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. 2023 Mar 15;93(3):229–236. doi: 10.1097/QAI.0000000000003190

Effect of Dolutegravir and Multimonth Dispensing on Viral Suppression Among Children With HIV

Cyrus Mugo a, Bashir Zubayr b, Nnenna Ezeokafor b, Babatunde Oyawola b, David Ochedomi Ekele b, Leila Madueke b, Zipporah Kpamor b, Bazghina-werq Semo c,✉
PMCID: PMC10256312  PMID: 36943698

Supplemental Digital Content is Available in the Text.

Key Words: dolutegravir, multimonth dispensing, viral suppression, undetectable viral load, children, HIV

Background:

Few studies in sub-Saharan Africa have assessed the impact of multimonth dispensing (MMD) of antiretroviral therapy (ART) and dolutegravir (DTG) beyond clinical trials among children with HIV (CWHIV). We assessed the effect of the 2 interventions on achieving undetectable viral load (VL) among CWHIV in the age group of 0–15 years in Nigeria.

Methods:

We used longitudinal routine records and cross-sectional survey data from caregivers of a subsample of children. VLs were considered suppressed at <1000 copies/mL and undetectable at <50 copies/mL. Multimonth dispensing (MMD) was defined as ART refill for >84 days. The effect of MMD and DTG on VL levels and associations between social factors and VL were estimated using generalized linear models, reporting adjusted relative risks/prevalence ratios and 95% confidence intervals (CIs).

Results:

Of 2490 CWHIV, 52% were male, with a median age of 10 years (interquartile ranges: 6–13) and a median duration on ART of 4.6 years (interquartile ranges: 2.8–7.1). Overall, 73% were on DTG and 55% received MMD. At baseline, 63% were suppressed, while 79% and 56% were suppressed and undetectable in their last VL, respectively. We found no differences in undetectable VL between those on MMD and not on MMD (adjusted relative risks: 1.05 [95% CI: 0.94–1.18]) and between those on DTG and not on DTG (1.07 [0.92–1.25]). In secondary analyses, poor adherence and being in a support group were associated with a lower likelihood of undetectable VL (adjusted prevalence ratios: 0.85 [95% CI: 0.74–0.96] and 0.81 [0.68–0.96], respectively).

Conclusion:

MMD did not compromise treatment outcomes for CWHIV. Poor adherence, however, remains a barrier to achieving treatment targets.

INTRODUCTION

Approximately 1.8 million children in the age group of 0–15 years globally are living with HIV; more than 150,000 newly acquired HIV, and close to 100,000 died of AIDS-related causes in 2020.1 Due to the prevention of mother-to-child transmission programs2 and the “test and treat” approach,3 there has been a significant reduction in the number of new HIV infections among children since 2010.1 However for this age group, the UNAIDS 95-95-95 targets are far from being met,1 with more than 40% of children with HIV (CWHIV) remaining undiagnosed globally,4 close to 50% of those diagnosed needing to be initiated on antiretroviral therapy (ART), and for those on treatment, more than a third not achieving viral suppression (viral load <1000 copies/mL).5 Nigeria had an estimated 130,000 CWHIV in 2020, with only 46% on ART,1 and 82% of those on treatment having achieved viral suppression.6

Previous studies have assessed the influence of some factors on viral suppression in children. For example, certain antiretroviral drugs have been shown to be more effective among children. Children on non-nucleoside reverse transcriptase inhibitors (NNRTIs), especially nevirapine, had poorer viral suppression compared with those on protease inhibitor (PI) such as lopinavir.7,8 Informed by results of clinical trials, the current World Health Organization and Nigeria treatment guidelines9,10 recommend the more efficacious7,8,11 dolutegravir (DTG)–based regimen as the first-line therapy for children. Globally, roll out of DTG-based pediatric regimen began in 2018,12 with the more palatable formulations for younger children introduced in 2020.13 The Nigeria National Data Repository reported that approximately 76% of CWHIV were initiated or switched to DTG-based regimen by December 2021.6 Due to challenges accessing viral load testing and to avoid market fragmentation, the guidelines recommended switching patients to DTG regardless of their viral load levels as long as they were clinically stable.14

