Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya

Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya Paul Wekesa, Margaret Ndisha, Boniface Makone, Marc Bulterys, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5675528/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 6 You are reading this latest preprint version Abstract Background Video directly observed therapy (VDOT) has been used as an acceptable, cost-effective, client-centered intervention for tuberculosis management. VDOT targeting children (0–14 years) and adolescents (15–19 years) living with HIV not achieving viral suppression (VS) [i.e., < 1000 copies/ml] was piloted in 73 facilities in Kenya. We conducted a feasibility study on the utilization and re-suppression rates of clients enrolled in VDOT. Methods A review of data from 223 virally unsuppressed clients aged between 0–19 years on antiretroviral therapy (ART) who were enrolled to use the VDOT application daily for at least 12 weeks between February 2021 and October 2022 at 73 health facilities was conducted. Clients stopped using the application upon achieving VS. VS was assessed after at least 12 weeks of VDOT follow-up through self-care or healthcare worker (HCW)-led approaches. Using a multivariable Cox Proportional Hazards regression model, we assessed demographic and clinical determinants of VS presenting adjusted hazard ratios (aHR). Results Most users, 163 (73.1%) were adolescents aged 10–19 years. Only 19 (8.5%) were on self-care VDOT. Median time on follow-up was 19 weeks, 126 videos uploaded, and 75% VDOT adherence. Over three-fourths, 176 (78.9%) had achieved VS during follow-up. Results showed a higher likelihood of VS among children on once-daily compared to twice-daily ARV dosage, aHR = 2.51 (95% CI: 2.06–3.05), and those on second- or third-line regimens compared to those on first-line regimens, aHR = 3.05 (95% CI: 1.78–5.22). Similarly, those on a DTG-based regimen had a higher likelihood of VS compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR = 1.95 (95% CI: 1.25–3.06). Children receiving care from guardians and siblings had a higher likelihood of VS compared to those receiving care from parent caregivers, 1.61 (95% CI: 1.27–2.03), and 2.00 (95% CI: 1.12–3.57), respectively. Conclusion Achieving VS using VDOT among children and adolescents living with HIV (CALHIV) was significantly associated with dosage frequency, antiretroviral regimen, first- or second-line therapy, antiretroviral regimen classification, and type of caregiver. Findings suggest VDOT could lead to a higher VS among children and adolescents living with HIV in resource-limited settings. Children and adolescents living with HIV video directly observed therapy (VDOT) viral suppression Kenya antiretroviral treatment Figures Figure 1 Figure 2 Background Globally, children living with HIV (CLHIV) constituted 4% of people living with HIV in 2022 ( 1 ). However, CLHIV had inferior treatment coverage (52% v 76% among adults) and contributed to 13% of AIDS-related deaths globally ( 1 , 2 ). In the same year, population-level viral suppression for children at 46%, lagged behind the global targeted trajectory to achieve 75% and 86% suppression rates by 2023 and 2025 respectively ( 3 ). In 2021, Kenya reported 4,098 AIDS-related deaths among children and adolescents. Deaths were attributed to late diagnosis, low antiretroviral treatment coverage, and lower viral suppression rates ( 4 ). Children and adolescents living with HIV (CALHIV) face unique issues affecting adherence to medication because of dependence on caregivers for their treatment among children, while more independent adolescents experience physical and psychological developmental transitions that can affect their fidelity to long-term treatment and chronic care management ( 5 – 7 ). Video directly observed treatment (VDOT) has been used as a tool to observe patients swallowing their medication remotely, which can then be reviewed by a health provider ( 8 ). VDOT embraces technology such as use of a phone or tablet video recording to monitor medication intake and serves as an alternative to in-person directly observed therapy. Since early pilots of VDOT using videophones connected to telephone landlines, the ubiquity of mobile phones, including smartphones, has enabled innovation and scale ( 9 , 10 ). Near universal mobile phone penetration in Kenya, reported at 98% among adults in 2020, and smartphone use for access to the internet and social media enable mobile-phone-based health interventions to efficiently and rapidly achieve treatment outcomes ( 11 ). The use of VDOT has been found to be feasible and acceptable in both high- and low-income settings ( 12 ). This has been demonstrated in sub-Saharan Africa settings in a recent study in Uganda ( 13 ). Studies have suggested the role of VDOT in addressing barriers to patient-centered care including distance ( 14 , 15 ), autonomy ( 9 , 12 , 14 , 16 ), increased efficiency through reduced travel costs ( 9 , 15 , 16 ), and maximizing health provider output ( 16 – 19 ). The use of VDOT has also been associated with less stigma among tuberculosis (TB) patients compared to in-person directly observed treatment approaches ( 20 ). VDOT could be synchronous or asynchronous. Synchronous VDOT is similar to video conferencing with live observation of medication ingestion compared to asynchronous, where videos are stored and forwarded with network availability for later review by a health provider ( 12 ). While synchronous VDOT has limitations of business hours and network availability, asynchronous VDOT provides greater flexibility to patients to take their scheduled medications wherever and whenever it is convenient, promoting a patient-centered approach ( 9 , 12 , 21 ). While VDOT has been adopted to support TB treatment, its use has been recommended for other health conditions requiring strict medication adherence and has been piloted among children with sickle cell disease and asthma ( 12 , 22 , 23 ). HIV programs have embraced the use of mobile telephony, particularly text messaging to support health education, appointment-keeping, data collection, adherence, and provider-patient communication ( 10 , 24 – 26 ). Among adolescents and youth living with HIV, text message reminders ( 22 , 27 – 29 ), web-based interventions ( 30 , 31 ), phone calls ( 32 , 33 ), digital gaming ( 34 , 35 ), and mobile phone application interventions( 36 , 37 ) have been reported as acceptable, feasible, and associated with improved medication adherence, HIV knowledge, and viral suppression. Among poorly adherent and unsuppressed children and adolescents on HIV treatment, hospital, and community-based directly observed treatment (DOT) interventions have been piloted with some reported improvements in adherence and viral suppression outcomes ( 38 , 39 ). We assessed feasibility of the use of smartphone-based asynchronous VDOT among virally unsuppressed children and adolescents living with HIV in Kenya. Methods Intervention description The name “NimeCONFIRM” was coined from Kenyan slang combining Kiswahili and English words meaning “I confirm” (in this case, that I have taken my medication). “NimeCONFIRM” is a video directly observed therapy (VDOT) application, designed to support enhanced adherence for children and adolescents who have an unsuppressed viral load > 1000c/ml. The application was designed to enable clients to take a short video confirming that they have swallowed their antiretroviral medication/dose for the day through an easy-to-use application interface. The NimeCONFIRM application was developed by the Centre for Health Solutions- Kenya (CHS), a local Kenyan non-profit, funded by the U.S. President's Emergency Plan for AIDS (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) – Kenya. NimeCONFIRM application is only available in the Google Play Store for pre-authorized users who are either clients, caregivers, or case managers. Caregivers of viremic children are counseled at the facility and provide consent to be enrolled in NimeCONFIRM. Based on the health worker assessment, enrollment can be done in two ways - case manager or health care worker (HCW)- led, whereby the smartphone used is held by the case manager/ HCW and they visit the client and take a video during medication intake daily. The second option is the self-care mode where the smartphone used is for a caregiver or someone who lives with the client and carries out the VDOT. These included parents, grandparents, guardians, relatives, and siblings. The application features a secure log-in with a one-time password, a coded user identifier using random alphanumeric digits, a screenshot restriction feature while taking the videos, which restricted saving or storing video in the mobile phone. Data were encrypted at upload of videos and decrypted at a secure server. NimeCONFIRM videos were recorded on a client's or caregivers’ or case managers’ smartphone using the device's camera application and sent to a secure database. All the features in the NimeCONFIRM application comply with HIPAA, European Union—General Data Protection Regulation (GDPR), and the Kenya 2019 Data Protection Act. NimeCONFIRM has several features that support medication adherence; a) A tailored pill calendar and alarm feature that sends a notification an hour and 30 minutes before the allocated time for taking medication, b) a closed group application, only accessible to authorized users among registered HIV positive children and adolescents, c) a time stamp for each video taken, d) a store and forward feature that allows videos taken off the internet to be pushed to the server, and, e) a visualization dashboard available to the clinical team to monitor adherence, with an interphase to the existing facility-based electronic medical records (EMR). VDOT adherence was measured as a percentage of the number of videos uploaded against the expected uploads to the database. Those taking two doses were expected to have two video uploads daily while those on a single dose were expected to have a single video uploaded. Other outcomes of interest were successful completion (VS), loss to follow-up (LFTU), and discontinuation. Study setting Children and adolescents were enrolled from 73 health facilities in Machakos, Makueni, and Kitui counties of Kenya. The facilities provide HIV services to children and adolescents, through implementing partners funded by PEPFAR through CDC. Participants freely chose to use the VDOT app without any formal randomization. Additionally, the self-care or HCW-assisted options were personally selected by each user. The HIV services included providing HIV care and treatment for children and adolescents per national HIV treatment guidelines (40). Viral suppression monitoring was evaluated through RNA polymerase chain reaction (PCR) viral load testing every 3 months until VS was achieved (41,42). Study design, population, and sample The retrospective data from children and adolescents who enrolled in the feasibility pilot study and used the NimeCONFIRM VDOT application between February 2021 and October 2022 for any period were collected. However, we only analyzed data from those virally unsuppressed children (0–9 years) and adolescents (10–19 years) living with HIV on antiretroviral therapy (ART) who enrolled in and used the NimeCONFIRM VDOT application for at least 12 weeks. Those who had less than 12 weeks of follow-up, which was considered insufficient time to determine clinical changes, were excluded from the analysis. Furthermore, the timing was convenient given that routine viral loads were done every 3 months. Data sources and collection We collected data using the NimeCONFIRM VDOT application. There were two options for data collection at the respective dosage times: (1) VDOT users using the self-care approach where individual clients and (or) their caregivers used their own mobile devices; and (2) Healthcare worker (HCW)-assisted recording and upload of VDOT for those who did not have their own devices or opted for this approach. The enrolment and follow-up data were extracted from the VDOT database and prepared for analysis. Variables We analyzed various demographic and clinical factors in our study, including age at enrollment, sex, county of enrolment, caregiver (such as grandparents, guardian, parent, relative, or siblings), frequency of dosage (once daily or twice daily), regimen line (first, second, or third), core regimen (abacavir [ABC], zidovudine [AZT], and tenofovir [TDF-based]), regimen classification (Lopinavir/Ritonavir [LPV/r] Based, Atazanavir/Ritonavir [ATV/r] Based, dolutegravir [DTG] based, Efavirenz [EFV Based], and Other), and type of care (self-care or healthcare worker-led). The core regimens were mutually exclusive. “Continuing on follow-up” clients were defined as children and adolescents who were enrolled in the VDOT application and currently unsuppressed but still being monitored through the VDOT application. We recorded the time it took for clients to achieve viral suppression in weeks, with a maximum follow-up period of 90 weeks. Viral suppression outcome was defined as <1000 copies per milliliter. Ethical Approval The AMREF Ethics and Scientific Review Committee, Nairobi, Kenya, approved the protocol to conduct this analysis (protocol number: P412/2017) and waived the need for consent from study participants given the retrospective data use. