Viral load suppression and retention in care among children and adolescents receiving multi-month anti-retroviral therapy refills: a program data review in Uganda.

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Bridget Ainembabazi, Rogers N. Ssebunya, Winnie Akobye, Alexander Mugume, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3743776/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Dec, 2024 Read the published version in BMC Pediatrics → Version 1 posted 11 You are reading this latest preprint version Abstract Background In July 2022, Uganda’s ministry of Health extended the 2021 WHO guidelines that recommended 3–6 monthly dispensing of antiretroviral therapy (ART) to include all children and adolescents living with HIV (CALHIV). Treatment outcomes following this recommendation have not yet been documented. We compared viral load (VL) suppression and retention in HIV care rates among CALHIV receiving 1, 2–5 and > = 6 monthly ART dispensation in Uganda. Methods A cross-sectional study of electronic medical records in 118 health facilities was conducted. Data for CALHIV 10–19 years captured at their most recent five clinic visits as of 15th May 2023 were analysed. Most recent two VL < 1000 copies/ml were used as measures for VL suppression and sustained VL suppression. A client was considered retained in care if they visited the clinic within 28 days from their expected return visit date. We used margins plots and a modified poisson model adjusting for facility level clustering to assess VL suppression and retention across multi-month ART categories. Results A total of 2864 CALHIV, 1609 (56.2%) being females and with a median age of 12 years (iqr = 7) were included. Overall suppression and retention rates were 80.4% (2133/2654) and 87.8% (2514/2864) respectively. A significant number had been dispensed ART for ≥ 2 months (50%, 2–5 months and 43.5%, ≥ 6 months). Probability of having a suppressed VL was higher among CALHIV that had received ≥ 6 months and 2–5 months of ART compared to those of 1 month i.e., 83% vs 79% vs 41% respectively. Probability of being retained in care didn’t differ across multi-month ART categories. CALHIV who received ART for 2–5 months and ≥ 6 months compared to 1 month were more likely to have a suppressed VL; (adj.PR = 1.98; 95%CI:1.41, 2.80) and (adj.PR = 2.21; 95% CI:1.59, 3.05) respectively. CALHIV with a Tuberculosis diagnosis history were less likely to have a suppressed VL (adj.PR = 0.73; 95%CI:0.65,0.81), however this was not statistically significantly different between multi-month categories. Conclusion CALHIV receiving multi-month ART including 6 months dispensation had better VL suppression rates. Retention rates however didn’t differ by multi-month dispensing categories. We recommend multi-month ART dispensation including more than 6 months among CALHIV irrespective of their age, clinical stage, and history of prior co-morbidities. HIV Multi-month Children Adolescents Figures Figure 1 Figure 2 Background Over the last two decades, the number of people living with HIV (PLHIV) accessing anti-retroviral therapy (ART) globally has exponentially increased from less than 3 million in 2003 1 to 29.8 million in 2022 2 . This trajectory has been associated with reduced AIDS related mortality as well as improved quality of life among PLHIV 3 , 4 . Similar trends have been observed among children and adolescents especially in high HIV burden sub–Saharan Africa 5 , 6 . Most recently the need to offer more than just ART and beyond viral load suppression is growing among recipients and providers of HIV care to also include health related quality of life (HRQoL) 7 , 8 , and patient-centered care 9 , 10 . Patient centered care (PCC) is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” 11 . Children and adolescents living with HIV (CALHIV) face unique challenges hindering them to achieve their treatment targets 12 . Globally adolescents have been shown to have poor viral load (VL) suppression and retention in HIV care rates compared to the adult population 13 – 15 and consequently children living with HIV and born to such adolescent mothers have the same fate. The need for better therapeutic options, systems in place to promote ART adherence and retention in HIV care for adolescents as well as offering a child centered approach in HIV programming have been underscored 16 , 17 . It is not uncommon therefore to recommend needs-tailored HIV services for children and adolescents to mitigate such challenges. According to the 2020 framework 18 guiding country programs to improve service delivery for infants, children and adolescents, decentralised care and differentiated service delivery (DSD) HIV approaches are some of the recommended strategies to improve continuity in care. Facility level multi-month dispensing (MMD) of ART is one of the strategies that has been shown to meet the needs to clients 19 as a way to offering patient centred care; reducing the burden for frequent clinic travels, long waiting times and high costs of travel among others. Published literature on treatment outcomes following multi-month ART dispensation already exist among the adult population 19 – 21 , but scarce among CALHIV. The few published studies among children or/and adolescents focused on trends in scale-up of MMD 22 and impact of covid-19 on MMD 23 but didn’t access for VL suppression and retention in care as part of their outcomes. One study however in Tanzania has shown that adolescents on 3 and 6 months ART were more likely to be virally suppressed 24 . Gray literature through the World Health Organisation 25 have now recommended ART MMD for children and adolescents including up to/or more than 6 months. Despite this however, treatment outcomes including viral load suppression have not been documented. Our study therefore set out to assess VL suppression and retention in care rates comparing children and adolescents who received 1, 2–5 and ≥ 6 + months of ART dispensation in eastern Uganda. Methods Study design, setting and population. This was a cross sectional analytic study design among CALHIV receiving care in facilities within districts of eastern Uganda. Data from electronic medical records (EMR) in 118 health facility HIV clinics supported by Baylor College of Medicine Children’s Foundation Uganda under the USAID Local Partner Health Services project were abstracted. The region has 161 HIV treatment Centres under this project and the selected facilities contributed 86% of the regional number of active clients in care by January-March 2023 quarter. The region started multi-month ART dispensation for CALHIV in July 2022. Clients included in this evaluation were managed as per Uganda’s HIV care and treatment guidelines. Comparing treatment outcomes by duration of ART dispensation provide insights of whether HIV programs can initiate ART six months and beyond without compromising treatment outcomes among children and adolescents. All sites included in this study provide the basic required HIV services including intensified adherence counselling and home-based HIV care & follow-up. Sampling, inclusion, and exclusion criteria Health facilities that contributed 86% of the regional clients in care for the January-March 2023 quarter were purposively selected for this evaluation. Data for CALHIV 10–19 years within facility EMRs captured at their most recent five clinic visits as of 14th June 2023 was used for analysis. Only CALHIV who had been on ART for at least 6 months were included in this analysis. Figure 1 below details the inclusion and exclusion criteria used in this evaluation. Data collection procedures Data was downloaded from the ministry of health EMR system as Microsoft spreadsheets guided by the following variables: socio-demographic characteristics, HIV diagnosis and treatment, viral load tests, ART regimen, adherence rates, TB status and last clinic encounter dates among others. Triangulation and data wrangling were done with facility registers for missing data not in the EMR databases. Data were cleaned in Microsoft spreadsheets and exported to Stata statistical software version 18.0 for analysis. Variables measurements The main outcomes of interest were viral load suppression and retention in care. VL suppression was defined as most recent VL < 1000 copies/ml while sustained VL suppression was measured as two consistent VL < 1000 copies/ml on the most recent viral load values. Retention was defined as keeping appointment within 28 days from the scheduled appointment date, factoring in the number of days medication prescribed to the client. Retention for charts with only one encounter visit date were evaluated based on the final date of data abstraction (14th June 2023) i.e., those who had not appeared despite being scheduled were considered as lost to follow-up from the clinic. Clients who were transferred out of the clinics were assessed by on their previous clinic encounters before being transferred. All those considered virally suppressed and those retained in care were coded 1 or otherwise 0 . Independent variables used in the multivariate model included socio-demographic characteristics (age, sex), clinical characteristics including ART regimen, duration in ART, and TB status. Statistical Analysis Descriptive statistics and margins plots were used to compare VL suppression and retention rates by multi-month ART dispensation. Determinants for viral load suppression were analysed using a modified Poison regression model with log-link and Poisson-family via a generalized linear model, adjusting for clustering at facility level. We report our findings in line with the recommended Strengthening of Observational Studies in Epidemiology (STROBE) statement guidelines. Results Participants individual characteristics and MMD. Table1 shows characteristics of participants included in this study. Majority of participants were older adolescents, 10-19 years (65.9%), females (56.2) from either health centre IIIs or IVs. Over eighty two percent (82.2%) had