BACKGROUND: Globally, 52% of the 1.7 million children living with HIV (CLHIV) aged 0-14 years received ART in 2021, but only 4 in 10 were virally suppressed (UNICEF 2022). CLHIV on ART are more likely to be virally non-suppressed due to clinical and behavioral aspects, e.g., poor adherence, non-optimized antiretrovirals (ARVs) and severe immunosuppression. We aimed to determine the impact of a behavioral science-informed therapeutic alliance (TA) on viral non-suppression among CLHIV in USAID DISCOVER-Health-supported facilities in two provinces of Zambia.
METHODS: Non-suppressed CLHIV on dolutegravir-containing ART for >6 months and assigned to a TA comprising a clinician, oriented community-based volunteer (CBV) and a household caregiver as standard care were enrolled in the study. The intervention arm enrolled CLHIV from 8 of the 15 districts, also assigned to a TA, but layered behavioral science informed approaches targeted at decision making biases and social/organizational norms:

Cascade data for CLHIV enrolled in enhanced adherence counseling (EAC) to viral suppression outcomes were collected for analysis with WINPEPI.
RESULTS: The study enrolled 188 non-suppressed CLHIV in November 2022. After 4 months, 177 CLHIV (94%) were enrolled in EAC with 89% completion rate. Additionally, 140 CLHIV underwent repeat VL testing with 25% viral non-suppression rate. No significant differences were observed in EAC enrolment (p=0.412) or completion rates (p=0.556) between the two study arms. VL retesting after EAC completion was statistically significantly higher in the intervention arm (risk ratio (RR)=1.12; CI=1.01-1.26, p=0.026). The risk of viral non-suppression was two-times less in the intervention arm (RR=0.472; CI=0.25-0.89, p=0.012) compared with standard care.
CONCLUSIONS: Applying behavioral science to TAs spearheading pediatric ART service provision can lead to optimized clinician and caregiver behavior, which increases positive treatment outcomes and reduces viral non-suppression. Applying behavioral science in such settings is crucial to achieving the goal of ending AIDS in children by 2030.

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