Service delivery interventions to improve adolescents' linkage, retention and adherence to antiretroviral therapy and HIV care

Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study

Background

While antiretroviral therapy (ART) availability for HIV patients has increased dramatically in Uganda, patient linkage to and retention in care remains a challenge. We assessed patterns of engagement in care in 20 Ugandan health facilities with low retention based on national reporting.

Methods

We assessed patient linkage to care (defined as registering for pre-ART or ART care at the facility within 1 month of HIV diagnosis) and 6-month retention in care (having a visit 3-6 months after ART initiation) and associations with patient−/facility-level factors using multivariate logistic regression.

Results

Among 928 newly HIV-diagnosed patients, only 53.0% linked to care within 1 month. Of these, 83.7% linked within 1 week. Among 678 newly initiated ART patients, 14.5% never returned for a follow-up visit at the facility. Retention was 71.7% according to our primary definition but much lower if stricter definitions were used. Most patients were already falling behind appointment schedules at their first ART follow-up (median: 28 days post-initiation vs. recommended 14 days). 27.3% of newly-initiated patients had follow-up appointments scheduled 45+ days apart rather than monthly per national guidelines. Linkage and retention were not strongly correlated with each other within facilities (r_s = 0.06; p = 0.82). Females, adolescents, and patients in rural settings tended to have lower linkage and retention in multivariable-adjusted models.

Conclusions

Linkage support may be most critical immediately after testing positive, as patients are less likely to link over time. More information is needed on reasons for appointment schedules by clinicians and implications on retention.

Trial registration

This study was registered in the Pan African Clinical Trial Registry database (#PACTR201611001756166).

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3042-8) contains supplementary material, which is available to authorized users.

Factors impacting antiretroviral therapy adherence among human immunodeficiency virus-positive adolescents in Sub-Saharan Africa: a systematic review

OBJECTIVES

Eighty-two percent of human immunodeficiency virus (HIV)-positive adolescents live in Sub-Saharan Africa (SSA). Despite the availability of antiretroviral therapy (ART), adherence levels are suboptimal, leading to poor outcomes. This systematic review investigated factors impacting ART adherence among adolescents in SSA, including religious beliefs and intimate relationships.

METHODS

A systematic review was conducted between June and August 2016 using eight electronic databases, including Cochrane and PubMed. Published, ongoing and unpublished research, conducted in SSA from 2004 to 2016, was identified and thematic analysis was used to summarise findings.

RESULTS

Eleven studies from eight SSA countries, published in English between 2011 and 2016, reported on factors impacting ART adherence among adolescents living with HIV (ALHIV). Forty-four barriers and 29 facilitators to adherence were identified, representing a complex web of factors. The main barriers were stigma, ART side-effects, lack of assistance and forgetfulness. Facilitators included caregiver support, peer support groups and knowledge of HIV status.

CONCLUSIONS

Stigma reflects difficult relations between ALHIV and their HIV-negative peers and adults. Most interventions target only those with HIV, suggesting a policy shift towards the wider community could be beneficial. Recommendations include engaging religious leaders and schools to change negative societal attitudes. Limitations of the review include the urban settings and recruitment of predominantly vertically infected participants in most included studies. Therefore, the findings cannot be extrapolated to ALHIV residing in rural locations or horizontally infected ALHIV, highlighting the need for further research in those areas.

Greater retention in care among adolescents on antiretroviral treatment accessing "Teen Club" an adolescent-centred differentiated care model compared with standard of care: a nested case-control study at a tertiary referral hospital in Malawi

Introduction

There are numerous barriers to the care and support of adolescents living with HIV (ALHIV) that makes this population particularly vulnerable to attrition from care, poor adherence and virological failure. In 2010, a Teen Club was established in Zomba Central Hospital (ZCH), Malawi, a tertiary referral HIV clinic. Teen Club provides ALHIV on antiretroviral treatment (ART) with dedicated clinic time, sexual and reproductive health education, peer mentorship, ART refill and support for positive living and treatment adherence. The purpose of this study was to evaluate whether attending Teen Club improves retention in ART care.

Methods

We conducted a nested case–control study with stratified selection, using programmatic data from 2004 to 2015. Cases (ALHIV not retained in care) and controls (ALHIV retained in care) were matched by ART initiation age group. Patient records were reviewed retrospectively and subjects were followed starting in March 2010, the month in which Teen Club was opened. Follow‐up ended at the time patients were no longer considered retained in care or on 31 December 2015. Cases and controls were drawn from a study population of 617 ALHIV. Of those, 302 (48.9%) participated in at least two Teen Club sessions. From the study population, 135 (non‐retained) cases and 405 (retained) controls were selected.