Few studies, beyond the clinical trials, have been conducted in sub-Saharan Africa to assess the impact of DTG on viral suppression among children. Despite having small sample sizes, these studies have affirmed the higher efficacy of DTG in viral suppression.15,16 Beyond ART, other studies have shown viral suppression in CWHIV is associated with younger age, longer ART duration, female sex, and caregiver viral suppression.17,18

Differentiated service delivery (DSD) is a patient-centered strategy that optimizes HIV services to better serve the needs of people living with HIV and reduce demands on the health system.19 DSD practices include multimonth dispensing (MMD) of ART, where patients get at least 3 months of treatment during a clinic visit or in their communities through community-based drug distribution models.20 The patients typically offered MMD were clinically stable with a suppressed viral load.21 While DSD approaches have been in place and have shown to improve adult patient treatment experiences and outcomes,22–26 only a few studies from countries in sub-Saharan Africa have described DSD models for children and even fewer have reported on the impact of DSD practices on viral suppression.27 Similar to other countries in sub-Saharan Africa, Nigeria adopted DSD through MMD and other models for most patients when COVID-19 restrictions were introduced in March 2020. The models continued after the restrictions were lifted due to high satisfaction from clients and providers.20,28–30 The objective of this study was to determine the effect of DTG-based regimen, MMD, and other individual-level/household-level factors on viral suppression among children aged 0–15 years in Nigeria.

METHODS

Study Design

This study used retrospective patient records for CWHIV for the period between April 1, 2019, and June 31, 2021, and cross-sectional survey data from a sample of caregivers of CWHIV conducted between October and December 2021.

Study Location

The study targeted 73 facilities in 11 states of Northern Nigeria supported by the United States Agency for International Development. The states included Adamawa, Bauchi, Borno, Jigawa, Kano, Kebbi, Kwara, Niger, Sokoto, Yobe, and Zamfara.

STUDY PROCEDURES

Records Abstraction

Relevant data were extracted for children aged 0–15 years from the national electronic medical records—the Lafiya Management Information System.31 Eligible records abstracted were clinic, pharmacy, and laboratory records between April 1, 2019, and June 31, 2021.

Supplementary Caregiver Survey

To collect information that was not available in the routine patient data, a sample of caregivers with CWHIV aged 0–15 years completed a survey. To identify the caregivers, data managers of the study identified all children with at least 1 viral load (VL) measure in the abstracted electronic medical records. They confidentially provided a list of unique patient identification numbers, allocated by the HIV program to the HIV clinic staff (eligible list) who used the list to identify caregivers (aged 18 years or older) who brought their children for a clinical evaluation, ART refill, or viral load test between October and December 2021. HIV clinic staff referred eligible caregivers to study staff who consented those willing to participate before requesting them to complete a survey providing personal and family sociodemographic and HIV-related information including the child's ART adherence, disclosure to the child their HIV status, and whether they are in a support group.

ANALYSIS

Measures and Definition of Variables

Viral load: VL measures were expected to be conducted every 12 months following the 2016 local guidelines and every 6 months after the adoption of the 2020 guidelines.10,32 As in other countries in sub-Saharan Africa, fidelity to the recommended VL testing schedules was challenging in Nigeria, resulting in missed measures.33–35 VL testing was completed at reference laboratories after whole blood sample collection at the facilities using Roche COBAS AmpliPrep/TaqMan HIV-1 Test. For the primary analyses, which used only routine patient data, we included participants with >1 VL measure in the study period. Two VL measures were identified—a baseline VL and the latest VL in the study period (primary outcome). For the baseline VL, we considered all VL measures conducted 3–15 months before the latest VL for each participant and selected the measure with a sample collection date closest to being 12 months before the latest VL. The VL was classified as suppressed (<1000 copies/mL) or unsuppressed and undetectable (<50 copies/mL) or detectable.10,32