been on HIV treatment for two years or more, with majority being on dolutegravir (DTG) based regimen. Most were with WHO clinical stage I (90.3%), and with no history of having been diagnosed with TB (98.6%). Table2 shows frequency distributions of MMD by participants individual and clinical characteristics. Overall, there were statistically significant differences in proportions across MMD categories. CALHIV receiving more or equal to 6 months of ART were majorly from health centre III level (50%, p=0.001). CALHIV receiving 2 or more months of ART drugs were majorly older adolescents 10-19 years of age (62.5%, 2-5 months, 71.6%, ≥6 months and 54.5%, 1 month, p=0.001). VL suppression, sustained VL suppression and retention by participant characteristics. Table3 illustrates frequency distributions of VL suppression, sustained VL suppression, and retention in care by participants characteristics. There were statistically significant differences in both VL suppression and sustained VL suppression rates across MMD categories, history of TB diagnosis and facility level. Compared to younger adolescents, older adolescents 10-19 years of age had significantly higher proportions of VL suppression; (68.3% vs. 31.7%, p=0.02), however this was not observed with sustained VL suppression (69.9% vs. 30.1%, p=0.05). Statistically significant differences in proportions of VL suppression and sustained VL suppression were observed across MMD categories; VL suppression (1 month: 3.0% vs. 2-5months: 51.2% vs. ≥6 months: 45.8%, p=0.001), sustained VL suppression (1 month: 2.0% vs. 2-5months: 51.8% vs. ≥6 months: 46.2%, p=0.001). Comparatively, there were significantly lower proportions of VL suppression among clients who had a TB diagnosis history. This however did not differ among those who received 1 month versus those who received ≥2 months of ART. Results in table3 also show that VL suppression and sustained VL suppression did not differ significantly by sex i.e., p=0.927 and p=0.813 respectively. Retention in HIV care on the other hand did not differ significantly by individual characteristics including MMD of ART. Results in figure2 underscore results in table3, highlighting that the probability of VL suppression across MMD categories differed significantly while retention in care did not. The predicted probability of VL suppression among CALHIV that received ≥6 months was approximately 83% compared to 79% and 41% for those that received 2-5 months and 1 month of ART respectively. Retention rates across MMD categories ranged from 86% to 87%. Predictors of VL suppression Results in table4 show both crude and adjusted prevalence ratio estimates from the multivariate regression model that assessed the predictors for VL suppression. Overall, MMD, history of TB diagnosis and duration on ART were statistically significantly different. Compared to CALHIV that received 1 month of ART, those that received 2-5 months and ≥ 6months were statistically significantly associated with VL suppression; (adj.PR=1.98; 95%CI:1.41, 2.80) and (adj.PR=2.21; 95% CI:1.59, 3.05) respectively. Those with a history of a TB diagnosis were less likely to have a suppressed VL; (adj.PR=0.73; 95%CI:0.65, 0.81), however this didn’t differ significantly among those who had TB and received 1 month versus those who received ≥2 months of ART. Duration on ART was statistically significantly associated with VL suppression with those who had spent 12 months or more on ART being less likely to have a suppressed VL. This probability however was marginally small i.e., 7% (adj.PR=0.93, 95%CI:0.65, 0.81) for those 2-5 months and 4% (adj.PR=0.96, 95%CI:0.94, 0.98) for those more than 24 months. Sex, age, health facility level, ART regimen, and WHO clinical stage were not statistically significantly different. Discussion Our study highlights that viral load suppression as well as sustained viral load suppression were better among CALHIV that received two or more months of ART compared to those receiving 1 month of ART. Significantly higher probability of being virally suppressed for those that received 2–5 months and ≥ 6 months of ART (adj.PR = 1.98; 95%CI:1.41, 2.80) and (adj.PR = 2.21; 95% CI:1.59, 3.05) respectively. Retention in care rates did not differ significantly by months of ART dispensed. These results indicate that clients given multi-months of ART drugs including beyond 6 months can still achieve and maintain suppressed VL rates as compared to those receiving monthly prescriptions. They also show that even with multi-month ART prescriptions, CALHIV can keep their scheduled clinic appointments. Overall VL suppression and retention rates in this study were below the global targets of 95% however these results were not surprising given that this age group has been documented elsewhere to be challenged even beyond the HIV treatment itself i.e., socially, emotionally, and physically 26 . CALHIV receiving multi-month ART showing good viral load suppression rates compared those on 1 month provides new evidence that multi-month dispensation of ART is feasible and could be improved even further in this vulnerable age group. Our results are similar to what has been documented in Tanzania among adolescents 24 . Because majority of the study participants had been on ART for 2 or more years, there is a likelihood that a large proportion of CALHIV had stabilised on ART and as such had higher chances of being virally suppressed compared to those just starting ART. Having said this however, given that a person’s viral load on average drops to undetectable viral load within 6 months or less while adhering to ART, we would also expect a significant number in this study to have suppressed in the early stages after starting ART. Comparably, CALHIV on multi-month ART significantly had higher rates of sustained viral load suppression compared to those on 1 month as illustrated in Table 3 . This finding underscores that notion that if well counselled and provided with adequate information on ART adherence, CALHIV can continue to adhere to their medication. Multi-variate results in Table 4 on the other hand showed that CALHIV who had been on ART for longer than 2 years were less likely to be virally suppressed. This result provides additional insights on long term viral load suppression among this age group i.e., even with good sustained viral load suppression rates, there could be some level of medication fatigue in some CALHIV receiving multi-month ART dispensation. ART fatigue among adolescents and adult population has well been documented before 27 and as such health care providers ought to rethink of long-term strategies to address this challenge if we are to achieve and sustain viral load suppression at or above the 95% global target. Additionally, because viral load suppression overall in this age group has been documented to be poor compared to the general population 25 , this should not hinder MMD scale-up in this age group. Having said this the probability of being suppressed was approx. 90% (≥ 6months) and approx. 79% (2–5 months). Caution therefore needs to be taken by health care providers in this cohort to identify barriers for viral load suppression at individual, family, and health facility level to improve the probability of being virally suppressed. Our study in Table 3 shows a significantly higher proportion of older CALHIV aged 10–19 years compared to the younger counterparts to have virally suppressed but this was not the same observation when it came to sustained viral load suppression (Table 3 ) as well as predicting suppression rates (Table 4 ). These results were surprising given that younger children (0–9 years) are oftentimes under the full care of their guardians, and we would expect a higher proportion virally suppressed. Despite this however, the final model results in Table 4 did not seem to show statistically significant differences in viral load suppression by age group. Our results are in agreement with other studies published elsewhere 28 where age is not a significant factor in viral load suppression. Despite these results showing not significant differences by age group, it is important to highlight that person-centred care in HIV also requires age specific interventions that are targeted to improve viral loas suppression. Retention in HIV care overall in our study didn’t come out significantly different across sex, age group, multi-month ART dispensing as well as health facility level. From Fig. 2 , retention rates ranged between 86% and 88% across multi-month ART dispensing which was not statistically significantly different. This is another cornerstone finding from our study revealing that even within this vulnerable group, multi-month prescription will not jeopardize retention rates as has been documented in the adult population 19 , 29 . We didn’t find contrasting results showing that retention rates were worse among cohorts on multi-month compared to 1 month ART dispensation. Because adolescents are at increased risk of lost to follow-up from HIV care 30 , and the fact that the probability of retention in our study was below the 95% targeted mark is an indication that more attention is needed to mitigate lost to follow-up. Identifying apriori CALHIV at higher risk of lost to follow-up and minimising multi-month ART dispensation in such individuals is thus recommended. Individual with history of a TB diagnosis were less likely to be virally suppressed while duration on ART, ART regimen, current WHO clinical stage was not significantly associated with vial load suppression. Despite this however, there was not statistically significant differences among TB clients by multi-month ART dispensation. HIV associated co-morbidities including TB have been linked to poor overall HIV treatment outcomes 31 which is the same finding in our study, however, getting multi-month ART drugs does not increase or reduce your probability of being virally suppressed. Conclusion CALHIV receiving multi-month ART including 6 months dispensation