Predictors of unsuppressed viral load among men who have sex with men living with HIV in South Africa

Introduction:South Africa has the largest HIV epidemic of the world, but predictors of unsuppressed viral load among MSM are scarce.Methods:We did a cross-sectional study to assess socio-demographic characteristics, year of antiretroviral therapy (ART) initiation, and viral load data from 1385 MSM registered in five key population clinics in five districts in South Africa in 2023 and 2024. We used logistic regression to assess predictors of unsuppressed viral load (≥200 copies/ml). We then conducted a case - control study involving 57 cases (viral load≥200 copies/ml) and 57 matched controls (viral load<200 copies/ml; matched on age, ART start date, clinic, and outreach vs. facility attendance) drawn from the cross-sectional study to explore additional differences between groups.Results:In the cross-sectional study, predictors for unsuppressed viral load included on ART for 1-2 years [odds ratio (OR) 3.53; 1.77-7.69] or 3-5 years (OR 2.33; 1.18-5.04) vs. more than 5 years, being an outreach vs. facility-based client (OR: 2.64; 1.79-3.94), and enrolled at Johannesburg (OR: 3.53; 2.25-5.64), or Durban (OR: 0.36; 0.84-0.70), vs. Pretoria. The case-control study identified predictors for unsuppressed viral load, which included missing more than four ART dosages per month (OR: 5.55; 1.19-41,03), having moderate to severe anxiety (OR: 3.90; 1.34-12,52), hazardous alcohol use (OR: 2.70; 1.14-6.81), and Christian vs. no religion (OR: 3.89; 1.34-12.29).Conclusion:We identified regional differences and key predictors of unsuppressed viral load among MSM living with HIV in South Africa. Screening for risk factors for unsuppressed viral load at ART continuation may inform where adherence support and other health services are needed.