The ART regimen in their latest refill visit at least 3 months before the last VL was classified as DTG based, NNRTI based for those on efavirenz or nevirapine, PI based for those on lopinavir or atazanavir, or other for those not on any of the 3 drug categories. We further dichotomized the variable as DTG based and non-DTG based. In addition, the variable classifying ART regimen as first line or second line as per the treatment guidelines was abstracted from routine data.32

We classified participants as being in the MMD group if they received ART to last >84 days in an ART refill visit at least 3 months before their last VL. We computed the follow-up time for those exposed to DTG and MMD, respectively, as follows: the duration between the first visit when DTG was prescribed and the sample collection date for the last VL and the duration between the first visit when patients had MMD and the sample collection date for the last VL. For those not on DTG and not on MMD, respectively, the duration between the first visit and last VL was considered the follow-up time.

Cross-sectional survey: To assess treatment adherence, caregivers were asked whether the child had missed any doses and the number of days missed. Those who had missed ≥2 days (<95% adherence) of ART were considered to have suboptimal adherence. Participants were classified as food insecure if the caregiver reported that in the past 30 days the household was without food on any day because of lack of resources. Caregiver depressive symptoms were assessed using the 2-item Patient Health Questionnaire designed for use in primary healthcare settings.36 Participants were classified as having depressive symptoms if their total score was ≥3 of a possible 6.37

Data Analysis

We used descriptive measures counts, proportions, medians, and interquartile ranges (IQRs) to summarize the sociodemographic and HIV-related data. For participants on MMD or DTG on the first visit in the abstracted data, we considered that visit the start date for that intervention.

Primary Analysis: Effect of MMD and DTG on Undetectable VL Levels

In the primary analyses, only participants in care for >6 months, with >1 VL measure, and complete ART refill information were included. We estimated the effect of MMD on viral suppression to undetectable levels and compared DTG with other ART regimen categories on viral suppression to undetectable levels, using generalized linear models (family = binomial (link = log)). We conducted bivariate and multivariate analyses, adjusting for duration on ART, sex, and baseline VL; we assessed the associations between follow-up time on DTG and follow-up time on MMD and further adjusted for the respective follow-up time in each model. Age was excluded as a confounder because of collinearity with duration on ART (P < 0.001 on linear regression). We reported relative risks (RRs) and adjusted relative risks (aRRs). The 95% confidence intervals (CIs) for the aRRs, and P values were computed using bootstrapping (1000 bootstrap samples from the full sample) to account for clustering of participants by facility.

Exploratory Analysis: Associations Between Other Modifiable Factors and Undetectable VL Levels

In secondary analyses, we assessed associations between modifiable sociodemographic and HIV-related characteristics (ART adherence, support group membership, school enrollment, enrollment in a boarding school, disclosure status, household food security, and caregiver depression) and undetectable VL levels using similar procedures as the primary analysis for the subsample of children whose caregivers completed a survey. In the multivariable analyses, we adjusted for duration on ART and sex, with the 95% CI for the adjusted prevalence ratios, and P values, computed using bootstrapping to account for clustering of participants by facility. There was no clustering at the caregiver level. All analyses were completed using R studio (R version 4.0.3, Foundation for Statistical Computing, Vienna, Austria).

Ethical Considerations

This study was approved by the National Health Research Ethics Committee of Nigeria (NHREC/01/01/2007-28/06/2021B). Individual consent for the abstraction of patient medical records was waived. The analysis used deidentified data, and the data managers who performed the data extraction are not coauthors. Caregivers who completed the survey provided informed written consent during recruitment.

RESULTS

Demographic and HIV-Related Characteristics (Overall Sample)

We abstracted records for 5000 children with VL data, of whom 2490 (50%) were included in the primary analyses. Among the 2510 not included, 399 (16%) did not have pharmacy refill data, 379 (15%) were in care for ≤6 months, while 1732 (69%) had only 1 VL measure in the study period. Compared to participants that were included in this analysis, the participants excluded from the study were younger, on ART for a shorter duration, and were started ART when younger; a higher proportion were on second-line ART, with a lower proportion on DTG and on MMD (P < 0.001 each). There were no differences in sex (0.06) or viral suppression (0.63) at the last VL measured (see Table 1, Supplemental Digital Content, http://links.lww.com/QAI/C36).