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. § ( § See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq). The study team only had access to de-identified data for analysis. The study procedures were done in accordance with the ethical principles outlined in the World Medical Association's Declaration of Helsinki, Kenya Government, Ministry of Health, CDC, and local IRB regulations. Data analysis Descriptive analysis of children and adolescent characteristics was done using counts and percentages as appropriate. Median and interquartile range (IQR) were presented for time to viral suppression outcome, and number of expected daily doses, the number of videos uploaded, and VDOTs adherence. Using Cox proportional hazards (CoxPH) models, survival regression analysis was done to assess the factors associated with viral suppression among children and adolescents who had used the VDOT application for at least 12 weeks and up to 90 weeks of follow-up (43). The time to suppression was calculated as the number of weeks starting from 12 weeks after the date of VDOT enrolment until the point of VL suppression.. Those who were still unsuppressed at 90 weeks of follow-up were censored. There was no missing data for all key variables. The estimated probability of viral suppression was based on the Kaplan-Meier estimates and presented as a plot. Using univariable and multivariable CoxPH models, we assessed demographic and clinical determinants of viral suppression presenting adjusted hazard ratios (aHR) and 95% confidence intervals (CI). The multivariable model included sex, age category, caregiver, dosage frequency, core regimen, regimen line, and type of care (healthcare worker-led or self-care user). Graphical and global tests were done to confirm that the assumption of proportional hazards was met. Overall global (Wald) hypothesis tests were done for categorical variables (age, and caregiver) with more than two categories to determine if the categories were jointly significantly associated with viral suppression. Survival plots by predictor categories were based on the multivariable CoxPH model estimates. All analyses were done using Stata, version 18.1 (StataCorp 2023. Stata Statistical Software, Release 18; College Station, TX). Results Description of client characteristics The total number of children and adolescents enrolled was 470, representing an uptake of 60%. A total of 164 (34.9%) discontinuations were recorded before 12 weeks of follow-up. However, only about half, 223 (47.5%), of the 470 enrolled on the application who had used it for at least 12 weeks were analyzed. Of all those with at least 12 weeks of follow-up, 223 (100%), were retained at 21 weeks of follow-up. Most users, 163 (73.1%), were adolescents (10-19 years). Over half, 128 (57.4%), were males. There were 19 (8.5%) on the self-care VDOT option. The median time on follow-up was 19 weeks (interquartile range [IQR]: 17– 23), with a median of one video uploaded(IQR: 0.7 - 1.5) per day, and a median of 126 (IQR: 96 -197) videos uploaded over a median follow-up of 19 weeks as shown in Table 1. {insert Table 1} The overall median VDOT adherence was 76% (IQR: 60 - 85), and it did not significantly differ by age, sex, and regimen as shown in Table 2. {insert Table 2} Viral suppression outcome All 223 had viral load outcomes available by 90 weeks of follow-up. The probability of viral suppression at 16, 20, 24, and 28 weeks was 16.1%, 45.3%, 74.2%, and 87.5%, respectively. More than three-fourths, 176 (78.9%), had achieved viral suppression over the follow-up period, as shown in Table 1. Achievement of viral suppression did not differ significantly by age group among those on self-care (p-value = 0.545) or Healthcare worker-led (p-value = 0.393). The overall probability of viral suppression over follow-up is shown in Figure 1. Results of VDOTs by Viral Suppression Status The overall median number of weeks on follow-up for all clients was 19 weeks (IQR: 17 - 23). Clients who achieved VS had an almost similar median number of weeks using the application compared to those who were continuing follow-up since they had not suppressed, 20 weeks (IQR: 17 - 23) vs. 19 weeks (IQR: 16 - 22) respectively, p-value = 0.260. Results showed that those who suppressed had a slightly lower median total number of daily doses compared to those who were continuing follow-up or discontinued, 186 doses (IQR: 128 - 288) vs. 210. doses (IQR: 164 - 262), respectively, p-value = 0.467. Results showed almost similar median adherence percentage among those who had viral suppression compared to those who were continuing follow-up or discontinued, 74% (IQR: 60% - 84%) vs. 81% (IQR: 55% - 86%), respectively, p-value = 0.241 as shown in Table 3. {insert Table 3} Factors associated with viral suppression. The univariable analysis results indicated significant associations of time to viral suppression with ARV once or twice daily dosage, regimen line, and regimen classification as shown in Table 4. On multivariable analysis, there was an over two-fold significantly higher likelihood of viral suppression for those who were on once-daily compared to twice-daily ARV dosage, aHR = 2.51 (95% CI: 2.06 – 3.05), as shown in Table 4 and model estimated probabilities of VS over time in Figure 2(a). Children and adolescents on second- or third-line regimens had a three-fold higher likelihood of viral suppression compared to those on first-line regimens, aHR = 3.05 (95% CI: 1.78 – 5.22), as shown in Table 4 and corresponding model estimated probabilities over time in Figure 2(b). Similarly, children and adolescents on DTG-based regimens had close to two-fold higher likelihood of viral suppression compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR = 1.95 (95% CI: 1.25 – 3.06), as shown in Table 4 and respective model estimated probabilities over time in Figure 2(c). Overall, the caregiver variable was associated with viral suppression based on a global (Wald) hypothesis test (P value = 0.003). Specifically, those with guardians and siblings as caregivers had a higher likelihood of viral suppression compared to parents, 1.61 (95% CI: 1.27 - 2.03), and 2.00 (95% CI: 1.12 – 3.57), respectively. {insert Table 4} Discussion Implementation of VDOT supported the achievement of HIV viral load suppression for nearly 80 percent of enrolled children and adolescents in the follow-up period. This is particularly important since evidence suggests that children and adolescents lag behind adults in the achievement of HIV viral suppression after ART and are more vulnerable to developing drug resistance (44,45). To our knowledge, this study is the first to explore the feasibility of VDOT among virally unsuppressed children and adolescents living with HIV receiving antiretroviral treatment in a resource limited setting. Our study included CALHIV aged between 0 and 19 years, a cohort that was comparable to the digital asthma study in West Baltimore that included children 2-18 years. Although the asthma study provided rewards for video upload, retention at 11-21 weeks was lower compared to our study’s 21-week retention at 100% among those with at least 12 weeks of follow up (23). The median follow-up time was just over 19 weeks, with at least 12 weeks of VDOT use for half the clients, and a median of 126 videos uploaded. This duration on the VDOT application contrasts with other studies. For example, a study in the United States and Mexico reported the mean duration of VDOT use at 22 weeks while another U.S. study reported a median time of 27 weeks (12,46). It is however notable that these studies involved TB patients on DOT follow-up for the duration of treatment. In our study, clients could exit the VDOT intervention upon achieving viral suppression, which could explain the shorter duration on the intervention. The use of VDOT has been associated with high levels of adherence. A recent study in Uganda reported high adherence and satisfaction levels among adult clients on TB treatment using a VDOT application (13). This finding has similarly been demonstrated in a study among adults in the United States and Mexico with adherence rates above 93% and 92% preference for VDOT over in-person TB DOT (12). This contrasts with the lower VDOT adherence in our study at 76%. A synchronous VDOT study in Nassau County Department of Health, Mineola, New York reported similar adherence rates of 79% which compared with a Uganda study at 82.2% (13,47). While these studies provide comparisons of VDOT use for TB treatment, lower adherence rates have been reported among children using VDOT to observe inhaled corticosteroid use for asthma control, ranging from 50% to 64% (23). Adherence levels measured from VDOT were likely affected by missed video uploads as has been observed in other studies (8). A recent study in Uganda discussed common reasons for missed video uploads including malfunctions of phones and the VDOT application as well as uncharged batteries (13). Other barriers reported in the literature included desire for face-to-face interaction, lack of familiarity with the use of videos, illiteracy, privacy and confidentiality concerns, adverse effects, and demographic profile differences with the use of technology (18,48,49). In this study, the likelihood of achieving viral suppression was higher among those on the self-care VDOT option compared to the HCW-led option. Further, a higher likelihood of viral suppression was also demonstrated among those with guardians and siblings as caregivers compared to parents. This is similar to studies that indicated that older adults are more likely to find the use of VDOT more challenging compared to younger and more educated adults, which could have affected uptake of the self-care VDOT option alongside access to smartphones (48,49). The study results showed over 3-fold higher likelihood of viral suppression among children and adolescents on second- and third-line regimens compared to those on first-line regimens. Poor adherence to treatment has been documented as a major reason for second-line failure, suggesting utility of the VDOT intervention in this population (50). Our study also found over 2-fold higher odds of viral suppression among those on a once daily dosage regimens and close to 2-fold higher odds for clients on DTG based regimens. This is similar to other studies that have demonstrated higher rates of viral suppression among children and adolescents receiving optimized DTG-based ART (51–53). This study had some limitations. First VDOT adherence only measured whether the video captured the client taking the medication and not reported ART adherence. This may underestimate the actual ART adherence in cases where medication was taken but a video was not uploaded on the application. Given this resource-limited setting, it is likely that there were challenges in regular access to VDOT by healthcare workers and to mobile devices for most participants, or the internet for video uploads especially for those on self-care (using their own devices). We acknowledge that there