Comprehensive evaluation of caregiver-reported antiretroviral therapy adherence for HIV-infected children

Longitudinal impacts of the COVID-19 pandemic on adolescents living with HIV in New York City

Adolescents living with HIV (ALWH) are particularly susceptible to disruptions in care, which may lead to poor HIV-related health outcomes. Here, we report the results of a longitudinal phone-based study investigating impacts of the COVID-19 pandemic on ALWH in New York City. Participants (N = 10, mean age 21.2 years, 50% female) demonstrated substantial COVID-19 knowledge and identified Instagram as their primary source of COVID-19 information. Nearly all participants reported loss of income, and 50% reported experiencing food insecurity as a result of the pandemic. These findings highlight existing vulnerabilities among ALWH that may threaten the continuum of care.

Effects of the COVID-19 pandemic on late postpartum women living with HIV in Kenya

Although an estimated 1.4 million women living with HIV (WHIV) are pregnant each year globally, data describing the effects of the COVID-19 pandemic on postpartum women in low- and middle-income countries (LMICs) are limited. To address this gap, we conducted phone surveys among 170 WHIV ≥18 years and 18-24 months postpartum enrolled in HIV care at the Academic Model Providing Access to Healthcare in western Kenya, and assessed the effects of the pandemic across health, social and economic domains. We found that 47% of WHIV experienced income loss and 71% experienced food insecurity during the pandemic. The majority (96%) of women reported having adequate access to antiretroviral treatment and only 3% reported difficulties refilling medications, suggesting that the program's strategies to maintain HIV service delivery during the early phase of the pandemic were effective. However, 21% of WHIV screened positive for depression and 8% for anxiety disorder, indicating the need for interventions to address the mental health needs of this population. Given the scale and duration of the pandemic, HIV programs in LMICs should work with governments and non-governmental organizations to provide targeted support to WHIV at highest risk of food and income insecurity and their associated adverse health outcomes.

Electronically Monitored Adherence to Short-Term Antibiotic Therapy in Children

BACKGROUND

Nonadherence to short-term antibiotic treatment in children can lead to treatment failure and the development of drug-resistant microorganisms. We aimed to provide reliable adherence estimates in this population.

METHODS

A prospective, blinded, electronically monitored, observational study between January 2018 and October 2021. Patients aged 2 months to 5 years diagnosed with an acute bacterial infection requiring short-term (5-10 days) oral antibiotic monotherapy, were provided with an electronically monitored medication bottle, recording every manipulation of the cap. Primary outcomes were overall adherence, predefined as administration of >75% of doses relative to the number of doses prescribed, and timing adherence, defined as the administration of >75% of prescribed doses taken within ±20% of the prescribed interval.

RESULTS

One hundred infants (49 boys, mean [range] age 1.87 years [0.2-5.1]) were included in the final analysis. Only 11 participants received all the recommended doses. Overall adherence was 62%, whereas timing adherence was 21%. After applying a logistic regression model, the only factor significantly associated with nonadherence was being a single parent (odds ratio = 5.7; 95% confidence interval [1.07-30.3]). Prescribers overestimated adherence, defining 49 of 62 (77.7%) participants as likely adherent. Patients predicted to be adherent were not more likely to be adherent than those predicted to be nonadherent (31/47 actual adherence among those predicted to be adherent vs 6/16, P = .77).

CONCLUSIONS

Adherence of children to the short-term antimicrobial treatment of an acute infection is suboptimal. Providers were unable to predict the adherence of their patients. These data are important when considering recommended treatment durations and developing interventional programs to increase adherence.