had better VL suppression rates. Retention rates however didn’t differ by multi-month dispensing categories. We recommend multi-month ART dispensation including more than 6 months among CALHIV irrespective of their age, clinical stage, and history of prior co-morbidities. We also recommend further research around facilitators and barriers to viral load suppression and retention in care for CALHIV on multi-month ART regimens. Study limitations Our study had some limitations; first some (210, 7%) has missing viral load values, however we believe the results would not be any different if none was missing such values and as such can be generalisable. Abbreviations AIDS : Acquired Immunodeficiency Syndrome ART : Anti-retroviral therapy CALHIV: Children and Adolescents living with HIV. DSD: Differentiated Service Delivery EMR: Electronic Medical Records HC : Health Facility HIV: Human immunodeficiency virus LTFU : Lost to follow-up. MoH : Ministry of Health MMD : Multi-Month Dispensing PLHIV: People Living with HIV VL: Viral load Declarations Ethics approval and consent to participate. Ethical approval for this study was obtained from Makerere University School of Medicine Research Ethics Committee (reference number, 2009-090) and the Uganda National Council for Science and Technology (UNCST), reference number (HS 649), under the Outcomes protocol before data collection. Consent for study participants was not required in this study since this was based on routinely captured secondary anonymised data and of minimal risk. We conducted this study under the UNCST guidelines of 2014 32 , section 5.5 that provides for a waiver of informed consent if the research project carries no more than minimal risk. Consent for publication - Not applicable Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests Authors declare no competing interest in this study. Funding : Not applicable However, data used in this manuscript came from a project that was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through US Agency for International Development (USAID) Uganda under the terms of cooperative agreement numbers 72061722CA00002. Author contribution Conceptualization : BA, RNS, Data curation : BA, Methodology and Formal analysis : RNS, Project administration : WA, AM, DJB, AKM, DK, Writing original draft : RNS, Review & editing : BA, RNS, WA, PN, AM, DJB, AKM, PJE, DK. All Authors read and approved the manuscript. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of either the USAD or PEPFAR. Acknowledgements We would like to thank all the monitoring and evaluation officers and health information system officers under the LPHS-E project in Eastern Uganda for their efforts in ensuring timely and accurate update of the EMR in different health facilities supported under this project. In a special way, we would like to acknowledge in special way; the contact persons at USAID Uganda for insightful review and technical guidance as well as Henry Balwa in the Baylor-Uganda research department for spearheading research administration and Institutional Review Boards (IRB) clearances. References The Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS Epidemic Update. ; 2003. Available from: https://data.unaids.org/pub/report/2003/2003_epiupdate_en.pdf . 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Emeka F, Okonji B, van Wyk B, Ferdinand C, Mukumbang, Gail D, Hughes. Determinants of viral suppression among adolescents on antiretroviral treatment in Ehlanzeni district, South Africa: a cross-sectional analysis. AIDS Res Therapy. 2021;18(1). 10.1186/s12981-021-00391-7 . Canada Parrish A, Basu P, Fishman JB, Koama E, Robin K, Francois, et al. Estimating the effect of increasing dispensing intervals on retention in care for people with HIV in Haiti. EClinicalMedicine. 2021;38. 10.1016/j.eclinm.2021.101039 . The World Health Organisation (WHO). Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach. ; 2016. Available from: https://www.who.int/publications-detail-redirect/9789241549684 , Accessed on 17 August 2023. Ali SA, Mavundla TR, Fantu R, Awoke T. Outcomes of TB treatment in HIV co-infected TB patients in Ethiopia: A cross-sectional analytic study. BMC Infect Dis. 2016;16(1). 10.1186/s12879-016-1967-3 . The Uganda National Council for Science and Technology (UNCST). National Guidelines for Research Involving Humans as Research Participants. ; 2014. Available from: https://www.uncst.go.ug/details.php?option=smenu&id=13&Downloads.html , Accessed on 21st December 2023. Tables Table1 . Characteristics of study participants Characteristics n (%) Overall n=2,864 Health facility level Hospital 484 (16.9) HCIV 986 (34.4) HCIII 1,394 (48.7) Sex Male 1,255 (43.8) Female 1,609 (56.2) Age group 0 – 9y 976 (34.1) 10 – 19y 1,888 (65.9) Duration on ART* 6 – 12m 221 (7.7) 13 – 24m 288 (10.1) ≥ 24m 2,355 (82.2) ART regimen DTG based regimen 2,826 (98.7) Other regimens 38 (1.3) WHO clinical stage Stage I 2,585 (90.3) Stage II 102 (3.6) Stage III 24 (0.8) Missing α 152 (5.3) Transfer-outs Yes 70 (2.4) No 2,794 (97.6) History of TB diagnosis Yes 40 (1.4) No 2,824 (98.6) * Duration in months. α – 152 missing clinical staging Table2 . Multi-month ART dispensation by individual characteristics Variable ART dispensation ≤1 month, n (%) 2-5 months, n (%) >= 6 months, n (%) p-value Health facility level 0.001 Hospital 30 (16.0) 210 (14.7) 244 (19.6) HC IV 49 (26.2) 559 (39.0) 378 (30.4) HC III 108 (57.8) 663 (46.3) 623 (50.0) Sex 0.028 Male 78 (41.7) 663 (46.3) 514 (41.3) Female 109 (58.3) 769 (53.7) 731 (58.7) Age group 0.001 0 – 9y 85 (45.5) 537 (37.5) 354 (28.4) 10 – 19y 102 (54.5) 895 (62.5) 891 (71.6) WHO clinical stage 0.001 Stage1 150 (90.9) 1277 (93.0) 1158 (98.6) Stage2 10 (6.1) 83 (6.0) 10 (0.9) Stage3 5 (3.0) 13 (1.0) 6 (0.5) Duration on ART 0.001 6 – 12m 31 (16.6) 62 (4.4) 128 (10.3) 13 – 24m 22 (11.8) 138 (9.6) 128 (10.3) >24m 134 (71.6) 1,232 (86.0) 989 (79.4) Table3: Viral load suppression and Retention by individual characteristics Variable Viral load ¶ , N=2,654 Sustained viral load ¥ , N=2,372 Retention in HIV care, N=2,864 =1,000 cp/ml n= 521 χ2 Yes n=1625 No n=747 χ2 Retained n=2514 Not retained n=350 χ2 Health facility level 0.032 0.003 0.599 Hospital 369 (17.3) 91 (17.5) 296 (18.2) 129 (17.3) 431 (17.1) 53 (15.1) HC IV 771 (36.2) 158 (30.3) 616 (37.9) 236 (31.6) 866 (34.5) 120 (34.3) HC III 993 (46.5) 272 (52.2) 713 (43.9) 382 (51.1) 1,217 (48.4) 177 (50.6) Age group 0.020 0.052 0.158 0 – 9y 676 (31.7) 193 (37.0) 490 (30.1) 255 (34.1) 845 (33.6) 131 (37.4) 10 – 19y 1,457 (68.3) 328 (63.0) 1,135 (69.9) 492 (65.9) 1,669 (66.4) 219 (62.6) Sex 0.927 0.813 0.098 Male 941 (44.1) 231 (44.3) 729 (44.9) 339 (45.4) 1,116 (44.4) 139 (39.7) Female 1,192 (55.9) 290 (55.7) 896 (55.1) 408 (54.6) 1,398 (55.6) 211 (60.3) ART dispensed 0.001 0.001 0.434 1 month 66 (3.0) 95 (18.2) 33 (2.0) 105 (14.0) 164 (6.5) 23 (6.6) 2 - 5 months 1,091 (51.2) 293 (56.3) 842 (51.8) 418 (56.0) 1,268 (50.5) 164 (46.8) >=6 months 976 (45.8) 133 (25.5) 750 (46.2) 224 (30.0) 1,082 (43.0) 163 (46.6) History of TB β 0.001 0.001 0.589 Yes 16 (0.8) 15 (2.9) 9 (0.6) 18 (2.4) 34 (1.4) 6 (1.7) No 2,117 (99.2) 506 (97.1) 1,616 (99.5) 729 (97.6) 2,480 (98.6) 344 (98.3) ¶ - Based on most recent viral load value. ¥ - based on most recent two viral load values. β - cases had missing VL values. Table4 . Crude and adjusted prevalence ratios associated with VL suppression among children and adolescents in Uganda. Variable VL suppression, [n= 2,654] Unadj.PR 95% CI adj.PR 95% CI p-value Sex Female 1,192 (55.9) 1.0 (ref) Male 941 (44.1) 0.99 0.94 - 1.05 1.00 0.95 - 1.06 0.916 Age group 0 – 9y 676 (31.7) 1.0 (ref) 10 – 19y 1,457 (68.3) 1.05 0.98 - 1.12 1.01 0.94 - 1.10 0.713 Months of ART dispensed 1 month 66 (3.0) 1.0 (ref) 2 - 5 months 1,091 (51.2) 1.92 1.31 - 2.82 1.98 1.41 - 2.80 0.001 >=6 months 976 (45.8) 2.15 1.48 - 3.11 2.21 1.59 - 3.05 0.001 History of TB No 2,117 (99.2) 1.0 (ref) Yes 16 (0.8) 0.64 0.53 - 0.78 0.73 0.65 - 0.81 0.001 Duration on ART 6 – 12m 85 (4.0) 1.0 (ref) 13 – 24m 192 (9.0) 0.95 0.88 - 1.03 0.93 0.88 - 0.99 0.031 >24m 1,856 (87.0) 0.99 0.94 - 1.03 0.96 0.94 - 0.98 0.001 ART regimen Other regimens 19 (0.9) 1.0 (ref) DTG-based regimen 2,114 (99.1) 1.53 0.74 - 3.16 1.49 0.81 - 2.74 0.199 WHO clinical stage Stage1 1,952 (95.9) 1.0 (ref) Stage2 71 (3.5) 0.93 0.82 - 1.05 1.01 0.91 - 1.11 0.848 Stage3 12 (0.6) 0.73 0.42 - 1.28 0.91 0.46 - 1.80 0.777 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Dec, 2024 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 25 Jun, 2024 Reviews received at journal 05 Jun, 2024 Reviews received at journal 20 May, 2024 Reviewers agreed at journal 20 May, 2024 Reviewers agreed at journal 17 May, 2024 Reviewers agreed at journal 08 May, 2024 Reviewers invited by journal 25 Apr, 2024 Editor assigned by journal 25 Apr, 2024 Editor invited by journal 26 Dec, 2023 Submission checks completed at journal 26 Dec, 2023 First submitted to journal 12 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Ssebunya","email":"data:image/png;base64,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","orcid":"","institution":"Baylor College of Medicine Children’s Foundation","correspondingAuthor":true,"prefix":"","firstName":"Rogers","middleName":"N.","lastName":"Ssebunya","suffix":""},{"id":263322171,"identity":"5fdf4722-0157-489e-919b-4cc0e9cf24c6","order_by":2,"name":"Winnie Akobye","email":"","orcid":"","institution":"USAID Local Partner Health Services - Eastern","correspondingAuthor":false,"prefix":"","firstName":"Winnie","middleName":"","lastName":"Akobye","suffix":""},{"id":263322173,"identity":"d18069e7-4142-4c77-bd62-9c652e318587","order_by":3,"name":"Alexander Mugume","email":"","orcid":"","institution":"USAID Local Partner Health Services - Eastern","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Mugume","suffix":""},{"id":263322174,"identity":"9f3d4666-2952-4727-8e6a-934f589e6d70","order_by":4,"name":"Patricia Nahirya-Ntege","email":"","orcid":"","institution":"Baylor College of Medicine Children’s