were unobserved factors that may affect viral suppression outcomes. The second limitation was the relatively high proportion of clients who were discontinued due to various reasons and incomplete follow-up for some clients who were also not included in the study. Even though the study had a large sample, these reasons may over or underestimate the observed adherence and viral suppression outcomes. Finally, we acknowledge that this was a feasibility study without a control group to demonstrate improved efficacy of VDOT over standard of care. Conclusion The use of VDOT to support the achievement of VS among unsuppressed children and adolescents living with HIV and on antiretroviral treatment was feasible and acceptable even with the limitations cited. Achieving VS using VDOT was associated with the type of caregiver, treatment regimen, dosing frequency, and self-care VDOT. Our findings highlight the beneficial impact of VDOT as an additional tool to ensure that HIV unsuppressed children and adolescents benefit from their access to life-saving care and treatment, especially in resource-limited settings such as Kenya. Abbreviations AIDS Acquired immunodeficiency syndrome aHR Adjusted Hazard Ratio AMREF African Medical and Research Foundation ABC Abacavir ART Antiretroviral therapy ATV/r Atazanavir/Ritonavir AZT Zidovudine DTG Dolutegravir GDPR General Data Protection Regulation DOT Directly observed therapy DGHT Division of Global HIV&TB EFV Efavirenz EMR Electronic medical records CALHIV Children and adolescents living with HIV CDC Centers for Disease Control CHS Center for Health Solution CoAg Co-agreement CI Confidence intervals HCW Health care worker HIPAA Health Insurance Portability and Accountability Act IRB Institutional Review Board IQR Interquartile range LFTU Loss to follow-up LPV/r Lopinavir/Ritonavir PEPFAR President's Emergency Plan for AIDS (PEPFAR) RNA-PCR Ribonucleic acid polymerase chain reaction TDF Tenofovir TB Tuberculosis US United States VDOT Video directly observed therapy VS Viral Suppression Declarations Ethics approval and consent to participate The AMREF Ethics and Scientific Review Committee, Nairobi, Kenya, approved the protocol to conduct this analysis (protocol number: P412/2017). As this study used retrospective data, the AMREF Ethics and Scientific Review Committee, Nairobi, Kenya, waived the need for consent or assent from study participants. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. § ( § See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq). The investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes or analysis. The study procedures were done in accordance with the ethical principles outlined in the World Medical Association's Declaration of Helsinki, Kenya Government, Ministry of Health, CDC, and local IRB regulations Consent for publication Not applicable Availability of data and materials Data used for this analysis is a deidentified dataset of individual-level data and is not currently publicly available. However, the dataset can be obtained from the corresponding author based on a reasonable request. Competing interests The authors declare that they have no competing interests. Funding The funding for this program and evaluation was supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under the terms of CoAg number 1U2GGH000097. U.S. CDC provided financial and technical support during the project design and implementation. They also assisted with the manuscript review. Data collection, analysis, interpretation, and writing were done by the CHS coauthors. Authors' contributions PW led the design, data collection, and interpretation, and wrote substantial portions and paper review. KO performed data analysis, interpretation, and results writeup, and paper review. IM guided the design, gave input on the analysis, and did paper reviews. MN, BM, MB, EN, KK, and AK assisted with the design, data collection, and paper review. All authors read and approved the final paper. Acknowledgments We acknowledge all the wonderful children and adolescents whose data was used for this analysis, caregivers, the health workers, and the facility in charges. We acknowledge the input of the programming, monitoring and evaluation teams that assisted with the application design, rollout, and data collection. CDC disclaimer The findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the funding agencies. Authors details Center for Health Solutions, Kenya Division of Global HIV&TB (DGHT), Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya Bill and Melinda Gates Foundation References The Joint United Nations Programme on HIV/AIDS. path that ends AIDS. 2023;80–2. The Joint United. Nations Programme on HIV/AIDS. 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Naar-King S, Outlaw AY, Sarr M, Parsons JT, Belzer M, MacDonell K, et al. Motivational Enhancement System for Adherence (MESA): Pilot randomized trial of a brief computer-delivered prevention intervention for youth initiating antiretroviral treatment. J Pediatr Psychol. 2013;38(6):638–48. Ivanova O, Wambua S, Mwaisaka J, Bossier T, Thiongo M, Michielsen K, et al. Evaluation of the elimika pilot project: Improving art adherence among hiv positive youth using an ehealth intervention in Mombasa, Kenya. Afr J Reprod Health. 2019;23(1):100–10. Puccio JA, Belzer M, Olson J, Martinez M, Salata C, Tucker D, et al. The use of cell phone reminder calls for assisting HIV-infected adolescents and young adults to adhere to highly active antiretroviral therapy: A pilot study. AIDS Patient Care STDS. 2006;20(6):438–44. Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, et al. 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Factors Associated With Viral Suppression and Drug Resistance in Children and Adolescents Living With HIV in Care and Treatment Programs in Southern Tanzania. J Pediatr Infect Dis Soc. 2023;12(6):353–63. Tables Table 1. Suppression outcome among participants at the end of 90 weeks of follow-up, Kenya, Feb 2021 - Oct 2022 Columns by: Suppression Outcome among those with least 12 weeks of follow up (n=223) Continuing Follow-up Suppressed Total P value n (%) 47 (21.1) 176 (78.9) 223 (100.0) Sex, n (%) 0.745 Girls 21 (44.7) 74 (42.0) 95 (42.6) Boys 26 (55.3) 102 (58.0) 128 (57.4) Age at enrollment (years), median (IQR) 13.3 (8.8 - 15.9) 13.7 (9.7 - 16.4) 13.7 (9.6 - 16.2) 0.628 Age Category at enrollment (years), n (%) 0.241 0-4 8 (17.0) 15 (8.5) 23 (10.3) 5-9 5 (10.6) 32 (18.2) 37 (16.6) 10-14 19 (40.4) 65 (36.9) 84 (37.7) 15-19 15 (31.9) 64 (36.4) 79 (35.4) Caregiver, n (%) 0.998 Grand parents 6 (12.8) 25 (14.2) 31 (13.9) Guardian 6 (12.8) 24 (13.6) 30 (13.5) Parent 32 (68.1) 117 (66.5) 149 (66.8) Relative 2 (4.3) 7 (4.0) 9 (4.0) Siblings 1 (2.1) 3 (1.7) 4 (1.8) Core ART regimen, n (%) 0.170 ABC Based 14 (29.8) 48 (27.3) 62 (27.8) AZT Based 27 (57.4) 83 (47.2) 110 (49.3) TDF Based 6 (12.8) 45 (25.6) 51 (22.9) Regimen Classification, n (%) 0.621 DTG Based 19 (40.4) 81 (46.0) 100 (44.8) LPV/r Based 22 (46.8) 69 (39.2) 91 (40.8) ATV/r Based 4 (8.5) 22 (12.5) 26 (11.7) EFV Based 2 (4.3) 3 (1.7) 5 (2.2) Other 0 (0.0) 1 (0.6) 1 (0.4) Regimen line, n (%) 0.716 First-line 18 (38.3) 76 (43.2) 94 (42.2) Second-line 29 (61.7) 99 (56.2) 128 (57.4) Third-line 0 (0.0) 1 (0.6) 1 (0.4) Type of care, n (%) 0.998 Healthcare worker led 43 (91.5) 161 (91.5) 204 (91.5) Self-care/User 4 (8.5) 15 (8.5) 19 (8.5) Dosage Frequency, n (%) 0.105 Once daily 17 (36.2) 87 (49.4) 104 (46.6) Twice daily 30 (63.8) 89 (50.6) 119 (53.4) IQR- interquartile range ABC - abacavir, AZT - zidovudine, and TDF - tenofovir LPV/r - Lopinavir/Ritonavir, ATV/r - Atazanavir/Ritonavir, DTG - dolutegravir, EFV - Efavirenz Table 2. VDOT adherence percentage by age, sex, and regimen, Kenya, Feb 2021 - Oct 2022 Variable n (%) DOTs adherence (Percent), median (IQR) P value Overall 223 (100) 76 (60 - 85) - Age Category at enrollment (years) 0.942 0-4 23 (10.3) 79 (41 - 85) 5-9 37 (16.6) 79 (63 - 86) 10-14 84 (37.7) 75 (56 - 88) 15-19 79 (35.4) 75 (62 - 85) Sex 0.364 Girls 95 (42.6) 78 (61 - 87) Boys 128 (57.4) 74 (56 - 84) Regimen Classification 0.207 LPV/r Based 91 (40.8) 74 (46 - 86) ATV/r Based 26 (11.7) 74 (30 - 85) DTG Based 100 (44.8) 76 (65 - 86) EFV Based 5 (2.2) 72 (16 - 78) Other 1 (0.4) 31 (31 - 31) Regimen line 0.141 First-line 94 (42.2) 77 (66 - 86) Second-line 128 (57.4) 74 (48 - 85) Third-line 1 (0.4) 31 (31 - 31) Core ART regimen 0.102 ABC Based 62 (27.8) 71 (39 - 83) AZT Based 110 (49.3) 76 (53 - 85) TDF Based 51 (22.9) 78 (67 - 87) IQR- interquartile range ABC - abacavir, AZT - zidovudine, and TDF - tenofovir LPV/r - Lopinavir/Ritonavir, ATV/r - Atazanavir/Ritonavir, DTG - dolutegravir, EFV - Efavirenz Table 3 VDOTS suppression outcome among children and adolescents living with HIV infection with at least 12 weeks of follow-up, Kenya, Feb 2021 - Oct 2022 Suppression Outcome (n=223) Continuing Follow-up Suppressed Total P value n (%) 47 (21.1) 176 (78.9) 223 (100.0) vDOTS Information Time using Application (Weeks), median (IQR) 19 (16 - 21.93) 20 (17 - 23) 19 (17 - 23) 0.260 Total number of expected daily doses per user, median (IQR) 210 (164 - 262) 186 (128 - 288) 188 (134 - 280) 0.467 Total number of videos uploaded per user, median (IQR) 147 (91 - 201) 124 (96 - 194) 126 (96 - 197) 0.419 vDOTs adherence (Percent), median (IQR) 81 (55 - 86) 74 (60 - 84) 76 (60 - 85) 0.241 IQR -interquartile range Table 4 Cox proportional hazards model for viral suppression among children and adolescents living with HIV infection during the follow-up period while using the NIMECONFIRM application with at least 12 weeks of follow-up, Kenya, Feb 2021 - Oct 2022 Outcome: Viral Suppression Hazard Ratio Adjusted Hazard Ratio HR (95% CI) P value aHR (95% CI) P value Sex Boys Reference Reference Girls 0.83 (0.57-1.20) 0.320 0.69 (0.45-1.06) 0.093 Age Category at enrollment (years) 0-4 0.88 (0.48 - 1.62) 0.680 1.35 (0.72 - 2.55) 0.351 5-9 0.94 (0.86 - 1.03) 0.210 1.16 (0.90 - 1.48) 0.256 10-14 0.88 (0.80 - 0.97) 0.008 1.00 (0.86 - 1.16) 0.967 15-19 Reference Reference Caregiver* Parent Reference Reference Grand parents 1.24 (0.94-1.65) 0.128 1.12 (0.91-1.38) 0.298 Guardian 1.38 (0.91-2.10) 0.126 1.61 (1.27-2.03) <0.001 Relative 0.99 (0.33-2.94) 0.983 0.89 (0.24-3.33) 0.864 Siblings 1.52 (1.24-1.87) <0.001 2.00 (1.12-3.57) 0.019 Dosage Frequency Twice Daily Reference Reference Once Daily 1.37 (1.26 - 1.49) <0.001 2.51 (2.06 - 3.05) <0.001 Regimen Line First line Reference Reference Second or Third line † 0.90 (0.82 - 0.98) 0.016 3.05 (1.78 - 5.22) <0.001 Regimen Classification LPV/r, ATV/s, or EFV based Reference Reference DTG based 1.27 (1.20 - 1.35) <0.001 1.95 (1.25 - 3.06) 0.003 Care Type Healthcare Worker Led Reference Reference Self-Care 1.39 (0.55 - 3.48) 0.483 1.37 (0.67 - 2.80) 0.387 * Global (Wald) hypothesis test for caregiver (P value = 0.003) † There was only 1 patient on the third line. ABC - abacavir, AZT - zidovudine, and TDF - tenofovir LPV/r - Lopinavir/Ritonavir, ATV/r - Atazanavir/Ritonavir, DTG - dolutegravir, EFV - Efavirenz Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 15 Apr, 2025 Reviews received at journal 10 Apr, 2025 Reviewers agreed at journal 07 Apr, 2025 Reviewers invited by journal 01 Apr, 2025 Submission checks completed at journal 31 Mar, 2025 First submitted to journal 28 Mar, 2025 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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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5675528","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436793903,"identity":"b44ee69c-9754-4143-b63c-f9eb90146c45","order_by":0,"name":"Paul Wekesa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYHACZhAhxyABYRCvxZh0LYkNRGsxl0g+bPDhj116/+z2xwYfdxyWZ2DvffwCnxbLGWnJiTPbknNn3DljnDjzzGHDBp7jZhb4tBjczjE+zNvAnLtBIof5MG/bYcYGiTQ2A/xa8j8f/vOnPt1AIv3x4b9th+2J0JLDnMzAdjjBQCLBOJmx7TAwHNKYH+D1y/xnxoa9bccNZ9zIATHSk9t4jrHh08FgznP4scSPP9Xy/DPSH0v8bLO27WdvY/6A12Fo/GYGoBVsEqRoqQMR+G0ZBaNgFIyCEQcAOqVK4qOIUEcAAAAASUVORK5CYII=","orcid":"","institution":"Centre for Health Solutions","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"","lastName":"Wekesa","suffix":""},{"id":436793905,"identity":"168a383a-c2c7-41ca-a1d3-ff9581c5d783","order_by":1,"name":"Margaret