ART Adherence among Adolescents & Young People Living with HIV in Southern Malawi: A Conditional Process Analysis

Adherence to antiretroviral therapy (ART) leads to achievement and maintenance of durable viral suppression. Viral suppression ensures immune reconstitution, decreased morbidity and mortality. However, youths living with HIV are particularly challenged to adhere to ART due to various factors associated with their developmental trajectory. This cross-sectional study (1) examined the rate of ART adherence and virological non-suppression, (2) validated three ART adherence measures: pill count, Likert scale and visual analogue scale to determine how well they could identify virally unsuppressed youths, (3) explored correlates of viral non-suppression, and (4) examined the interactive mechanisms through which depression, HIV-related stigma, self-efficacy, and gender influence ART adherence among 450 youths (13-24 years) engaged in care and treatment in public health facilities in Blantyre, Zomba, Mwanza, Mangochi, Chikwawa and Chiradzulu in southern Malawi. Viral non-suppression and its correlates were examined among 209 youths for whom a viral load (VL) within the 60 days preceding the day of the interview was available. Viral non-suppression was defined as HIV RNA >1,000 copies/ml. Findings showed that 81 (39%) were virally non-suppressed. Male gender and stigma were independently associated with VL non-suppression, while social support and self-efficacy were independently protective of VL non-nonsuppression. Of the three adherence measures, pill count had the highest positive predictive value (66.3%) followed by the Likert scale (48.2%) while the visual analogue scale (VAS) came last (45.16%). Using Pill count at <80% nonadherence cutoff point, 36 (17.2%) of the youth were nonadherent. Of those who were adherent, just 120 (69.4%) were VL suppressed. Guided by Social Action Theory (SAT), a conditional process analysis revealed that gender moderated both the direct and indirect effects of depression and stigma via self-efficacy on ART adherence. Furthermore, self-efficacy simultaneously mediated and moderated the relationship between stigma and ART adherence. This study revealed high rates of ART nonadherence and virological non-suppression. It also highlighted various key factors that affected ART adherence among youths in southern Malawi. Interventions should aim at reducing the impact of stigma and bolster social support and self-efficacy while taking into account gender in their design and implementation.