Association of Adolescent- and Caregiver-Reported Antiretroviral Therapy Adherence with HIV Viral Load Among Perinatally-infected South African Adolescents

Longitudinal Trajectories of Antiretroviral Treatment Adherence and Associations With Durable Viral Suppression Among Adolescents Living With HIV in South Africa

BACKGROUND

Compared with other age groups, adolescents living with HIV (ALHIV) are estimated to have lower levels of adherence to antiretroviral treatment. Despite this, we lack evidence on adolescents' adherence patterns over time to inform the customization of intervention strategies.

SETTING

Eastern Cape province, South Africa.

METHODS

We analyzed data from a cohort of ALHIV (N = 1046, aged 10-19 years at baseline) recruited from 53 public health facilities. The cohort comprised 3 waves of data collected between 2014 and 2018 and routine viral load data from the National Institute for Communicable Disease data warehouse (2014-2019). Durable viral suppression was defined as having suppressed viral load (<1000 copies/mL) at ≥2 consecutive study waves. Group-based multitrajectory model was used to identify adherence trajectories using 5 indicators of self-reported adherence. Logistic regression modeling evaluated the associations between adherence trajectories and durable viral suppression.

RESULTS

Overall, 933 ALHIV (89.2%) completed all 3 study waves (55.1% female, mean age: 13.6 years at baseline). Four adherence trajectories were identified, namely, "consistent adherence" (49.8%), "low start and increasing" (20.8%), "gradually decreasing" (23.5%), and "low and decreasing" (5.9%). Adolescents experiencing inconsistent adherence trajectories were more likely to be older, live in rural areas, and have sexually acquired HIV. Compared with the consistent adherence trajectory, the odds of durable viral suppression were lower among adolescents in the low start and increasing (adjusted odds ratio [aOR]: 0.62, 95% CI: 0.41 to 0.95), gradually decreasing (aOR: 0.40, 95% CI: 0.27 to 0.59), and the low and decreasing adherence (aOR: 0.25, 95% CI: 0.10 to 0.62) trajectories.

CONCLUSIONS

Adherence to antiretroviral treatment remains a challenge among ALHIV in South Africa. Identifying adolescents at risk of nonadherence, based on their adherence trajectories may inform the tailoring of adolescent-friendly support strategies.

'Remember there is that thing called confidentiality': experiences of institutional discrimination in the health system among adolescent boys and young men living with HIV in the Eastern Cape province of South Africa

Adolescents and men are two populations that perform poorly within the HIV cascade of care, having worse AIDS-related health outcomes, and experiencing higher levels of HIV-related stigma. This paper explores institutional health system discrimination as experienced by adolescent boys with perinatally-acquired HIV, situating them within the social and gendered contexts of the Eastern Cape Province, South Africa. Life history narratives (n = 36) and in-depth semi-structured interviews (n = 32) with adolescent boys living with HIV aged 13-22 were conducted in 2017-2018. In-depth semi-structured interviews with biomedical and traditional health practitioners (n = 14), analysis of health facility files (n = 41) and clinic observations were also conducted. Together, triangulated sources point to an incongruence between the complex needs of adoelscent boys and young men living with HIV and their experiences within the health system. Two institutional discrimination-related deterrents to retention in care were identified: (1) lack of confidentiality due to health facility layouts and practices that visibilised people living with HIV; and (2) mistreatment in the form of shouting. This article contributes to the limited literature on the experiences of young men within the HIV continuum of care, focusing on how stigma influences how young men experience and engage with the health sector.

Comparison of Self and Caregiver Reports of Antiretroviral Treatment Adherence among Children and Adolescents Living with HIV in Western Kenya

BACKGROUND

Youth living with HIV with perinatal infection spend a lifetime taking antiretroviral treatment (ART) to suppress the virus, and face significant challenges to successfully maintaining ART adherence. Tools to measure adherence include self-report, medication event monitoring system (MEMS) pill bottle caps, pill counts, and plasma or hair drug levels; however, the inter-rater agreement between child and caregiver self-report has not been validated in an African setting. This study aims to assess inter-rater agreement between child and caregiver self-reports, compared to reporting from MEMS pill bottle caps.