Ndisha","email":"","orcid":"","institution":"Global Health Center, U.S. Centers for Disease Control and Prevention (CDC), Nairobi \u0026 Kisumu","correspondingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"","lastName":"Ndisha","suffix":""},{"id":436793907,"identity":"f26f9edc-98dd-4d4c-ad5a-d4c2d04e976a","order_by":2,"name":"Boniface Makone","email":"","orcid":"","institution":"Global Health Center, U.S. Centers for Disease Control and Prevention (CDC), Nairobi \u0026 Kisumu","correspondingAuthor":false,"prefix":"","firstName":"Boniface","middleName":"","lastName":"Makone","suffix":""},{"id":436793909,"identity":"7549e2e3-4024-416a-9f99-89fd90edf78c","order_by":3,"name":"Marc Bulterys","email":"","orcid":"","institution":"Bill and Melinda Gates Foundation","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Bulterys","suffix":""},{"id":436793910,"identity":"9a82405c-92e8-412e-99a2-e655d1d83757","order_by":4,"name":"Evelyn Ngugi","email":"","orcid":"","institution":"Global Health Center, U.S. Centers for Disease Control and Prevention (CDC), Nairobi \u0026 Kisumu","correspondingAuthor":false,"prefix":"","firstName":"Evelyn","middleName":"","lastName":"Ngugi","suffix":""},{"id":436793911,"identity":"62b910ee-6768-4345-8102-129678641077","order_by":5,"name":"Kevin Kamenwa","email":"","orcid":"","institution":"Centre for Health Solutions","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Kamenwa","suffix":""},{"id":436793913,"identity":"fe6bff4a-66bb-4a9e-9fac-55e8fa04f1e4","order_by":6,"name":"Abraham Katana","email":"","orcid":"","institution":"Global Health Center, U.S. Centers for Disease Control and Prevention (CDC), Nairobi \u0026 Kisumu","correspondingAuthor":false,"prefix":"","firstName":"Abraham","middleName":"","lastName":"Katana","suffix":""},{"id":436793917,"identity":"4956be9e-e721-4023-b7b6-ba244fe43a16","order_by":7,"name":"Kevin Owuor","email":"","orcid":"","institution":"Centre for Health Solutions","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Owuor","suffix":""},{"id":436793919,"identity":"a4b0f5f1-a2ad-4986-bbfc-715c1849be5c","order_by":8,"name":"Immaculate Mutisya","email":"","orcid":"","institution":"Global Health Center, U.S. Centers for Disease Control and Prevention (CDC), Nairobi \u0026 Kisumu","correspondingAuthor":false,"prefix":"","firstName":"Immaculate","middleName":"","lastName":"Mutisya","suffix":""}],"badges":[],"createdAt":"2024-12-19 09:39:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5675528/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5675528/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-11036-9","type":"published","date":"2025-04-30T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79804917,"identity":"c7c9cb02-abd7-49a2-831d-6f3ac2e6783b","added_by":"auto","created_at":"2025-04-03 05:09:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4547,"visible":true,"origin":"","legend":"\u003cp\u003eOverall probability of viral suppression after at least 12 weeks of using the NimeCONFIRM application, Kenya, Feb 2021 - Oct 2022\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5675528/v1/ce1d2453b6b21709cde56d12.png"},{"id":79804918,"identity":"c10e3931-c782-4d56-869e-a2c842fdbc7f","added_by":"auto","created_at":"2025-04-03 05:09:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5460,"visible":true,"origin":"","legend":"\u003cp\u003eViral Suppression by antiretroviral regimen line, dosage, and regimen after at least 12 weeks of using the NimeCONFIRM application, Kenya, Feb 2021 - Oct 2022.\u003c/p\u003e\n\u003cp\u003eLegend: LPV/r – Lopinavir/Ritonavir, ATV/r – Atazanavir/Ritonavir, EFV – Efavirenz, and DTG – Dolutegravir\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5675528/v1/bbe81b61a94be61335e2d955.png"},{"id":81987727,"identity":"b1a3052f-9bd1-46c2-95e2-9b3e7d7c04ce","added_by":"auto","created_at":"2025-05-05 16:05:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1123119,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5675528/v1/f809c08c-87b0-4f2f-a2ae-a7945b22fbc8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, children living with HIV (CLHIV) constituted 4% of people living with HIV in 2022 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). However, CLHIV had inferior treatment coverage (52% v 76% among adults) and contributed to 13% of AIDS-related deaths globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In the same year, population-level viral suppression for children at 46%, lagged behind the global targeted trajectory to achieve 75% and 86% suppression rates by 2023 and 2025 respectively (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In 2021, Kenya reported 4,098 AIDS-related deaths among children and adolescents. Deaths were attributed to late diagnosis, low antiretroviral treatment coverage, and lower viral suppression rates (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Children and adolescents living with HIV (CALHIV) face unique issues affecting adherence to medication because of dependence on caregivers for their treatment among children, while more independent adolescents experience physical and psychological developmental transitions that can affect their fidelity to long-term treatment and chronic care management (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVideo directly observed treatment (VDOT) has been used as a tool to observe patients swallowing their medication remotely, which can then be reviewed by a health provider (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). VDOT embraces technology such as use of a phone or tablet video recording to monitor medication intake and serves as an alternative to in-person directly observed therapy. Since early pilots of VDOT using videophones connected to telephone landlines, the ubiquity of mobile phones, including smartphones, has enabled innovation and scale (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Near universal mobile phone penetration in Kenya, reported at 98% among adults in 2020, and smartphone use for access to the internet and social media enable mobile-phone-based health interventions to efficiently and rapidly achieve treatment outcomes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe use of VDOT has been found to be feasible and acceptable in both high- and low-income settings (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This has been demonstrated in sub-Saharan Africa settings in a recent study in Uganda (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Studies have suggested the role of VDOT in addressing barriers to patient-centered care including distance (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), autonomy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), increased efficiency through reduced travel costs (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and maximizing health provider output (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The use of VDOT has also been associated with less stigma among tuberculosis (TB) patients compared to in-person directly observed treatment approaches (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVDOT could be synchronous or asynchronous. Synchronous VDOT is similar to video conferencing with live observation of medication ingestion compared to asynchronous, where videos are stored and forwarded with network availability for later review by a health provider (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). While synchronous VDOT has limitations of business hours and network availability, asynchronous VDOT provides greater flexibility to patients to take their scheduled medications wherever and whenever it is convenient, promoting a patient-centered approach (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile VDOT has been adopted to support TB treatment, its use has been recommended for other health conditions requiring strict medication adherence and has been piloted among children with sickle cell disease and asthma (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). HIV programs have embraced the use of mobile telephony, particularly text messaging to support health education, appointment-keeping, data collection, adherence, and provider-patient communication (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong adolescents and youth living with HIV, text message reminders (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), web-based interventions (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), phone calls (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), digital gaming (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), and mobile phone application interventions(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) have been reported as acceptable, feasible, and associated with improved medication adherence, HIV knowledge, and viral suppression. Among poorly adherent and unsuppressed children and adolescents on HIV treatment, hospital, and community-based directly observed treatment (DOT) interventions have been piloted with some reported improvements in adherence and viral suppression outcomes (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). We assessed feasibility of the use of smartphone-based asynchronous VDOT among virally unsuppressed children and adolescents living with HIV in Kenya.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eIntervention description\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe name \u0026ldquo;NimeCONFIRM\u0026rdquo; was coined from Kenyan slang combining Kiswahili and English words meaning \u0026ldquo;I confirm\u0026rdquo; (in this case, that I have taken my medication). \u0026ldquo;NimeCONFIRM\u0026rdquo; is a video directly observed therapy (VDOT) application, designed to support enhanced adherence for children and adolescents who have an unsuppressed viral load \u0026gt; 1000c/ml. The application was designed to enable clients to take a short video confirming that they have swallowed their antiretroviral medication/dose for the day through an easy-to-use application interface. The NimeCONFIRM application was developed by the Centre for Health Solutions- Kenya (CHS), a local Kenyan non-profit, funded by the U.S. President\u0026apos;s Emergency Plan for AIDS (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) \u0026ndash; Kenya.\u003c/p\u003e\n\u003cp\u003eNimeCONFIRM application is only available in the Google Play Store for pre-authorized users who are either clients, caregivers, or case managers. Caregivers of viremic children are counseled at the facility and provide consent to be enrolled in NimeCONFIRM. Based on the health worker assessment, enrollment can be done in two ways - case manager or health care worker (HCW)- led, whereby the smartphone used is held by the case manager/ HCW and they visit the client and take a video during medication intake daily. The second option is the self-care mode where the smartphone used is for a caregiver or someone who lives with the client and carries out the VDOT. These included parents, grandparents, guardians, relatives, and siblings.\u003c/p\u003e\n\u003cp\u003eThe application features a secure log-in with a one-time password, a coded user identifier using random alphanumeric digits, a screenshot restriction feature while taking the videos, which restricted saving or storing video in the mobile phone. Data were encrypted at upload of videos and decrypted at a secure server. NimeCONFIRM videos were recorded on a client\u0026apos;s or caregivers\u0026rsquo; or case managers\u0026rsquo; smartphone using the device\u0026apos;s camera application and sent to a secure database. All the features in the NimeCONFIRM application comply with HIPAA, European Union\u0026mdash;General Data Protection Regulation (GDPR), and the Kenya 2019 Data Protection Act.\u003c/p\u003e\n\u003cp\u003eNimeCONFIRM has several features that support medication adherence; a) A tailored pill calendar and alarm feature that sends a notification an hour and 30 minutes before the allocated time for taking medication, b) a closed group application, only accessible to authorized users among registered HIV positive children and adolescents, c) a time stamp for each video taken, d) a store and forward feature that allows videos taken off the internet to be pushed to the server, and, e) a visualization dashboard available to the clinical team to monitor adherence, with an interphase to the existing facility-based electronic medical records (EMR).