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

Experiences of support by unsuppressed adolescents living with HIV and their caregivers in Windhoek, Namibia: a qualitative study

Background

Adolescents living with HIV (ALHIV) lag behind younger children and adults in the achievement of HIV care and treatment targets for HIV epidemic control. Treatment outcomes for adolescents may be influenced by their experiences with the support provided in HIV programs. We report on the experiences of virally unsuppressed adolescents and their caregivers with the current support in primary healthcare settings in Namibia.

Methods

A qualitative descriptive and exploratory study was conducted in 13 public primary healthcare facilities in Windhoek, Namibia. A total of 25 in-depth interviews were conducted with unsuppressed adolescents (n = 14) and their caregivers (n = 11) between August and September 2023. The audio-recorded interviews were transcribed verbatim, and uploaded into ATLAS.ti software, and subjected to thematic content analysis.

Findings

Three main support domains for the unsuppressed adolescents emerged from our analysis, namely: psychosocial, clinical and care, and socioeconomic support. The psychosocial support was delivered through peer support (teen clubs and treatment supporters) and enhanced adherence counselling mostly. The clinical and care support included implementing adolescent-friendly HIV services, differentiated service delivery approaches, and caregivers and healthcare worker care support for improved ART adherence, clinic attendance and continuous engagement in care. Socioeconomic support was provided for nutritional support, transport to access clinics, and school supplies, as well as income-generating projects.

Conclusion

Psychosocial, clinical and care, and socioeconomic support are key elements in addressing the needs of adolescents challenged with achieving viral suppression. Health systems may benefit from whole-of-society and whole-of-government approaches to meet the needs of ALHIV that are beyond the scope of health service delivery such as nutritional, education and socioeconomic influences on both the health and well-being of ALHIV.

Friendship Bench Intervention to Address Depression and Improve HIV Care Engagement Among Adolescents Living with HIV in Malawi: Study Protocol for a Pilot Randomized Controlled Trial

Background

Adolescents in Sub-Saharan Africa are disproportionately affected by the HIV epidemic. Comorbid depression is prevalent among adolescents living with HIV (ALWH) and poses numerous challenges to HIV care engagement and retainment. We present a pilot trial designed to investigate feasibility, fidelity, and acceptability of an a dapted and an e nhanced F riendship B ench intervention (henceforth: AFB and EFB) in reducing depression and improving engagement in HIV care among ALWH in Malawi.

Methods

Design: Participants will be randomized to one of three conditions: the Friendship Bench intervention adapted for ALWH (AFB, n=35), the Friendship Bench intervention enhanced with peer support (EFB, n=35), or standard of care (SOC, n=35). Recruitment is planned for early 2024 in four clinics in Malawi.Participants: Eligibility criteria (1) aged 13-19; (2) diagnosed with HIV (vertically or horizontally); (3) scored ≥ 13 on the self-reported Beck's Depression Inventory (BDI-II); (4) living in the clinic's catchment area with intention to remain for at least 1 year; and (5) willing to provide informed consent.Interventions: AFB includes 6 counseling sessions facilitated by young, trained non-professional counselors. EFB consists of AFB plus integration of peer support group sessions to facilitate engagement in HIV care. SOC for mental health in public facilities in Malawi includes options for basic supportive counseling, medication, referral to mental health clinics or psychiatric units at tertiary care hospitals for more severe cases.Outcomes: The primary outcomes are feasibility, acceptability, and fidelity of the AFB and EFB assessed at 6 months and 12 months and compared across 3 arms. The secondary outcome is to assess preliminary effectiveness of the interventions in reducing depressive symptoms and improving HIV viral suppression at 6 months and 12 months.

Discussion

This pilot study will provide insights into youth-friendly adaptations of the Friendship Bench model for ALWH in Malawi and the value of adding group peer support for HIV care engagement. The information gathered in this study will lead to a R01 application to test our adapted intervention in a large-scale cluster randomized controlled trial to improve depression and engagement in HIV care among ALWH.

Trial registration

ClinicalTrials.gov Identifier NCT06173544.

Re-engagement and retention in HIV care after preventive default tracking in a cohort of HIV-infected patients in rural Malawi: A mixed-methods study

Loss-to-follow-up (LTFU) in the era of test-and-treat remains a universal challenge, especially in rural areas. To mitigate LTFU, the HIV program in Neno District, Malawi, utilizes a preventive default tracking strategy named Tracking for Retention and Client Enrollment (TRACE). We utilized a mixed-methods descriptive study of the TRACE program on patient's re-engagement and retention in care (RiC). In the quantitative arm, we utilized secondary data of HIV-infected patients in the TRACE program from January 2018 to June 2019 and analyzed patients' outcomes at 6-, 12-, and 24-months post-tracking. In the qualitative arm, we analyzed primary data from 25 semi-structured interviews. For the study period, 1028 patients were eligible with median age was 30 years, and 52% were women. We found that after tracking, 982 (96%) of patients with a 6-week missed appointment returned to care. After returning to care, 906 (88%), 864 (84%), and 839 (82%) were retained in care respectively at 6-,12-, and 24-months. In the multivariate analysis, which included all the covariates from the univariate analysis (including gender, BMI, age, and the timing of ART initiation), the results showed that RiC at 6 months was linked to WHO stage IV at the start of treatment (with an adjusted odds ratio (aOR) of 0.18; 95% confidence interval (CI) of 0.06-0.54) and commencing ART after the test-and-treat recommendation (aOR of 0.08; 95% CI: 0.06-0.18). RiC after 12 months was associated with age between 15 and 29 years (aOR = 0.18; 95%CI: 0.03-0.88), WHO stage IV (aOR = 0.12; 95%CI: 0.04-0.16) and initiating ART after test-and-treat recommendations (aOR = 0.08; 95%CI: 0.04-0.16). RiC at 24 months post-tracking was associated with being male (aOR = 0.61; 95%CI: 0.40-0.92) and initiating ART after test-and-treat recommendations (aOR = 0.16; 95%CI:0.10-0.25). The qualitative analysis revealed that clarity of the visit's purpose, TRACE's caring approach changed patient's mindset, enhanced sense of responsibility and motivated patients to resume care. We recommend integrating tracking programs in HIV care as it led to increase patient follow up and patient behavior change.

HIV epidemiology, prevention, treatment, and implementation strategies for public health

The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.

Emotional and behavioural difficulties among children and adolescents attending "ART teen clubs" in Mzuzu City in northern Malawi: a cross-sectional study

BACKGROUND

While triple anti-retroviral therapy (ART) has improved HIV-infected children surviving into adolescence and adulthood, these children remain vulnerable to HIV-related psychological disturbance due to both the direct HIV infection effects on the brain and indirect effects related to coping with a range of medical, psychological and social stresses associated with HIV, which makes it vital to identify their mental health needs. This study assessed the emotional and behavioural challenges of HIV perinatally infected children and adolescents with a completed disclosure process attending "ART teen club" in Malawi.

METHODS

A cross-sectional descriptive study design was conducted to obtain quantitative descriptive descriptions of emotional and behavioural challenges among HIV-infected children and adolescents between 10 and 22 years of age. They were interviewed on their family socio-demographic characteristics, clinical characteristics as well as emotional, conduct, hyperactivity, peer and prosocial problems using the Chichewa version of the Strengths and Difficulties Questionnaire. Data were analyzed using descriptive analysis and logistic regression.

RESULTS

Based on the four-band categorization of the SDQ, higher scores for total difficulties score were observed in 72.9% of the children. According to the subscales of the SDQ, results show that children had higher scores in peer problems (62.8%), emotional (68.2%), conduct (68.6%) and prosocial (57.8%) subscales while lower scores were identified in the hyperactivity (16.6%) subscale. Results show that within each level, males are having lower frequencies as compared to females. Results from multivariate binary logistic regression indicate that those with a single parent or not as well as the WHO HIV clinical stage had an impact on the mental health status of the children. Children who do not have a single parent (AOR 3.404; 95% CI:1.563-7.416, p = 0.002) had 3.404 odds of having abnormal mental health status unlike those children with a single parent and children who were in WHO HIV clinical stage 2 (AOR 2.536; 95% CI:1.005-6.395, p = 0.049) or 3 and 4 (AOR 8.459; 95% CI:1.5.820-10.544, p < 0.001) had more odds of having the mental disorder as compared with those children in WHO HIV clinical stage 1.

CONCLUSION

The findings of this research underscore the multifaceted nature of mental well-being among children and adolescents living with HIV. Elevated scores in total difficulties, emotional, conduct, and peer problems signify areas of concern, while disparities in hyperactivity and prosocial behavior highlight the nuanced nature of their behavioral challenges. Recognizing the inadequacy of a one-size-fits-all approach, the research emphasizes the necessity of a comprehensive strategy, incorporating factors like religious background, family structure, and clinical HIV stage. Furthermore, the role of "ART teen clubs" in this context is pivotal. Beyond addressing identified risk factors, these clubs must actively foster resilience. Creating an inclusive environment, tapping into individual strengths, and nurturing a sense of community are vital components. By adopting such a holistic approach, Teen support clubs can significantly contribute to the overall mental well-being of adolescents living with HIV, enabling them to navigate challenges effectively and thrive amidst their circumstances.