METHODS

This was a secondary analysis of a cluster-randomized trial to evaluate an intervention for children living with HIV, conducted at the Academic Model Providing Access to Healthcare in western Kenya. We analyzed data from 285 child-caregiver dyads to compare adherence self-reported by children and their caregivers, and subsequently compared all self-reports to adherence reported by MEMS pill bottle caps to determine whether child or caregiver self-reports aligned more closely with adherence measured by MEMS.

RESULTS

Children and their caregivers reported similar levels of adherence and numbers of missed doses in the past month, and both reports were similarly associated with adherence reported by MEMS pill bottle caps. Children with a caregiver that was not a biological parent were significantly more likely to report more missed doses than their caregiver. The correlation coefficient for the relationship between the child and caregiver self-reports was 0.71; for the relationship between child report and MEMS was 0.23; and for the relationship between caregiver report and MEMS was 0.20. Both children and caregivers under-reported non-adherence compared to MEMS data.

CONCLUSION

Children and caregiver self-reports were generally similar in reporting adherence and were not highly correlated with MEMS reports of adherence, with children and caregivers reporting higher level of adherence than the MEMS data. This may indicate that children and caregiver reports are similarly inaccurate or biased; however, further research with larger sample sizes is required to further understand the differences in these reports.

Prevalence and predictors of virological failure in pediatric patients on HAART in sub-Saharan Africa: a systematic review and meta-analysis

Antiretroviral treatment failure has emerged as a challenge in the management of pediatric human immunodeficiency virus (HIV) patients, especially in resource-limited countries despite accessibility to Highly Active Antiretroviral Therapy (HAART). A systematic review and meta-analysis was conducted to synthesize virological failure (VF) prevalence and ascertain its predictors in children in sub-Saharan Africa. An electronic database search strategy was conducted from January to September 2021 on PubMed, EMBASE, SCOPUS, HINARI, and CINAHL. Further, manual searching was conducted on non-indexed journals. Utilizing the JASP© version 0.17.2 (2023) statistical software, a meta-analysis of pooled prevalence of VF was estimated using the standardized mean differences. Further, selection models were used to assess the risk of bias and heterogeneity. The pooled odds ratios were estimated for the respective studies reporting on predictors of VF. The overall pooled estimate of the prevalence of VF in sub-Saharan Africa among the sampled population was 29% (95% CI: 27.0-32.0; p<0.001). Predictors of VF were drug resistance (OR: 1.68; 95% CI: 0.88-2.49; p < 0.001), poor adherence (OR: 5.35; 95% CI: 5.26-5.45; p < 0.001), nevirapine (NVP)-based regimen (OR: 5.11; 95% CI: 4.66-5.56; p < 0.001), non-usage of cotrimoxazole prophylaxis (OR: 4.30; 95% CI: 4.13-4.47; p < 0.001), higher viral load at the initiation of antiretroviral therapy (ART) (OR: 244.32; 95% CI: 244.2-244.47; p <0.001), exposure to the prevention of mother to child transmission (PMTCT) (OR: 8.02; 95%CI: 7.58-8.46; p < 0.001), increased age/older age (OR: 3.37; 95% CI: 2.70-4.04; p < 0.001), advanced World Health Organization (WHO) stage (OR: 6.57; 95% CI: 6.17-6.98; p < 0.001), not having both parents as primary caregivers (OR: 3.01; 95% CI: 2.50-3.53; p < 0.001), and tuberclosis (TB) treatment (OR: 4.22; 95% CI: 3.68-4.76; p <0.001). The mean VF prevalence documented is at variance with studies in other developing countries outside the sub-Saharan region. The high prevalence of HIV cases contrasting with the limited expertise in the management of pediatric ART patients could explain this variance.