Results

In multivariable analyses, Teen Club exposure, age at the time of selection and year of ART initiation were independently associated with attrition. ALHIV with no Teen Club exposure were less likely to be retained than those with Teen Club exposure (adjusted odds ratio (aOR) 0.27; 95% CI 0.16, 0.45) when adjusted for sex, ART initiation age, current age, reason for ART initiation and year of ART initiation. ALHIV in the age group 15 to 19 were more likely to have attrition from care than ALHIV in the age group 10 to 14 years of age (aOR 2.14; 95% CI 1.12, 4.11).

Conclusions

This study contributes to the limited evidence evaluating the effectiveness of service delivery interventions to support ALHIV within healthcare settings. Prospective evaluation of the Teen Club package with higher methodological quality is required for programmes and governments in low‐ and middle‐income settings to prioritize interventions for ALHIV and determine their cost‐effectiveness.

Scaling a waterfall: a meta-ethnography of adolescent progression through the stages of HIV care in sub-Saharan Africa

Introduction: Observational studies have shown considerable attrition among adolescents living with HIV across the “cascade” of HIV care in sub-Saharan Africa, leading to higher mortality rates compared to HIV-infected adults or children. We synthesized evidence from qualitative studies on factors that promote or undermine engagement with HIV services among adolescents living with HIV in sub-Saharan Africa.

Methods: We systematically searched five databases for studies published between 2005 and 2016 that met pre-defined inclusion criteria. We used a meta-ethnographic approach to identify first, second and third order constructs from eligible studies, and applied a socio-ecological framework to situate our results across different levels of influence, and in relation to each stage of the HIV cascade.

Results and discussion: We identified 3089 citations, of which 24 articles were eligible for inclusion. Of these, 17 were from Southern Africa while 11 were from Eastern Africa. 6 explored issues related to HIV testing, 11 explored treatment adherence, and 7 covered multiple stages of the cascade. Twelve third-order constructs emerged to explain adolescents’ engagement in HIV care. Stigma was the most salient factor impeding adolescents’ interactions with HIV care over the past decade. Self-efficacy to adapt to life with HIV and support from family or social networks were critical enablers supporting uptake and retention in HIV care and treatment programmes. Provision of adolescent-friendly services and health systems issues, such as the availability of efficient, confidential and comfortable services, were also reported to drive sustained care engagement. Individual-level factors, including past illness experiences, identifying mechanisms to manage pill-taking in social situations, financial (in)stability and the presence/absence of future aspirations also shaped adolescents HIV care engagement.

Conclusions: Adolescents’ initial and ongoing use of HIV care was frequently undermined by individual-level issues; although family, community and health systems factors played important roles. Interventions should prioritise addressing psychosocial issues among adolescents to promote individual-level engagement with HIV care, and ultimately reduce mortality. Further research should explore issues relating to care linkage and ART initiation in different settings, particularly as “test and treat” policies are scaled up.

Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature

Introduction

Globally, an estimated 30% of new HIV infections occur among adolescents (15–24 years), most of whom reside in sub-Saharan Africa. Moreover, HIV-related mortality increased by 50% between 2005 and 2012 for adolescents 10–19 years while it decreased by 30% for all other age groups. Efforts to achieve and maintain optimal adherence to antiretroviral therapy are essential to ensuring viral suppression, good long-term health outcomes, and survival for young people. Evidence-based strategies to improve adherence among adolescents living with HIV are therefore a critical part of the response to the epidemic.

Methods

We conducted a systematic review of the peer-reviewed and grey literature published between 2010 and 2015 to identify interventions designed to improve antiretroviral adherence among adults and adolescents in low- and middle-income countries. We systematically searched PubMed, Web of Science, Popline, the AIDSFree Resource Library, and the USAID Development Experience Clearinghouse to identify relevant publications and used the NIH NHLBI Quality Assessment Tools to assess the quality and risk of bias of each study.

Results and discussion

We identified 52 peer-reviewed journal articles describing 51 distinct interventions out of a total of 13,429 potentially relevant publications. Forty-three interventions were conducted among adults, six included adults and adolescents, and two were conducted among adolescents only. All studies were conducted in low- and middle-income countries, most of these (n = 32) in sub-Saharan Africa. Individual or group adherence counseling (n = 12), mobile health (mHealth) interventions (n = 13), and community- and home-based care (n = 12) were the most common types of interventions reported. Methodological challenges plagued many studies, limiting the strength of the available evidence. However, task shifting, community-based adherence support, mHealth platforms, and group adherence counseling emerged as strategies used in adult populations that show promise for adaptation and testing among adolescents.

