Factors associated with HIV RNA viral non-suppression among children and adolescents with HIV attending public health facilities in Gulu City, Uganda: a retrospective cohort study

Background: Human immunodeficiency virus (HIV) RNA viral load testing is the gold standard for monitoring antiretroviral therapy (ART), and sustained viral suppression is critical for preventing HIV-related morbidity and transmission. However, children and adolescents with HIV (CAWH) often experience lower viral suppression rates than adults. Data on the incidence of HIV RNA viral non-suppression and its determinants among CAWH in northern Uganda remain limited. Objectives: To determine the incidence and factors associated with HIV RNA viral load non-suppression among CAWH receiving ART in Gulu City, Uganda. Design: Retrospective cohort study. Methods: We reviewed records of CAWH receiving ART at public health facilities in Gulu City. Data were abstracted for HIV RNA viral load outcomes at 6, 12, 18, and 24 months and at the most recent follow-up. The primary outcome was HIV RNA viral non-suppression during follow-up. Bivariable and multivariable Cox proportional hazards regression models were used to identify factors associated with viral load non-suppression. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) were reported. Results: Among 218 participants, the median age was 12.5 years (interquartile range (IQR), 7-18), and 153 (70.2%) were female. During follow-up, 99 participants (45.4%) experienced viral load non-suppression. The incidence rate of viral load non-suppression was 25.6 cases per 100 person-years. Factors independently associated with non-suppression included age <5 years (aHR: 2.59, 95% CI: 1.30-5.17), poor ART adherence (aHR: 1.96, 95% CI: 1.21-3.17), non-disclosure of HIV status (aHR: 2.19, 95% CI: 1.27-3.80), advanced WHO clinical stage (III-IV) at presentation (aHR: 3.07, 95% CI: 1.41-6.69), and economic hardship (aHR: 2.13, 95% CI: 1.32-3.42). Conclusion: Viral load non-suppression among CAWH in Gulu City was high, with the majority experiencing viral non-suppression by approximately 6 months after ART initiation. Strengthening adherence support, early disclosure of HIV status, and targeted interventions for younger children and socioeconomically vulnerable households may improve viral suppression outcomes in this population.