Of 2,490 CWHIV, 52% were male, and the median age was 10 years (IQR: 6–13). The median age at ART initiation and the median duration on ART were 5 years (IQR: 2–8) and 4.6 years (IQR: 2.8–7.1), respectively. Overall, 73% of the children were on a DTG-based regimen and 55% were in the MMD group; approximately 20% of those classified in the MMD group received MMD in their first visit from the abstracted records. At baseline, 63% were suppressed (<1000 copies/mL), while 79% and 56% were suppressed and had undetectable VL levels (<50 copies/mL) in their latest VL, respectively (Table 1). For those on MMD, the median duration on MMD before the last VL was 11 months (IQR: 7–15). For those on DTG, the median duration on DTG before the last VL was 14 months (IQR: 9–18).

TABLE 1.

Demographic and HIV Characteristics for Study Participants

Characteristics Overall (N = 2490), n (%) Not in MMD (N = 1128), n (%) In MMD, (N = 1362) n (%) P (χ2 Test) Non-DTG (N = 660), n (%) DTG (N = 1830), n (%) P (χ2 Test)
Age (yr) <0.001 <0.001
<2 73 (3) 41 (4) 32 (2) 43 (7) 30 (2)
2–9 1098 (44) 606 (54) 492 (36) 447 (68) 651 (35)
≥10 1317 (53) 479 (42) 838 (62) 168 (25) 1149 (63)
Sex 0.175
Female 1206 (48) 529 (47) 677 (50) 279 (42) 927 (51) <0.001
Male 1284 (52) 599 (53) 685 (50) 381 (58) 903 (49)
Age at ART initiation (yr) <0.001
<2 469 (19) 242 (21) 227 (17) 162 (25) 307 (17) <0.001
2–9 1561 (63) 167 (15) 293 (21) 40 (6) 420 (23)
≥10 460 (18) 719 (64) 842 (62) 458 (69) 1103 (60)
Duration since ART initiation (yr) <0.001 <0.001
≤5 1365 (55) 698 (62) 667 (49) 461 (70) 904 (49)
>5 1122 (45) 429 (38) 693 (51) 199 (30) 923 (51)
ART regimen <0.001
DTG based 1830 (73) 688 (61) 1142 (83)
NNRTI based 216 (9) 141 (12) 75 (6)
PI based 428 (17) 291 (26) 137 (10)
Other 16 (1) 8 (1) 8 (1)
ART regimen line <0.001 <0.001
First line 2422 (97) 1088 (96) 1334 (98) 592 (90) 1830 (100)
Second line 68 (3) 40 (4) 28 (2) 68 (10) 0
Baseline viral load <0.001 <0.001
Suppressed 1579 (63) 610 (54) 969 (71) 333 (50) 1246 (68)
Unsuppressed 911 (37) 518 (46) 393 (29) 327 (50) 584 (32)
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Differences in summation of “n” for different variables and the overall N are due to missing values.

Description of Social Factors for the Subsample of Children Whose Caregivers Completed a Survey

Of the 1584 children whose caregivers completed a survey, 77% had good adherence. Of the 394/598 (66%) children aged 10 years or older who knew their HIV status, 44% were in a support group. More than one-third (34%) of the caregivers had some depressive symptoms (Table 2). Caregivers for 634 (75%) CWHIV on DTG reported that the children had good adherence, compared with 287 (71%) of those on a PI (P = 0.134), 92 (84%) of those on an NNRTI (P = 0.03), and 15 (79%) of those on other regimen (P = 0.68). On the contrary, 459 (75%) and 569 (74%) of those on MMD and not on MMD, respectively, reported good adherence, P = 0.63 (data not in tables).

TABLE 2.