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVDOT adherence was measured as a percentage of the number of videos uploaded against the expected uploads to the database. Those taking two doses were expected to have two video uploads daily while those on a single dose were expected to have a single video uploaded. Other outcomes of interest were successful completion (VS), loss to follow-up (LFTU), and discontinuation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildren and adolescents were enrolled from 73 health facilities in Machakos, Makueni, and Kitui counties of Kenya. \u0026nbsp;The facilities provide HIV services to children and adolescents, through implementing partners funded by PEPFAR through CDC. Participants freely chose to use the VDOT app without any formal randomization. Additionally, the self-care or HCW-assisted options were personally selected by each user. \u0026nbsp;The HIV services included providing HIV care and treatment for children and adolescents per national HIV treatment guidelines (40). Viral suppression monitoring was evaluated through RNA polymerase chain reaction (PCR) viral load testing every 3 months until VS was achieved (41,42).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design, population, and sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe retrospective data from children and adolescents who enrolled in the feasibility pilot study and used the NimeCONFIRM VDOT application between February 2021 and October 2022 for any period were collected. However, we only analyzed data from those virally unsuppressed children (0\u0026ndash;9 years) and adolescents (10\u0026ndash;19 years) living with HIV on antiretroviral therapy (ART) who enrolled in and used the NimeCONFIRM VDOT application for at least 12 weeks. Those who had less than 12 weeks of follow-up, which was considered insufficient time to determine clinical changes, were excluded from the analysis. Furthermore, the timing was convenient given that routine viral loads were done every 3 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sources and collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe collected data using the NimeCONFIRM VDOT application. There were two options for data collection at the respective dosage times: (1) VDOT users using the self-care approach where individual clients and (or) their caregivers used their own mobile devices; and (2) Healthcare worker (HCW)-assisted recording and upload of VDOT for those who did not have their own devices or opted for this approach. The enrolment and follow-up data were extracted from the VDOT database and prepared for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe analyzed various demographic and clinical factors in our study, including age at enrollment, sex, county of enrolment, caregiver (such as grandparents, guardian, parent, relative, or siblings), frequency of dosage (once daily or twice daily), regimen line (first, second, or third), core regimen (abacavir [ABC], zidovudine [AZT], and tenofovir [TDF-based]), regimen classification (Lopinavir/Ritonavir [LPV/r] Based, Atazanavir/Ritonavir [ATV/r] Based, dolutegravir [DTG] based, Efavirenz [EFV Based], and Other), and type of care (self-care or healthcare worker-led). The core regimens were mutually exclusive. \u0026ldquo;Continuing on follow-up\u0026rdquo; clients were defined as children and adolescents who were enrolled in the VDOT application and currently unsuppressed but still being monitored through the VDOT application. We recorded the time it took for clients to achieve viral suppression in weeks, with a maximum follow-up period of 90 weeks. Viral suppression outcome was defined as \u0026lt;1000 copies per milliliter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe AMREF Ethics and Scientific Review Committee, Nairobi, Kenya, approved the protocol to conduct this analysis (protocol number: P412/2017) and waived the need for consent from study participants given the retrospective data use. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.\u003csup\u003e\u0026nbsp;\u0026sect;\u003c/sup\u003e (\u003csup\u003e\u0026sect;\u003c/sup\u003eSee e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. \u0026sect;241(d); 5 U.S.C. \u0026sect;552a; 44 U.S.C. \u0026sect;3501 et seq). The study team only had access to de-identified data for analysis. The study procedures were done in accordance with the ethical principles outlined in the World Medical Association\u0026apos;s Declaration of Helsinki, Kenya Government, Ministry of Health, CDC, and local IRB regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive analysis of children and adolescent characteristics was done using counts and percentages as appropriate. Median and interquartile range (IQR) were presented for time to viral suppression outcome, and number of expected daily doses, the number of videos uploaded, and VDOTs adherence. Using Cox proportional hazards (CoxPH) models, survival regression analysis was done to assess the factors associated with viral suppression among children and adolescents who had used the VDOT application for at least 12 weeks and up to 90 weeks of follow-up (43). The time to suppression was calculated as the number of weeks starting from 12 weeks after the date of VDOT enrolment until the point of VL \u0026nbsp;suppression.. Those who were still unsuppressed at 90 weeks of follow-up were censored. There was no missing data for all key variables. The estimated probability of viral suppression was based on the Kaplan-Meier estimates and presented as a plot. Using univariable and multivariable CoxPH models, we assessed demographic and clinical determinants of viral suppression presenting adjusted hazard ratios (aHR) and 95% confidence intervals (CI). The multivariable model included sex, age category, caregiver, dosage frequency, core regimen, regimen line, and type of care (healthcare worker-led or self-care user). Graphical and global tests were done to confirm that the assumption of proportional hazards was met. Overall global (Wald) hypothesis tests were done for categorical variables (age, and caregiver) with more than two categories to determine if the categories were jointly significantly associated with viral suppression. Survival plots by predictor categories were based on the multivariable CoxPH model estimates. All analyses were done using Stata, version 18.1 (StataCorp 2023. Stata Statistical Software, Release 18; College Station, TX).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDescription of client characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe total number of children and adolescents enrolled was 470, representing an uptake of 60%. A total of 164 (34.9%) discontinuations were recorded before 12 weeks of follow-up. However, only about half, 223 (47.5%), of the 470 enrolled on the application who had used it for at least 12 weeks were analyzed. Of all those with at least 12 weeks of follow-up, 223 (100%), were retained at 21 weeks of follow-up. \u0026nbsp;Most users, 163 (73.1%), were adolescents (10-19 years). Over half, 128 (57.4%), were males. There were 19 (8.5%) on the self-care VDOT option. \u0026nbsp;The median time on follow-up was 19 weeks (interquartile range [IQR]: 17\u0026ndash; 23), with a median of one video uploaded(IQR: 0.7 - 1.5) per day, and a median of 126 (IQR: 96 -197) videos uploaded over a median follow-up of 19 weeks as shown in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e{insert Table 1}\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe overall median VDOT adherence was 76% (IQR: 60 - 85), and it did not significantly differ by age, sex, and regimen as shown in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e{insert Table 2}\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eViral suppression outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 223 had viral load outcomes available by 90 weeks of follow-up. The probability of viral suppression at 16, 20, 24, and 28 weeks was 16.1%, 45.3%, 74.2%, and 87.5%, respectively. \u0026nbsp; More than three-fourths, 176 (78.9%), had achieved viral suppression over the follow-up period, as shown in Table 1. Achievement of viral suppression did not differ significantly by age group among those on self-care (p-value = 0.545) or Healthcare worker-led (p-value = 0.393). The overall probability of viral suppression over follow-up is shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults of VDOTs by Viral Suppression Status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall median number of weeks on follow-up for all clients was 19 weeks (IQR: 17 - 23). Clients who achieved VS had an almost similar median number of weeks using the application compared to those who were continuing follow-up since they had not suppressed, 20 weeks (IQR: 17 - 23) vs. 19 weeks (IQR: 16 - 22) respectively, p-value = 0.260. Results showed that those who suppressed had a slightly lower median total number of daily doses compared to those who were continuing follow-up or discontinued, 186 doses (IQR: 128 - 288) vs. 210. doses (IQR: 164 - 262), respectively, p-value = 0.467. Results showed almost similar median adherence percentage among those who had viral suppression compared to those who were continuing follow-up or discontinued, 74% (IQR: 60% - 84%) vs. 81% (IQR: 55% - 86%), respectively, p-value = 0.241 as shown in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e{insert Table 3}\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with viral suppression.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe univariable analysis results indicated significant associations of time to viral suppression with ARV once or twice daily dosage, regimen line, and regimen classification as shown in Table 4. On multivariable analysis, there was an over two-fold significantly higher likelihood of viral suppression for those who were on once-daily compared to twice-daily ARV dosage, aHR = 2.51 (95% CI: 2.06 \u0026ndash; 3.05), as shown in Table 4 and model estimated probabilities of VS over time in Figure 2(a). Children and adolescents on second- or third-line regimens had a three-fold higher likelihood of viral suppression compared to those on first-line regimens, aHR = 3.05 (95% CI: 1.78 \u0026ndash; 5.22), as shown in Table 4 and corresponding model estimated probabilities over time in Figure 2(b). Similarly, children and adolescents on DTG-based regimens had close to two-fold higher likelihood of viral suppression compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR = 1.95 (95% CI: 1.25 \u0026ndash; 3.06), as shown in Table 4 and respective model estimated probabilities over time in Figure 2(c). Overall, the caregiver variable was associated with viral suppression based on a global (Wald) hypothesis test (P value = 0.003). Specifically, those with guardians and siblings as caregivers had a higher likelihood of viral suppression compared to parents, 1.61 (95% CI: 1.27 - 2.03), and 2.00 (95% CI: 1.12 \u0026ndash; 3.57), respectively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e{insert Table 4}\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eImplementation of VDOT supported the achievement of HIV viral load suppression for nearly 80 percent of enrolled children and adolescents in the follow-up period. This is particularly important since evidence suggests that children and adolescents lag behind adults in the achievement of HIV viral suppression after ART and are more vulnerable to developing drug resistance (44,45). \u0026nbsp;To our knowledge, this study is the first to explore the feasibility of VDOT among virally unsuppressed children and adolescents living with HIV receiving antiretroviral treatment in a resource limited setting.