Identifying Adolescents at Highest Risk of ART Non-adherence, Using the World Health Organization-Endorsed HEADSS and HEADSS+ Checklists

Brief tools are necessary to identify adolescents at greatest risk for ART non-adherence. From the WHO's HEADSS/HEADSS+ adolescent wellbeing checklists, we identify constructs strongly associated with non-adherence (validated with viral load). We conducted interviews and collected clinical records from a 3-year cohort of 1046 adolescents living with HIV from 52 South African government facilities. We used least absolute shrinkage and selection operator variable selection approach with a generalized linear mixed model. HEADSS constructs most predictive were: violence exposure (aOR 1.97, CI 1.61; 2.42, p < 0.001), depression (aOR 1.71, CI 1.42; 2.07, p < 0.001) and being sexually active (aOR 1.80, CI 1.41; 2.28, p < 0.001). Risk of non-adherence rose from 20.4% with none, to 55.6% with all three. HEADSS+ constructs were: medication side effects (aOR 2.27, CI 1.82; 2.81, p < 0.001), low social support (aOR 1.97, CI 1.60; 2.43, p < 0.001) and non-disclosure to parents (aOR 2.53, CI 1.91; 3.53, p < 0.001). Risk of non-adherence rose from 21.6% with none, to 71.8% with all three. Screening within established checklists can improve identification of adolescents needing increased support. Adolescent HIV services need to include side-effect management, violence prevention, mental health and sexual and reproductive health.

Ethnographic understandings of sexual and reproductive health and HIV care for adolescents in Blantyre, Malawi

Sexual and reproductive health (SRH) care and support are provided to adolescents living with HIV, with the aim to build safer sex negotiation skills, sexual readiness and reproductive preparedness while reducing unintended pregnancies and sexually transmitted infections. We consider how different settings might either constrain or facilitate access to resources and support. Ethnographic research was conducted in Malawi in teen club clinic sessions at an enhanced antiretroviral clinic from November 2018 to June 2019. Twenty-one individual and five group interviews were conducted with young people, caregivers, and healthcare workers, and were digitally recorded, transcribed, and translated into English for thematic analysis. Drawing on socio-ecological and resilience theories, we considered the different ways in which homes, schools, teen club clinics, and community settings all functioned as interactional, relational, and transformational spaces to allow young people to talk about and receive information on sexuality and health. Young people perceived that comprehensive SRH support enhanced their knowledge, sexual readiness, and reproductive preparedness. However, their desire to reproduce at an early age complicated their adoption of safer sex negotiation skills and SRH care. Engaging and talking about SRH and related issues varied according to physical and social space, suggesting the value of multiple locations for support and resources for young people with HIV.

Comprehensive sexuality education for out-of-school young people living with HIV and young people with disabilities: findings from a formative research study in Malawi

This formative study was undertaken between June 2020 and April 2021 to provide evidence to inform the design and delivery of comprehensive sexuality education (CSE) in Malawi for young people living with HIV (YPLHIV) and young people with disabilities (YPWD). The study included a desk review of the situation of these two groups and a mapping of CSE programmes and delivery approaches in Malawi. The study findings show that YPWD and YPLHIV in Malawi are marginalised groups, face stigma and discrimination, and are more vulnerable to abuse, warranting CSE that addresses their needs. Yet, they are often left out of sexuality education such as school-based programmes (due to early school drop-outs) and out-of-school programmes, as well as traditional modes. Furthermore, in instances where they have access to sexuality education, there is little evidence to suggest that the sexuality education that they receive is designed to address their needs, thus raising questions about its relevance. There is need for tailored CSE that addresses the needs of these groups and that is delivered using an approach that is easily accessible to them.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

Navigating antiretroviral adherence in boarding secondary schools in Nairobi, Kenya: A qualitative study of adolescents living with HIV, their caregivers and school nurses

In Kenya, adolescents spend much of their formative years in boarding secondary schools, which presents a challenging environment for antiretroviral (ART) adherence support among adolescents living with HIV (ALHIV). We examined the experiences of ALHIV, caregivers of adolescents, and school nurses regarding navigating ART adherence in boarding secondary schools. Between July and November 2022, we conducted focus group discussions (FGDs) among ALHIV attending boarding schools in Nairobi, Kenya, and caregivers of ALHIV, and in-depth interviews (IDIs) with school nurses. Clinic records were used to identify ALHIV and caregivers, who were invited to participate based on their availability. We categorized boarding schools into national, county, and sub-county levels and selected two schools from each category. We obtained permission from head teachers and invited school nurses to take part in virtual IDIs. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. We conducted two FGDs with 11 caregivers, two FGDs with 18 adolescents, and 7 IDIs with school nurses. Most of the ALHIV reported having disclosed their HIV status to a school nurse or teacher during admission. School nurse friendliness, being understanding, fair, and confidential were qualities associated with ALHIV willingness to confide in them. Strategies ALHIV used to adhere to medication included: waiting until students were engaged in other activities, waking up early, stepping away from others, and stating their drugs were for different ailments. Caregivers were nervous about school-based adherence counseling, fearing it could lead to inadvertent disclosure of adolescents' HIV status and stigmatization by fellow students. All school nurses reported lacking appropriate training in HIV adherence counseling for adolescents. ALHIV have devised innovative strategies to navigate pill-taking and enlist quiet support while operating in stigmatized school environments. Establishment of a strong school nurse-adolescent rapport and building nurses' skills are key to improving school-based support for ALHIV.

A comparison of clinical outcomes among people living with HIV of different age groups attending queen Elizabeth central hospital outpatient ART Clinic in Malawi

Introduction

Adherence to Antiretroviral Treatment (ART) in children and adolescents living with HIV in low-resource settings is not extensively studied in large cohort studies including both adults and pediatric patients. We compared rates of virological suppression, adherence and defaulting among children, adolescents and adults attending a family ART clinic at Queen Elizabeth Central Hospital; a tertiary hospital situated in the southern region of Malawi.

Methods

The study was longitudinal and made use of routinely collected data for all 27,229 clinic attendees. Clinical information obtained at routine clinical visits entered electronically since 2008 was extracted in February 2017. This data was used to ascertain differences across the different age groups. Logistic regression and Cox regression models were fitted to compare rates of Virological Suppression (VS), adherence, and defaulting, respectively.

Results

Younger and older adolescents (ages 10-14 years and 15-19 years respectively) were less likely to achieve VS compared to adults in the final model AOR 0.4 (0.2-0.9, 95% CI) and AOR 0.2 (0.1-0.4, 95% CI) respectively. Young children (ages 0-4 years), older children (ages 5-9 years) and younger adolescents were less adherent to ART compared to adults AOR 0.1 (0.1-0.2, 95% CI), AOR 0.2 (0.1-0.3, 95% CI), and AOR 0.4 (0.3-0.5, 95% CI) respectively. Young adults and younger children had an increased likelihood of defaulting compared to adults.

Conclusion

Poor performance on ART of children and adolescents highlights unaddressed challenges to adherence. Ongoing research to explore these potential barriers and possible interventions needs to be carried out. The adherence assessment methods used and strategies for improving it among children and adolescents need to be revised at the clinic.

Youth perspectives of working with near peer youth lay counsellors: The Safe Haven Pilot

Youth living with HIV (YLWH) have higher rates of common mental disorders (CMDs) when compared with HIV-negative youth. We adapted the Friendship Bench to create a problem solving-based counselling intervention in Botswana delivered by near peer youth lay counsellors for YLWH called Safe Haven. In August 2020, and from June to August 2021, we conducted 22 semistructured interviews with youth aged 13-25 years with mild-to-moderate symptoms of CMDs. Two independent coders carried out an inductive thematic analysis of the transcribed interviews with discrepancies discussed to consensus. Safe Haven was seen as largely acceptable among the youth. Youth felt Safe Haven was a place where they had freedom of expression and could receive practical advice from well-trained and approachable counsellors. Trained youth lay peer counsellors show promise to meet the mental health needs of mild and moderately symptomatic youth, where mental health professionals are in short supply.

Improving Outcomes for Adolescents and Young Adults Living With HIV

Adolescents and young adults living with HIV (AYLHIV), ages 10-24, experience inferior outcomes across the HIV care continuum compared to adults. Inferior outcomes are caused by clinical systems that are not tailored to AYLHIV, structural barriers that prevent equitable care, and lack of engagement of AYLHIV by care teams. This position paper outlines three recommendations to bridge these gaps in care outcomes. The first advocates for offering differentiated and integrated health services. The second addresses structural changes that can improve outcomes for AYLHIV. The third calls for actively including input from AYLHIV about the care designed for them.

A multilevel health system intervention for virological suppression in adolescents and young adults living with HIV in rural Kenya and Uganda (SEARCH-Youth): a cluster randomised trial

BACKGROUND

Social and cognitive developmental events can disrupt care and medication adherence among adolescents and young adults living with HIV in sub-Saharan Africa. We hypothesised that a dynamic multilevel health system intervention helping adolescents and young adults and their providers navigate life-stage related events would increase virological suppression compared with standard care.