HIV status disclosure and antiretroviral therapy adherence among children in Masaka region, Uganda

HIV-infected children are now living into adolescence and early adulthood in large numbers due to the availability and increased use of antiretroviral therapy (ART). However, receipt of HIV status disclosure among children remains low. We assessed the association between disclosure of HIV status and adherence to ART among children in the Masaka region of Uganda using multivariable logistic regression with generalised linear models with Poisson log-link function and robust variance in Stata software version 15.1. Data were collected from 524 assenting children aged 12-17 years between March and December 2020. Results show that, although not statistically significant, children who received disclosure of their HIV status reported improved ART adherence compared to children with no disclosure. Out-of-school children with post-primary education and children on first-line ART regimens were significantly more likely to report improved ART in both crude and adjusted analyses. Innovative interventions to promote progressive disclosure of HIV status to children on ART, in school, are needed to improve their ART adherence. There is also a need to evaluate the suitability of current counselling interventions provided to children being switched to second-line ART regimens to delay the need for third-line ART regimens.

HIV-1 Treatment Failure, Drug Resistance, and Clinical Outcomes in Perinatally Infected Children and Adolescents Failing First-Line Antiretroviral Therapy in Western Kenya

BACKGROUND

Long-term impact of drug resistance in perinatally infected children and adolescents living with HIV (CALWH) is poorly understood. We determined drug resistance and examined its long-term impact on failure and mortality in Kenyan CALWH failing first-line non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy (ART).

SETTING

Academic Model Providing Access to Healthcare, western Kenya.

METHODS

Participants were enrolled in 2010-2013 (timepoint 1) and a subsample re-enrolled after 4-7 years (timepoint 2). Viral load (VL) was performed on timepoint 1 samples, with genotyping of those with detectable VL. Primary endpoints were treatment failure (VL >1000 copies/mL) at and death before timepoint 2. Multinomial regression analysis was used to characterize resistance effect on death, failure, and loss-to-follow-up, adjusting for key variables.

RESULTS

The initial cohort (n = 480) was 52% (n = 251) female, median age 8 years, median CD4% 31%, 79% (n = 379) on zidovudine/abacavir + lamivudine + efavirenz/nevirapine for median 2 years. Of these, 31% (n = 149) failed at timepoint 1. Genotypes at timepoint 1, available on n = 128, demonstrated 93% (n = 119) extensive resistance, affecting second line. Of 128, 22 failed at timepoint 2, 17 died, and 32 were lost to follow-up before timepoint 2. Having >5 resistance mutations at timepoint 1 was associated with higher mortality [relative risk ratio (RRR) = 8.7, confidence interval (CI) 2.1 to 36.3] and loss to follow-up (RRR = 3.2, CI 1.1 to 9.2). Switching to second line was associated with lower mortality (RRR <0.05, CI <0.05 to 0.1) and loss to follow-up (RRR = 0.1, CI <0.05 to 0.3).

CONCLUSION

Extensive resistance and limited switch to second line in perinatally infected Kenyan CALWH failing first-line ART were associated with long-term failure and mortality. Findings emphasize urgency for interventions to sustain effective, life-long ART in this vulnerable population.

Social, economic, and health effects of the COVID-19 pandemic on adolescents retained in or recently disengaged from HIV care in Kenya

INTRODUCTION

Adolescents living with HIV (ALHIV, ages 10-19) experience complex challenges to adhere to antiretroviral therapy (ART) and remain in care, and may be vulnerable to wide-scale disruptions during the COVID-19 pandemic. We assessed for a range of effects of the pandemic on ALHIV in western Kenya, and whether effects were greater for ALHIV with recent histories of being lost to program (LTP).

METHODS

ALHIV were recruited from an ongoing prospective study at 3 sites in western Kenya. The parent study enrolled participants from February 2019-September 2020, into groups of ALHIV either 1) retained in care or 2) LTP and traced in the community. Phone interviews from July 2020-January 2021 assessed effects of the pandemic on financial and food security, healthcare access and behaviors, and mental health. Responses were compared among the parent study groups.

