Retention to Care and Viral Load Suppression: Insights from Young People Receiving HIV Treatment at Mpilo Centre of Excellence in Bulawayo, Zimbabwe.

This mixed-methods study of 110 HIV-positive youths at Mpilo Centre of Excellence in Zimbabwe identifies that younger age, male sex, adherence challenges, insufficient clinical and social support, and low self-efficacy are significant barriers to viral load suppression, highlighting the urgent need for tailored, youth-friendly interventions to improve retention in care.

The Gist

Imagine the fight against HIV as a long, difficult marathon. For the runners (the patients) to finish strong and stay healthy, they need to keep running every day without stopping (taking their medication) and they need to check their pace regularly (viral load tests) to make sure they are winning.

This study is like a post-race debriefing for a specific group of runners: young people aged 15 to 24 at the Mpilo Centre of Excellence in Bulawayo, Zimbabwe. The researchers wanted to know: Why are some of these young runners stumbling or quitting the race, while others are sprinting toward the finish line?

Here is the breakdown of what they found, using simple analogies:

🏁 The Goal: The "Undetectable" Finish Line

The ultimate goal in HIV treatment is Viral Load Suppression. Think of the virus as a tiny, invisible weed in a garden. If you take your medicine perfectly, the weed dies down so much that your garden tests show "zero weeds." This is called being "undetectable."

• The Result: In this study, about 68% of the young people successfully kept their "weeds" down. That's good, but it means about 1 in 3 were struggling to keep their garden weed-free.

🚧 The Roadblocks: Why Some Runners Stumble

The researchers found that the race isn't just about willpower; it's about the terrain and the support team. Here are the main obstacles they identified:

1. The "Growing Pains" of Age (15–19 vs. 20–24)

• The Metaphor: Imagine a teenager learning to drive a car. They are still figuring out the rules, getting distracted, and relying on their parents to remind them to check the mirrors. An older driver (20–24) has more experience and confidence.
• The Finding: The younger teens (15–19) were much more likely to struggle than the older young adults. They are in a tricky transition phase where they are moving from "Mom and Dad drive the car" to "I have to drive myself," and that shift is hard.

2. The "Silent Passenger" (Gender)

• The Metaphor: Think of the runners as a relay team. In this race, the female runners seemed to have a better support system or a clearer map, while the male runners were often running alone in the fog.
• The Finding: Young men were significantly less likely to suppress the virus than young women. Men often face more stigma (shame) and are less likely to ask for help or talk about their struggles.

3. The "Tangled Shoes" (Adherence Challenges)

• The Metaphor: Trying to run a marathon with your shoelaces tied together. It's not that you don't want to run; it's that something is physically or mentally tripping you up.
• The Finding: If a young person said, "I have trouble remembering to take my pills," they were almost guaranteed to fail the race. School schedules, work shifts, and fear of people finding out they are HIV-positive made it hard to keep their "shoelaces" untied.

4. The "Coach's Attitude" (Staff Support)

• The Metaphor: Imagine a coach who yells at you when you miss a step versus a coach who says, "Let's figure out why you missed that step and how to fix it."
• The Finding: This was huge. If the young people felt the clinic staff were unsupportive, judgmental, or cold, they were three times more likely to fail. A friendly, encouraging doctor or nurse acts like a cheerleader that keeps you running.

5. The "Confidence Meter" (Self-Efficacy)

• The Metaphor: Do you believe you can actually win the race? If you think, "I'm too weak to do this," you probably won't try your hardest.
• The Finding: Young people who didn't feel confident in their ability to take their meds correctly were more likely to have the virus return. It's a mindset game.

🗣️ What the Young People Said (The "Story" Behind the Stats)

The researchers didn't just look at numbers; they listened to stories.

• School & Work: "I can't take my pill at 2 PM because my teacher is watching, and I'm scared they'll ask why I'm taking a pill."
• Stigma: "I can't tell my boss I'm sick, so I skip work to get my meds, and then I get fired."
• Family: "I live with my aunt, but she doesn't know I'm HIV positive, so I have to hide my pills in my sock drawer."

🛠️ The Game Plan: How to Help Them Win

The study suggests a new playbook for the coaches (doctors) and the league (the government):

1. Special Training for the Coaches: Doctors need to learn how to talk to teenagers without being scary. They need to be friendly, not judgmental.
2. The "Peer Squad": Create more groups where young people can support each other (like a running club). Since girls were doing better, maybe they can help mentor the boys.
3. Fix the "Shoelaces": Help students and workers find ways to take meds without getting caught or fired. Maybe flexible clinic hours?
4. Teach the Rules: Many kids didn't even know what their "viral load" number meant. They need simple education so they understand why they are running this race.
5. Money Matters: If a kid can't afford the bus fare to the clinic, they won't come. The system needs to help with transport and food costs.

🏆 The Bottom Line

This study tells us that for young people in Zimbabwe, winning the fight against HIV isn't just about giving them a pill. It's about fixing the environment around them. It's about making sure they feel safe at school, supported by their doctors, confident in their own abilities, and financially able to get to the clinic.

If we fix these "roadblocks," more young runners will cross the finish line, stay healthy, and stop the virus from spreading to others.