Traditional and biomedical health practices of adolescent boys and young men living with perinatally-acquired HIV in the Eastern Cape Province of South Africa

Men are less vulnerable to HIV acquisition than women, but have poorer HIV-related health outcomes. They access HIV services less, and are more likely to die on antiretroviral therapy. The adolescent epidemic presents further challenges, and AIDS-related illness is the leading cause of death among adolescents in sub-Saharan Africa. We explored the health practices of adolescent boys and young men (aged 13-22) living with perinatally-acquired HIV and the processes through which these practices are formed and sustained. We engaged health-focused life history narratives (n = 35), semi-structured interviews (n = 32) and analysis of health facility files (n = 41), alongside semi-structured interviews with traditional and biomedical health practitioners (n = 14) in the Eastern Cape, South Africa. Participants did not access traditional products and services for HIV, a finding that deviates from much of the literature. Findings suggest that health practices are mediated not only by gender and culture, but also childhood experiences of growing up deeply embedded in the biomedical health system.

Reasons for discordance between antiretroviral adherence measures in adolescents

Adolescents with suboptimal medication taking may deceive caregivers about non-adherence. We conducted a 5-year longitudinal study of adolescents monitored simultaneously with both easily manipulated (e.g., self-report) and hard to manipulate (e.g., microelectronic data) strategies. Adolescents with repeatedly high adherence on the former and low adherence on the latter were invited along with their parental figures ("parents") to participate. We conducted focus groups and semi-structured interviews, separately for adolescents and parents, to elucidate drivers of discordant measures. Forty-seven adolescents and 26 parents participated in focus groups and 4 adolescents were interviewed. Adolescents described hiding pills, discarding pills, and lying. Their motivations included fear of disappointing those who care about them, desire to avoid admonishment by parents and clinic staff, and desire to avoid remedial adherence counseling. Both adolescents and parents considered negative feedback for prior poor adherence to be key motivation to hide current poor adherence from clinic staff. Providing positive feedback for truth-telling, rather than for "evidence" of excellent adherence, might help adolescent patients and their parents to develop stronger treatment alliances with each other and with clinic staff. Such alliances would allow adherence interventions to be better targeted and more fruitful in increasing adherence.

Predictors and consequences of HIV status disclosure to adolescents living with HIV in Eastern Cape, South Africa: a prospective cohort study

INTRODUCTION

The World Health Organization recommends full disclosure of HIV-positive status to adolescents who acquired HIV perinatally (APHIV) by age 12. However, even among adolescents (aged 10-19) already on antiretroviral therapy (ART), disclosure rates are low. Caregivers often report the child being too young and fear of disclosure worsening adolescents' mental health as reasons for non-disclosure. We aimed to identify the predictors of disclosure and the association of disclosure with adherence, viral suppression and mental health outcomes among adolescents in sub-Saharan Africa.

METHODS

Analyses included three rounds (2014-2018) of data collected among a closed cohort of adolescents living with HIV in Eastern Cape, South Africa. We used logistic regression with respondent random-effects to identify factors associated with disclosure, and assess differences in ART adherence, viral suppression and mental health symptoms between adolescents by disclosure status. We also explored differences in the change in mental health symptoms and adherence between study rounds and disclosure groups with logistic regression.

RESULTS

Eight hundred and thirteen APHIV were interviewed at baseline, of whom 769 (94.6%) and 729 (89.7%) were interviewed at the second and third rounds, respectively. The proportion aware of their HIV-positive status increased from 63.1% at the first round to 85.5% by the third round. Older age (adjusted odds ratio [aOR]: 1.27; 1.08-1.48) and living in an urban location (aOR: 2.85; 1.72-4.73) were associated with disclosure between interviews. There was no association between awareness of HIV-positive status and ART adherence, viral suppression or mental health symptoms among all APHIV interviewed. However, among APHIV not aware of their status at baseline, adherence decreased at the second round among those who were disclosed to (N = 131) and increased among those not disclosed to (N = 151) (interaction aOR: 0.39; 0.19-0.80). There was no significant difference in the change in mental health symptoms between study rounds and disclosure groups.