RESULTS

Phone surveys were completed with 334 ALHIV or their caregivers, including 275/308 (89.3%) in the retained group and 59/70 (84.3%) among those LTP at initial enrollment. During the pandemic, a greater proportion of LTP adolescents were no longer engaged in school (45.8% vs. 36.4%, p = 0.017). Over a third (120, 35.9%) of adolescents reported lost income for someone they relied on. In total, 135 (40.4%) did not have enough food either some (121, 36.2%) or most (14, 4.2%) of the time. More LTP adolescents (4/59, 6.8% vs. 2/275, 0.7%, p = 0.010) reported increased difficulties refilling ART. Adolescent PHQ-2 and GAD-2 scores were ≥3 for 5.6% and 5.2%, respectively.

CONCLUSIONS

The COVID-19 pandemic has had devastating socioeconomic effects for Kenyan ALHIV and their households. ALHIV with recent care disengagement may be especially vulnerable. Meanwhile, sustained ART access and adherence potentially signal resilience and strengths of ALHIV and their care programs. Findings from this survey indicate the critical need for support to ALHIV during this crisis.

Novel Long Non-coding RNA and LASSO Prediction Model to Better Identify Pulmonary Tuberculosis: A Case-Control Study in China

Introduction

The insufficient understanding and misdiagnosis of clinically diagnosed pulmonary tuberculosis (PTB) without an aetiological evidence is a major problem in the diagnosis of tuberculosis (TB). This study aims to confirm the value of Long non-coding RNA (lncRNA) n344917 in the diagnosis of PTB and construct a rapid, accurate, and universal prediction model.

Methods

A total of 536 patients were prospectively and consecutively recruited, including clinically diagnosed PTB, PTB with an aetiological evidence and non-TB disease controls, who were admitted to West China hospital from Dec 2014 to Dec 2017. The expression levels of lncRNA n344917 of all patients were analyzed using reverse transcriptase quantitative real-time PCR. Then, the laboratory findings, electronic health record (EHR) information and expression levels of n344917 were used to construct a prediction model through the Least Absolute Shrinkage and Selection Operator algorithm and multivariate logistic regression.

Results

The factors of n344917, age, CT calcification, cough, TBIGRA, low-grade fever and weight loss were included in the prediction model. It had good discrimination (area under the curve = 0.88, cutoff = 0.657, sensitivity = 88.98%, specificity = 86.43%, positive predictive value = 85.61%, and negative predictive value = 89.63%), consistency and clinical availability. It also showed a good replicability in the validation cohort. Finally, it was encapsulated as an open-source and free web-based application for clinical use and is available online at https://ziruinptb.shinyapps.io/shiny/.

Conclusion

Combining the novel potential molecular biomarker n344917, laboratory and EHR variables, this web-based prediction model could serve as a user-friendly, accurate platform to improve the clinical diagnosis of PTB.

Validation of an HIV/AIDS Stigma Measure for Children Living with HIV and Their Families

BACKGROUND

There are few validated tools to measure stigma, particularly among children living with HIV and their families.

METHODS

This study was nested within a larger study that followed 240 child-caregiver dyads (children aged 10-15 years) at 8 clinics in western Kenya. The stigma instrument was administered to all child-caregiver dyads at 2 time points 6 months apart. The primary end point was to construct validity assessed by comparison to criterion constructs using generalized estimating equation models.

RESULTS

Mean age of child participants was 12.3 years and 52% were female. Generally, caregivers reported experiencing higher levels of HIV stigma compared to their children. Children (9%) and caregivers (14%) reported that HIV stigma made them feel stressed, anxious, and depressed. Child and caregiver stigma items showed high construct validity by emotional and behavioral outcomes.

CONCLUSIONS

The stigma instrument showed high validity when compared to emotional and behavioral outcomes.

A cross-sectional study on caregivers' perspective of the quality of life and adherence of paediatric HIV patients to highly active antiretroviral therapy

Background

Poor compliance to highly active antiretroviral therapy (HAART) can result in the poor quality of life in children living with Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS) because of low plasma drug concentration and the possibility of drug resistance. This study evaluates the response of caregivers for determination of adherence and the four quality of life domains in children (aged 14 years and under) on HAART.