Conclusions

Despite the sizeable body of evidence for adults, few studies were high quality and no single intervention strategy stood out as definitively warranting adaptation for adolescents. Among adolescents, current evidence is both sparse and lacking in its quality. These findings highlight a pressing need to develop and test targeted intervention strategies to improve adherence among this high-priority population.

Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa

Objective

To determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site.

Design

Retrospective cohort analysis.

Setting

Government supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa.

Participants

Two hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015.

Intervention

Attendance in an adolescent-friendly clinic compared to a standard pediatric clinic.

Outcomes measures

Retention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml.

Results

Overall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2–11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3–32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1–5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5–9.7; p = 0.005).

Conclusion

Adolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.

Simulated patient encounters to improve adolescent retention in HIV care in Kenya: study protocol of a stepped-wedge randomized controlled trial

Background

Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10–24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care.

Methods/design

The trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves – time periods when they receive the intervention – with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention.

Discussion

This trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population.

Trial registration

ClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2266-z) contains supplementary material, which is available to authorized users.

Health Technology-Enabled Interventions for Adherence Support and Retention in Care Among US HIV-Infected Adolescents and Young Adults: An Integrative Review

The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13-29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005-March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.

The effect of community-based support for caregivers on the risk of virological failure in children and adolescents with HIV in Harare, Zimbabwe (ZENITH): an open-label, randomised controlled trial

BACKGROUND

Children and adolescents have poorer HIV treatment outcomes than adults. We aimed to assess the effect of community-based support for caregivers of HIV-infected children and adolescents, who are key mediators to children engaging with care, on treatment outcomes.

METHODS

In this open-label, randomised contolled trial, we recruited children aged 6-15 years with newly-diagnosed HIV attending primary health-care clinics in Harare, Zimbabwe. Children were randomly assigned to receive decentralised primary health-care clinic-based HIV care (control group), according to national guidelines for 18 months, or decentralised care plus structured support visits by trained community health workers (intervention group) according to national guidelines for 18 months. Primary outcomes were the proportion of participants who died or had an HIV viral load of 400 copies per mL or higher at 12 months after antiretroviral therapy (ART) initiation (among those who started ART within 6 months of enrolment); and the proportion who missed two or more scheduled clinic visits by 18 months post-enrolment (among all participants). Analyses were complete-case, modified-intention-to-treat. This trial is registered with the Pan African Clinical Trials Registry, number PACTR201212000442288.

FINDINGS

Between January, 2013, and January, 2015, 470 participants tested HIV-positive at seven study primary health-care clinics and were screened for eligibility. Of the 334 eligible children and adolescents, 166 were randomly assigned to the intervention group and 168 to the control group. The median age of participants was 11 years (IQR 8-13) and 178 (53%) were girls. Among the 238 participants who started ART within 6 months of enrolment, the proportion who died or had a viral load of 400 copies/mL or higher at 12 months post-ART initiation was significantly lower in the intervention group than in the control group (31 [33%] of 94 participants vs 42 [49%] of 86 participants, respectively, adjusted odds ratio [aOR] 0·46, 95% CI 0·23-0·89; p=0·02). The proportion of children missing two or more scheduled visits was similar in the intervention group and control group (27 [17%] of 155 vs 30 [18%] of 165, aOR 0·92, 95% CI 0·49-1·74; p=0·79). One participant withdrew from the trial 240 days after enrolment and 12 died during follow-up (five in the intervention group; seven in the control group).

INTERPRETATION

Community-based support for caregivers has high potential for scalability and could have a substantial effect on HIV virological suppression in children and adolescents, a group with disproportionately poor treatment outcomes.

FUNDING

Wellcome Trust.

What is it going to take to move youth-related HIV programme policies into practice in Africa?

Introduction: HIV has been reported to be the leading cause of mortality amongst adolescents in Africa. This has brought attention to the changes in service provision and health management that many adolescents living with HIV experience when transferring from specialized paediatric- or adolescent-focused services to adult care. When transition is enacted poorly, adherence may be affected and the continuum of care disrupted. As the population of HIV-infected adolescents grows, effective and supported transition increases in significance as an operational imperative.