METHODS

We did a cluster randomised, open-label trial of young individuals aged 15-24 years with HIV and receiving care in eligible clinics (operated by the government and with ≥25 young people receiving care) in rural Kenya and Uganda. After clinic randomisation stratified by region, patient population, and previous participation in the SEARCH trial, participants in intervention clinics received life-stage-based assessment at routine visits, flexible clinic access, and rapid viral load feedback. Providers had a secure mobile platform for interprovider consultation. The control clinics followed standard practice. The primary, prespecified endpoint was virological suppression (HIV RNA <400 copies per mL) at 2 years of follow-up among participants who enrolled before Dec 1, 2019, and received care at the study clinics. This trial is registered with ClinicalTrials.gov, NCT03848728, and is closed to recruitment.

FINDINGS

28 clinics were enrolled and randomly assigned (14 control, 14 intervention) in January, 2019. Between March 14, 2019, and Nov 26, 2020, we recruited 1988 participants at the clinics, of whom 1549 were included in the analysis (785 at intervention clinics and 764 at control clinics). The median participant age was 21 years (IQR 19-23) and 1248 (80·6%) of 1549 participants were female. The mean proportion of participants with virological suppression at 2 years was 88% (95% CI 85-92) for participants in intervention clinics and 80% (77-84) for participants in control clinics, equivalent to a 10% beneficial effect of the intervention (risk ratio [RR] 1·10, 95% CI 1·03-1·16; p=0·0019). The intervention resulted in increased virological suppression within all subgroups of sex, age, and care status at baseline, with greatest improvement among those re-engaging in care (RR 1·60, 95% CI 1·00-2·55; p=0·025).

INTERPRETATION

Routine and systematic life-stage-based assessment, prompt adherence support with rapid viral load testing, and patient-centred, flexible clinic access could help bring adolescents and young adults living with HIV closer towards a goal of universal virological suppression.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development, US National Institutes of Health.

Depression-Mediating Pathways From Household Adversity to Antiretroviral Therapy Nonadherence Among Children and Adolescents Living With HIV in Zambia: A Structural Equation Modeling Approach

BACKGROUND

In Zambia, half of children and adolescents living with HIV (CALWH) on antiretroviral therapy (ART) are virologically unsuppressed. Depressive symptoms are associated with ART nonadherence but have received insufficient attention as mediating factors in the relationship between HIV self-management and household-level adversities. We aimed to quantify theorized pathways from indicators of household adversity to ART adherence, partially mediated by depressive symptoms, among CALWH in 2 Zambian provinces.

SETTING

In July-September 2017, we enrolled 544 CALWH aged 5-17 years and their adult caregivers into a year-long prospective cohort study.

METHODS

At baseline, CALWH-caregiver dyads completed an interviewer-administered questionnaire, which included validated measures of recent (past 6 months) depressive symptomatology and self-reported past-month ART adherence (never versus sometimes or often missing medication doses). We used structural equation modeling with theta parameterization to identify statistically significant ( P < 0.05) pathways from household adversities (past-month food insecurity and caregiver self-reported health) to depression (modeled latently), ART adherence, and poor physical health in the past 2 weeks.

RESULTS

Most CALWH (mean age: 11 years, 59% female) exhibited depressive symptomatology (81%). In our structural equation model, food insecurity significantly predicted elevated depressive symptomatology ( ß = 0.128), which was associated inversely with daily ART adherence ( ß = -0.249) and positively with poor physical health ( ß = 0.359). Neither food insecurity nor poor caregiver health was directly associated with ART nonadherence or poor physical health.

CONCLUSIONS

Using structural equation modeling, we found that depressive symptomatology fully mediated the relationship between food insecurity, ART nonadherence, and poor health among CALWH.

Improving retention and HIV viral load suppression among adolescents living with HIV in TASO Soroti and TASO Mbale centers of excellence using Operation Triple Zero model: a before and after study protocol

BACKGROUND

Retention in care and HIV viral load suppression remains sub-optimal among HIV positive adolescents in many settings including TASO Uganda, despite the implementation of interventions such as regimen optimization and community-based approaches like multi-month drug dispensing. To this end, the implementation of additional intervention is urgently required to address gaps in current programming which include inadequate centralization of the HIV positive adolescents and their caregivers in the designs. This study, thus, proposes to adapt and implement the Operation Triple Zero (OTZ) model in TASO Soroti and Mbale centers to improve both retention and viral load suppression among the adolescents living with HIV.

METHODOLOGY

A before and after study design is preferred, employing both qualitative and quantitative approaches. To identify barriers and facilitators to retention and HIV viral load suppression among the HIV positive adolescents, secondary data, focused group discussions, and key informant interviews will be used to understand perspectives of the adolescents, their caregivers, and the health-workers. The Consolidated Framework for Implementation Research (CFIR) will help in designing the intervention, while Knowledge to Action (K2A) will support the adaptation process. To test the intervention, Reach, Effectiveness, Adaption, Implementation and Maintenance (RE-AIM) framework will be used. A paired t-test will be used to compare means of retention and viral load suppression in the before and after study periods.

DISCUSSION

This study aims at adapting and implementing the OTZ model in TASO Soroti and Mbale Centers of Excellence (COEs) to attain optimal retention and HIV viral load suppression rates among the HIV positive adolescents in care. Uganda is yet to adapt the touted OTZ model and findings from this study will be important in providing the necessary lessons to inform a policy shift for potential scale up of the model. Furthermore, results of this study could provide additional evidence for the effectiveness of OTZ in attaining optimal HIV treatment outcomes among the adolescents living with HIV.

Delivery of Community-based Antiretroviral Therapy to Maintain Viral Suppression and Retention in Care in South Africa

BACKGROUND

To determine whether the Centralized Chronic Medication Dispensing and Distribution (CCMDD) program in South Africa's differentiated ART delivery model affects clinical outcomes, we assessed viral load (VL) suppression and retention in care between patients participating in the program and those receiving the clinic-based standard of care.

METHODS

Clinically stable people living with HIV (PLHIV) eligible for differentiated care were referred to the national CCMDD program and followed up for up to 6 months. In this secondary analysis of trial cohort data, we estimated the association between routine patient participation in the CCMDD program and their clinical outcomes of viral suppression (<200 copies/mL) and retention in care.

RESULTS

Among 390 PLHIV, 236 (61%) were assessed for CCMDD eligibility; 144 (37%) were eligible, and 116 (30%) participated in the CCMDD program. Participants obtained their ART in a timely manner at 93% (265/286) of CCMDD visits. VL suppression and retention in care was very similar among CCMDD-eligible patients who participated in the program compared with patients who did not participate in the program (aRR: 1.03; 95% CI: 0.94-1.12). VL suppression alone (aRR: 1.02; 95% CI: 0.97-1.08) and retention in care alone (aRR: 1.03; 95% CI: 0.95-1.12) were also similar between CCMDD-eligible PLHIV who participated in the program and those who did not.

CONCLUSION

The CCMDD program successfully facilitated differentiated care among clinically stable participants. PLHIV participating in the CCMDD program maintained a high proportion of viral suppression and retention in care, indicating that community-based ART delivery model did not negatively affect their HIV care outcomes.

The Status of Adolescent Testing and Treatment in PEPFAR-Supported Programs, October 2017 to September 2020

BACKGROUND

Adolescents have poorer outcomes across the HIV cascade compared with adults. We aimed to assess progress in HIV case finding, antiretroviral treatment (ART), viral load coverage (VLC), and viral load suppression (VLS) among adolescents enrolled in the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported programs over a 3-year period that included the beginning of the COVID-19 pandemic.

METHODS

We analyzed PEPFAR program data in 28 countries/regions for adolescents aged 10-19 years between year 1 (October 2017to September 2018), year 2 (October 2018 to September 2019), and year 3 (October 2019 to September 2020). We calculated the number and percent change for HIV tests, HIV-positive tests, and total number on ART. Calculated indicators included positivity, percent of positives newly initiated on ART (ART linkage), VLC (percent of ART patients on ART for ≥6 months with a documented viral load result within the past 12 months), and VLS (percent of viral load tests with <1000 copies/mL).

RESULTS

Between years 1 and 3, the number of HIV tests conducted decreased by 44.2%, with a 29.1% decrease in the number of positive tests. Positivity increased from 1.3%-1.6%. The number of adolescents receiving ART increased by 10.4%. In addition, ART linkage increased (77.8%-86.7%) as did VLC (69.4%-79.4%) and VLS (72.8%-81.5%).