Associations Between Other Factors and Undetectable Viral Load Levels Among Children

Characteristics Overall (N = 1584) n (%) Undetectable Viral Load (N = 898) n (%) PR (95% CI) *aPR
†(95% CI)		 P (Adjusted analysis)
Age (yr) ‡1.01 (1.00–1.03)
<2 83 (5) 44 (53)
2–9 705 (46) 380 (54)
≥10 734 (48) 440 (60)
Sex
 Female 771 (49) 461 (60) Reference
 Male 813 (51) 437 (54) 0.9 (0.82–0.98)
 Duration since ART initiation (yr) ‡1.02 (1.01–1.04)
 ≤5 1161 (73) 644 (55)
 >5 422 (27) 168 (60)
Adherence (Past 30 days)
 ≥95% adherent 1217 (77) 716 (59) Reference Reference
 Missed ≥ 2 days 367 (23) 182 (50) 0.84 (0.75–0.94) 0.85 (0.74–0.96) 0.012
School enrollment
 In school 1361 (86) 780 (57) Reference Reference
 Dropped out of school 223 (14) 118 (53) 0.92 (0.81–1.05) 0.96 (0.84–1.09) 0.469
In a boarding school
 No 1422 (96) 808 (57) Reference Reference
 Yes 63 (4) 39 (62) 1.09 (0.89–1.33) 1.07 (0.90–1.27) 0.483
Know HIV status (≥10 years) N = 598
 No 204 (34) 127 (62) Reference Reference
 Yes 394 (66) 229 (58) 0.93 (0.82–1.07) 0.93 (0.79–1.08) 0.316
In a support group (those who knew their HIV status) N = 351
 No 196 (56) 121 (62) Reference Reference
 Yes 155 (44) 78 (50) 0.82 (0.67–0.99) 0.81 (0.68–0.96) 0.026
Household food insecurity
 Food secure 1018 (64) 594 (58) Reference Reference
 Food insecure 566 (36) 304 (54) 0.92 (0.84–1.01) 0.92 (0.83–1.02) 0.101
 Caregiver depression 2 (2–3)
 No depressive symptoms 1048 (66) 592 (56) Reference Reference
 Depressive symptoms 536 (34) 306 (57) 1.01 (0.92–1.11) 1.03 (0.92–1.15) 0.612
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Differences in n for different variables and the overall N are due to missing values.

*

aPR: prevalence ratios adjusted for sex and duration on ART.

†

Bootstrapped 95% CIs and P values to account for clustering by facility.

‡

Predictor variable was in continuous form.

Effects of MMD and DTG on Undetectable VL Levels

In bivariate analyses, participants on MMD had a 14% higher likelihood of undetectable VL levels compared with those not on MMD (RR: 1.14 [95% CI: 1.07–1.23], P < 0.001), while participants on DTG had a 21% higher likelihood of undetectable VL compared with those on non-DTG regimen (RR: 1.21 [95% CI: 1.11–1.32], P < 0.001). Each additional month on DTG was associated with a 1% higher likelihood of undetectable VL levels (RR: 1.01 [95% CI: 1.01–1.02], P < 0.001). Duration on MMD was not associated with undetectable VL levels (RR: 1.00 [95% CI: 0.99–1.00], P = 0.561). After adjusting for confounders, we found no differences in achieving undetectable VL between those on MMD and those not on MMD (aRR: 1.05 [95% CI: 0.94–1.18], P = 0.326). Similarly, there were no differences in achieving undetectable VL between those on DTG and those not on DTG (aRR: 1.07 [0.92–1.25], P = 0.349) (Fig. 1).

FIGURE 1.

FIGURE 1.

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Predictors of viral suppression among children in northern Nigeria. MMD: Multimonth dispensing. 1Row percentages. aAdjusted for duration on ART, sex, baseline VL, and duration of follow-up. bBootstrapped 95% CIs and P values to account for clustering by facility.