CONCLUSIONS

Awareness of HIV-positive status was not associated with higher rates of mental health symptoms, or lower rates of viral suppression among adolescents. Disclosure was not associated with worse mental health. These findings support the recommendation for timely disclosure to APHIV; however, adherence support post-disclosure is important.

Blood and Blood: Anti-retroviral Therapy, Masculinity, and Redemption among Adolescent Boys in the Eastern Cape Province of South Africa

Adolescents living with perinatally acquired HIV are among the first generation in South Africa to grow up with anti‐retroviral therapy and democratic freedoms. In this article, we explore the biosocial lives of adolescent boys and young men living with HIV in the Eastern Cape Province of South Africa. We conducted qualitative research with 36 adolescent boys and young men in 2016‒2018, including life history narratives, semi‐structured interviews, and analysis of health facility files. [masculinity, South Africa, HIV, adolescence]

'If you are found taking medicine, you will be called names and considered less of a man': young men's engagement with HIV treatment and care during ulwaluko (traditional initiation and circumcision) in the Eastern Cape Province of South Africa

This paper explores how HIV-positive abakhwetha (young male initiates) undergoing ulwaluko (traditional Xhosa initiation and circumcision) engage with HIV-related biomedical care and treatment. Health-focused life history narratives (n = 36), semi-structured interviews (n = 32) and analysis of health facility files (n = 41) with adolescent boys and young men (ages 13-24) living with HIV, and semi-structured interviews with traditional and biomedical health practitioners (n = 14) were conducted in 2017 and 2018. This research was part of the Mzantsi Wakho study, a longitudinal, mixed methods study of adolescents living with HIV (n = 1060). Findings demonstrate that ulwaluko rules of not engaging with biomedical care and treatment pose a challenge for initiates who are taking chronic medicine. Fears of inadvertent disclosure of their HIV-positive status collide with the pressure to successfully complete ulwaluko in order to be legitimised as men. In response to this dilemma, they engage a variety of strategies - including taking medicine in secret by hiding them, having a trusted person deliver them discretely, and stopping medicine-taking altogether. The three months following ulwaluko also pose a challenge in accessing biomedical treatment and care. In this time of high surveillance, amakrwala (new men) do not present at health facilities for fear of being thought to have had a botched circumcision or to have contravened 'manhood rules' and left ulwaluko before having healed properly. To get around this, those who continued taking medicine engaged caregiver pick-ups. Beyond suggesting that ulwaluko is a high-risk time for disengagement from biomedical treatment and care, this paper builds on a robust scholarship on the importance of locality and context in gender and health research. It documents the creativity, agency and resilience of initiates and their families as they subvert and re-signify health-related masculine norms.

The secret life of young adolescents living with HIV in northern Mozambique - a mixed methods study

Background

In Mozambique, HIV infection remains a leading cause of adolescent mortality. With advances in antiretroviral treatment (ART), the population of adolescents living with vertically-acquired HIV is growing. Most studies of adolescents living with HIV (ALHIV) focus on older youth with horizontal infection. As part of a larger study, we examined the characteristics and health care needs of younger ALHIV, including those with vertically-acquired infection to inform preventive interventions.

Methods

We used a convergent mixed-methods design and recruited ALHIV aged 12–14 years who were enrolled in HIV care in three health clinics in Nampula, Mozambique. From 11/2019–3/2020, we conducted 61 quantitative surveys and 14 in-depth interviews with a purposively selected subset of ALHIV who were aware of their HIV status. Descriptive statistical analysis was conducted for quantitative data. Qualitative data were transcribed and analyzed using thematic analysis.

