Violence as an obstacle to HIV medication adherence and viral suppression: A daily diary investigation among adolescent boys

For the 1.6 million adolescents currently living with HIV, adherence to antiretroviral therapy (ART) is vitally important for reducing HIV-associated morbidity and mortality, and for preventing onward HIV transmission. Unfortunately, ART adherence is particularly low among adolescents. One important barrier to adherence is exposure to violence; however, the impact of cumulative versus acute exposure to violence on adherence is unclear. We tested whether violence exposure was associated with ART adherence and viral load over a one-year period among adolescent boys living with HIV in Soweto, South Africa. Participants (N = 239) completed weekly ecological momentary assessment (EMA) surveys of their recent experiences with violence and ART adherence. They provided biological samples at baseline and at the one-year follow-up to measure viral load. Higher average exposure to violence over the course of the study year was significantly associated with lower ART adherence (i. e., a cumulative impact). When we restricted violence exposure to intimate partner violence only, we found that participants were significantly less likely to take their HIV medication on days when they experienced physical intimate partner violence (i.e., an acute impact). We also found a significant positive association between exposure to violence over the course of the study and participants' viral load at follow-up, even after controlling for baseline viral load. Our findings suggest that violence impacts two important HIV care outcomes through multiple pathways and highlight the importance of differentiating cumulative versus acute victimization in violence research. To improve health outcomes among adolescents with HIV and prevent new infections, it will be necessary to include boys in violence prevention and support services and to address violence exposure in HIV care.