Methods

We conducted a cross-sectional study of 188 children, each accompanied by their caregivers at Ola During Children’s Hospital and Makeni Government Hospital between September and November 2016. Adherence to HAART and Quality of life was assessed using the WHO Quality of life summary questionnaire (WHOQOL-BREF). We obtained ethical approval from the Sierra Leone Ethics and Scientific Review Committee.

Results

The study revealed 5.9% adherence amongst paediatric patients, and a strong association of adherent patients(p = 0.019*) to the physical health domain (mean = 64.61 SD = 8.1). Caregiver HIV status showed a strong association with the physical (mean = 58.3, SD = 11.7 and p = 0.024*), and psychological health domains (mean = 68.2, SD = 14.7 and p = 0.001). Caregiver type (mother/father/sibling) accompanying child to hospital also showed strong associated with the physical (mean = 58.0, SD = 10.6, p <  0.001), psychological (mean 68.2 SD = 14.81 p <  0.001) and environmental health domains (mean = 59.7, SD = 13.47, p <  0.001). Further regression analysis showed a strong association with physical health domain for HIV positive caregivers (p = 0.014) and adherent paediatric patients (p = 0.005). Nuclear family also showed a strong association with psychological (p <  0.001) and environmental (p = 0.001) health domains.

Conclusion

This study showed a strong association between the quality of life domains and the involvement of nuclear family caregiver, HIV-positive caregiver and adherence to HAART. Our study suggests that the involvement of any member of the nuclear family, HIV positive parents and patient adherence to therapy can improve the quality of life of paediatric HIV/AIDS patients on highly active antiretroviral therapy in the two hospitals.

Validation of a self-report adherence measurement tool among a multinational cohort of children living with HIV in Kenya, South Africa and Thailand

INTRODUCTION

There are few data on adherence and low-cost measurement tools for children living with HIV. We collected prospective data on adherence to antiretroviral therapy (ART) among a multinational cohort of children to evaluate an adherence questionnaire.

METHODS

We enrolled 319 children ages 0 to 16 years on ART in Kenya (n = 110), South Africa (n = 109) or Thailand (n = 100). Children were followed up for six months of adherence monitoring between March 2015 and August 2016 using Medication Event Monitoring Systems (MEMS^® ) with at least one viral load measure. At month 3 and 6, children or their caregivers were administered a 10-item adherence questionnaire. Repeated measures analyses were used to compare responses on questionnaire items to external adherence criteria: MEMS^® dichotomized adherence (≥90% of doses taken vs. <90%), 48-hour MEMS^® treatment interruptions and viral suppression (<1000 copies/mL). Items associated with outcomes (p < 0.10) were coefficient-weighted to calculate a total adherence score, which was tested in multivariate regression against MEMS^® and viral suppression outcomes. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Mean child age was 11 years and 54% were female. Children from Thailand (median age 14 years) were significantly older compared to Kenya (10 years) and South Africa (10 years). Prevalence of viral suppression was 97% in Thailand, 81% in South Africa and 69% in Kenya, while the prevalence of MEMS^® adherence ≥90% was 57% in Thailand, 58% in South Africa and 40% in Kenya. Across sites, child-reported adherence using the questionnaire was significantly associated with dichotomized MEMS^® adherence (OR 1.8, 95% CI 1.4 to 2.4), 48-hour treatment interruptions (OR 0.41, 95% CI 0.3 to 0.6), and viral suppression (OR 3.4, 95% CI 1.7 to 6.7). We did find, however, that different cut-points for the adherence score may be context-specific. For example, MEMS^® non-adherent children in Kenya had a lower adherence score (0.98) compared to South Africa (1.77) or Thailand (1.58).