Association Between Other Modifiable Factors and Undetectable VL Levels

In the bivariate analyses, higher age, female sex, longer duration on ART, ≥95% ART adherence, and being in a support group were associated with undetectable VL levels. After adjusting for duration on ART and sex, we found that children who missed ≥2 days of ART in a month had a 15% lower likelihood of undetectable VL levels compared with those who were at least 95% adherent (aRR: 0.85 [95% CI: 0.74–0.96], P = 0.012). Being in a support group was associated with a 19% lower likelihood of undetectable VL levels (aRR: 0.81 [95% CI: 0.68–0.96], P = 0.026). School enrollment, enrollment in a boarding school, disclosure, food security, and caregiver depression were not associated with undetectable VL levels (Table 2).

DISCUSSION

This study showed that multimonth dispensing of ART to children with HIV did not result in poorer treatment outcomes. The study, however, did not demonstrate a higher likelihood of achieving undetectable viral load levels for children on DTG when compared with those on other regimen. The study highlighted gaps in ART adherence and viral suppression among ART-experienced children in Northern Nigeria. Less than one-fifth of the children were started on treatment before the age of 2 years, highlighting the historical gaps in early infant diagnosis in this region.38–40 Close to three-quarters of the children in this study were on DTG, which was the recommended first-line regimen during the study period for children weighing 20 kgs or more (pill containing 50 mg of DTG), with pediatric formulations made available at the end of the study period.7,10 We did not establish from the routine data available in this study the DTG formulation the children were taking.

Newer ART regimen (eg, integrase inhibitors) and improved access to ART for CWHIV, though lagging behind adults, has resulted in the significant improvement in survival of children due to better tolerance and improved adherence.41–45 DTG is considered safe in children7 and is more tolerable than other antiretroviral drugs such as the PIs. The pediatric DTG rollout lags behind that of adults because children were not included in initial trials, and child-friendly formulations were manufactured and tested later than the adult formulations.7,11,46 There are probable explanations for the results from our study showing that DTG did not result in higher likelihood of undetectable VL. The data showed that CWHIV who were already suppressed were more likely to be switched to DTG compared with those with a high VL, probably limiting the benefit of the superior regimen for those who really needed it and in turn limiting the population-level impact of DTG. However, the finding that those on DTG had poorer adherence compared with those on NNRTIs (84% versus 75%) and only slightly better than those on PIs (71%) may be another explanation for the lack of higher effect of DTG on viral suppression. The higher adherence to NNRTIs compared with DTG mirrors reports among adults in sub-Saharan Africa and requires further interrogation.47 For CWHIV on PI-based regimen, the poorer adherence may partly be due to the poorer tolerability of PIs.48 There is a need for continued vigilance and reinforcement of adherence strategies even as the switch to DTG is accelerated.

MMD has been studied in several settings in sub-Saharan Africa.20,28,30 Prior studies among adults have demonstrated that providing 3–6 months ART refills to stable patients (virally suppressed and no AIDS-defining illness) did no harm and improved treatment outcomes.23,24,49 Several studies have described MMD as a feasible model among CWHIV in sub-Saharan Africa with some studies assessing the impact of MMD on viral suppression.27,50 Overall, previous studies showed that children on MMD had slightly better viral suppression.50 Our study, on the contrary, while not showing benefit was reassuring because it showed that the likelihood of achieving undetectable VL was not lower for CWHIV using MMD. Previous studies have outlined other benefits of MMD, including significant cost savings to patients and improved adherence to treatment and clinic schedules and better quality of life.21,51,52 We note, however, that in our study, there was no difference in adherence between those on MMD and those not on MMD in our study (74% versus 75%, respectively). For children, caution should be taken to ensure that they are not on suboptimal doses due to failure to adjust doses with increasing weight. The use of pragmatic weight bands in NNRTI and DTG dosing for children allows for the implementation of MMD among children.7,53 The WHO guidelines on MMD for children has included considerations for dosing of DTG using weight bands and endorsed the practice.54 Although this study did not provide evidence for a direct link between DTG, MMD, and undetectable VL, the overall trend of improved viral suppression during the study period, comparing the baseline and last VLs, which happened during the rollout and adoption of the 2 key interventions, and at a difficult period during the COVID-19 pandemic, is encouraging.55