\u003c/p\u003e\n\u003cp\u003eOur study included CALHIV aged between 0 and 19 years, a cohort that was comparable to the digital asthma study in West Baltimore that included children 2-18 years. Although the asthma study provided rewards for video upload, retention at 11-21 weeks was lower compared to our study\u0026rsquo;s 21-week retention at 100% among those with at least 12 weeks of follow up (23). The median follow-up time was just over 19 weeks, with at least 12 weeks of VDOT use for half the clients, and a median of 126 videos uploaded. This duration on the VDOT application contrasts with other studies. For example, a study in the United States and Mexico reported the mean duration of VDOT use at 22 weeks while another U.S. study reported a median time of 27 weeks (12,46). It is however notable that these studies involved TB patients on DOT follow-up for the duration of treatment. In our study, clients could exit the VDOT intervention upon achieving viral suppression, which could explain the shorter duration on the intervention. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe use of VDOT has been associated with high levels of adherence. A recent study in Uganda reported high adherence and satisfaction levels among adult clients on TB treatment using a VDOT application (13). This finding has similarly been demonstrated in a study among adults in the United States and Mexico with adherence rates above 93% and 92% preference for VDOT over in-person TB DOT (12). This contrasts with the lower VDOT adherence in our study at 76%. A synchronous VDOT study in Nassau County Department of Health, Mineola, New York reported similar adherence rates of 79% which compared with a Uganda study at 82.2% (13,47). While these studies provide comparisons of VDOT use for TB treatment, lower adherence rates have been reported among children using VDOT to observe inhaled corticosteroid use for asthma control, ranging from 50% to 64% (23).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdherence levels measured from VDOT were likely affected by missed video uploads as has been observed in other studies (8). A recent study in Uganda discussed common reasons for missed video uploads including malfunctions of phones and the VDOT application as well as uncharged batteries (13). Other barriers reported in the literature included desire for face-to-face interaction, lack of familiarity with the use of videos, illiteracy, privacy and confidentiality concerns, adverse effects, and demographic profile differences with the use of technology (18,48,49).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, the likelihood of achieving viral suppression was higher among those on the self-care VDOT option compared to the HCW-led option. Further, a higher likelihood of viral suppression was also demonstrated among those with guardians and siblings as caregivers compared to parents. This is similar to studies that indicated that older adults are more likely to find the use of VDOT more challenging compared to younger and more educated adults, which could have affected uptake of the self-care VDOT option alongside access to smartphones (48,49). \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study results showed over 3-fold higher likelihood of viral suppression among children and adolescents on second- and third-line regimens compared to those on first-line regimens. Poor adherence to treatment has been documented as a major reason for second-line failure, suggesting utility of the VDOT intervention in this population (50). Our study also found over 2-fold higher odds of viral suppression among those on a once daily dosage regimens and close to 2-fold higher odds for clients on DTG based regimens. This is similar to other studies that have demonstrated higher rates of viral suppression among children and adolescents receiving optimized DTG-based ART (51\u0026ndash;53).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study had some limitations. First VDOT adherence only measured whether the video captured the client taking the medication and not reported ART adherence. This may underestimate the actual ART adherence in cases where medication was taken but a video was not uploaded on the application. Given this resource-limited setting, it is likely that there were challenges in regular access to VDOT by healthcare workers and to mobile devices for most participants, or the internet for video uploads especially for those on self-care (using their own devices). We acknowledge that there were unobserved factors that may affect viral suppression outcomes. The second limitation was the relatively high proportion of clients who were discontinued due to various reasons and incomplete follow-up for some clients who were also not included in the study. Even though the study had a large sample, these reasons may over or underestimate the observed adherence and viral suppression outcomes. Finally, we acknowledge that this was a feasibility study without a control group to demonstrate improved efficacy of VDOT over standard of care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of VDOT to support the achievement of VS among unsuppressed children and adolescents living with HIV and on antiretroviral treatment was feasible and acceptable even with the limitations cited. Achieving VS using VDOT was associated with the type of caregiver, treatment regimen, dosing frequency, and self-care VDOT. Our findings highlight the beneficial impact of VDOT as an additional tool to ensure that HIV unsuppressed children and adolescents benefit from their access to life-saving care and treatment, especially in resource-limited settings such as Kenya.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIDS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acquired immunodeficiency syndrome\u003c/p\u003e\n\u003cp\u003eaHR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Adjusted Hazard Ratio\u003c/p\u003e\n\u003cp\u003eAMREF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;African Medical and Research Foundation\u003c/p\u003e\n\u003cp\u003eABC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Abacavir\u003c/p\u003e\n\u003cp\u003eART\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Antiretroviral therapy\u003c/p\u003e\n\u003cp\u003eATV/r\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Atazanavir/Ritonavir\u003c/p\u003e\n\u003cp\u003eAZT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Zidovudine\u003c/p\u003e\n\u003cp\u003eDTG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Dolutegravir\u003c/p\u003e\n\u003cp\u003eGDPR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;General Data Protection Regulation\u003c/p\u003e\n\u003cp\u003eDOT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Directly observed therapy\u003c/p\u003e\n\u003cp\u003eDGHT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Division of Global HIV\u0026amp;TB\u003c/p\u003e\n\u003cp\u003eEFV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Efavirenz\u003c/p\u003e\n\u003cp\u003eEMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Electronic medical records\u003c/p\u003e\n\u003cp\u003eCALHIV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Children and adolescents living with HIV\u003c/p\u003e\n\u003cp\u003eCDC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Centers for Disease Control\u003c/p\u003e\n\u003cp\u003eCHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Center for Health Solution\u003c/p\u003e\n\u003cp\u003eCoAg\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Co-agreement\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Confidence intervals\u003c/p\u003e\n\u003cp\u003eHCW\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Health care worker\u003c/p\u003e\n\u003cp\u003eHIPAA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Health Insurance Portability and Accountability Act\u003c/p\u003e\n\u003cp\u003eIRB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Institutional Review Board\u003c/p\u003e\n\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Interquartile range\u003c/p\u003e\n\u003cp\u003eLFTU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Loss to follow-up\u003c/p\u003e\n\u003cp\u003eLPV/r \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Lopinavir/Ritonavir\u003c/p\u003e\n\u003cp\u003ePEPFAR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;President\u0026apos;s Emergency Plan for AIDS (PEPFAR)\u003c/p\u003e\n\u003cp\u003eRNA-PCR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ribonucleic acid polymerase chain reaction\u003c/p\u003e\n\u003cp\u003eTDF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tenofovir\u003c/p\u003e\n\u003cp\u003eTB \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Tuberculosis\u003c/p\u003e\n\u003cp\u003eUS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United States\u003c/p\u003e\n\u003cp\u003eVDOT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Video directly observed therapy\u003c/p\u003e\n\u003cp\u003eVS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Viral Suppression\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe AMREF Ethics and Scientific Review Committee, Nairobi, Kenya, approved the protocol to conduct this analysis (protocol number: P412/2017). As this study used retrospective data, the AMREF Ethics and Scientific Review Committee, Nairobi, Kenya, waived the need for consent or assent from study participants. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.\u003csup\u003e\u0026nbsp;\u0026sect;\u003c/sup\u003e (\u003csup\u003e\u0026sect;\u003c/sup\u003eSee e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. \u0026sect;241(d); 5 U.S.C. \u0026sect;552a; 44 U.S.C. \u0026sect;3501 et seq). The investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes or analysis. The study procedures were done in accordance with the ethical principles outlined in the World Medical Association\u0026apos;s Declaration of Helsinki, Kenya Government, Ministry of Health, CDC, and local IRB regulations\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData used for this analysis is a deidentified dataset of individual-level data and is not currently publicly available. However, the dataset can be obtained from the corresponding author based on a reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe funding for this program and evaluation was supported by the U.S. President\u0026apos;s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under the terms of CoAg number 1U2GGH000097. U.S. CDC provided financial and technical support during the project design and implementation. They also assisted with the manuscript review. Data collection, analysis, interpretation, and writing were done by the CHS coauthors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePW led the design, data collection, and interpretation, and wrote substantial portions and paper review. KO performed data analysis, interpretation, and results writeup, and paper review. IM guided the design, gave input on the analysis, and did paper reviews. MN, BM, MB, EN, KK, and AK assisted with the design, data collection, and paper review. All authors read and approved the final paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge all the wonderful children and adolescents whose data was used for this analysis, caregivers, the health workers, and the facility in charges. We acknowledge the input of the programming, monitoring and evaluation teams that assisted with the application design, rollout, and data collection.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCDC disclaimer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the funding agencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors details\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eCenter for Health Solutions, Kenya \u0026nbsp; \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDivision of Global HIV\u0026amp;TB (DGHT), Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya\u003c/li\u003e\n \u003cli\u003eBill and Melinda Gates Foundation\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe Joint United Nations Programme on HIV/AIDS. path that ends AIDS. 2023;80\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Joint United. 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Journal of the Royal Statistical Society1. 1972;34(2):187\u0026ndash;220.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFord N, Orrell C, Shubber Z, Apollo T, Vojnov L. HIV viral resuppression following an elevated viral load: a systematic review and meta-analysis. J Int AIDS Soc [Internet]. 