Foundation","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"","lastName":"Nahirya-Ntege","suffix":""},{"id":263322175,"identity":"c1fec3da-ac24-41d7-8c96-505936379b0e","order_by":5,"name":"Denise J. Birungi","email":"","orcid":"","institution":"Baylor College of Medicine Children’s Foundation","correspondingAuthor":false,"prefix":"","firstName":"Denise","middleName":"J.","lastName":"Birungi","suffix":""},{"id":263322176,"identity":"7fd984ea-5a1d-4a8f-afa1-20efe04bf930","order_by":6,"name":"Albert K. Maganda","email":"","orcid":"","institution":"Baylor College of Medicine Children’s Foundation","correspondingAuthor":false,"prefix":"","firstName":"Albert","middleName":"K.","lastName":"Maganda","suffix":""},{"id":263322178,"identity":"f916f890-23cf-4cb9-8294-958761f78dbd","order_by":7,"name":"Peter J. Elyanu","email":"","orcid":"","institution":"Baylor College of Medicine Children’s Foundation","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"J.","lastName":"Elyanu","suffix":""},{"id":263322179,"identity":"82cf9ace-1492-4dd5-83d7-2830655b127b","order_by":8,"name":"Dithan Kiragga","email":"","orcid":"","institution":"Baylor College of Medicine Children’s Foundation","correspondingAuthor":false,"prefix":"","firstName":"Dithan","middleName":"","lastName":"Kiragga","suffix":""}],"badges":[],"createdAt":"2023-12-12 12:29:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3743776/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3743776/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-024-05295-9","type":"published","date":"2024-12-07T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49079488,"identity":"4b64b8c8-0b8d-4560-af09-26b4a82af2db","added_by":"auto","created_at":"2024-01-02 19:49:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":127235,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic details of study population\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3743776/v1/96190b6dda5262befbea270f.png"},{"id":49079489,"identity":"91838b7f-f189-44ba-9a6d-ead9e9c35b27","added_by":"auto","created_at":"2024-01-02 19:49:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35741,"visible":true,"origin":"","legend":"\u003cp\u003eMargin plots of Viral load suppression and retention in care by multi-month ART dispensation\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3743776/v1/edfb09a1ba453ed5ac15634c.png"},{"id":70964433,"identity":"c33e0e61-1667-49cb-9aaa-f4564a317ddb","added_by":"auto","created_at":"2024-12-09 16:00:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1139322,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3743776/v1/5c3704da-02fa-49f3-993c-9f9e0c3f9602.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Viral load suppression and retention in care among children and adolescents receiving multi-month anti-retroviral therapy refills: a program data review in Uganda.","fulltext":[{"header":"Background","content":"\u003cp\u003eOver the last two decades, the number of people living with HIV (PLHIV) accessing anti-retroviral therapy (ART) globally has exponentially increased from less than 3\u0026nbsp;million in 2003\u003csup\u003e1\u003c/sup\u003e to 29.8\u0026nbsp;million in 2022\u003csup\u003e2\u003c/sup\u003e. This trajectory has been associated with reduced AIDS related mortality as well as improved quality of life among PLHIV\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Similar trends have been observed among children and adolescents especially in high HIV burden sub\u0026ndash;Saharan Africa\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Most recently the need to offer more than just ART and beyond viral load suppression is growing among recipients and providers of HIV care to also include health related quality of life (HRQoL)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, and patient-centered care\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Patient centered care (PCC) is defined as \u0026ldquo;providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions\u0026rdquo;\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eChildren and adolescents living with HIV (CALHIV) face unique challenges hindering them to achieve their treatment targets\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Globally adolescents have been shown to have poor viral load (VL) suppression and retention in HIV care rates compared to the adult population\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and consequently children living with HIV and born to such adolescent mothers have the same fate. The need for better therapeutic options, systems in place to promote ART adherence and retention in HIV care for adolescents as well as offering a child centered approach in HIV programming have been underscored\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. It is not uncommon therefore to recommend needs-tailored HIV services for children and adolescents to mitigate such challenges. According to the 2020 framework\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e guiding country programs to improve service delivery for infants, children and adolescents, decentralised care and differentiated service delivery (DSD) HIV approaches are some of the recommended strategies to improve continuity in care.\u003c/p\u003e \u003cp\u003eFacility level multi-month dispensing (MMD) of ART is one of the strategies that has been shown to meet the needs to clients\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e as a way to offering patient centred care; reducing the burden for frequent clinic travels, long waiting times and high costs of travel among others. Published literature on treatment outcomes following multi-month ART dispensation already exist among the adult population\u003csup\u003e\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, but scarce among CALHIV. The few published studies among children or/and adolescents focused on trends in scale-up of MMD\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and impact of covid-19 on MMD\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e but didn\u0026rsquo;t access for VL suppression and retention in care as part of their outcomes. One study however in Tanzania has shown that adolescents on 3 and 6 months ART were more likely to be virally suppressed\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Gray literature through the World Health Organisation\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e have now recommended ART MMD for children and adolescents including up to/or more than 6 months. Despite this however, treatment outcomes including viral load suppression have not been documented. Our study therefore set out to assess VL suppression and retention in care rates comparing children and adolescents who received 1, 2\u0026ndash;5 and \u0026ge;\u0026thinsp;6\u0026thinsp;+\u0026thinsp;months of ART dispensation in eastern Uganda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy design, setting and population.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e This was a cross sectional analytic study design among CALHIV receiving care in facilities within districts of eastern Uganda. Data from electronic medical records (EMR) in 118 health facility HIV clinics supported by Baylor College of Medicine Children\u0026rsquo;s Foundation Uganda under the USAID Local Partner Health Services project were abstracted. The region has 161 HIV treatment Centres under this project and the selected facilities contributed 86% of the regional number of active clients in care by January-March 2023 quarter. The region started multi-month ART dispensation for CALHIV in July 2022. Clients included in this evaluation were managed as per Uganda\u0026rsquo;s HIV care and treatment guidelines. Comparing treatment outcomes by duration of ART dispensation provide insights of whether HIV programs can initiate ART six months and beyond without compromising treatment outcomes among children and adolescents. All sites included in this study provide the basic required HIV services including intensified adherence counselling and home-based HIV care \u0026amp; follow-up.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSampling, inclusion, and exclusion criteria\u003c/h2\u003e \u003cp\u003e Health facilities that contributed 86% of the regional clients in care for the January-March 2023 quarter were purposively selected for this evaluation. Data for CALHIV 10\u0026ndash;19 years within facility EMRs captured at their most recent five clinic visits as of 14th June 2023 was used for analysis. Only CALHIV who had been on ART for at least 6 months were included in this analysis. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below details the inclusion and exclusion criteria used in this evaluation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection procedures\u003c/h2\u003e \u003cp\u003eData was downloaded from the ministry of health EMR system as Microsoft spreadsheets guided by the following variables: socio-demographic characteristics, HIV diagnosis and treatment, viral load tests, ART regimen, adherence rates, TB status and last clinic encounter dates among others. Triangulation and data wrangling were done with facility registers for missing data not in the EMR databases. Data were cleaned in Microsoft spreadsheets and exported to Stata statistical software version 18.0 for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eVariables measurements\u003c/h2\u003e \u003cp\u003eThe main outcomes of interest were viral load suppression and retention in care. VL suppression was defined as most recent VL\u0026thinsp;\u0026lt;\u0026thinsp;1000 copies/ml while sustained VL suppression was measured as two consistent VL\u0026thinsp;\u0026lt;\u0026thinsp;1000 copies/ml on the most recent viral load values. Retention was defined as keeping appointment within 28 days from the scheduled appointment date, factoring in the number of days medication prescribed to the client. Retention for charts with only one encounter visit date were evaluated based on the final date of data abstraction (14th June 2023) i.e., those who had not appeared despite being scheduled were considered as lost to follow-up from the clinic. Clients who were transferred out of the clinics were assessed by on their previous clinic encounters before being transferred. All those considered virally suppressed and those retained in care were coded \u003cb\u003e1\u003c/b\u003e or otherwise \u003cb\u003e0\u003c/b\u003e. Independent variables used in the multivariate model included socio-demographic characteristics (age, sex), clinical characteristics including ART regimen, duration in ART, and TB status.