We assessed associations between other modifiable factors and viral suppression to undetectable levels including the role of support groups, the school environment (including boarding schools), HIV status disclosure to children, socioeconomic status of the child's household, and caregiver mental health. There was a lower likelihood of undetectable VL for children in support groups, likely pointing to the selection of children who join support groups. Understandably, CWHIV not achieving target outcomes are the right candidates for the support groups.56 Beyond this study, we have not come across other studies that have evaluated peer support groups for older children and young adolescents with HIV in SSA. We did not demonstrate any associations between the other factors and undetectable VL levels. In contrast to findings in our study, poor socioeconomic status and poor caregiver mental health have been shown to negatively affect treatment outcomes among children.57–59 Although the current literature is largely positive, some previous studies have also reported no association or a negative association between HIV status disclosure to children and improved treatment outcomes.60–64 Last, the school environment, especially being in a boarding school has been evaluated in previous studies and shown to negatively influence access to HIV care for children and their treatment outcomes.65,66

The strength of this study was the utilization of a large data set of program data complemented by survey data from caregivers, which enabled a robust assessment of factors hypothesized to affect viral suppression to undetectable levels. We recognize some limitations in this study, including the reduced generalizability of our findings introduced by only including participants who had more than 1 VL in the study period. Including these participants would have limited our ability to adjust for baseline VL, which was likely a determinant on who was exposed to DTG and MMD, resulting in residual confounding. The participants who were excluded were slightly younger, with other characteristics including lower duration on ART and lower likelihood of being on DTG and MMD. Of note, however, they did not differ in viral suppression, which was the main study outcome. Finally, we assessed treatment adherence through proxy report (caregiver reporting on behalf of the child), which for older children who take medication without assistance from their caregivers may be inaccurate.

CONCLUSIONS

Multimonth dispensing is a feasible strategy for scale-up among children with HIV. This study showed that it did not compromise treatment outcomes for children. Although the study demonstrated a significant improvement in viral suppression, there was no evidence of improved suppression with DTG, likely due to implementation strategies that favored switching those already suppressed from other ART molecules to DTG and poor adherence even among those on DTG. Poor adherence remains a key barrier to achieving treatment targets. Overall, the scaling up of DTG, MMD, and adherence interventions is going to be crucial in Nigeria to reach the third 95 of the UNAIDS 95-95-95 targets by the year 2030.

Supplementary Material

SUPPLEMENTARY MATERIAL
qai-93-229-s001.docx (22.5KB, docx)

ACKNOWLEDGMENTS

The authors thank the children in HIV care in Northern Nigeria whose data they relied on to conduct this study and their caregivers who volunteered their time to complete the survey. The authors also thank the clinic staff across the 73 facilities that assisted with identifying and recruiting the children and their caregivers and the study staff who conducted the data collection. Lastly, The authors appreciate the funders for this study, the United States Agency for International Development through the Nigeria Strategic HIV/AIDS and TB Response Program IDIQ Contract Number 72062019D00009-Task Order 01 Number 72062020F00002 and Task Order 03 Number 72062020F00004, the data managers working in the program who performed the abstraction of routine data in LAMIS, and the administrative team at Chemonics International who supported the study team.

Footnotes

The study was funded by the United States Agency for International Development (USAID) through the Nigeria Strategic HIV/AIDS and TB Response Program (SHARP) IDIQ Contract Number 72062019D00009-Task Order 01 Number 72062020F00002 and Task Order 03 Number 72062020F00004.

Authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jaids.com).

Contributor Information

Cyrus Mugo, Email: cyrusmugodr@gmail.com.

Bashir Zubayr, Email: bashonipe@gmail.com.

Nnenna Ezeokafor, Email: asnnenna@gmail.com.

Babatunde Oyawola, Email: boyawola@gmail.com.

David Ochedomi Ekele, Email: ochedomi@gmail.com.

Leila Madueke, Email: leilamadueke@gmail.com.

Zipporah Kpamor, Email: zmkpamor@gmail.com.

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