2019; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://onlinelibrary.wiley.com/doi/\u003c/span\u003e\u003cspan address=\"http://onlinelibrary.wiley.com/doi/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jia2.25415/full\u003c/span\u003e\u003cspan address=\"10.1002/jia2.25415/full\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. HIV prevention, infant diagnosis, antiretroviral initiation and monitoring guidelines [Internet]. 2021 [cited 2024 Apr 23]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int\u003c/span\u003e\u003cspan address=\"https://www.who.int\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry A, Chitnis A, Chin A, Hoffmann C, Chang L, Robinson M, et al. Real-world implementation of video-observed therapy in an urban TB program in the United States. Int J Tuberculosis Lung Disease. 2021;25(8):655\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuchman T, Cabello C. A New Method to Directly Observe Tuberculosis Treatment: Skype Observed Therapy, a Patient-Centered Approach. J Public Health Manage Pract. 2017;23(2):175\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabinovich L, Molton JS, Ooi WT, Paton NI, Batra S, Yoong J. Perceptions and acceptability of digital interventions among tuberculosis patients in Cambodia: Qualitative study of video-based directly observed therapy. J Med Internet Res. 2020;22(7):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar AA, De Costa A, Das A, Srinivasa GA, D\u0026rsquo;souza G, Rodrigues R. Mobile health for tuberculosis management in South India: Is video-based directly observed treatment an acceptable alternative? JMIR Mhealth Uhealth. 2019;7(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChimbetete C, Shamu T, Keiser O. Zimbabwe\u0026rsquo;s national third-line antiretroviral therapy program: Cohort description and treatment outcomes. PLoS ONE. 2020;15(3):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBacha JM, Dlamini S, Anabwani F, Gwimile J, Kanywa JB, Farirai J et al. Achieving Antiretroviral Therapy Uptake and Viral Suppression among Children and Adolescents Living with HIV in the UNAIDS 90-90-90 Era Across Six Countries in Eastern and Southern Africa-Lessons from the BIPAI Network. J Acquir Immune Defic Syndr (1988). 2022;90(3):300\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFokam J, Nka AD, Dzukam FYM, Pabo W, Gabisa JE, Bouba Y et al. Viral suppression in the era of transition to dolutegravir-based therapy in Cameroon. Medicine. 2023;102(20).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhamadi SA, Bahemana E, Dear N, Mavere C, George F, Kapene R, et al. Factors Associated With Viral Suppression and Drug Resistance in Children and Adolescents Living With HIV in Care and Treatment Programs in Southern Tanzania. J Pediatr Infect Dis Soc. 2023;12(6):353\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Suppression outcome among participants at the end of 90 weeks of follow-up, Kenya, Feb 2021 - Oct 2022\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"113%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eColumns by: Suppression Outcome among those with least 12 weeks of follow up (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinuing Follow-up\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuppressed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\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 style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e47 (21.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e176 (78.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e223 (100.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\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 valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Girls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e21 (44.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e74 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e95 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Boys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e26 (55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e102 (58.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e128 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eAge at enrollment (years), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e13.3 (8.8 - 15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e13.7 (9.7 - 16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e13.7 (9.6 - 16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eAge Category at enrollment (years), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; 0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e8 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e15 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e23 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; 5-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e32 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e37 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; 10-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e19 (40.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e65 (36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e84 (37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; 15-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e15 (31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e64 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e79 (35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eCaregiver, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Grand parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e25 (14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e31 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Guardian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e24 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e30 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e32 (68.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e117 (66.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e149 (66.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Relative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e7 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Siblings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eCore ART regimen, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; ABC Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e14 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e48 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e62 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; AZT Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e27 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e83 (47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e110 (49.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; TDF Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e45 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e51 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRegimen Classification, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; DTG Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e19 (40.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e81 (46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e100 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; LPV/r Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e22 (46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e69 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e91 (40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; ATV/r Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e22 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e26 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; EFV Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRegimen line, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; First-line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e18 (38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e76 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e94 (42.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Second-line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e29 (61.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e99 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e128 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Third-line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eType of care, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Healthcare worker led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e43 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e161 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e204 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Self-care/User\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e15 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e19 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003eDosage Frequency, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Once daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e17 (36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e87 (49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e104 (46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp; Twice daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e30 (63.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e89 (50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e119 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eIQR- interquartile range\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eABC - abacavir, AZT - zidovudine, and TDF - tenofovir\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eLPV/r - Lopinavir/Ritonavir, ATV/r - Atazanavir/Ritonavir, DTG - dolutegravir, EFV - Efavirenz\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. VDOT adherence percentage by age, sex, and regimen, Kenya, Feb 2021 - Oct 2022\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDOTs adherence (Percent), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;Overall\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e223 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e76 (60 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;Age Category at enrollment (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e23 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e79 (41 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e37 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e79 (63 - 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e10-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e84 (37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e75 (56 - 88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e15-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e79 (35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e75 (62 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eGirls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e95 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e78 (61 - 87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBoys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e128 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e74 (56 - 84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRegimen Classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLPV/r Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e91 (40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e74 (46 - 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eATV/r Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e26 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e74 (30 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDTG Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e76 (65 - 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eEFV Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e72 (16 - 78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31 (31 - 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRegimen line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFirst-line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e94 (42.