In this study, we assess HIV virological non-suppression and associated factors among adolescents and youth attending ART in Ethiopia. We found that having depressive symptoms is associated with a higher conditional likelihood of both viral non-suppression and non-adherence to ART medications. The association was stronger among those adolescents who have moderate or severe depressive symptoms (AOR = 5, and Crude OR = 6.8). The findings in our study are supported by several other studies. Psychosocial interventions demonstrate small to moderate effect size on ART medication adherence, Pascalle Spaan et al, 2018 [12]. According to data from HIV-infected persons enrolled at a cohort study in Washington DC between January 2011 and June 2014, those with diagnoses of mental health issues or depression have a lower likelihood of sustained viral suppression. This is in agreement with a previous systematic review from 29 studies that included a total of 12,243 participants (Ref).
Data synthesized from these studies revealed that depression treatments and mental health interventions are effective for enhancing adherence to antiretroviral regimens. The odds of a person adhering to ART are 83% better if the patient is treated for depression, and the risk of no adherence is 35% greater among those who do not receive depression treatment. Studies in which participants were diagnosed with clinical depression or had, on average, moderate-to-severe depressive symptoms demonstrated larger effects than studies in which participants had mild depressive symptoms [9]. One study in Ethiopia performed a detailed systematic review to assess the prevalence of depression and the associated factors for the co-occurrence of depression in people living with HIV [11]. Our finding is however is significantly larger with depression prevalence 59.35 and 82% among controls and cases. This difference might be due to study population difference as our study targets only adolescents and youth aged 12-24 years. The figure is also significantly larger than the expected burden in the general population which stands at 17%. This difference might be explained by the most commonly reported additional risk factors among HIV positive patients, according to the systematic review mentioned above, Mogessie Necho, Ethiopia, 2018, presence of perceived HIV stigma, poor social support, poor medication adherence, opportunistic infection and advanced stage of AIDS are most commonly identified risks to depression. The pooled adjusted odds ratio (AOR) of perceived HIV stigma among the indicated studies was 3.75. Six studies reported poor social support as an associated factor for depression in HIV patients and the pooled AOR was found to be 6.22. Moreover, the average odds ratio of poor medication adherence, presence of opportunistic infection, and advanced stages of AIDS were 3.03, 5.5, and 5.43 respectively. Despite this high burden of depression among HIV clients, psychiatric disorders are neither well addressed nor studied in Ethiopia HIV care.
We have assessed possible confounding variables and sociodemographic variables. Of the assessed sociodemographic variables, orphan status and living status were associated significantly with virological failure. Being a double orphan was associated with higher odds of virological failure compared to single orphan or non-orphan (crude OR=1.5, P < 0.001). There was also a slightly higher association between living status and virological failure (crude OR = 0.6, p < 0.01. Having a caregiver was associated with a lower conditional likelihood of virological failure and non-adherence (crude OR = 1.6).
This is in agreement with other studies done in Ethiopia and other countries. According to Zvanaka Sithole et al. 2017, Zambia, of the socio-demographic factors assessed, only two of the variables impacted the outcome. Those who had treatment buddies were 0.6 times less likely to have virological failure compared to those who did not (13). Another study on the importance of caregivers in the outcome of pediatric HIV management in Kenya found that treatment failure was associated with not having both parents as caregivers. In Ethiopia, several studies evaluate the association of having caregivers and caregivers being HIV serology positive with viral suppression. Those who had HIV-positive caregivers were 0.5 times less likely to develop Virological failure as compared to those who did not [1, 2, 5, 13]. However, in our study, we do not assess the HIV status of caregivers and families due to ethical reasons.
We also assessed behavioral risk factors including adherence to ART medications, smoking, and alcohol use and chewing khat. However, none of the adolescents/youths smoke or chew khat. Alcohol use rate is also low among adolescents and there is no significant difference among groups. Nonadherence to ART medications as a risk behavior to ART treatment outcome has a strong association with Virological failure on both univariate and multivariate conditional logistic regression (crude OR= 7.97, adOR= 10.95, p < 0.0001). This in agreement with recent study in Ethiopia, poor adherence to ART increased Virological failure by higher odds (AOR =16.09)[2], with similar country-specific findings in Africa (Zimbabwe n = 102, 18.5. ; SA n = 134, 14.5, Zambia n= 256, 18.15) [1, 2, 13, 14, 22]. The good adherence rate, in our study, among the total participants and cases, was 72% and 45%, respectively. This is in agreement with another study by Jeremy L Ross 2019, a prospective cohort study among 250 HIV infected and 59 matched HIV uninfected adolescents in Malaysia, Thailand, and Vietnam from July 2013-March 2017, which found 60% self-reported adherence ≥95% at week 144 [8].
Despite the higher odds of Virological failure among non-adherent adolescents, 29 (45%) and 41 (64%) of cases good have good and fair adherence to ART medications respectively. Thus our study found a high burden of virological non suppression among sufficiently adhered adolescents, 45% of all adolescents who did not achieve viral suppression were sufficiently adhered [10]. This clearly indicates the presence of other independent risk factors for viral suppression regardless of adherence status, like depression. Our finding is also supported by several other studies as mentioned in the literature review part. This may also be an important indicator and notification for the necessity in developing a highly sensitive and specific approach to adherence measurement in adolescents and youth. Despite this fact, strict adherence monitoring using available methods is the single most important method of measurement for Virological failure and/or treatment outcome. This study has a limitation in that it was conducted in a single referral hospital and the generalizability of the results could be affected. The study has strengths in that it indicated the association of an important and less understood mental health condition, depression, and viral suppression among adolescents and youth living with HIV using a hypothesis-driven matched case-control method.