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics and margins plots were used to compare VL suppression and retention rates by multi-month ART dispensation. Determinants for viral load suppression were analysed using a modified Poison regression model with log-link and Poisson-family via a generalized linear model, adjusting for clustering at facility level. We report our findings in line with the recommended Strengthening of Observational Studies in Epidemiology (STROBE) statement guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants individual characteristics and MMD.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable1 shows characteristics of participants included in this study. Majority of participants were older adolescents, 10-19 years (65.9%), females (56.2) from either health centre IIIs or IVs. Over eighty two percent (82.2%) had been on HIV treatment for two years or more, with majority being on dolutegravir (DTG) based regimen. Most were with WHO clinical stage I (90.3%), and with no history of having been diagnosed with TB (98.6%). Table2 shows frequency distributions of MMD by participants individual and clinical characteristics. Overall, there were statistically significant differences in proportions across MMD categories. CALHIV receiving more or equal to 6 months of ART were majorly from health centre III level (50%, p=0.001). CALHIV receiving 2 or more months of ART drugs were majorly older adolescents 10-19 years of age (62.5%, 2-5 months, 71.6%, \u0026ge;6 months and 54.5%, 1 month, p=0.001). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVL suppression, sustained VL suppression and retention by participant characteristics.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable3 illustrates frequency distributions of VL suppression, sustained VL suppression, and retention in care by participants characteristics. There were statistically significant differences in both VL suppression and sustained VL suppression rates across MMD categories, history of TB diagnosis and facility level. Compared to younger adolescents, older adolescents 10-19 years of age had significantly higher proportions of VL suppression; (68.3% vs. 31.7%, p=0.02), however this was not observed with sustained VL suppression (69.9% vs. 30.1%, p=0.05). Statistically significant differences in proportions of VL suppression and sustained VL suppression were observed across MMD categories; VL suppression (1 month: 3.0% vs. 2-5months: 51.2% vs. \u0026ge;6 months: 45.8%, p=0.001), sustained VL suppression (1 month: 2.0% vs. 2-5months: 51.8% vs. \u0026ge;6 months: 46.2%, p=0.001). Comparatively, there were significantly lower proportions of VL suppression among clients who had a TB diagnosis history. This however did not differ among those who received 1 month versus those who received \u0026ge;2 months of ART. Results in table3 also show that VL suppression and sustained VL suppression did not differ significantly by sex i.e., p=0.927 and p=0.813 respectively. Retention in HIV care on the other hand did not differ significantly by individual characteristics including MMD of ART. Results in figure2 underscore results in table3, highlighting that the probability of VL suppression across MMD categories differed significantly while retention in care did not. The predicted probability of VL suppression among CALHIV that received \u0026ge;6 months was approximately 83% compared to 79% and 41% for those that received 2-5 months and 1 month of ART respectively. Retention rates across MMD categories ranged from 86% to 87%. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of VL suppression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults in table4 show both crude and adjusted prevalence ratio estimates from the multivariate regression model that assessed the predictors for VL suppression. Overall, MMD, history of TB diagnosis and duration on ART were statistically significantly different. Compared to CALHIV that received 1 month of ART, those that received 2-5 months and \u0026ge; 6months were statistically significantly associated with VL suppression; (adj.PR=1.98; 95%CI:1.41, 2.80) and (adj.PR=2.21; 95% CI:1.59, 3.05) respectively. Those with a history of a TB diagnosis were less likely to have a suppressed VL; (adj.PR=0.73; 95%CI:0.65, 0.81), however this didn\u0026rsquo;t differ significantly among those who had TB and received 1 month versus those who received \u0026ge;2 months of ART. Duration on ART was statistically significantly associated with VL suppression with those who had spent 12 months or more on ART being less likely to have a suppressed VL. This probability however was marginally small i.e., 7% (adj.PR=0.93, 95%CI:0.65, 0.81) for those 2-5 months and 4% (adj.PR=0.96, 95%CI:0.94, 0.98) for those more than 24 months. Sex, age, health facility level, ART regimen, and WHO clinical stage were not statistically significantly different.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study highlights that viral load suppression as well as sustained viral load suppression were better among CALHIV that received two or more months of ART compared to those receiving 1 month of ART. Significantly higher probability of being virally suppressed for those that received 2\u0026ndash;5 months and \u0026ge;\u0026thinsp;6 months of ART (adj.PR\u0026thinsp;=\u0026thinsp;1.98; 95%CI:1.41, 2.80) and (adj.PR\u0026thinsp;=\u0026thinsp;2.21; 95% CI:1.59, 3.05) respectively. Retention in care rates did not differ significantly by months of ART dispensed. These results indicate that clients given multi-months of ART drugs including beyond 6 months can still achieve and maintain suppressed VL rates as compared to those receiving monthly prescriptions. They also show that even with multi-month ART prescriptions, CALHIV can keep their scheduled clinic appointments.\u003c/p\u003e \u003cp\u003eOverall VL suppression and retention rates in this study were below the global targets of 95% however these results were not surprising given that this age group has been documented elsewhere to be challenged even beyond the HIV treatment itself i.e., socially, emotionally, and physically\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. CALHIV receiving multi-month ART showing good viral load suppression rates compared those on 1 month provides new evidence that multi-month dispensation of ART is feasible and could be improved even further in this vulnerable age group. Our results are similar to what has been documented in Tanzania among adolescents\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Because majority of the study participants had been on ART for 2 or more years, there is a likelihood that a large proportion of CALHIV had stabilised on ART and as such had higher chances of being virally suppressed compared to those just starting ART. Having said this however, given that a person\u0026rsquo;s viral load on average drops to undetectable viral load within 6 months or less while adhering to ART, we would also expect a significant number in this study to have suppressed in the early stages after starting ART.\u003c/p\u003e \u003cp\u003eComparably, CALHIV on multi-month ART significantly had higher rates of sustained viral load suppression compared to those on 1 month as illustrated in Table\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. This finding underscores that notion that if well counselled and provided with adequate information on ART adherence, CALHIV can continue to adhere to their medication. Multi-variate results in Table\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e on the other hand showed that CALHIV who had been on ART for longer than 2 years were less likely to be virally suppressed. This result provides additional insights on long term viral load suppression among this age group i.e., even with good sustained viral load suppression rates, there could be some level of medication fatigue in some CALHIV receiving multi-month ART dispensation. ART fatigue among adolescents and adult population has well been documented before\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e and as such health care providers ought to rethink of long-term strategies to address this challenge if we are to achieve and sustain viral load suppression at or above the 95% global target.\u003c/p\u003e \u003cp\u003eAdditionally, because viral load suppression overall in this age group has been documented to be poor compared to the general population\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, this should not hinder MMD scale-up in this age group. Having said this the probability of being suppressed was approx. 90% (\u0026ge;\u0026thinsp;6months) and approx. 79% (2\u0026ndash;5 months). Caution therefore needs to be taken by health care providers in this cohort to identify barriers for viral load suppression at individual, family, and health facility level to improve the probability of being virally suppressed.