adults.

Results:

Among 552 young people living with HIV enrolled with RNA load data and ART status available, 51% (n = 279) had undetectable HIV-1 RNA, including 54% of young women and 32% of young men [sex prevalence ratio (PR): 0.53; 95% confidence interval (CI): 0.43 to 0.80; P < 0.001]. Compared with older adults (30–64 years old), young HIV-infected adults were significantly less likely to have undetectable HIV-1 RNA (PR: 0.65; 95% CI: 0.59 to 0.70; P < 0.0001), including both men (PR: 0.43; 95% CI: 0.34 to 0.56; P < 0.0001) and women (PR: 0.67; 95% CI: 0.62 to 0.74; P < 0.0001). Among a subset of people living with HIV receiving ART, young adults also were less likely to have undetectable HIV-1 RNA load than older adults (PR: 0.93; 95% CI: 0.90 to 0.95; P = <0.0001). Analysis of the care continuum revealed that inferior HIV diagnosis and suboptimal linkage to care are the primary reasons for low virologic suppression among young adults.

Conclusions:

Young adults in Botswana are significantly less likely to have undetectable HIV-1 RNA load compared with older adults. In the era of broad scale-up of ART, interventions able to diagnose young adults living with HIV and link them to effective therapy are urgently needed.

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Lack of Virological Suppression Among Young HIV-Positive Adults in Botswana

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