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Background: In Malawi, compared to adults, adolescents have higher rates of high HIV viremia and poorer antiretroviral therapy (ART) outcomes. The Ministry of Health, supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), implemented the provision of differentiated care clubs for adolescents living with HIV (ALHIV), called "teen clubs," to provide psychosocial support and an HIV care package to improve clinical outcomes. We evaluated teen club attendance and factors associated with unsuppressed viral load (VL) in ALHIV enrolled in these teen clubs., Methods: This cross-sectional study used program data from 35 health facilities in four districts that offered teen club services. We enrolled all ALHIV receiving ART ages 10-19 years who attended teen clubs between July 2018- September 2019 and had documented viral load results. Unsuppressed VL was defined as HIV RNA = > 1000 copies/mL, and optimal ART adherence was defined as having an expected pill count suggesting that between 95 and 105% of pills prescribed were consumed. We used multivariable logistic regression to identify factors associated with unsuppressed VL, adjusting for sex, age, education, district, adherence assessment, disclosure of one's HIV status, and teen club attendance., Results: Our analysis included 1,162 ALHIV with a median age of 15 years (IQR 13-17). The majority were female (n = 614, 53%) and attended one or two teen club visits (n = 665, 57%). Unsuppressed VL was identified in 28% of ALHIV. ALHIV with sub-optimal ART adherence were twice as likely to have unsuppressed VL (adjusted odds ratio [aOR] 2.0, 95% confidence interval (CI): 1.42-2.62) compared to those with optimal ART adherence. ALHIV on second-line treatments, were nearly four times more likely to have unsuppressed VL (aOR 3.7, 95% CI: 1.64-9.09) compared with those on first-line ART. ALHIV who had attained secondary school education were less likely to have unsuppressed VL (aOR 0.42, 95% CI 0.21-0.81) than those who only attained primary school education., Conclusion: Even amongst adolescents enrolled in teen clubs, teen club attendance is low and high HIV viremia prevails. A continual focus on adolescents is needed to promote consistent teen club attendance and consistent ART adherence among the adolescents enrolled in differentiated service delivery., Competing Interests: Declarations. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the funding agencies. Ethics approval and consent to participate: The National Health Science Research Committee and the Advarra Research Committee approved this study. The Centers for Disease Control and Prevention also reviewed and cleared the data collection protocol. There was no consent or assent required for this study as this study used secondary data which had been de-identified. The informed consent was waived by the National Health Science Research Committee and the Advarra Research Committee. Consent for publication: N/A. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Viral suppression (VS) in children has remained suboptimal compared to that in adults. We evaluated the impact of transitioning children weighing < 20 kg to a pediatric formulation of dolutegravir (pDTG) on VS in Malawi. We analyzed routine retrospective program data from electronic medical record systems pooled across 169 healthcare facilities in Malawi supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). We included children who weighed < 20 kg and received antiretroviral therapy (ART) between July 2021-June 2022. Using descriptive statistics, we summarized demographic and clinical characteristics, ART regimens, ART adherence, and VS. We used logistic regression to identify factors associated with post-transition VS. A total of 2468 Children Living with HIV (CLHIV) were included, 55.3% of whom were < 60 months old. Most (83.8%) had initiated on non-DTG-based ART; 71.0% of these had a viral load (VL) test result before transitioning to pDTG, and 62.5% had VS. Nearly all (99.9%) CLHIV transitioned to pDTG-based regimens. Six months after the transition, 52.7% had good ART adherence, and 38.6% had routine VL testing results; 81.7% achieved VS. Post-transition VS was associated with good adherence and pre-transition VS: adjusted odds ratios of 2.79 (95% CI 1.65-4.71), p < 0.001 and 5.32 (95% CI 3.23-9.48), p < 0.001, respectively. After transitioning to pDTG, VS was achieved in most children tested within the first 6 months. However, adherence remained suboptimal post-transition and VL testing at 6 months was limited. Interventions to improve VL testing and enhance ART adherence are still needed in CLHIV on pDTG-based regimens., (© 2024. The Author(s).)