CONCLUSIONS

Our findings demonstrate PEPFAR's success in increasing the adolescent treatment cohort. We identified ongoing gaps in adolescent case finding, linkage, VLC, and VLS that could be addressed with a strategic mix of testing strategies, optimal ART regimens, and adolescent-focused service delivery models.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

"Whenever you need support, you first turn to the group": motivations and functions of WhatsApp groups for youth living with HIV

Social support is a critical component of achieving positive health outcomes for youth living with HIV (YLWH). Mobile health (mHealth) has significant potential for providing social support to YLWH. However, little is known about the domains of social support most needed by YLWH which mHealth interventions might address. Drawing on the spontaneous creation of WhatsApp support groups by YLWH in Nairobi, Kenya, we characterized Kenyan YLWH's social support needs and potential roles of social media groups in meeting them. We conducted interviews and focus-groups with 68 YLWH, 24 caregivers and 20 healthcare workers, and observed two YLWH-led WhatsApp groups for 6 weeks. Youth reported that existing support systems, including family and healthcare workers, already provided informational and instrumental support. However, they emphasized unmet companionship and emotional support needs, leading to isolation, hopelessness, and medication adherence challenges. Participants identified connection with other YLWH as a unique source of emotional and companionship support that allowed them to feel more secure and less isolated. Interviews and observed WhatsApp chats demonstrated that WhatsApp groups were a desirable medium for companionship support that overcame barriers to in-person connection.

Mobility and HIV care engagement: a research agenda

INTRODUCTION

Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research.

DISCUSSION

Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations.

CONCLUSIONS

Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.

Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania

HIV treatment outcomes may be improved by ameliorating psychosocial challenges adolescents living with HIV (ALHIV) face. This analysis describes participation in existing facility-based adolescent clubs and the associations between club attendance, adolescent well-being and HIV treatment outcomes. Data were collected through interviews with a sub-sample of adolescents age 10-19 years and medical record abstraction of all adolescents attending HIV services at seven clinics in Tanzania. Independent variables included adolescent club attendance, self-esteem, self-efficacy, mental distress, social capital and other health utilization or HIV experience characteristics. Study outcomes included visit adherence, viral suppression (<1000 cp/ml), and retention. Of 645 adolescents attending HIV services, 75% attended clubs at least once with a median of eight club sessions attended over a two-year period. Mental distress was prevalent, with 67% of the adolescents scoring above a recognized cut-off of ≥5. Adolescents who attended 10 or more clubs, compared to those not attending any clubs over a two-year period were at an almost three-fold increased odds of having good visit adherence (odds ratio [OR] 2.72, 95% confidence interval [CI]: 1.25, 5.94). Club attendance was also associated with sustained retention in the following year: adolescents who attended some clubs (1-9) had three-times the odds of being retained (OR 3.01; 95%CI: 1.86, 4.87) while those who attended 10+ had over seven-times the odds (OR 7.29; 95%CI: 4.34, 12.22). Among the 154 adolescents who were interviewed, being in the top self-efficacy tertile was positively associated with viral suppression (OR 3.04, 95%CI: 1.08, 8.60) and retention (OR 4.44, 95%CI: 1.19, 17.40). Attending the HIV clinic with a guardian/treatment supporter (OR 3.29, 95%CI: 1.17, 9.22) was also associated with viral suppression. Self-efficacy, social capital and treatment support are associated with better health outcomes among adolescents. However, many ALHIV either never attended or did not regularly attend clubs.

Systematic review of interventions aimed at improving HIV adherence to care in low- and middle-income countries in Sub-Saharan Africa

Long-term adherence to antiretroviral medication continues to present as a challenge along the continuum of the HIV care cascade. HIV interventions and support programs are significantly threatened in resource-limited settings by challenges in maintaining long-term follow-up for ART adherence. We sought to complete a systematic review to comprehensively examine ART adherence and retention in care interventions in Sub-Saharan Africa and to report on the implementation of interventions in real-world settings to inform future health investments in HIV care. Interventions were grouped according to their impact on individual, community, and health-systems levels. While a vast majority of studies evaluated a combination of interventions, those studies that incorporated the community as a resource were most successful. In addition, providing education and behavior reminders proved effective and should be accompanied by community and peer efforts for best results. Multi-level interventions, such as combining individual and community-level interventions showed promising results for long term ART adherence.

The proportion of loss to follow-up from antiretroviral therapy (ART) and its association with age among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta-analysis

Background

Human immunodeficiency virus (HIV) remains a global health threat, especially in developing countries. The successful scale-up of antiretroviral therapy (ART) programs to address this threat is hindered by a high proportion of patient loss to follow-up (LTFU). LTFU is associated with poor viral suppression and increased mortality. It is particularly acute among adolescents, who face unique adherence challenges. Although LTFU is a critical obstacle on the continuum of care for adolescents, few regional-level studies report the proportion of LTFU among adolescents receiving ART. Therefore, a systematic review and meta-analysis were conducted to estimate the pooled LTFU in ART programs among adolescents living with HIV in sub-Saharan Africa (SSA).

Methods

We searched five databases (PubMed, Embase (Elsevier), PsycINFO, CINAHL, and Scopus) for articles published between 2005 and 2020 and reference lists of included articles. The PRISMA guidelines for systematic reviews were followed. A standardised checklist to extract data was used. Descriptive summaries were presented using narrative tables and figures. Heterogeneity within the included studies was examined using the Cochrane Q test statistics and I² test. Random effect models were used to estimate the pooled prevalence of LTFU among ALHIV. We used Stata version 16 statistical software for our analysis.

Results

Twenty-nine eligible studies (n = 285,564) were included. An estimated 15.07% (95% CI: 11.07, 19.07) of ALHIV were LTFU. Older adolescents (15–19 years old) were 43% (AOR = 0.57, 95% CI: 0.37, 0.87) more likely to be LTFU than younger (10–14 years old) adolescents. We find an insignificant relationship between gender and LTFU (AOR = 0.95, 95% CI: 0.87, 1.03). A subgroup analysis found that regional differences in the proportion of adolescent LTFU were not statistically significant. The trend analysis indicates an increasing proportion of adolescent LTFU over time.

Conclusions and recommendations

The proportion of LTFU among HIV-positive adolescents in SSA seems higher than those reported in other regions. Older adolescents in the region are at an increased risk for LTFU than younger adolescents. These findings may help policymakers develop appropriate strategies to retain ALHIV in ART services. Such strategies could include community ART distribution points, appointment spacing, adherence clubs, continuous free access to ART, and community-based adherence support.

Predictors of loss to follow up from antiretroviral therapy among adolescents with HIV/AIDS in Tanzania

Access to Antiretroviral Therapy (ART) is threatened by the increased rate of loss to follow-up (LTFU) among adolescents on ART care. We investigated the rate of LTFU from HIV care and associated predictors among adolescents living with HIV/AIDS in Tanzania. A retrospective cohort analysis of adolescents on ART from January 2014 to December 2016 was performed. Kaplan-Meier method was used to determine failure probabilities and the Cox proportion hazard regression model was used to determine predictors of loss to follow up. A total of 25,484 adolescents were on ART between 2014 and 2016, of whom 78.4% were female and 42% of adolescents were lost to follow-up. Predictors associated with LTFU included; adolescents aged 15–19 years (adjusted hazard ratio (aHR): 1.57; 95% Confidence Interval (CI); 1.47–1.69), having HIV/TB co-infection (aHR: 1.58; 95% CI, 1.32–1.89), attending care at dispensaries (aHR: 1.12; 95% CI, 1.07–1.18) or health center (aHR: 1.10; 95% CI, 1.04–1.15), and being malnourished (aHR: 2.27; 95% CI,1.56–3.23). Moreover, residing in the Lake Zone and having advanced HIV disease were associated with LTFU. These findings highlight the high rate of LTFU and the need for intervention targeting older adolescents with advanced diseases and strengthening primary public facilities to achieve the 2030 goal of ending HIV as a public health threat.

Qualitative inquiry into adolescents' experience of ethical challenges during enrollment and adherence to antiretroviral therapy (ART) in Temeke Regional Referral Hospital, Tanzania

Background

Adolescents living with human immunodeficiency virus (HIV) experience challenges, including lack of involvement in their care as well nondisclosure of HIV status, which leads to poor adherence to antiretroviral therapy (ART). Parents have authority over their children, but during adolescence there is an increasing desire for independence. The aim of the study was to explore adolescents’ experience of challenges identified by adolescents ages 10–19 years attending HIV care and treatment at Temeke Regional Referral Hospital in Tanzania.

Methods

An exploratory descriptive qualitative design was employed in the HIV Care and Treatment Centre (CTC) in the Out-Patient Department at the Temeke Regional Referral Hospital in Tanzania with adolescents living with HIV who were 10–19 years of age. A total of 22 adolescents participated in semi-structured face-to-face interviews after parental consent and adolescent assent were obtained. Participants were interviewed about their participation in decisions to be tested for HIV and enrolled in the CTC, concerns surrounding disclosure of their HIV status to the adolescent or to others, stigma and discrimination, and the effect of these challenges on their adherence to medication. All interviews were audio-taped, transcribed verbatim in Swahili, and back-translated to English. Data analysis included both inductive and deductive thematic analysis.

Results

Qualitative themes identified included lack of participation in decisions about HIV testing, challenges to enrollment in care and treatment; issues around disclosure of HIV status, such as delays in disclosure to the adolescent and disclosure to other persons and benefits and harms of such disclosures; and factors supporting and interfering with adherence to ART, such as parental support, organizational (clinic) support and problems, and self-stigmatization and shame.