Technical Summary

1. Problem Statement

Despite global efforts to control the HIV epidemic, adolescents and young adults (AYAs) aged 15–24 remain a vulnerable population with suboptimal treatment outcomes. In Zimbabwe, retention in care and viral load suppression rates among this demographic fall short of the UNAIDS 95-95-95 targets. While differentiated service delivery models (e.g., Community Adolescent Treatment Supporters) exist, significant gaps persist in understanding the specific demographic, clinical, and psychosocial determinants driving poor adherence and viral failure at the Mpilo Centre of Excellence (MCoE). There is an urgent need to identify actionable factors to tailor youth-friendly interventions.

2. Methodology

• Study Design: A mixed-methods cross-sectional study combining quantitative surveys with qualitative inquiry (Focus Group Discussions, In-Depth Interviews, and Key Informant Interviews).
• Setting & Population: Conducted at the Mpilo Centre of Excellence in Bulawayo, Zimbabwe. The target population was HIV-positive individuals aged 15–24 years on Antiretroviral Therapy (ART) with documented status disclosure.
• Sampling & Size:
  • Initial Recruitment: 227 youths were approached.
  • Final Analysis: 110 participants were included in the quantitative analysis after excluding 117 due to missing or incomplete viral load data.
  • Qualitative Component: Included 6 Focus Group Discussions (FGDs), 16 In-Depth Interviews (IDIs) with patients, and 9 Key Informant Interviews (KIIs) with healthcare workers/caregivers.
• Data Collection: Structured questionnaires captured demographic, clinical, and behavioral data. Qualitative data explored contextual barriers and facilitators.
• Statistical Analysis:
  • Quantitative: Descriptive statistics and logistic regression (univariable and multivariable) were used to identify predictors of viral suppression (<50 copies/ml).
  • Qualitative: Thematic analysis was performed using Dedoose software.
  • Integration: Triangulation was used to validate quantitative findings with qualitative themes.
• Ethical Considerations: Approved by the National AIDS Council Internal Review Board. Informed consent/assent was obtained, with strict confidentiality measures.

3. Key Contributions

• Granular Demographic Insights: The study provides specific data on the disparity between younger adolescents (15–19) and older youths (20–24) within the same facility, highlighting the critical transition period from caregiver-supported to self-managed care.
• Multidimensional Determinants: It moves beyond simple adherence metrics to integrate structural (school/work), psychosocial (stigma, self-efficacy), and clinical (staff support) factors into a cohesive model of viral suppression.
• Gender-Specific Findings: The research explicitly identifies male sex as a significant risk factor for non-suppression, contrasting with the generally higher retention seen in females, necessitating gender-responsive interventions.
• Treatment Literacy Gap: The study highlights a critical, often overlooked barrier: the inability of many youths to recall or interpret their own viral load results, indicating a failure in patient-provider communication regarding treatment goals.

4. Key Results

Viral Suppression Status:

• Overall viral suppression rate was 68.19% (<50 copies/ml).
• 31.81% of participants had unsuppressed viral loads.

Significant Predictors of Poor Viral Suppression (Multivariable Logistic Regression):

1. Age: Younger adolescents (15–19 years) had significantly lower odds of suppression compared to older youths (AOR: 0.81; 95% CI: 0.67–0.97; p=0.041).
2. Sex: Males were significantly less likely to achieve suppression than females (AOR: 0.43; 95% CI: 0.21–0.96; p=0.032).
3. Adherence Challenges: Participants reporting challenges in taking ART were at higher risk of non-suppression (AOR: 0.12 for no challenges, implying challenges increase risk).
4. Clinical Staff Support: Perceived lack of support from clinical staff was associated with a threefold increase in the risk of unsuppressed viral load (AOR: 3.01; 95% CI: 1.34–7.69; p=0.046).
5. Self-Efficacy: Lower confidence in taking ART as directed significantly reduced suppression odds (AOR: 2.65; 95% CI: 1.11–7.83; p=0.046).
6. Social Support: Lack of friend support for clinic visits reduced the likelihood of suppression (AOR: 0.31; 95% CI: 0.09–0.89; p=0.001).

Qualitative Themes:

• Barriers: Stigma (family and community), economic hardship (transport, food insecurity), school/work conflicts (inflexible schedules), and fear of disclosure.
• Facilitators: Strong family involvement, supportive peer networks, and empathetic healthcare providers.
• Literacy Gap: Many participants could not recall their viral load status, suggesting ineffective counseling on the meaning of test results.

5. Significance and Implications

• Policy & Programmatic Impact: The findings necessitate a shift from generic youth programs to differentiated, age-specific interventions. Specifically, programs must address the unique developmental needs of the 15–19 age group and the specific barriers faced by young men.
• Clinical Practice: There is an urgent need to train healthcare workers in adolescent-friendly communication to improve the provider-patient relationship, which was a strong predictor of success.
• Treatment Literacy: Interventions must focus on improving "viral load literacy," ensuring patients understand why they are tested and what the results mean for their health, thereby boosting self-efficacy.
• Structural Support: Addressing socioeconomic barriers (transport, school/work flexibility) through multi-sectoral partnerships is essential for sustained retention.
• UNAIDS Targets: Addressing these specific determinants is critical for Zimbabwe to progress toward the 95-95-95 targets and reduce HIV transmission among its youth population.

Limitations: The study is cross-sectional (precluding causal inference), relies on self-reported adherence (potential social desirability bias), and is limited to a single facility, which may affect generalizability to out-of-care populations.