\u003c/p\u003e \u003cp\u003eOur study in Table\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows a significantly higher proportion of older CALHIV aged 10\u0026ndash;19 years compared to the younger counterparts to have virally suppressed but this was not the same observation when it came to sustained viral load suppression (Table\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) as well as predicting suppression rates (Table\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These results were surprising given that younger children (0\u0026ndash;9 years) are oftentimes under the full care of their guardians, and we would expect a higher proportion virally suppressed. Despite this however, the final model results in Table\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e did not seem to show statistically significant differences in viral load suppression by age group. Our results are in agreement with other studies published elsewhere\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e where age is not a significant factor in viral load suppression. Despite these results showing not significant differences by age group, it is important to highlight that person-centred care in HIV also requires age specific interventions that are targeted to improve viral loas suppression.\u003c/p\u003e \u003cp\u003eRetention in HIV care overall in our study didn\u0026rsquo;t come out significantly different across sex, age group, multi-month ART dispensing as well as health facility level. From Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, retention rates ranged between 86% and 88% across multi-month ART dispensing which was not statistically significantly different. This is another cornerstone finding from our study revealing that even within this vulnerable group, multi-month prescription will not jeopardize retention rates as has been documented in the adult population\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. We didn\u0026rsquo;t find contrasting results showing that retention rates were worse among cohorts on multi-month compared to 1 month ART dispensation. Because adolescents are at increased risk of lost to follow-up from HIV care\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e, and the fact that the probability of retention in our study was below the 95% targeted mark is an indication that more attention is needed to mitigate lost to follow-up. Identifying apriori CALHIV at higher risk of lost to follow-up and minimising multi-month ART dispensation in such individuals is thus recommended.\u003c/p\u003e \u003cp\u003eIndividual with history of a TB diagnosis were less likely to be virally suppressed while duration on ART, ART regimen, current WHO clinical stage was not significantly associated with vial load suppression. Despite this however, there was not statistically significant differences among TB clients by multi-month ART dispensation. HIV associated co-morbidities including TB have been linked to poor overall HIV treatment outcomes\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e which is the same finding in our study, however, getting multi-month ART drugs does not increase or reduce your probability of being virally suppressed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCALHIV receiving multi-month ART including 6 months dispensation had better VL suppression rates. Retention rates however didn\u0026rsquo;t differ by multi-month dispensing categories. We recommend multi-month ART dispensation including more than 6 months among CALHIV irrespective of their age, clinical stage, and history of prior co-morbidities. We also recommend further research around facilitators and barriers to viral load suppression and retention in care for CALHIV on multi-month ART regimens.\u003c/p\u003e "},{"header":"Study limitations","content":"\u003cp\u003eOur study had some limitations; first some (210, 7%) has missing viral load values, however we believe the results would not be any different if none was missing such values and as such can be generalisable.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAIDS\u003c/strong\u003e: Acquired Immunodeficiency Syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eART\u003c/strong\u003e: Anti-retroviral therapy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCALHIV:\u003c/strong\u003e Children and Adolescents living with HIV.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDSD:\u003c/strong\u003e Differentiated Service Delivery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEMR:\u003c/strong\u003e Electronic Medical Records\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHC\u003c/strong\u003e: Health Facility\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIV:\u0026nbsp;\u003c/strong\u003eHuman immunodeficiency virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLTFU\u003c/strong\u003e: Lost to follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMoH\u003c/strong\u003e: Ministry of Health\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMMD\u003c/strong\u003e: Multi-Month Dispensing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePLHIV:\u0026nbsp;\u003c/strong\u003ePeople Living with HIV\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVL:\u0026nbsp;\u003c/strong\u003eViral load\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from Makerere University School of Medicine Research Ethics\u0026nbsp;Committee (reference number, 2009-090) and the Uganda National Council for Science and Technology (UNCST), reference number (HS 649), under the Outcomes protocol before data collection. Consent for study participants was not required in this study since this was based on routinely captured secondary anonymised data and of minimal risk. We conducted this study under the UNCST guidelines of 2014\u003csup\u003e32\u003c/sup\u003e, section 5.5 that provides for a waiver of informed consent if the research project carries no more than minimal risk.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e - Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no competing interest in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, data used in this manuscript came from a project that was supported by the President\u0026rsquo;s Emergency Plan for AIDS Relief (PEPFAR) through US Agency for International Development (USAID) Uganda under the terms of cooperative agreement numbers 72061722CA00002. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization\u003c/strong\u003e: BA, RNS, \u003cstrong\u003eData curation\u003c/strong\u003e: BA, \u003cstrong\u003eMethodology and\u003c/strong\u003e \u003cstrong\u003eFormal analysis\u003c/strong\u003e: RNS, \u003cstrong\u003eProject administration\u003c/strong\u003e: WA, AM, DJB, AKM, DK, \u003cstrong\u003eWriting original draft\u003c/strong\u003e: RNS, \u003cstrong\u003eReview \u0026amp; editing\u003c/strong\u003e: BA, RNS, WA, PN, AM, DJB, AKM, PJE, DK. All Authors read and approved the manuscript. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of either the USAD or PEPFAR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the monitoring and evaluation officers and health information system officers under the LPHS-E project in Eastern Uganda for their efforts in ensuring timely and accurate update of the EMR in different health facilities supported under this project. In a special way, we would like to acknowledge in special way; the contact persons at USAID Uganda for insightful review and technical guidance as well as Henry Balwa in the Baylor-Uganda research department for spearheading research administration and Institutional Review Boards (IRB) clearances.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS Epidemic Update. ; 2003. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unaids.org/pub/report/2003/2003_epiupdate_en.pdf\u003c/span\u003e\u003cspan address=\"https://data.unaids.org/pub/report/2003/2003_epiupdate_en.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.uncst.go.ug/details.php?option=smenu\u0026amp;id=13\u0026amp;Downloads.html\u003c/span\u003e\u003cspan address=\"https://www.uncst.go.ug/details.php?option=smenu\u0026amp;id=13\u0026amp;Downloads.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, Accessed on 21st December 2023.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable1\u003c/strong\u003e. \u0026nbsp;Characteristics of study participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.80415944540728%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.19584055459272%\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e\u003cstrong\u003en=2,864\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e484 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eHCIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e986 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eHCIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e1,394 (48.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e1,255 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e1,609 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e0 \u0026ndash; 9y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e976 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e10 \u0026ndash; 19y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e1,888 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration on ART*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e6 \u0026ndash; 12m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e221 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e13 \u0026ndash; 24m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e288 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u0026ge; 24m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e2,355 (82.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eART regimen\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eDTG based regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e2,826 (98.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eOther regimens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e38 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO clinical stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eStage I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e2,585 (90.