Conclusion

Lack of adolescents’ involvement in their care decision making and delayed disclosure of HIV status to the adolescent were identified concerns, leading to poor adherence to ART among adolescents. Disclosure to others, especially teachers, helped adolescents at school to take their medication properly. Disclosure to others led to stigma and discrimination for some adolescents. More research is needed to better understand the role of disclosure and its benefits and challenges for HIV-positive adolescents in Tanzania.

Evaluations of training and education interventions for improved infectious disease management in low-income and middle-income countries: a systematic literature review

OBJECTIVES

To identify most vital input and outcome parameters required for evaluations of training and education interventions aimed at addressing infectious diseases in low-income and middle-income countries.

DESIGN

Systematic review.

DATA SOURCES

PubMed/Medline, Web of Science and Scopus were searched for eligible studies between January 2000 and November 2021.

STUDY SELECTION

Health economic and health-outcome studies on infectious diseases covering an education or training intervention in low-income and middle-income countries were included.

RESULTS

A total of 59 eligible studies covering training or education interventions for infectious diseases were found; infectious diseases were categorised as acute febrile infections (AFI), non-AFI and other non-acute infections. With regard to input parameters, the costs (direct and indirect) were most often reported. As outcome parameters, five categories were most often reported including final health outcomes, intermediate health outcomes, cost outcomes, prescription outcomes and health economic outcomes. Studies showed a wide range of per category variables included and a general lack of uniformity across studies.

CONCLUSIONS

Further standardisation is needed on the relevant input and outcome parameters in this field. A more standardised approach would improve generalisability and comparability of results and allow policy-makers to make better informed decisions on the most effective and cost-effective interventions.

Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment

In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.

Factors associated with antiretroviral therapy adherence among adolescents living with HIV in the era of isoniazid preventive therapy as part of HIV care

High levels of adherence to antiretroviral therapy (ART) are essential to promoting viral suppression and consequential good treatment outcomes. Adolescents living with HIV (ALHIV) in sub-Saharan Africa are less adherent to ART compared to adults, leading to lower rates of viral suppression and immunological recovery. We conducted a mixed-method study utilizing a convergent parallel approach to explore factors associated with ART adherence among ALHIV in the era of isoniazid preventive therapy (IPT) as part of HIV care. The quantitative data were collected from patient records from the period between 1 February 2017 and 31 January 2018 (6 months before and after IPT introduction), while qualitative data was collected from purposively selected patients and healthcare workers by in-depth interviews through a pretested interview guide. A total of 385 patient records (age 10-19 years) were analyzed in the two time periods, while 16 ALHIV (age 10-19 years) and three healthcare workers directly involved in adolescent care were interviewed. Quantitative data utilized logistic regression to measure the strength of association between IPT addition and ART adherence, whereas, qualitative data were analyzed using a thematic analysis approach. The mean age of participants in the quantitative section was 14.3 years (SD 2.7) and 178 were females, while the median age for adolescents interviewed was 14 (IQR 12-17) and 8 were females. Overall, we found an interaction of factors that influenced ART adherence. Added pill burden, on its own, did not affect ART adherence. Commonly reported factors that led to poor adherence were lack of status disclosure within the family, school pressure, and inadequate support from guardians and parents. According to retrospective patient records, complex ART regimens also worsened adherence (p = 0.0462). ART regimen was independently associated with adherence (OR 2.11 95% CI 0.97-4.53). Being on ART for a longer duration, enrolment into teen clubs, clinical psychosocial support, and self-reinforcement techniques were suggested to improve ART adherence. The interplay of multiple factors leads to poor rates of adherence. The introduction of IPT to ART packages may not independently affect ART adherence. Readily available psychosocial services and the presence of peer and guardian support is critical to optimal ART adherence. There is a need for ART centers that provide HIV care to adolescents to consider integrating psychosocial and other youth-friendly services into day-to-day clinic operations.

Attrition from HIV care among youth initiating ART in youth-only clinics compared with general primary healthcare clinics in Khayelitsha, South Africa: a matched propensity score analysis

INTRODUCTION

Youth living with HIV (YLWH) are less likely to initiate antiretroviral therapy (ART) and remain in care than older adults. It is important to identify effective strategies to address the needs of this growing population and prevent attrition from HIV care. Since 2008, two clinics have offered youth-targeted services exclusively to youth aged 12-25 in Khayelitsha, a high HIV-prevalence, low-income area in South Africa. We compared ART attrition among youth in these two clinics to youth in regular clinics in the same area.

METHODS

We conducted a propensity score matched cohort study of individuals aged 12-25 years initiating ART at eight primary care clinics in Khayelitsha between 1 January 2008 and 1 April 2018. We compared attrition, defined as death or loss to follow-up, between those attending two youth clinics and those attending general primary healthcare clinics, using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer or dataset closure. We conducted sub-analyses of patients attending adherence clubs.

RESULTS

The distribution of age, sex and CD4 count at ART initiation was similar across Youth Clinic A (N = 1383), Youth Clinic B (N = 1299) and general clinics (N = 3056). Youth at youth clinics were more likely than those at general clinics to have initiated ART before August 2011 (Youth Clinic A: 16%, Youth Clinic B: 23% and general clinics: 11%). Youth clinics were protective against attrition: HR 0.81 (95% CI: 0.71-0.92) for Youth Clinic A and 0.85 (0.74-0.98) for Youth Clinic B, compared to general clinics. Youth Clinic A club patients had lower attrition after joining an adherence club than general clinic patients in adherence clubs (crude HR: 0.56, 95% CI: 0.32-0.96; adjusted HR: 0.48, 95% CI: 0.28-0.85), while Youth Clinic B showed no effect (crude HR: 0.83, 95% CI: 0.48-1.45; adjusted HR: 1.07, 95% CI: 0.60-1.90).

CONCLUSIONS

YLWH were more likely to be retained in ART care in two different youth-targeted clinics compared to general clinics in the same area. Our findings suggest that multiple approaches to making clinics more youth-friendly can contribute to improving retention in this important group.

The Silent Pandemic: the Impact of COVID-19 on the Mental Health of Adolescents Living with HIV

Purpose of Review

The pandemic caused by the coronavirus disease (COVID-19) has resulted in millions of confirmed cases and likely more than six million deaths globally Worldometer (2022). We sought to understand secondary mental effects in adolescents living with HIV (ALHIV) on the African continent caused by lockdowns, school closures, and other restriction measures for infection control. We reviewed the broader literature and conducted 86 retrospective chart reviews of mental health disorders of ALHIV and interventions utilized at a pediatric clinic in Eswatini.

Recent Findings

ALHIVs are disproportionately affected by mental health disorders. The COVID-19 pandemic has exacerbated adverse mental health outcomes of adolescents on the African continent, especially for ALHIV. There have been many calls for researchers, clinicians, and governments to prioritize mental health in adolescents going forward.

Summary

In pediatric clinics in Eswatini, Malawi, and Uganda, there were psychosocial measures in place prior to the COVID-19 pandemic for ALHIV. After looking closely at a pediatric clinic in Eswatini, we found that many interventions were paused and new psychosocial interventions compatible with social distancing were instead utilized by clinicians. Even so, after multidisciplinary management comprising of interventions such as psychotherapy, pharmacotherapy, referral to psychologists/psychiatrists, and enrollment in peer support groups, the PHQ-9 depressions scores of ALHIV during the COVID-19 significantly improved. We found that there is a need for age-specific standardized tools to measure depression in ALHIV. Furthermore, more research is needed on the effectiveness and scope of psychosocial interventions for ALHIV post-COVID-19 throughout Eswatini and the African continent.

The CombinADO study to assess the impact of a combination intervention strategy on viral suppression, antiretroviral therapy adherence, and retention in HIV care among adolescents and young people living with HIV: protocol for a cluster-randomized controlled trial

Background

Adolescents and youth living with HIV (AYAHIV) have worse HIV outcomes than other age groups, particularly in sub-Saharan Africa (SSA). AYAHIV in SSA face formidable health system, interpersonal- and individual-level barriers to retention in HIV care, uptake of ART, and achievement of viral suppression (VS), underscoring an urgent need for multi-component interventions to address these challenges. This cluster-randomized control trial (cRCT) aims to evaluate the effectiveness and monitor implementation of a community-informed multi-component intervention (“CombinADO strategy”) addressing individual-, facility-, and community-level factors to improve health outcomes for AYAHIV.

Methods

This trial will be conducted in 12 clinics in Nampula Province, Northern Mozambique. All clinics will implement an optimized standard of care (control) including (1) billboards/posters and radio shows, (2) healthcare worker (HCW) training, (3) one-stop adolescent and youth-friendly services, (4) information/motivation walls, (5) pill containers, and (6) tools to be used by HCW during clinical visits. The CombinADO strategy (intervention) will be superadded to control conditions at 6 randomly selected clinics. It will include five additional components: (1) peer support, (2) informational/motivational video, (3) support groups for AYAHIV caregivers, (4) AYAHIV support groups, and (5) mental health screening and linkage to adolescent-focused mental health support. The study conditions will be in place for 12 months; all AYAHIV (ages 10–24 years, on ART) seeking care in the participating sites will be exposed to either the control or intervention condition based on the clinic they attend. The primary outcome is VS (viral load < 50 copies/mL) at 12 months among AYAHIV attending participating clinics. Secondary outcomes include ART adherence (self-reported and TDF levels) and retention in care (engagement in the preceding 90 days). Uptake, feasibility, acceptability, and fidelity of the CombinADO strategy during implementation will be measured. Trial outcomes will be assessed in AYAHIV, caregivers, healthcare workers, and key informants. Statistical analyses will be conducted and reported in line with CONSORT guidelines for cRCTs.