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77 (66 - 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSecond-line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e128 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e74 (48 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eThird-line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31 (31 - 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCore ART regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eABC Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e62 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e71 (39 - 83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAZT Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e110 (49.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e76 (53 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTDF Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e78 (67 - 87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cem\u003eIQR- interquartile range\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eABC - abacavir, AZT - zidovudine, and TDF - tenofovir\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eLPV/r - Lopinavir/Ritonavir, ATV/r - Atazanavir/Ritonavir, DTG - dolutegravir, EFV - Efavirenz\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 VDOTS suppression outcome among children and adolescents living with HIV infection with at least 12 weeks of follow-up, Kenya, Feb 2021 - Oct 2022\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"683\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuppression Outcome (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinuing Follow-up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuppressed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\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 style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e47 (21.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e176 (78.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e223 (100.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\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 style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003evDOTS Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eTime using Application (Weeks), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 137px;\"\u003e\n \u003cp\u003e19 (16 - 21.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\n \u003cp\u003e20 (17 - 23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e19 (17 - 23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eTotal number of expected daily doses per user, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e210 (164 - 262)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e186 (128 - 288)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e188 (134 - 280)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eTotal number of videos uploaded per user, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e147 (91 - 201)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e124 (96 - 194)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e126 (96 - 197)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003evDOTs adherence (Percent), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 137px;\"\u003e\n \u003cp\u003e81 (55 - 86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\n \u003cp\u003e74 (60 - 84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e76 (60 - 85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.241\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\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\u003cem\u003eIQR -interquartile range\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4 Cox proportional hazards model for viral suppression among children and adolescents living with HIV infection during the follow-up period while using the NIMECONFIRM application with at least 12 weeks of follow-up, Kenya, Feb 2021 - Oct 2022\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"104%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome: Viral Suppression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHazard Ratio\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Hazard Ratio\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\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 valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaHR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\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 valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003e\u0026nbsp; Boys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003e\u0026nbsp; Girls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0.83 (0.57-1.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e0.69 (0.45-1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eAge Category\u0026nbsp;at enrollment (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0.88 (0.48 - 1.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.35 (0.72 - 2.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e5-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0.94 (0.86 - 1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.16 (0.90 - 1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e10-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0.88 (0.80 - 0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.00 (0.86 - 1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e15-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eCaregiver*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eParent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eGrand parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.24 (0.94-1.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.12 (0.91-1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eGuardian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.38 (0.91-2.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.61 (1.27-2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eRelative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0.99 (0.33-2.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e0.89 (0.24-3.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.864\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eSiblings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.52 (1.24-1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e2.00 (1.12-3.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDosage Frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eTwice Daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eOnce Daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.37 (1.26 - 1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e2.51 (2.06 - 3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eRegimen Line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eFirst line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eSecond or Third line\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0.90 (0.82 - 0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e3.05 (1.78 - 5.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eRegimen Classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eLPV/r, ATV/s, or EFV based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDTG based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.27 (1.20 - 1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.95 (1.25 - 3.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eCare Type\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eHealthcare Worker Led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eSelf-Care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.39 (0.55 - 3.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1.37 (0.67 - 2.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e* Global (Wald) hypothesis test for caregiver (P value = 0.003)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/em\u003e\u003cem\u003e\u0026nbsp;There was only 1 patient on the third line.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eABC - abacavir, AZT - zidovudine, and TDF - tenofovir\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLPV/r - Lopinavir/Ritonavir, ATV/r - Atazanavir/Ritonavir, DTG - dolutegravir, EFV - Efavirenz\u003c/em\u003e\u003c/p\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-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children and adolescents living with HIV, video directly observed therapy (VDOT), viral suppression, Kenya, antiretroviral treatment","lastPublishedDoi":"10.21203/rs.3.rs-5675528/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5675528/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eVideo directly observed therapy (VDOT) has been used as an acceptable, cost-effective, client-centered intervention for tuberculosis management. VDOT targeting children (0\u0026ndash;14 years) and adolescents (15\u0026ndash;19 years) living with HIV not achieving viral suppression (VS) [i.e., \u0026lt;\u0026thinsp;1000 copies/ml] was piloted in 73 facilities in Kenya. We conducted a feasibility study on the utilization and re-suppression rates of clients enrolled in VDOT.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA review of data from 223 virally unsuppressed clients aged between 0\u0026ndash;19 years on antiretroviral therapy (ART) who were enrolled to use the VDOT application daily for at least 12 weeks between February 2021 and October 2022 at 73 health facilities was conducted. Clients stopped using the application upon achieving VS. VS was assessed after at least 12 weeks of VDOT follow-up through self-care or healthcare worker (HCW)-led approaches. Using a multivariable Cox Proportional Hazards regression model, we assessed demographic and clinical determinants of VS presenting adjusted hazard ratios (aHR).\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMost users, 163 (73.1%) were adolescents aged 10\u0026ndash;19 years. Only 19 (8.5%) were on self-care VDOT. Median time on follow-up was 19 weeks, 126 videos uploaded, and 75% VDOT adherence. Over three-fourths, 176 (78.9%) had achieved VS during follow-up. Results showed a higher likelihood of VS among children on once-daily compared to twice-daily ARV dosage, aHR\u0026thinsp;=\u0026thinsp;2.51 (95% CI: 2.06\u0026ndash;3.05), and those on second- or third-line regimens compared to those on first-line regimens, aHR\u0026thinsp;=\u0026thinsp;3.05 (95% CI: 1.78\u0026ndash;5.22). Similarly, those on a DTG-based regimen had a higher likelihood of VS compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR\u0026thinsp;=\u0026thinsp;1.95 (95% CI: 1.25\u0026ndash;3.06). Children receiving care from guardians and siblings had a higher likelihood of VS compared to those receiving care from parent caregivers, 1.61 (95% CI: 1.27\u0026ndash;2.03), and 2.00 (95% CI: 1.12\u0026ndash;3.57), respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAchieving VS using VDOT among children and adolescents living with HIV (CALHIV) was significantly associated with dosage frequency, antiretroviral regimen, first- or second-line therapy, antiretroviral regimen classification, and type of caregiver. Findings suggest VDOT could lead to a higher VS among children and adolescents living with HIV in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 05:09:16","doi":"10.21203/rs.3.rs-5675528/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-15T08:29:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-10T09:15:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155672808461821495185978039781591110492","date":"2025-04-07T07:04:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-01T09:34:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-31T07:18:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-03-28T14:09:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"75f49b16-f97e-42db-8f22-2516067a457e","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T16:00:46+00:00","versionOfRecord":{"articleIdentity":"rs-5675528","link":"https://doi.org/10.1186/s12879-025-11036-9","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-04-30 15:57:30","publishedOnDateReadable":"April 30th, 2025"},"versionCreatedAt":"2025-04-03 05:09:16","video":"","vorDoi":"10.1186/s12879-025-11036-9","vorDoiUrl":"https://doi.org/10.1186/s12879-025-11036-9","workflowStages":[]},"version":"v1","identity":"rs-5675528","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5675528","identity":"rs-5675528","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}