Achieving antiretroviral therapy uptake and viral suppression among children and adolescents living with HIV in the UNAIDS 90-90-90 era across six countries in Eastern and Southern Africa - lessons from the BIPAI Network.

BACKGROUND: While achievements have been made globally since the UNAIDS 90-90-90 targets were announced, paediatric data remains sparse. We describe achievements towards ART uptake and viral load suppression, existing gaps, and potential best practices among CALHIV across six Eastern and Southern African countries.

SETTING: Baylor College of Medicine International Paediatric AIDS Initiative (BIPAI) Network sites in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda.

METHODS: We performed retrospective data analysis among CALHIV ages 0-19 years between 2014 and 2019.

RESULTS: A total of 25,370 CALHIV received care, 85.8% (21773/25370) received ART, 84.4% (18376/21773) had documented VL results, and 74.6% (13715/18376) had VL<1000 cps/mL. By 2019, the pooled proportion of CALHIV receiving ART and having viral suppression increased to 99.8% (95% CI 98.1-100.0) and 89.8% (95 CI 88.2-91.5) respectively. Lower rates of viral suppression and higher lost-to-follow up (LTFU) were seen in the 0-4 year and 15-19 year cohorts. CALHIV on ART not achieving viral suppression were younger, received care in Malawi or Mbeya, had a history of TB, lower rates of integrase-strand inhibitor-based ART, and were on ART for shorter durations. Best practices reported included adopting universal ART, ART optimization with protease inhibitor- and/or dolutegravir-based regimens, peer-supported activities, child/adolescent-friendly services, community-supported activities, and technology-driven quality improvement activities and digital solutions.

CONCLUSIONS: High rates of CALHIV receiving ART and having viral suppression can be achieved in settings in Eastern and Southern Africa through utilizing pediatric best practices. Increased efforts must be made to address LTFU and to support under-fives and adolescents.