CONCLUSIONS

We found suboptimal adherence to ART was common by multiple measures in this multi-country cohort of children. The short-form questionnaire demonstrated reasonable validity to screen for non-adherence in these diverse settings.

Patient perspectives on medication self-management in rural Kenya: a cross-sectional survey

OBJECTIVES

The presence of HIV, tuberculosis and non-communicable diseases result in a double burden of disease in the East African community. Most studies have focused on urban Nairobi and western Kenya, leading to a lack of information on rural regions that make up 75% of the population. This study determined baseline rates and barriers to medication self-management in rural Meru County.

DESIGN

A cross-sectional, descriptive community survey focused on Meru, Kenya.

SETTING

Participants were surveyed at a local Kithoka dispensary and the government operated Meru Level 5 Hospital.

PARTICIPANTS

Seventy-five chronic illness patients between June 2016 and July 2016.

INTERVENTION

Twelve-question Measures of Drug Self-Management Scale (MeDS).

MAIN OUTCOME MEASURE

Baseline rates of medication self-management. A score of 10 or more defined 'adequate' medication drug self-management.

RESULTS

The average MeDS score was 8.16 ± 2.4, indicating inadequate medication self-management. There was no significant difference across age (P = 0.75), and between the scores of males and females (8.1 ± 2.4 and 8.2 ± 2.5, respectively, P = 0.89). Minor side effects and the idea that taking medicines disrupt life were highly associated with inadequate drug self-management (r = 0.58). Forgetfulness and non-adherence had the highest correlation (r = 0.64). Cost is a large barrier, with 64% agreeing that they have a hard time paying for their medicines.

CONCLUSIONS

All questions on the MeDS survey had statistically significant correlations with the overall score, while gender and age did not. The MeDS questionnaire showed to be an effective tool to evaluate risk of long-term non-adherence globally in rural populations.

Retention and adherence: global challenges for the long-term care of adolescents and young adults living with HIV

PURPOSE OF REVIEW

Adolescents living with HIV are the only age group with increasing HIV mortality at a time of global scale-up of access to antiretroviral therapy (ART). As a 'treat all' strategy is implemented worldwide, it is critically important to optimize retention and adherence for this vulnerable group.

RECENT FINDINGS

Adolescents and young adults living with HIV have poorer outcomes when compared with adults at each stage of the HIV care cascade, irrespective of income setting. Rates of viral suppression are lowest for adolescents living with HIV, and adherence to ART remains an enormous challenge. High-quality studies of interventions to improve linkage to, and retention in, care on suppressive ART are starkly lacking for adolescents and young adults living with HIV across the globe. However, examples of good practice are beginning to emerge but require large-scale implementation studies with outcome data disaggregated by age, route of infection, and income setting, and include young pregnant women and key populations groups.

SUMMARY

There is an urgent need for evidence-based interventions addressing gaps in the adolescent HIV care cascade, including supporting retention in care and adherence to ART.

Posttraumatic Stress Symptoms and Disorders in Parents of Children and Adolescents With Chronic Physical Illnesses: A Meta-Analysis

The present meta-analysis analyzed whether parents of young people with pediatric chronic physical illnesses experience higher levels of posttraumatic stress symptoms (PTSS) and higher rates of posttraumatic stress disorder (PTSD) than other adults and searched for correlates of PTSS in these parents. Based on a systematic search in electronic databases, 184 studies were included in the meta-analysis. On average, 18.9% of the parents fulfilled the criteria for PTSD, and PTSS were more common among parents of young people with pediatric chronic physical illnesses than in other adults, with Hedges' g showing a 0.85 increase in standard deviation units. Parental PTSS were most prevalent among parents of children with epilepsy, g = 1.25, and diabetes, g = 1.16, and were positively associated with being the mother, r = .19; illness severity, r = .18; treatment duration/intensity, r = .21; and PTSS of the child, r = .34. In contrast, longer illness duration, r = -.19; longer time since active treatment, r = -.10; and better social resources, rs = -.17 to -.07, were associated with lower parental PTSS. The findings indicate that parents who have faced traumatic events in the context of their child's chronic illnesses should be screened for PTSS and PTSD and receive psychological interventions when needed.

