Sex differences in delayed antiretroviral therapy initiation among adolescents and young adults living with HIV in DR Congo

Background: In DR Congo, adolescent girls are disproportionately vulnerable to HIV. Nonetheless, females are often more engaged in the health-care system, including during antenatal care, when women enrolled on Option B+ for prevention of mother-to-child transmission of HIV initiate antiretroviral therapy (ART). We aimed to understand the extent of delayed ART initiation among adolescents and young adults newly enrolled in HIV care, and to assess whether there were any sex differences. Methods: Aggregate data from 365 ICAP-supported sites in Kinshasa and Haut-Katanga provinces in DR Congo from April 2016 to May 2017 were reviewed to describe delayed ART uptake among adolescents and young adults aged 15–24 years. Delayed uptake was defined as not beginning treatment within 1 month of enrolling in care among those eligible for ART. Pregnant and non-pregnant women were combined since available data did not disaggregate by pregnancy status. DR Congo began implementing “test and start” during the study period. All analyses used group-level data and were conducted using multivariable logistic regression, adjusting for setting and age group. Findings: Between April 2016 and May 2017, 861 adolescents and young adults (128 male and 733 female) enrolled in HIV care and treatment services. 21 (16%) males and 58 (8%) females had not begun treatment within 1 month of enrolling in care, despite eligibility for ART (odds ratio [OR] 2·28, 95% CI 1·33–3·92). The male predominance remained after controlling for setting (urban vs rural) and age group (15–19 years vs 20–24 years) (adjusted OR 2·03, 95% CI 1·17–3·53). Aggregate data did not allow for analysis of individual explanations, but reasons for delayed ART may include the need to stabilise patients before starting treatment and patients’ preferences. Interpretation: Despite being more vulnerable to HIV, female adolescents and young adults have faster ART initiation than males after enrolling in HIV treatment. It is likely that Option B+ expedites ART initiation for females. Going forwards, ICAP will strengthen its adolescent package of support with community-based adolescent-friendly interventions targeting males, with the goal to enrol all adolescents and young adults on ART in accordance with DRC's test and start guidelines. Funding: CDC/PEPFAR