Discussion

The CombinADO study will provide evidence on effectiveness and inform implementation of a novel community-informed multi-component intervention to improve retention, adherence, and VS among AYAHIV. If found effective, results will strengthen the rationale for scale up in SSA.

Trial registration

ClinicalTrials.gov NCT04930367. Registered on 18 June 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05943-w.

Impact of using creative arts programming to support HIV treatment in adolescents and young adults in Eswatini

Background

In 2018, approximately 1.6 million adolescents (aged 10–19) were living with HIV worldwide, with the highest HIV prevalence found in Eswatini. Adolescents and young adults living with HIV are a vulnerable population due to unique psychosocial challenges that come with having a stigmatizing disease. This group struggles more than other age-groups with medication adherence and requires novel approaches to supporting treatment, including peer-group encouragement, and self-expression.

Methods

We piloted a theater camp for a group of adolescents and young adults enrolled at our HIV clinic in Mbabane, Eswatini, to determine the impact of having an outlet for creative expression and peer support on treatment and feelings of stigma. Pre- and post-camp surveys were administered to the participants to assess perceived stigma and impact of the camp. The results were analyzed using a Wilcoxon-signed rank test.

Results

Twenty individuals (ages 12–23) living with HIV participated in the camp concurrently with standard treatment. 25% showed a substantial decrease in viral load within six months of completing the camp (> 0.1 log₁₀ change) while only 10% showed a substantial increase. Those who completed the survey felt the camp helped them with confidence, teamwork, and friendships. A comparison of pre- and post- surveys showed an overall decrease in personalized stigma. Quotes from participants reinforced these results.

Conclusions

Adolescents and young adults living with HIV are an important population for further program development. Our study showed creative arts programming has beneficial psychosocial effects, aids in community building, and potentially enhances the effectiveness of medical treatment. Further programs and studies should continue to investigate creative arts as an avenue for self-expression and community building among vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00423-2.

A Facility-based Family Support Intervention to Improve Treatment Outcomes for Adolescents on Antiretroviral Therapy in the Cape Metropole, South Africa

Adolescents living with human immunodeficiency virus (HIV) (ALHIV) globally, report worse treatment outcomes compared to adults and children on antiretroviral therapy (ART). We conducted a photovoice study with eighteen ALHIV to explore experiences and challenges of being on ART, and individual interviews with 5 health workers to describe the challenges in treating ALHIV. The facility implemented the Family club intervention to facilitate caregivers (parent/guardians) supporting ALHIV on treatment. The health workers revealed that "disclosing HIV status" to children was the biggest challenge for caregivers and health workers. Participating ALHIV reported that family support and having a positive mentality were instrumental for continued treatment adherence. However, disclosure of HIV status to friends remained a challenge due to pervasive community stigma. Treatment fatigue and side-effects were also barriers to adherence. Family support was instrumental in facilitating adherence support for ALHIV. However, this (intervention) should include peer support to improve positive mental well-being in ALHIV.

Service Use and Resilience among Adolescents Living with HIV in Blantyre, Malawi

Introduction:

Adolescents living with HIV (ALHIV) experience social and health challenges that warrant the provision of services and relational support to build resilience. Little is known about how social, community and health services help. We examine formal and alternative service use by and resilience of ALHIV participating in an enhanced teen-club clinic (TCC) programme.

Description:

TCC is an adolescent-centred differentiated care model offering a ‘one-stop-shop’ for HIV/Sexual and Reproductive Health (SRH) services to ALHIV. A survey was conducted with 406 ALHIV to determine frequency of use and satisfaction with services. In addition, we conducted 26 in-depth interviews with ALHIV, 12 group discussions with 144 caregivers, and observations of workshops held for 35 health workers to capture multiple perspectives on service use and relational support systems for adolescent’s wellbeing.

Discussion:

About 70% of ALHIV were concurrently clients of three or more services. The multi-method analysis showed variations on risks, range of services, frequency of use and satisfaction. Interview data reflected complex factors influencing access to formal services, and caregivers and adolescents also sought alternative care from spiritual and traditional healers.

Conclusion:

Adolescent centred-approaches have the potential to enhance resilience promoting resources and outcomes. A multi-sectoral approach to service use and provision is critical to inform adolescent intervention programs and wellbeing.

Determinants of viral suppression among adolescents on antiretroviral treatment in Ehlanzeni district, South Africa: a cross-sectional analysis

BACKGROUND

Achieving undetectable viral load is crucial for the reduction of HIV transmissions, AIDS-related illnesses and death. Adolescents (10 to19 years) living with HIV (ALHIV) on antiretroviral treatment (ART) have worse treatment adherence and lower viral suppression rates compared to adults. We report on the clinical factors associated with viral suppression among ALHIV in the Ehlanzeni district, Mpumalanga in South Africa.

METHODS

A cross-sectional analysis was conducted with 9386 ALHIV, aged 10 to 19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Clinical and immunological data were obtained from electronic medical records (Tier.net). ALHIV were categorised as having achieved viral suppression if their latest viral load count was < 1000 ribonucleic acid (RNA) copies/mL. Using a backward stepwise approach, a multivariate logistic regression analysis was performed to identify factors independently associated with viral suppression.

RESULTS

The mean age of the participants was 14.75 years (SD = 2.9), and 55.43% were female. Mean duration on ART was 72.26 (SD = 42.3) months. Of the 9386 adolescents with viral load results recorded, 74% had achieved viral suppression. After adjusting for other covariates, the likelihood of achieving viral suppression remained significantly higher among ALHIV who were: female (AOR = 1.21, 95% CI 1.05-1.39), and had most recent CD4 count > 200 (AOR = 2.53, 95% CI 2.06-3.11). Furthermore, the likelihood of having viral suppression was lower among adolescents with CD4 count > 200 at baseline (AOR = 0.73, 95% CI 0.61-0.87), and who were switched to second line regimen (AOR = 0.41, 95% CI 0.34-0.49).

CONCLUSIONS

Viral suppression amongst ALHIV at 74% is considerably lower than the WHO target of 95%. Of particular concern for intervention is the lower rates of viral suppression amongst male ALHIV. Greater emphasis should be placed to early enrolment of ALHIV on ART and keeping them engaged in care (beyond 6 months). Furthermore, improved and regular viral load monitoring will help to adequately identify and manage ALHIV with unsuppressed viral load and subsequently switching to second line treatment.

Effect of Text Messaging Plus Peer Navigation on Viral Suppression Among Youth With HIV in the iCARE Nigeria Pilot Study

BACKGROUND

Consistent with the global trend, youth with HIV (YWH) in Nigeria have high rates of viral nonsuppression. Hence, novel interventions are needed.

SETTING

Infectious Diseases Institute, College of Medicine, University of Ibadan, Nigeria.

METHODS

In a single-arm trial, participants aged 15-24 years received 48 weeks of a combination intervention, comprising daily 2-way text message medication reminders plus peer navigation. The primary outcome measure was viral suppression less than 200 copies/mL. The secondary outcome measures included self-reported adherence on a visual analog scale and medication possession ratio, each dichotomized as ≥90% (good) or <90% (poor) adherence. The outcomes were analyzed using McNemar test. Retention in care, intervention feasibility and acceptability, and participants' satisfaction were also assessed.

RESULTS

Forty YWH (50% male participants) were enrolled: mean age 19.9 years (SD = 2.5), 55% perinatally infected, and 35% virologically suppressed at baseline. Compared with baseline, the odds of virologic suppression was higher at 24 weeks (odds ratio = 14.00, P < 0.001) and 48 weeks (odds ratio = 6.00, P = 0.013). Self-reported adherence (≥90%) increased from baseline at 24 weeks (63%, P = 0.008) and 48 weeks (68%, P = 0.031). Medication possession ratio ≥90% increased at weeks 24 and 48 (85% and 80%, respectively), achieving statistical significance at 24 weeks alone (P = 0.022). Retention in care at 48 weeks was 87.5%. All (37/37) participants at week 48 were fully or mostly satisfied with the intervention.

CONCLUSION

Daily 2-way text message reminders plus peer navigation is a promising combination intervention to improve viral suppression among YWH in Nigeria.

Importance of support groups to the health and well-being of vulnerable children and young people living with HIV: a case study of the Kids Clubs program in Haiti

BACKGROUND

Although access to antiretroviral therapy (ART) among children and young people living with HIV has increased in recent years, adherence to medication and viral suppression remain challenges. Evidence of benefits of support groups is growing and reflects a range of models and approaches. Since 2014, hospital-linked psychosocial support groups for children and young people living with HIV, known as Kids Clubs, have been established throughout Haiti. The program provides safe spaces for them to meet with peers, supports medication adherence, delivers health and life skills education, and facilitates linkages with clinic visits and social services. This study describes program enrollment and participant engagement, ART adherence and viral suppression among participants, and other outcomes attributed to the program by participants, caregivers, and program implementers.

