First degree social networks and initiation of antiretroviral therapy and viral suppression among HIV-infected youth age 15-24 years in East Africa
Lillian Brown, Yiqun Chen, James Ayieko, Moses Kamya, James Moody, Diane Havlir, Maya PetersenBackground: HIV-infected youth in sub-Saharan Africa have not benefited from expanded access to life-saving antiretroviral therapy (ART) to the same degree as older adults, in part because they are less likely to start treatment after diagnosis and, among those who do start treatment, are less likely to successfully suppress viral replication. High levels of stigma and lack of social support contribute to this disparity, and peer support within social networks may improve clinical outcomes. We used comprehensive social network and HIV testing and treatment data from the SEARCH HIV test-and-treat study (NCT01864683) to evaluate whether baseline social network characteristics predicted ART initiation and viral suppression among HIV-infected ART-naïve youth in rural East Africa.
Methods: All residents ≥15 years in 32 communities in rural Kenya and Uganda were enumerated during a door-to-door census. A name generator was administered which elicited social contacts in five domains: health, money, emotional support, food, and free time. Named contacts were matched to enumerated residents to build social networks among 150,395 adult residents; 90% were tested for HIV. Among HIV-infected youth (15-24 years) who were ART-naive at baseline (2013-2014), we evaluated whether the baseline HIV and ART status of their first-degree contacts predicted ART initiation and viral suppression (HIV RNA<400 copies/ml) 3 years later, and whether this association was modified by age of the contact. We used logistic regression with robust standard errors to adjust for total number of contacts, sex, study arm, new diagnosis, and region.
Results: Among 1,120 HIV-infected youth who were ART-naive at baseline, 805 remained alive and resident in the community after 3 years of follow-up. At 3 years, 70% (569/805) had engaged in ART care, of which 398 (70%) were virally suppressed. Youth named an average of 2.7 contacts (SD 3.1); 270 (33.5%) named ≥1 HIV-infected contact. Youth who named at least one same-age HIV-infected contact were more likely to initiate ART within 3 years than those without a same-age HIV-infected contact (aOR 2.95; 95%CI 1.49-5.86). Youth having a contact who initiated ART between baseline and follow-up year 3 were also more likely to themselves initiate ART, compared with youth without such a contact (aOR 2.01; 95%CI 1.17-3.45). HIV-infected contacts who were older-age (age≥25 years) or already on ART at the time of baseline testing were not associated with ART initiation. Among youth who initiated ART, those with an older-age contact already on ART at the time of baseline testing (aOR 3.07; 95%CI 1.52-6.19) or who initiated ART between baseline and follow-up year 3 (aOR 2.17; 95%CI 1.18-4.00) were more likely to have suppressed viral load at 3 years compared to youth without such contacts.
Conclusions: Initiating ART and achieving viral suppression is associated with the HIV status and HIV care status of contacts in the local social networks of HIV-infected ART-naïve youth in rural East Africa. Social support from same-age peers may play an important role in ART initiation, while support from older, ART-experienced individuals may be more important for the ongoing adherence to ART necessary to achieve viral suppression.