Discussion: Considerable gaps remain in moving policy to practice at global, national, and local levels. Policies that give clear definition to transition and provide standard operating procedures or tools to support this process are lacking. National guidelines tend to neglect transition. Beyond transition itself, there has been slow progress on the inclusion of adolescents in national policies and strategies. Guidance often overlooks the specific needs and rights of adolescents, in particular for those living with HIV. In some cases, prohibitive laws can impede adolescent access by applying age of consent restriction to HIV testing, counselling and treatment, as well as SRH services. Where adolescent-focused policies do exist, they have been slow to emerge as tangible operating procedures at health facility level. A key barrier is the nature of existing transition guidance, which tends to recommend an individualized, client-centred approach, driven by clinicians. In low- and middle-income settings, flexible responses are resource intensive and time consuming, and therefore challenging to implement amidst staff shortages and administrative challenges. First, national governments must adopt transition-specific policies to ensure that adolescents seamlessly receive appropriate and supportive care. Second, transition policies must form part of a broader adolescent-centred policy landscape and adolescent-friendly orientation and approach at health system level. Third, national actors must ensure that transition policies are supported at implementation level. Fourth, youth involvement and community mobilization are essential. Finally, further implementation research is urgently needed to better understand how to support young people and providers in achieving smooth transitions.

Conclusions: Only by moving from policy to practice through supportive policies and their implementation will we be closer to including adolescents in the 2030 goal of ending AIDS.

HIV treatment and care services for adolescents: a situational analysis of 218 facilities in 23 sub-Saharan African countries

Introduction: In 2013, an estimated 2.1 million adolescents (age 10–19 years) were living with HIV globally. The extent to which health facilities provide appropriate treatment and care was unknown. To support understanding of service availability in 2014, Paediatric‐Adolescent Treatment Africa (PATA), a non‐governmental organisation (NGO) supporting a network of health facilities across sub‐Saharan Africa, undertook a facility‐level situational analysis of adolescent HIV treatment and care services in 23 countries.

Methods: Two hundred and eighteen facilities, responsible for an estimated 80,072 HIV‐infected adolescents in care, were surveyed. Sixty per cent of the sample were from PATA's network, with the remaining gathered via local NGO partners and snowball sampling. Data were analysed using descriptive statistics and coding to describe central tendencies and identify themes.

Results: Respondents represented three subregions: West and Central Africa (n = 59; 27%), East Africa (n = 77, 35%) and southern Africa (n = 82, 38%). Half (50%) of the facilities were in urban areas, 17% peri‐urban and 33% rural settings. Insufficient data disaggregation and outcomes monitoring were critical issues. A quarter of facilities did not have a working definition of adolescence. Facilities reported non‐adherence as their key challenge in adolescent service provision, but had insufficient protocols for determining and managing poor adherence and loss to follow‐up. Adherence counselling focused on implications of non‐adherence rather than its drivers. Facilities recommended peer support as an effective adherence and retention intervention, yet not all offered these services. Almost two‐thirds reported attending to adolescents with adults and/or children, and half had no transitioning protocols. Of those with transitioning protocols, 21% moved pregnant adolescents into adult services earlier than their peers. There was limited sexual and reproductive health integration, with 63% of facilities offering these services within their HIV programmes and 46% catering to the special needs of HIV‐infected pregnant adolescents.

Conclusions: Results indicate that providers are challenged by adolescent adherence and reflect an insufficiently targeted approach for adolescents. Guidance on standard definitions for adherence, retention and counselling approaches is needed. Peer support may create an enabling environment and sensitize personnel. Service delivery gaps should be addressed, with standardized transition and quality counselling. Integrated, comprehensive sexual reproductive health services are needed, with support for pregnant adolescents.

Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic

Introduction: With increasing survival of vertically HIV‐infected children and ongoing new horizontal HIV infections, the population of adolescents (age 10–19 years) living with HIV is increasing. This review aims to describe the epidemiology of the adolescent HIV epidemic and the ability of national monitoring systems to measure outcomes in HIV‐infected adolescents through the adolescent transition to adulthood.

Methods: Differences in global trends between younger (age 10–14 years) and older (age 15–19 years) adolescents in key epidemic indicators are interrogated using 2016 UNAIDS estimates. National population‐based survey data in the 15 highest adolescent HIV burden countries are evaluated and examples of national case‐based surveillance systems described. Finally, we consider the potential impact of adolescent‐specific recommendations in the 2016 WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection.

Discussion: UNAIDS estimates indicate the population of adolescents living with HIV is increasing, new HIV infections in older adolescents are declining, and while AIDS‐related deaths are beginning to decline in younger adolescents, they are still increasing in older adolescents. National population‐based surveys provide valuable estimates of HIV prevalence in older adolescents and recent surveys include data on younger adolescents. Only a few countries have nationwide electronic case‐based HIV surveillance, with the ability to provide population‐level data on key HIV outcomes in the diagnosed population living with HIV. However, in the 15 highest adolescent HIV burden countries, there are no systems tracking adolescent transition to adulthood or healthcare transition. The strength of the 2016 WHO adolescent‐specific recommendations on antiretroviral therapy and provision of HIV services to adolescents was hampered by the lack of evidence specific to this age group.