METHODS

Our mixed methods study included quantitative analysis of program monitoring data on rollout and attendance, and medication adherence and viral load results extracted from medical records. We collected qualitative data from club members, caregivers, and implementers about their experiences with the clubs and the impact of participation.

RESULTS

From January 2014-December 2018, 1330 individuals aged 8-29 were enrolled in the program; over three-quarters participated for at least 12 months. In 2018, 1038 members attended at least one club meeting; more than half missed three or fewer monthly meetings. Three-quarters of ever-enrolled members reported consistent medication use at their most recent clinic visit; 64.2% (600/935) of those with a recent viral load test were virally suppressed. Level of club attendance was positively associated with ART adherence (p < 0.01) and viral suppression (p < 0.05). Club members, caregivers, and implementers noted the value of the clubs to participants' retention in care and medication adherence, health knowledge, and capacity to deal with peer pressure, stigma, shyness, and depression.

CONCLUSIONS

The Kids Club program has been successful in scaling HIV support services to highly vulnerable children and young people through peer-based groups, and program participation has led to a range of benefits. Efforts to innovate, evaluate, and scale support strategies for vulnerable young populations must be accelerated in order to ensure that they survive, thrive, and reach their full potential.

Challenges to Antiretroviral Therapy Adherence and Coping Strategies to Overcome Them: Qualitative Investigations of Adolescents Living with HIV, their Caregivers, and Clinicians in Vietnam

Background:

Adolescents living with HIV (ALHIV) in Vietnam are known to struggle with adherence to Antiretroviral Therapy (ART).

Objective:

To examine treatment challenges and facilitators experienced by ALHIV from the perspective of adolescents, their caregivers, and providers, and to inform an adherence intervention.

Methods:

In-depth Interviews (IDIs) of adolescent/caregiver dyads and Focus Group Discussions (FGDs) with adolescents, caregivers, and clinicians were conducted in Hanoi, Vietnam. We used semi-structured guides to encourage open-ended responses. We queried the challenges adolescents experience taking ART medications and being adherent, their awareness of disease status, and facilitators to support high adherence. Audio-recorded IDIs were translated into English, and coded and analyzed in NVivo using a thematic approach.

Results:

A total of 78 individuals participated in the study. Forty individuals participated in IDIs (20 adolescents and 20 caregivers). All adolescents had acquired HIV perinatally. We conducted six FGDs: four with adolescents, and one each with caregivers and clinicians. We identified major themes regarding awareness of HIV status (most caregivers reported they had disclosed to their child, while few adolescents revealed the knowledge of their status); perceived barriers to adherence (medication-related challenges, stigma, school-associated issues, financial obstacles, system challenges, awareness of HIV status); and adherence facilitators (development of dose-taking habits, reminder systems, social support). Differences between adolescents and caregivers related to key issues were evident.

Conclusion:

Further research is needed to elucidate discrepancies in adolescent-caregiver viewpoints and develop interventions tailored to both ALHIV and their caregivers.

Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10-24 years): a scoping review

Background

Mental health disorders such as high levels of anxiety, isolation, depression and suicide ideation reported among young people living with HIV (10–24 years;YPLHIV) contribute significantly to poor medication adherence and retention in care. While there is evidence supporting the role of psychosocial support interventions in promoting adherence and retention in antiretroviral treatment (ART) among adults living with HIV, there is little evidence on the role of psychosocial support on medication adherence among YPLHIV. This scoping review was designed to identify and classify the types and effects of psychosocial support interventions designed to improve adherence and retention in ART among YPLHIV globally.

Method

We searched six electronic databases (i.e., Scopus, Pubmed and EBSCOHost (Academic Search Premier, CINAHL, Psycarticles and Medline). Six relevant articles published between 2011 and 2019 met our inclusion criteria. We extracted information relevant to the nature and outcomes of the reported interventions using thematic content analysis informed by the Population, Intervention, comparison, outcome, and time (PICOT) framework.

Results

Four distinctive treatment modalities that focused on improving ART adherence and retention in care were identified: individual counselling, support groups, family-centered services, and treatment supporters.

Conclusion

There is a dearth of psychosocial support interventions to improve adherence and retention in ART amongst adolescents and young adults living with HIV. Future research and programming should seek to address psychosocial support interventions or approaches specifically designed to address the needs of YPLHIV.

Trial registration

PROSPERO: Registration CRD42018105057.

The Comparison of Teen Clubs vs. Standard Care on Treatment Outcomes for Adolescents on Antiretroviral Therapy in Windhoek, Namibia

Background

Adolescents living with HIV (ALHIV) are challenged to adhere to antiretroviral therapy (ART) and achieve and maintain virologic suppression. Group-based adherence support interventions, such as adherence clubs, have been shown to improve long-term adherence in ART patients. The teen club intervention was introduced in 2010 in Namibia to improve treatment outcomes for ALHIV by providing adherence support in a peer-group environment. Adolescents who have completed the full HIV disclosure process can voluntarily join the teen clubs. The current study compared treatment outcomes of ALHIV receiving ART at a specialized paediatric HIV clinic between 1 July 2015 and 30 June 2017 in Windhoek, Namibia.

Methods

A retrospective cohort analysis was conducted on routine patient data extracted from the electronic Patient Monitoring System, individual Patient Care Booklets, and teen club attendance registers. A sample of 385 adolescents were analysed: 78 in teen clubs and 307 in standard care. Virologic suppression was determined at 6, 12, and 18 months from study start date, and compared by model of care, age, sex, disclosure status, and ART regimen. Comparisons between adolescents in teen clubs and those receiving standard care were performed using the chi-square test, and risk ratios were calculated to analyze differences in ART adherence and virologic suppression.

Results

The average clinician-measured ART adherence was 89% good, 6% fair, and 5% poor amongst all adolescents, with no difference between teen club members and adolescents in standard care (p = 0.277) at 3 months. Virologic suppression over the 2-year observation period was 87% (68% fully suppressed <40 copies/ml and 19% suppressed between 40–999 copies/ml), with no difference between teen club members and those in standard care. However, there were statistically significant differences in virologic suppression levels between the younger (10–14 years) adolescents and older (15–19 years) adolescents at 6 months (p = 0.015) and at 12 months (p = 0.021) and between adolescents on first-line and second-line ART regimen at 6 months (p = 0.012), 12 months (p = 0.004), and 18 months (p = 0.005).

Conclusion

The teen club model delivering psychosocial support only did not improve adherence and virologic suppression levels for adolescents in a specialized paediatric ART clinic, neither were they inferior to standard care. Considering the limitations of this study, teen clubs may still hold potential for improving adherence and virologic suppression levels for older adolescents, and more robust research on adherence interventions for adolescents with higher methodological quality is required.

Validating a Child Youth Resilience Measurement (CYRM-28) for Adolescents Living With HIV (ALHIV) in Urban Malawi

Resilience as a strength-based notion, measured across cultures, age groups, and sub-populations, contributes to understanding health and well-being. Yet, there is limited evidence of how the construct performs in resource-limited countries. We explored the psychometric properties of the CYRM-28 and validated the scale with adolescents living with HIV (ALHIV), a key sub-population. The participants included members of an advisory panel and 406 ALHIV, aged 15–19 years, attending an antiretroviral therapy and teen-club clinic in Blantyre, Malawi. This study employed a mixed-method study using an exploratory sequential design. The advisory panel discussed the CYRM-28, and select ALHIV then translated it into Chichewa, pilot-tested it using cognitive interviews, and back-translated it for clarity and appropriateness. The resultant CYRM-28 was tested using a survey with purposefully selected ALHIV. The overall median score was 123, with an interquartile range of 110–130. Minimum and maximum scores were 53 and 140. Cronbach’s alpha of 0.863 and Kaiser–Meyer–Olkin measure (0.866) confirmed internal consistency and the sample size adequacy, respectively. Bartlett’s tests of sphericity (p < 0.001) informed factor analysis. Exploratory factor analysis determined possible dimensions of resilience and the sub-scales. The confirmatory factor analysis (CFA) confirmed the construct validity and supported a three-factor model consistent with the conceptualization of resilience as a multi-dimensional construct. Structural equation modeling was applied to perform CFA to measure model of resilience. Multiple fit indices showed a good fit for the model. The CYRM-28 has good internal consistency, test and re-test reliability, and moderate convergent validity which render it useful as a self-report resilience measure to inform and evaluate interventions for the health and well-being of adolescents in Malawi.

Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa

BACKGROUND

Long-term retention of adolescents aged 10 -19 years on antiretroviral therapy (ART) is crucial to achieve viral load suppression. However, it is reported globally that adolescents have lower retention in care (RiC) on ART, compared with children and adults.