Validation of a Short Adherence Questionnaire for Children Living with HIV on Antiretroviral Therapy in Kenya

Background:

There are few validated tools to measure adherence for children living with HIV. We identified questionnaire items for caregivers of Kenyan children aged <15 years living with HIV.

Methods:

Caregiver–child dyads were followed for 6 months. At monthly visits, the child’s HIV provider administered a 10-item questionnaire to the caregiver. Children were given electronic dose monitors (Medication Event Monitoring Systems [MEMS]). Correlation between questionnaire items and dichotomized MEMS adherence (≥90% doses taken versus <90%) was investigated using logistic regression models.

Results:

In 95 caregiver–child dyads, mean age of children (40% female) was 8.3 years. Items associated with higher odds of MEMS adherence in multivariable analysis included the father giving the child medication, being enrolled in a nutrition program, and the caregiver reporting no difficulties giving the child medication.

Conclusion:

Providers typically ask about missed doses, but asking about caregiver responsibilities and difficulties in giving the child medication may better detect suboptimal adherence.

How clinicians experience a simulated antiretroviral therapy adherence exercise: A qualitative study

Background

With the shift of paediatric antiretroviral therapy (ART) from tertiary to primary health care, there has been a need to train clinicians working in primary health care facilities to support adherence to treatment. An adherence simulation exercise was included in a course on paediatric human immunodeficiency virus (HIV) and tuberculosis (TB) to stimulate health care providers’ awareness and generate empathy of complex paediatric adherence practices.

Aim

The aim of this study was to describe the experience of clinicians completing the simulation exercise and to assess whether enhancing their empathy with patients and treatment supporters would improve their perceived clinical and counselling skills.

Setting

The study was conducted at the Faculty of Medicine and Health Sciences, Stellenbosch University, and a guesthouse in Cape Town.

Methods

The adherence module used blended learning methodology consisting of face-to-face contact sessions and distance learning. A qualitative thematic approach was used to understand the participant experiences through focus-group discussions and semi-structured interviews.

Results

Three thematic clusters emerged, namely, experiences of the simulated exercise, patient–provider relationships and adherence strategies. Their experiences were both positive and challenging, especially when a ‘caregiver and/or treatment supporter’ scenario encouraged participants to reflect on their own relationships with their patients. Clinicians had also considered how empathy fits into their scope of responsibilities. Text messaging and adherence counselling strategies were identified.

Conclusion

Simulated learning activities have the potential to create awareness of relationships between clinicians and their patients and generate ideas and discussion that could lead to improvements in clinical practice, and adherence promotion strategies.

"We did not know what was wrong"-Barriers along the care cascade among hospitalized adolescents with HIV in Gaborone, Botswana

High mortality among adolescents with HIV reflects delays and failures in the care cascade. We sought to elucidate critical missed opportunities and barriers to care among adolescents hospitalized with HIV at Botswana's tertiary referral hospital. We enrolled all HIV-infected adolescents (aged 10-19 years) hospitalized with any diagnosis other than pregnancy from July 2015 to January 2016. Medical records were reviewed for clinical variables and past engagement in care. Semi-structured interviews of the adolescents (when feasible) and their caregivers explored delays and barriers to care. Twenty-one eligible adolescents were identified and 15 were enrolled. All but one were WHO Clinical Stage 3 or 4. Barriers to diagnosis included lack of awareness about perinatal HIV infection, illness or death of the mother, and fear of discrimination. Barriers to adherence to antiretroviral therapy included nondisclosure, isolation, and mental health concerns. The number of hospitalized HIV-infected adolescents was lower than expected. However, among those hospitalized, the lack of timely diagnosis and subsequent gaps in the care cascade elucidated opportunities to improve outcomes and quality of life for this vulnerable group.

Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa

OBJECTIVE

To describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium.

METHODS

This study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis.

RESULTS

In East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]).

CONCLUSIONS

Self-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.

Pharmacokinetics-based adherence measures for antiretroviral therapy in HIV-infected Kenyan children

BACKGROUND

Traditional medication adherence measures do not account for the pharmacokinetic (PK) properties of the drugs, potentially misrepresenting true therapeutic exposure.

METHODS

In a population of HIV-infected Kenyan children on antiretroviral therapy including nevirapine (NVP), we used a one-compartment model with previously established PK parameters and Medication Event Monitoring Systems (MEMS®)-recorded dosing times to estimate the mean plasma concentration of NVP (Cp) in individual patients during 1 month of follow-up. Intended NVP concentration (Cp') was calculated under a perfectly followed dosing regimen and frequency. The ratio between the two (R = Cp/Cp') characterized the patient's NVP exposure as compared to intended level. Smaller R values indicated poorer adherence. We validated R by evaluating its association with MEMS®-defined adherence, CD4%, and spot-check NVP plasma concentrations assessed at 1 month.

RESULTS

In data from 152 children (82 female), children were mean age 7.7 years (range 1.5-14.9) and on NVP an average of 2.2 years. Mean MEMS® adherence was 79%. The mean value of R was 1.11 (SD 0.37). R was positively associated with MEMS® adherence (p < 0.0001), and lower-than-median R values were significantly associated with lower NVP drug concentrations (p = 0.0018) and lower CD4% (p = 0.0178), confirming a smaller R value showed poorer adherence.

CONCLUSION

The proposed adherence measures, R, captured patient drug-taking behaviours and PK properties.

Challenges and perspectives of compliance with pediatric antiretroviral therapy in Sub-Saharan Africa

More than 3 million children aged less than 15years are infected with HIV worldwide, mainly in Sub-Saharan Africa. The survival of HIV-infected children depends on their access to antiretroviral therapy whose success mainly depends on a good life-long compliance with antiretroviral therapy. Given its complexity and specificity, assessment and monitoring of pediatric compliance with antiretroviral therapy is a major challenge. There is no consensus on a gold standard for monitoring compliance with antiretroviral therapy. Compliance is also influenced by many factors related to the child, the caregiver, the healthcare staff, the healthcare system, and antiretroviral drugs. This review aimed to assess scientific knowledge on pediatric compliance with antiretroviral therapy in Sub-Saharan Africa, and to identify areas for future interventions to improve compliance. Good compliance is essential to achieve the "90% coverage of children on antiretroviral therapy" gold standard of the World Health Organization, and to eliminate HIV infection by 2030.

Impact of HIV-Status Disclosure on Adherence to Antiretroviral Therapy Among HIV-Infected Children in Resource-Limited Settings: A Systematic Review

Pediatric HIV remains a significant global health dilemma, especially in resource-constrained nations. As access to ART increases around the world, areas of concern in pediatric HIV treatment include age-appropriate disclosure of HIV status to children and development of adherence habits over time. This review was conducted to synthesize quantitative associations reported between disclosure and adherence among children living with HIV in resource-limited settings. An electronic database search of PubMed, MEDLINE and Cochrane returned 1348 results after removal of duplicates, 14 of which were found to meet inclusion criteria. Review of these reports showed conflicting results regarding the impact of disclosure on adherence, with 5 showing no association, 4 showing a negative impact of disclosure on adherence, and 5 showing positive benefits of disclosure for adherence habits. Thus, there was no clear consensus on the effect, if any, that disclosure has on medication adherence. Longitudinal, prospective research needs to be conducted to evaluate further impacts that disclosure may have on adherence habits over time, and interventions must be structured to link the two processes together in order to maximize health benefit to the child or adolescent.