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eStage II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e102 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eStage III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e24 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eMissing\u003cstrong\u003e\u003csup\u003e\u0026alpha;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e152 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransfer-outs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e70 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e2,794 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of TB diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e40 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.375%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.25%\"\u003e\n \u003cp\u003e2,824 (98.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eDuration in months. \u003cstrong\u003e\u0026alpha;\u003c/strong\u003e \u0026ndash; 152 missing clinical staging\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable2\u003c/strong\u003e. Multi-month ART dispensation by individual characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.22239031770046%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eART dispensation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.826446280991735%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026le;1 month, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.272727272727273%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2-5 months, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.33884297520661%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;= 6 months, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.56198347107438%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e30 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e210 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e244 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eHC IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e49 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e559 (39.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e378 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e108 (57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e663 (46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e623 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e78 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e663 (46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e514 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e109 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e769 (53.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e731 (58.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e0 \u0026ndash; 9y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e85 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e537 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e354 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e10 \u0026ndash; 19y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e102 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e895 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e891 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO clinical stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eStage1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e150 (90.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e1277 (93.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e1158 (98.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eStage2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e10 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e83 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e10 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003eStage3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e5 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e13 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e6 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration on ART\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e6 \u0026ndash; 12m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e31 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e62 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e128 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e13 \u0026ndash; 24m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e22 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e138 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e128 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.777609682299545%\"\u003e\n \u003cp\u003e\u0026gt;24m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.910741301059%\"\u003e\n \u003cp\u003e134 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.969742813918305%\"\u003e\n \u003cp\u003e1,232 (86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.482602118003026%\"\u003e\n \u003cp\u003e989 (79.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable3:\u003c/strong\u003e Viral load suppression and Retention by individual characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"966\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.57497414684592%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eViral load\u003csup\u003e\u0026para;\u003c/sup\u003e, N=2,654\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.43950361944157%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eSustained viral load\u003csup\u003e\u0026yen;\u003c/sup\u003e, N=2,372\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.680455015511892%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetention in HIV care, N=2,864\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.407814407814408%\"\u003e\n \u003cp\u003e\u0026lt;1,000 cp/ml \u003cstrong\u003en=2,133\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.30891330891331%\"\u003e\n \u003cp\u003e\u0026gt;=1,000 cp/ml\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en= 521\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.744810744810744%\"\u003e\n \u003cp\u003e\u0026chi;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5995115995116%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=1625\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.378510378510379%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=747\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.058608058608058%\"\u003e\n \u003cp\u003e\u0026chi;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.477411477411477%\"\u003e\n \u003cp\u003eRetained\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=2514\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5995115995116%\"\u003e\n \u003cp\u003eNot retained\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=350\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.424908424908425%\"\u003e\n \u003cp\u003e\u0026chi;2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e369 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e91 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e296 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e129 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e431 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e53 (15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n 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width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003eHC III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e993 (46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e272 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e713 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e382 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e1,217 (48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e177 (50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n 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(34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e845 (33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e131 (37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e10 \u0026ndash; 19y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e1,457 (68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e328 (63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e1,135 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\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e66 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e95 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e33 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e105 (14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e164 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e23 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e2 - 5 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e1,091 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e293 (56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e842 (51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e418 (56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e1,268 (50.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e164 (46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e\u0026gt;=6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e976 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e133 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e750 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e224 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e1,082 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e163 (46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of TB\u003csup\u003e\u0026beta;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e0.589\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e16 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e15 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e9 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e18 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e34 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e6 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.305067218200621%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.20268872802482%\"\u003e\n \u003cp\u003e2,117 (99.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27197518097208%\"\u003e\n \u003cp\u003e506 (97.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.100310237849017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e1,616 (99.