Conclusions: Progress is being made in national surveillance and global monitoring systems to specifically identify trends in adolescents living with HIV. However, HIV programmes responsive to the evolving HIV prevention and treatment needs of adolescents can be facilitated further by: data disaggregation to younger and older adolescents and mode of HIV infection where feasible; implementation of tools to achieve expanded national case‐based surveillance; streamlining consent/assent procedures in younger adolescents and consensus on indicators of adolescent healthcare transition and transition to adulthood.

Improving retention in HIV care among adolescents and adults in low- and middle-income countries: A systematic review of the literature

INTRODUCTION

Adolescents living with HIV are an underserved population, with poor retention in HIV health care services and high mortality, who are in need of targeted effective interventions. We conducted a literature review to identify strategies that could be adapted to meet the needs of adolescents living with HIV.

METHODS

We searched PubMed, Web of Science, Popline, USAID's AIDSFree Resource Library, and the USAID Development Experience Clearinghouse for relevant studies published within a recent five-year period. Studies were included if they described interventions to improve the retention in care of HIV-positive patients who are initiating or already receiving antiretroviral therapy in low- and middle-income countries. To assess the quality of the studies, we used the NIH NHLBI Study Quality Assessment Tools.

RESULTS AND DISCUSSION

Of 13,429 potentially relevant citations, 23 were eligible for inclusion. Most studies took place in sub-Saharan Africa. Only one study evaluated a retention intervention for youth (15-24 years); it found no difference in loss to follow-up between a youth-friendly clinic and a family-oriented clinic. A study of community-based service delivery which was effective for adults found no effect for youths. We found no relevant studies conducted exclusively with adolescent participants (10-19 years). Most studies were conducted with adults only or with populations that included adults and adolescents but did not report separate results for adolescents. Interventions that involved community-based services showed the most robust evidence for improving retention in care. Several studies found statistically significant associations between decentralization, down-referral of stable patients, task-shifting of services, and differentiated care, and retention in care among adults; however, most evidence comes from retrospective, observational studies and none of these approaches were evaluated among adolescents or youth.

CONCLUSIONS

Interventions that target retention in care among adolescents living with HIV are rare in the published literature. We found only two studies conducted with youth and no studies with adolescents. Given the urgent need to increase the retention of adolescents in HIV care, interventions that are effective in increasing adult retention in care should be considered for adaptation and evaluation among adolescents and interventions specifically targeting the needs of adolescents must be developed and tested.

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.

Antiretroviral Therapy Adherence Enhancing Interventions for Adolescents and Young Adults 13-24 Years of Age: A Review of the Evidence Base

INTRODUCTION

Youth living with HIV are highly under-represented in the evidence base for adherence interventions, despite their diverse and unique needs and barriers.

OBJECTIVE

This systematic review aimed to identify antiretroviral therapy (ART) adherence interventions specifically targeting adolescents and young adults (defined as ages 13-24) with the goal of characterizing the evidence base.

METHODS

Articles were identified using the PubMed database and cover work published through September 14, 2015.

INCLUSION CRITERIA

(1) average age 13 to 24, (2) HIV positive, (3) on or beginning ART, (4) intervention targeted ART adherence in full or in part, (5) reported adherence, viral load, and/or CD4 count outcomes. Strength of evidence was defined as level 1 [randomized controlled trial (RCT) with significance testing on outcomes], 2 (within group studies with statistical testing on outcomes), 3 (RCTs with descriptive results), or 4 (within group studies with descriptive results).

RESULTS

Of 151 articles, 10 met inclusion criteria. Published between 2003 and 2014, these studies evaluated diverse intervention approaches. Most were conducted in the US and were small pilots that have yet to be replicated despite promising results. Only 3 studies met criteria for highest level strength of evidence; 2 supported a phone-based counseling approach with adherence monitors and 1 for weekly individual and family counseling.

CONCLUSIONS

Despite nearly 20 years passing since the wide-scale availability of ART, and clear recognition that adolescents and youth adults fair worse on the cascade of HIV care, the evidence base remains sparse and underdeveloped. Promising approaches need replication and more rigorous studies are desperately needed.

Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi

Malawi launched Option B+, a program for all pregnant or breastfeeding HIV-positive women to begin lifelong combination antiretroviral therapy (cART), in July 2011. This study characterises a portion of the continuum of care within an antenatal setting in Lilongwe. Women testing HIV-positive and having a cART initiation record at Bwaila Antenatal Clinic from July 2013 to January 2014 were included. Using logistic regression models, we analysed relationships between maternal characteristics and return for infant testing. Among 490 HIV-positive women with a cART initiation record, 360 (73%) were retained at three months. Of these, 203 (56%) were adherent. Records of infant testing were located for 204 women (42%). Women who were not retained were less likely to have an early infant diagnosis record (aOR = 0.20; 95% CI: 0.10, 0.41). Among the women retained, there was a non-significant association between maternal adherence and infant testing (OR = 1.35; 95% CI: 0.89, 2.06). Women lost at earlier continuum stages, who are at higher risk for mother-to-child-transmission, were less likely to bring infants for testing. Even with a test-and-treat program, many women did not remain in care or bring their infant for testing. Facilitating strategies to improve these measures remains an important unmet need.

Optimizing linkage to care and initiation and retention on treatment of adolescents with newly diagnosed HIV infection

OBJECTIVE

Unsuccessful linkage to care and treatment increases adolescent HIV-related morbidity and mortality. This study evaluated the effect of a novel adolescent and youth Red Carpet Program (RCP) on the timing and outcomes of linkage to care.

DESIGN

A prepost implementation evaluation of the pilot RCP program.

SETTINGS

Healthcare facilities (HCFs) and schools in Homa Bay County, Kenya.

STUDY PARTICIPANTS

HIV-infected adolescents (15-19 years) and youth (20-21 years).

INTERVENTIONS

RCP provided fast-track peer-navigated services, peer counseling, and psychosocial support at HCFs and schools in six Homa Bay subcounties in 2016. RCP training and sensitization was implemented in 50 HCFs and 25 boarding schools.

MAIN OUTCOME MEASURES

New adolescent and youth HIV diagnosis, linkage to and retention in care and treatment.

RESULTS

Within 6 months of program rollout, 559 adolescents and youths (481 women; 78 men) were newly diagnosed with HIV (15-19 years n = 277; 20-21 years, n = 282). The majority (n = 544; 97.3%) were linked to care, compared to 56.5% at preimplementation (P < 0.001). All (100.0%; n = 559) adolescents and youths received peer counseling and psychosocial support, and the majority (n = 430; 79.0%) were initiated on treatment. Compared to preimplementation, the proportion of adolescents and youths who were retained on treatment increased from 66.0 to 90.0% at 3 months (P < 0.001), and from 54.4 to 98.6% at 6 months (P < 0.001).

CONCLUSION

Implementation of RCP was associated with significant improvement in linkage to and early retention in care among adolescent and youth. The ongoing study will fully assess the efficacy of this linkage-to-care approach.

"At our age, we would like to do things the way we want: " a qualitative study of adolescent HIV testing services in Kenya

Supplemental Digital Content is available in the text

Objectives:

Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs.

Design:

We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13–18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya.

Methods:

Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices.

Results:

All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents’ wishes.

Conclusion:

Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining ‘90-90-90’ targets for adolescents.

Adolescents, young people, and the 90-90-90 goals: a call to improve HIV testing and linkage to treatment

The current low rates of HIV diagnosis and treatment initiation among adolescents and young people ages 15–24 continues to present a significant challenge to the epidemic control of HIV. With a ‘business as usual’ approach to HIV testing and linkage to treatment, new infections among adolescents and youth will likely increase, with the burden compounded by the increasing number of youth in Africa, expected to reach 293 million by 2025. Recent studies reveal significant gaps in the HIV clinical cascade among young people as the global community pursues the Joint United Nations Programme on HIV and AIDS 90–90–90 targets. This AIDS supplement was commissioned with the goal of informing program planners, researchers, policymakers, and funding agencies about the development and design of effective adolescent and youth programs, policies, and strategies for improving the first two 90s among adolescents and youth: HIV testing and diagnosis and linkage to care and treatment. Emerging evidence should inform efforts to better target the youth and adolescents who are most at risk, aiming for early diagnosis and treatment initiation for those who are HIV positive, while also ensuring appropriate primary prevention so that those identified as HIV negative remain so.

Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe

Supplemental Digital Content is Available in the Text.

Background:

Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown.

Objective:

To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents.

Methods:

We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models.

Results:

Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively.

Conclusions:

Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.

