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Multi-level modeling and multiple group analysis of disparities in continuity of care and viral suppression among Nigerian adolescents and youths living with HIV

Substantial disparities in care outcomes exist between different sub-groups of adolescents and youths living with HIV(ALHIV). Understanding variation in individual and health-facility characteristics could be key to identifying targets for interventions to reduce these disparities. We modeled variation in ALHIV retention in care and viral suppression, and quantified the extent to which individual and facility characteristics account for observed variations.We included 1,177 young adolescents (10-14 years), 3,206 older adolescents (15-19 years) and 9,151 young adults (20-24 years) who were initiated on antiretroviral therapy (ART) between January 2015 and December 2017 across 124 healthcare facilities in Nigeria. For each age-group, we used multilevel modeling to partition observed variation of main outcomes(retention in care and viral suppression at 12 months post ART initiation) by individual (level one) and health facility (level two) characteristics. We used multiple group analysis to compare the effects of individual and facility characteristics across age-groups.Facility characteristics explained most of the observed variance in retention in care in all the age-groups, with smaller contributions from individual-level characteristics (14-22.22% vs 0 - 3.84%). For viral suppression, facility characteristics accounted for a higher proportion of variance in young adolescents (15.79%), but not in older adolescents (0%) and young adults(3.45%). Males were more likely to not be retained in care(aOR=1.28; p<0.001 young adults) and less likely to achieve viral suppression (aOR=0.69; p<0.05 older adolescent). Increasing facility-level viral load testing reduced the likelihood of non-retention in care, while baseline regimen TDF/3TC/EFV or NVP increased the likelihood of viral suppression.Differences in characteristics of healthcare facilities accounted for observed disparities in retention in care and, to a lesser extent, disparities in viral suppression. An optimal combination of individual and health-services approaches is, therefore, necessary to reduce disparities in the health and wellbeing of ALHIV.Adolescents and youths living with HIV have worse care and treatment outcomes compared to other groupsSignificant disparity in care and treatment outcomes exist between different adolescent and youth subgroupsDifferences in characteristics of healthcare facilities delivering services are associated with disparities in outcomes within and across adolescent and youth age-groups.An optimal combination of individual and health-services approaches is necessary to reduce disparities in the health and wellbeing of adolescent and youths living with HIV.