Background: In the Central African Republic (CAR), HIV prevalence was estimated at 2.4% in 2024. Antiretroviral therapy (ART) is central to HIV control; however, achieving sustained adherence in children remains difficult. This study assessed ART adherence and identified factors associated with nonadherence among children living with HIV.

Methods: We conducted a descriptive and analytical case–control study from January to December 2024 at the Chronic Diseases Unit of the Bangui Pediatric University Hospital. Cases were children living with HIV (0–14 years) with poor ART adherence; controls were children with good adherence. Data were collected from medical records, ART dispensing registers, program reports, and structured interviews with caregivers and/or children. Analyses were performed using Epi Info 7.2. Factors associated with nonadherence were explored using logistic regression, with results reported as odds ratios (ORs), 95% confidence intervals (CIs), and p-values.

Results: A total of 142 children were included (71 cases, 71 controls); mean age was 10.0 ± 3.7 years. In bivariate analysis, nonadherence was associated with caregiver relationship (self-managed treatment vs parental care; OR = 8.0; 95% CI: 1.04– 70.4; p = 0.019). In multivariable analysis, nonadherence was independently associated with high viral load (OR = 27.9; 95% CI: 7.58–103.1; p < 0.001), presence of comorbidities (OR = 15.1; 95% CI: 1.79–127.3; p = 0.013), and participation in differentiated service delivery models (OR = 7.3; 95% CI: 4.06–13.13; p < 0.001).

Conclusion: ART nonadherence among children living with HIV in Bangui appears to be driven by clinical, organizational, and socio-behavioral factors. Integrated clinical and behavioral interventions are needed to strengthen adherence and improve outcomes.