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.790072388831437%\"\u003e\n \u003cp\u003e729 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.825232678386763%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.720785935884178%\"\u003e\n \u003cp\u003e2,480 (98.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.824198552223372%\"\u003e\n \u003cp\u003e344 (98.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.135470527404343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026para;\u003c/strong\u003e- Based on most recent viral load value. \u003cstrong\u003e\u0026yen;\u003c/strong\u003e - based on most recent two viral load values. \u003cstrong\u003e\u0026beta;\u003c/strong\u003e - cases had missing VL values.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable4\u003c/strong\u003e. Crude and adjusted prevalence ratios associated with VL suppression among children and adolescents in Uganda.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1009\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.32472691161867%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVL suppression,\u0026nbsp;\u003c/strong\u003e[n= 2,654]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadj.PR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003eadj.PR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e1,192 (55.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e941 (44.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.94 - 1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.95 - 1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.916\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e0 \u0026ndash; 9y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e676 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e10 \u0026ndash; 19y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e1,457 (68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.98 - 1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.94 - 1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonths of ART dispensed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e66 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e2 - 5 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e1,091 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e1.31 - 2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.41 - 2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e\u0026gt;=6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e976 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e1.48 - 3.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.59 - 3.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of TB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e2,117 (99.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e16 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.53 - 0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.65 - 0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration on ART\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e6 \u0026ndash; 12m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e85 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e13 \u0026ndash; 24m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e192 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.88 - 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.88 - 0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003e\u0026gt;24m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e1,856 (87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.94 - 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.94 - 0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eART regimen\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eOther regimens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e19 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eDTG-based regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e2,114 (99.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.74 - 3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.81 - 2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO clinical stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eStage1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e1,952 (95.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.0 (ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eStage2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e71 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.82 - 1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.91 - 1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.06653426017875%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.25819265143992%\"\u003e\n \u003cp\u003eStage3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.902681231380338%\"\u003e\n \u003cp\u003e12 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.420059582919563%\"\u003e\n \u003cp\u003e0.42 - 1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.46 - 1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.838133068520358%\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV, Multi-month, Children, Adolescents","lastPublishedDoi":"10.21203/rs.3.rs-3743776/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3743776/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e In July 2022, Uganda\u0026rsquo;s ministry of Health extended the 2021 WHO guidelines that recommended 3\u0026ndash;6 monthly dispensing of antiretroviral therapy (ART) to include all children and adolescents living with HIV (CALHIV). Treatment outcomes following this recommendation have not yet been documented. We compared viral load (VL) suppression and retention in HIV care rates among CALHIV receiving 1, 2\u0026ndash;5 and \u0026gt;\u0026thinsp;=\u0026thinsp;6 monthly ART dispensation in Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study of electronic medical records in 118 health facilities was conducted. Data for CALHIV 10\u0026ndash;19 years captured at their most recent five clinic visits as of 15th May 2023 were analysed. Most recent two VL\u0026thinsp;\u0026lt;\u0026thinsp;1000 copies/ml were used as measures for VL suppression and sustained VL suppression. A client was considered retained in care if they visited the clinic within 28 days from their expected return visit date. We used margins plots and a modified poisson model adjusting for facility level clustering to assess VL suppression and retention across multi-month ART categories.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 2864 CALHIV, 1609 (56.2%) being females and with a median age of 12 years (iqr\u0026thinsp;=\u0026thinsp;7) were included. Overall suppression and retention rates were 80.4% (2133/2654) and 87.8% (2514/2864) respectively. A significant number had been dispensed ART for \u0026ge;\u0026thinsp;2 months (50%, 2\u0026ndash;5 months and 43.5%, \u0026ge;\u0026thinsp;6 months). Probability of having a suppressed VL was higher among CALHIV that had received\u0026thinsp;\u0026ge;\u0026thinsp;6 months and 2\u0026ndash;5 months of ART compared to those of 1 month i.e., 83% vs 79% vs 41% respectively. Probability of being retained in care didn\u0026rsquo;t differ across multi-month ART categories. CALHIV who received ART for 2\u0026ndash;5 months and \u0026ge;\u0026thinsp;6 months compared to 1 month were more likely to have a suppressed VL; (adj.PR\u0026thinsp;=\u0026thinsp;1.98; 95%CI:1.41, 2.80) and (adj.PR\u0026thinsp;=\u0026thinsp;2.21; 95% CI:1.59, 3.05) respectively. CALHIV with a Tuberculosis diagnosis history were less likely to have a suppressed VL (adj.PR\u0026thinsp;=\u0026thinsp;0.73; 95%CI:0.65,0.81), however this was not statistically significantly different between multi-month categories.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCALHIV receiving multi-month ART including 6 months dispensation had better VL suppression rates. Retention rates however didn\u0026rsquo;t differ by multi-month dispensing categories. We recommend multi-month ART dispensation including more than 6 months among CALHIV irrespective of their age, clinical stage, and history of prior co-morbidities.\u003c/p\u003e","manuscriptTitle":"Viral load suppression and retention in care among children and adolescents receiving multi-month anti-retroviral therapy refills: a program data review in Uganda.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-02 19:49:12","doi":"10.21203/rs.3.rs-3743776/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-25T06:18:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-05T20:33:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-20T10:00:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268986380684506114525929860349756596022","date":"2024-05-20T06:53:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270123514357359644826240016465182870361","date":"2024-05-17T09:46:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150797047295795725109664533265245477659","date":"2024-05-08T05:31:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-25T13:47:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-25T07:02:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-12-26T09:03:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-12-26T09:01:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2023-12-12T12:17:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2fc8a66a-5341-4ac0-b8d0-3b04eed283fa","owner":[],"postedDate":"January 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-09T15:58:24+00:00","versionOfRecord":{"articleIdentity":"rs-3743776","link":"https://doi.org/10.1186/s12887-024-05295-9","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2024-12-07 15:56:50","publishedOnDateReadable":"December 7th, 2024"},"versionCreatedAt":"2024-01-02 19:49:12","video":"","vorDoi":"10.1186/s12887-024-05295-9","vorDoiUrl":"https://doi.org/10.1186/s12887-024-05295-9","workflowStages":[]},"version":"v1","identity":"rs-3743776","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3743776","identity":"rs-3743776","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}