Antiretroviral Treatment Adherence: Knowledge and Experiences among Adolescents and Young Adults in Soweto, South Africa

Human immunodeficiency virus (HIV) management of adolescents and young adults (AYAs) is particularly pertinent to sub-Saharan Africa, where the pediatric HIV burden is marked. Antiretroviral treatment (ART) adherence is a major challenge for AYAs. This qualitative study explored knowledge and experiences of adherence amongst AYAs attending treatment at the Perinatal HIV Research Unit (PHRU), Soweto, South Africa. Four focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with HIV-infected 15-25-year-old ART recipients. Transcripts were coded thematically. Participants (n = 26) were aged median 18.5 years, 59.1% female and 69.2% virally suppressed <400 cp/ml. Three main themes emerged during FGDs and IDIs: (i) correct knowledge about how to be adherent, benefits, and nonadherence consequences, (ii) social, personal, and medication-related barriers to adherence, and (iii) reminder, concealment, and motivational strategies to optimize adherence. Interventions to improve AYA adherence could focus on practical strategies, including status disclosure and medication concealment.

Keeping kids in care: virological failure in a paediatric antiretroviral clinic and suggestions for improving treatment outcomes

The burden of paediatric HIV in South Africa is extremely high. Antiretrovirals (ARVs) are now widely accessible in the country and the clinical emphasis has shifted from initiation of treatment to retention in care. This study describes the cumulative virological failure rate amongst children on ARVs in a peri-urban clinic, and suggests ways in which clinics and partners could improve treatment outcomes. The study was conducted by the non-profit organisation HOPE Cape Town Association. A retrospective file audit determined the cumulative virological failure rate, that is, the sum of all children with a viral load >1000 copies/ml, children on monotherapy, children who had stopped treatment, children lost to follow-up (LTFU) and children who had died. Interviews were conducted with a purposive sample of 12 staff members and a random sample of 21 caregivers and 4 children attending care. Cumulative virological failure rate was 42%, with most of those children having been LTFU. Both staff and caregivers consistently identified pharmacy queues, ongoing stigma and unpalatable ARVs as barriers to adherence. Staff suggestions included use of adherence aids, and better education and support groups for caregivers. Caregivers also requested support groups, as well as "same day" appointments for caregivers and children, but rejected the idea of home visits. Simple, acceptable and cost-effective strategies exist whereby clinics and their partners could significantly reduce the cumulative virological failure rate in paediatric ARV clinics. These include actively tracing defaulters, improving education, providing support groups, and campaigning for palatable ARV formulations.

Retention in Continuous Care and Sustained Viral Suppression

OBJECTIVES

To examine the relationship between retention in continuous care and sustained viral suppression.

METHODS

The authors retrospectively followed 653 persons who were virally suppressed and seeking care at an infectious disease clinic in Kentucky for an average of 6 years to determine the rates of retention in medical care (≥2 visits separated by ≥3 months within a 12-month period) and sustained viral suppression (<400 copies/mL). A generalized linear mixed model was used to determine an association between retention and suppression over time.

RESULTS

Approximately 61% of the study population were retained in continuous care and 75% had sustained viral suppression for all patient-years. Persons retained in care were 3 times the odds of sustaining viral suppression over time ( P < .001).

CONCLUSION

Retention is essential to achieving and maintaining viral suppression. Strategies should be set in place that emphasize increasing the rates of retention, which in turn may increase the rates of suppression.

The Challenge of and Opportunities for Transitioning and Maintaining a Continuum of Care Among Adolescents and Young Adults Living with HIV in Resource Limited Settings

An unprecedented number of youth living with HIV (YLHIV) are aging into adolescence and young adulthood, increasing concerns about the possibility of these youth being lost in the transition from supported care (sometimes in pediatric settings) to more independent healthcare settings and perhaps furthering the emerging disparities in outcomes (e.g., higher nonadherence to treatment, increased morbidity and mortality). In resource-rich settings where there is likely greater recognition of adolescent cognitive and developmental challenges, transitioning YLHIV to adult healthcare has emerged as a major challenge. In resource limited settings (RLS), where the burden of HIV is significant and healthcare resources often stretched, the challenge to move toward healthcare independence and maintain a fluid continuum of care for YLHIV may be the greatest. We review key issues in transitioning YLHIV in RLS, highlighting steps in the transition process, examining evidence where available, and discussing challenges and opportunities to understanding and optimizing outcomes.

