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

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.

Figures

Figure 1.

Proportions of PLHIV meeting the UNAIDS 90–90-90 targets, on ART, and virologically suppressed, overall by age and by gender in Botswana. Study participants were sampled in 20% of households in 30 Botswana communities. See Supplementary Table 1 for the number of participants in each group. A: General population (total, both genders) is shown as the darkest gray bar. Young adults (16–29 years old) are shown as medium tone graybar. Older adults (30–64 years old) are presented as the lightest graybar. B: Men. The darkest gray bars indicate men of any age (16–64 years old). Medium tone gray bars show young men (16–29 years old). The lightest gray bars delineate older men (30–64 years old). C: Women. The darkest gray bars indicate women of any age (16–64 years old). Medium tone gray bars show young women (16–29 years old). The lightest gray bars delineate older women (30–64 years old).

Figure 2.

A: HIV prevalence among adults tested in 30 Botswana communities stratified by age and gender. B: Proportion of individuals aware of their positive HIV status stratified by age and gender. Women are represented by circles; men are represented by triangles. Dashed line in B denotes the first 90 in the UNAIDS targets. See Supplementary Table 2 for the number of participants in each group.

Figure 3.

A: Proportion of all PLHIV receiving ART in 30 Botswana communities, stratified by age and gender. Dashed line denotes the 81% target (0.90 × 0.90) among PLHIV. B: Proportion of previously diagnosed participants living with HIV currently on ART. Women are represented by circles; men are represented by triangles. Dashed line denotes the second 90 in the UNAIDS targets. See Supplementary Table 2 for the number of participants in each group.

Figure 4.

A: Proportion of all PLHIV with undetectable HIV-1 RNA load (≤400 copies/mL) in 30 Botswana communities, stratified by age and gender. Dashed line denotes the 73% target (0.90 × 0.90 × 0.90) among PLHIV. B: Proportion of PLHIV with undetectable HIV-1 RNA load among participants who were diagnosed previously and were receiving ART at the time of household visit. Women are represented by circles; men are represented by triangles. Dashed line denotes the third 90 in the UNAIDS targets. See Supplementary Table 2 for the number of participants in each group.