OBJECTIVES

To determine the prevalence and predictors of RiC of adolescents over 2 years following initiation onto ART in public health facilities in the Metropole District Health Services of the Western Cape province in 2013.

METHODS

Data of 220 adolescent patients who were newly initiated on ART in 2013 were extracted from the provincial electronic database, and subjected to univariate and bivariate analyses using SPSS.

RESULTS

The rate of RiC post-initiation was low throughout the study period, that is, 68.6%, 50.5% and 36.4% at 4, 12 and 24 months, respectively. The corresponding post-initiation viral load suppression levels on ART of those remaining in care and who had viral loads monitored were 84.1%, 77.4% and 68.8% at 4, 12 and 24 months, respectively. Retention in care after initiation on ART was higher amongst younger adolescents (10-14 years), compared with older adolescents (15-19 years). Male adolescents were significantly more likely to be retained, compared with females. Pregnant adolescents were significantly less likely to be retained compared with those who were not pregnant.

CONCLUSION

Key interventions are needed to motivate adolescents to remain in care, and to adhere to their treatment regimen to achieve the target of 90% viral load suppression, with specific emphasis on older and pregnant adolescents.

Psychological care in low-resource settings for adolescents

Adolescents living in low-resource settings lack access to adequate psychological care. The barriers to mental health care in low- and middle-income countries (LMIC) include high disease burden, low allocation of resources, lack of national mental health policy and child and adolescent mental health (CAMH) professionals and services, poverty, illiteracy and poor availability of adolescent friendly health services. WHO has recommended a stepped task shifting approach to mental health care in LMIC. Training of non-mental health specialists like peers, teachers, community health workers, paediatricians and primary care physicians by CAMH and framing country-specific evidence-based national mental health policies are vital in overcoming barriers to psychological care in LMIC. Digital technology and telemedicine can be used in providing economical and accessible mental health care services to adolescents.

Adolescents living with HIV, complex needs and resilience in Blantyre, Malawi

BACKGROUND

Adolescents living with HIV (ALHIV) in Malawi experience multiple challenges associated with their illness and various social, environmental, economic and cultural factors. In exploring their various medical concerns and social vulnerabilities, we consider the role of multiple services in creating a pathway for resilience.

METHODS

Multiple methods and case studies allowed for triangulation of evidence and provided a holistic understanding of resilience among adolescents with complex needs. The research methods included: (1) a survey to identify examples of young people with complex needs, (2) qualitative interviews and field notes to further explore these needs, (3) patient files and health passports to identify clinical challenges, and (4) ecomapping exercises to personalize cases and identify resilience-enabling resources and supports. We present four case studies to highlight the complex experiences and access to services of ALHIV, and to illustrate their growing power and decision-making capacity over time.

RESULTS

Adversity experienced by ALHIV varied by gender, family situation, years of schooling, and use of teen-clubs for support. The two female adolescents emphasised their need to be accepted and how this impacted sexuality and reproduction. The two males illustrated how ideas of masculinity influenced their sexual practice and involvement with health services and the correctional justice system. Multiple risks (alcohol use, sexual activities) and complex needs (belonging, having a purpose in life/productive activities, autonomy, desire for offspring) influence pathways to resilience. ALHIV were able to strengthen their own wellbeing by resisting negative behaviours and peer pressure and caregiver interactions through 'strategic silence'.

CONCLUSION

ALHIV experienced self-transformation as a result of taking ART, with fewer severe episodes of illness and distressing skin conditions. Continuous engagement at the teen-club clinic transformed both productive activities and social relationships among ALHIV as they set life goals, gained a sense of empowerment, requested SRH services, and formed intimate relationships. These transformative opportunities allowed them to learn ways of minimizing risk of reinfection and violence, and of navigating health worker-caregiver-adolescent interactions.

Dual Analysis of Loss to Follow-up for Perinatally HIV-Infected Adolescents Receiving Combination Antiretroviral Therapy in Asia

BACKGROUND

Perinatally HIV-infected adolescents (PHIVA) are an expanding population vulnerable to loss to follow-up (LTFU). Understanding the epidemiology and factors for LTFU is complicated by varying LTFU definitions.

SETTING

Asian regional cohort incorporating 16 pediatric HIV services across 6 countries.

METHODS

Data from PHIVA (aged 10-19 years) who received combination antiretroviral therapy 2007-2016 were used to analyze LTFU through (1) an International epidemiology Databases to Evaluate AIDS (IeDEA) method that determined LTFU as >90 days late for an estimated next scheduled appointment without returning to care and (2) the absence of patient-level data for >365 days before the last data transfer from clinic sites. Descriptive analyses and competing-risk survival and regression analyses were used to evaluate LTFU epidemiology and associated factors when analyzed using each method.

RESULTS

Of 3509 included PHIVA, 275 (7.8%) met IeDEA and 149 (4.3%) met 365-day absence LTFU criteria. Cumulative incidence of LTFU was 19.9% and 11.8% using IeDEA and 365-day absence criteria, respectively. Risk factors for LTFU across both criteria included the following: age at combination antiretroviral therapy initiation <5 years compared with age ≥5 years, rural clinic settings compared with urban clinic settings, and high viral loads compared with undetectable viral loads. Age 10-14 years compared with age 15-19 years was another risk factor identified using 365-day absence criteria but not IeDEA LTFU criteria.

CONCLUSIONS

Between 12% and 20% of PHIVA were determined LTFU with treatment fatigue and rural treatment settings consistent risk factors. Better tracking of adolescents is required to provide a definitive understanding of LTFU and optimize evidence-based models of care.

A Social Media-Based Support Group for Youth Living With HIV in Nigeria (SMART Connections): Randomized Controlled Trial

BACKGROUND

Youth living with HIV (YLHIV) enrolled in HIV treatment experience higher loss to follow-up, suboptimal treatment adherence, and greater HIV-related mortality compared with younger children or adults. Despite poorer health outcomes, few interventions target youth specifically. Expanding access to mobile phone technology, in low- and middle-income countries (LMICs) in particular, has increased interest in using this technology to improve health outcomes. mHealth interventions may present innovative opportunities to improve adherence and retention among YLHIV in LMICs.

OBJECTIVE

This study aimed to test the effectiveness of a structured support group intervention, Social Media to promote Adherence and Retention in Treatment (SMART) Connections, delivered through a social media platform, on HIV treatment retention among YLHIV aged 15 to 24 years and on secondary outcomes of antiretroviral therapy (ART) adherence, HIV knowledge, and social support.

METHODS

We conducted a parallel, unblinded randomized controlled trial. YLHIV enrolled in HIV treatment for less than 12 months were randomized in a 1:1 ratio to receive SMART Connections (intervention) or standard of care alone (control). We collected data at baseline and endline through structured interviews and medical record extraction. We also conducted in-depth interviews with subsets of intervention group participants. The primary outcome was retention in HIV treatment. We conducted a time-to-event analysis examining time retained in treatment from study enrollment to the date the participant was no longer classified as active-on-treatment.

RESULTS

A total of 349 YLHIV enrolled in the study and were randomly allocated to the intervention group (n=177) or control group (n=172). Our primary analysis included data from 324 participants at endline. The probability of being retained in treatment did not differ significantly between the 2 study arms during the study. Retention was high at endline, with 75.7% (112/163) of intervention group participants and 83.4% (126/161) of control group participants active on treatment. HIV-related knowledge was significantly better in the intervention group at endline, but no statistically significant differences were found for ART adherence or social support. Intervention group participants overwhelmingly reported that the intervention was useful, that they enjoyed taking part, and that they would recommend it to other YLHIV.

CONCLUSIONS

Our findings of improved HIV knowledge and high acceptability are encouraging, despite a lack of measurable effect on retention. Retention was greater than anticipated in both groups, likely a result of external efforts that began partway through the study. Qualitative data indicate that the SMART Connections intervention may have contributed to retention, adherence, and social support in ways that were not captured quantitatively. Web-based delivery of support group interventions can permit people to access information and other group members privately, when convenient, and without travel. Such digital health interventions may help fill critical gaps in services available for YLHIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03516318; https://clinicaltrials.gov/ct2/show/NCT03516318.

Peer Support for Adolescents and Young People Living with HIV in sub-Saharan Africa: Emerging Insights and a Methodological Agenda

PURPOSE

Despite clear need and disproportionate risk, adolescents, and young people living with HIV (AYPLHIV) are underserved within the HIV response. "Peer support" increasingly forms part of adolescent and youth-responsive service packages as a class of implementation strategies that can support adolescents to access, engage, and sustain treatment. This paper examines examples of peer support for AYPLHIV within sub-saharan Africa to explore the determinants of successful implementation, outcomes and scale-up, as well as policy and programmatic implications.

RECENT FINDINGS

Although adolescent peer support has been observed to be widely implemented, there are few examples of detailed program descriptions describing operational logistics or outcomes around peer support interventions. Nevertheless the few examples available provide preliminary support for the potential utility of peer support to improve AYPLHIV outcomes. Implementation science research is an urgent imperative to examine applicability of peer support for this priority population. In the meantime, programs should move forward with implementation based on promising outcomes, programmatic experience, contextual understanding of challenges and gaps, and best practice examples.