Posted: Jan 19, 2017
Treatment Outcomes of HIV-Infected Adolescents Attending Public-Sector HIV Clinics Across Gauteng and Mpumalanga, South Africa
There is little evidence comparing treatment outcomes between adolescents and other age groups, particularly in resource-limited settings. A retrospective analysis of data from seven HIV clinics across urban Gauteng (n = 5) and rural Mpumalanga (n = 2), South Africa was conducted. The analysis compared HIV-positive antiretroviral treatment (ART)-naive young adolescents (10–14 years), older adolescents (15–19), and young adults (20–24 years) to adults ( ‡ 25 years) initiated onto standard ﬁrst-line ART between April 2004 and August 2010. Log-binomial regression was used to estimate relative risk (RR) of failure to suppress viral load ( ‡ 400 copies/ml) or failure to achieve an adequate CD4 response at 6 or 12 months. The effect of age group on virological failure, mortality, and loss to follow-up (LTFU; ‡ 90 days since scheduled visit date) was estimated using Cox pro-portional hazards models. Of 42,427 patients initiating ART, 310 (0.7%) were young adolescents, 342 (0.8%) were older adolescents, and 1599 (3.8%) were young adults. Adolescents were similar to adults in terms of proportion male, baseline CD4 count, hemoglobin, and TB. Compared to adults, both older adolescents (6 months RR 1.75 95% CI 1.25–2.47) and young adults (6 months RR 1.33 95% CI 1.10–1.60 and 12 months RR 1.64 95% CI 1.23–2.19) were more likely to have an unsuppressed viral load and were more likely to fail virologically (HR 2.90 95%CI 1.74–4.86; HR 2.94 95% CI 1.63–5.31). Among those that died or were LTFU, the median time from ART initiation until death or LTFU was 4.7 months (IQR 1.5–13.2) and 10.9 months (IQR 5.0–22.7), respectively. There was no difference in risk of mortality by age category, compared to adults. Young adolescents were less likely to be LTFU at any time period after ART initiation (HR 0.43 95% CI 0.26–0.69) whereas older adolescents and young adults were more likely to be LTFU after ART initiation (HR 1.78 95% CI 1.34–2.36; HR 1.63 95% CI 1.41–1.89) compared to adults. HIV-infected adolescents and young adults between 15 and 24 years have poorer ART treatment outcomes in terms of virological response, LTFU, and virological failure than adults receiving ART. Interventions are needed to help improve outcomes and retention in care in this unique population.
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Evans, D., Menezes, C., Mahomed, K., Macdonald, P., Untiedt, S., Levin, L., … Maskew, M. (2013). Treatment Outcomes of HIV-Infected Adolescents Attending Public-Sector HIV Clinics Across Gauteng and Mpumalanga, South Africa. AIDS Research and Human Retroviruses, 29(6), 892–900. http://doi.org/10.1089/aid.2012.0215
Posted: Jan 19, 2017
‘HIV is like a tsotsi. ARVs are your guns’: associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa
Objectives: WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa.
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Design: A cross-sectional study of the largest known community-traced sample of HIV-positive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10–19 years (52% female, 79% perinatally infected) were interviewed.
Methods: In a low-resource health district, all adolescents who had ever initiated ART in a stratiﬁed sample of 39 health facilities were identiﬁed and traced to 150 commu-nities [n ¼ 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative inter-views used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers.
Results: About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40–0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47–3.24). Among perinatally infected adolescents who knew their status (n ¼ 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34–5.22). Qualitative ﬁndings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status.
Conclusion: Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.
Cluver LD, Hodes RJ, Toska E, et al. 'HIV is like a tsotsi. ARVs are your guns': associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa. AIDS (London, England) 2015;29 Suppl 1:S57-65. doi: 10.1097/qad.0000000000000695 [published Online First: 2015/06/08] file:///C:/Users/astretton-downes/Downloads/AIDS%20revised%20paper-Disclosure%20and%20Adherence-final.pdf
Posted: Jan 19, 2017
Focus on adolescents with HIV and AIDS
Adolescents living with HIV, including those infected perinatally and non-perinatally, bear a disproportionate burden of the HIV epidemic in South Africa. This article discusses HIV management in adolescents including the following aspects: (i) burden of HIV disease, modes of HIV acquisition and implications for management; (ii) initiation of combination antiretroviral therapy (ART), outcomes and complications of ART in adolescents, including virological failure and switching regimens; (iii) adherence in adolescence, including factors that may contribute to poor adherence and advice to improve adherence; (iv) issues particular to adolescents, including sexual and reproductive health needs, disclosure to adolescents and by adolescents, and transition to adult care. This article aims to provide insights based on the literature and experience to assist the clinician to navigate the difficulties of managing HIV in adolescence and achieving successful transition to adult care.
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Fairlie L, Sipambo N, Fick C, Moultrie H: Focus on adolescents with HIV and AIDS. South African Medical Journal 2014, 104(12):897.
Posted: Jan 19, 2017
Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART- adherence in South Africa?
Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews ﬁnd no effective adolescent adherence-promoting interventions. Social protection has demonstrated beneﬁts for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10–19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa’s Eastern Cape were traced and interviewed in 2014–2015 (n = 1175 eligible). About 90% of the eligible sample was included (n = 1059). Social protection provisions were “cash/cash in kind”: government cash transfers, food security, school fees/materials, school feeding, clothing; and “care”: HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p = .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1–3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42–.76, p < .001); HIV support group attendance (aOR .60, CI .40–.91, p < .02), and high parental/caregiver supervision (aOR .56, CI .43–.73, p < .001). Combination social protection showed additive beneﬁts. With no social protection, non-adherence was 54%, with any one protection 39–41%, with any two social protections, 27–28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of “cash plus care”, may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents.
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L. D. Cluver, E. Toska, F. M. Orkin, F. Meinck, R. Hodes, A. R. Yakubovich & L. Sherr (2016) Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa?, AIDS Care, 28:sup2, 73-82, DOI: 10.1080/09540121.2016.1179008
Posted: Jan 16, 2017
Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review
Introduction: Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world’s HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour.
Methods: We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included ‘‘adherence,’’ ‘‘compliance,’’ ‘‘antiretroviral use’’ and ‘‘antiretroviral adherence,’’ in combination with ‘‘adolescents,’’ ‘‘youth,’’ ‘‘HIV,’’ ‘‘Africa,’’ ‘‘interventions’’ and the MeSH term ‘‘Africa South of the Sahara.’’ Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed.
Discussion: Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV.
Conclusions: Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.
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Adejumo, O. A., Malee, K. M., Ryscavage, P., Hunter, S. J., & Taiwo, B. O. (2015). Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review. Journal of the International AIDS Society, 18(1), 20049.