Nephrology consultations incorporated into HIV care - non-compliance is an important issue

Although infrequent, kidney disease is a potentially serious co-morbidity among human immunodeficiency virus (HIV)-infected patients. The spectrum of renal impairment is very wide from clinically insignificant to end stage renal disease and often requires nephrologist's consultation. Therefore, we established combined renal and HIV care in the HIV Out-Patient Clinic in Warsaw. Medical records of patients consulted by nephrologist from March 2014 to March 2015 were included in analyses. Patients changing medication without consulting the physician or persistently not coming for follow-up visits were defined as non-compliant. In statistical analyses, non-parametric tests and logistic regression models were used as appropriate. In total, 100 patients were consulted by a nephrologist during the study period. All patients were white Europeans, 88 (88%) male, 42 (42%) infected through men having sex with men and 16 (16%) through intravenous drug users. Fifteen (15%) patients had hepatitis C virus (HCV) infections and 11 (11%) confirmed with positive HCV RNA. The most common reasons for referral were proteinuria and increased serum creatinine. In 6 out of 31 patients (19.3% of those referred for increased creatinine level) elevated serum creatinine was due to illegal substances or diet supplements use. Fifty-seven (57%) of patients were non-compliant. In univariate logistic regression models, all tested factors were non-significant. In most cases, patients were referred to nephrologist due to possible link between laboratory abnormalities and antiretroviral treatment. In one out of five cases, elevated creatinine level was linked with substance/dietary abuse. Poor compliance is an important problem in integrated nephrological care, however we were not able to identify any factors associated with non-compliance.

Factors associated with long-term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study

INTRODUCTION

As access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004.

METHODS

Using a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10-19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation.

RESULTS

A total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3-6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02-1.86), having a higher CD4 count (250+ cells/mm(3)) at treatment initiation (AHR=0.49, 95% CI 0.34-0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27-4.02) and Masindi (AHR=3.30, 95% CI 1.87-5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08-0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition.

CONCLUSIONS

We found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.

Impact of a youth-friendly HIV clinic: 10 years of adolescent outcomes in Port-au-Prince, Haiti

Introduction

Adolescents account for over 40% of new HIV infections in Haiti. This analysis compares outcomes among HIV-positive adolescents before and after implementation of an adolescent HIV clinic in Port-au-Prince, Haiti.

Methods

We conducted a cohort study using programmatic data among HIV-positive adolescents aged 13 to 19. Data from 41,218 adolescents who were HIV tested from January 2003 to December 2012 were included. Outcomes across the HIV care cascade were assessed before and after implementation of an adolescent clinic (2009), including HIV testing, enrolment in care, assessment for antiretroviral therapy (ART) eligibility, ART initiation and 12-month retention. Pre-ART outcomes were assessed 12 months after HIV testing. Factors associated with pre-ART and ART attrition were identified through multivariable competing risk and Cox proportional hazards regression modelling.

Results

Cumulatively, 1672 (4.1%) adolescents tested HIV positive (80% female, median age 16 years). Retention by cascade step comparing pre- and post-clinic included the following: 86% versus 87% of patients enrolled in care, 61% versus 79% were assessed for ART eligibility, 85% versus 92% initiated ART and 68% versus 66% were retained 12 months after ART initiation. Pre-ART attrition decreased from 61% pre-clinic to 50% post-clinic (p<0.001). Pre-ART attrition was associated with being female (sub-distributional hazard ratio (sHR): 1.59; CI: 1.31–1.93), syphilis diagnosis (sHR: 1.47; CI: 1.16–1.85) and slum residence (sHR: 0.84; CI: 0.72–0.97). ART attrition was associated with syphilis diagnosis (hazard ratio (HR): 2.23; CI: 1.35–3.68) and CD4 <50 cells/µL (HR: 1.88; CI: 1.15–3.06).

Conclusions

Implementation of a youth-friendly adolescent clinic improved retention in HIV care among adolescents, particularly in the assessment of ART eligibility and ART initiation. Additional interventions are needed to improve retention among pre-ART patients and support long-term retention among ART patients.

Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa

HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.

Recent Evidence for Emerging Digital Technologies to Support Global HIV Engagement in Care

Antiretroviral therapy is a powerful tool to reduce morbidity and mortality for the 35 million people living with HIV globally. However, availability of treatment alone is insufficient to meet new UNAIDS 90-90-90 targets calling for rapid scale-up of engagement in HIV care to end the epidemic in 2030. Digital technology interventions (mHealth, eHealth, and telehealth) are emerging as one approach to support lifelong engagement in HIV care. This review synthesizes recent reviews and primary studies published since January 2014 on digital technology interventions for engagement in HIV care after diagnosis. Technologies for health provide emerging and proven solutions to support achievement of the United Nations targets for the generalized HIV-affected population. Much of the existing evidence addresses antiretroviral therapy (ART) adherence; however, studies have begun to investigate programs to support linkage and retention in care as well as interventions to engage key populations facing extensive barriers to care.

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.