Results

The median age of ALHIV was 13 years, 50% were female, 67% lived with ≥1 parent, 70% had lost a parent, 100% were in school; 10% were in a relationship, and 3% had initiated sexual activity. Among 31 ALHIV aware of their serostatus, the median age of antiretroviral treatment (ART) initiation was 8 years (IQR: 6–11); 55% received caregiver support for ART management; 35% reported missing ≥1 ART dose in the last 30 days; 6% had disclosed their HIV-status to friends and 48% reported no one to talk to about HIV-specific issues. Four main themes emerged from the qualitative interviews with ALHIV: a) learning one’s HIV-positive status as the beginning of a secret life; b) importance of caregivers’ support for ART management; c) high value of ALHIV peer support to overcome isolation, increase HIV literacy, and support adherence; and d) unmet needs for sexual and reproductive health education.

Conclusion

HIV-related secrecy prevails among ALHIV, a situation exacerbated by caregivers and healthcare providers. Caregivers play a major role in supporting adherence among young ALHIV, yet ALHIV could also benefit from adolescent-friendly services, including peer support, sexual and reproductive health services and preparation for independent health management. Integrating such programs into ART services in Mozambique may be critical to promoting ALHIV health.

Tuberculosis infection and disease in South African adolescents with perinatally acquired HIV on antiretroviral therapy: a cohort study

INTRODUCTION

There are limited data on Tuberculosis (TB) in adolescents with perinatally acquired HIV (APHIV). We examined the incidence and determinants of TB infection and disease in the Cape Town Adolescent Antiretroviral Cohort (CTAAC).

METHODS

Youth between nine and fourteen years on antiretroviral therapy (ART) for more than six months in public sector care, and age-matched HIV-negative adolescents, were enrolled between July 2013 through March 2015 and followed six-monthly. Data were censored on 31 October 2018. Symptom screening, chest radiograph, viral load, CD4 count, QuantiFERON (QFT) and sputum for Xpert MTB/RIF, microscopy, culture and sensitivity were performed annually. TB infection was defined by a QFT of >0.35 IU/mL. TB diagnosis was defined as confirmed (culture or Xpert MTB/RIF positive) or unconfirmed (clinical diagnosis and started on TB treatment). Analyses examined the incidence and determinants of TB infection and disease.

RESULTS

Overall 496 HIV+ and 103 HIV-negative participants (median age at enrolment 12 years (interquartile range, IQR 10.6 to 13.3) were followed for a median of 3.1 years (IQR 3.0 to 3.4); 50% (298/599) were male. APHIV initiated ART at median age 4.4 years (IQR 2.1 to 7.6). At enrolment, 376/496 (76%) had HIV viral load <40 copies/mL, median CD4 count was 713 cells/mm3 and 179/559 (32%) were QFT+, with no difference by HIV status (APHIV 154/468, 33%; HIV negative 25/91, 27%; p = 0.31). The cumulative QFT+ prevalence was similar (APHIV 225/492, 46%; 95%CI 41% to 50%; HIV negative 44/98, 45%; 95% CI 35% to 55%; p = 0.88). APHIV had a higher incidence of all TB disease than HIV-negative adolescents (2.2/100PY, 95% CI 1.6 to 3.1 vs. 0.3/100PY, 95% CI 0.04 to 2.2; IRR 7.36, 95% CI 1.01 to 53.55). The rate of bacteriologically confirmed TB in APHIV was 1.3/100 PY compared to 0.3/100PY for HIV-negative adolescents, suggesting a fourfold increased risk of developing TB disease in APHIV despite access to ART. In addition, a positive QFT at enrolment was not predictive of TB in this population.

CONCLUSIONS

High incidence rates of TB disease occur in APHIV despite similar QFT conversion rates to HIV-negative adolescents. Strategies to prevent TB in this vulnerable group must be strengthened.

Youth perinatal HIV-associated neurocognitive disorders: association with functional impairment

HIV-associated functional impairment may cause cognitive impairment secondary to the viral infection, hence, associations between cognitive impairment and functional impairment in youth living with HIV are important to assess. We sought to determine whether cognitive impairment is associated with functional impairment and if it carries higher risk for also having functional impairment. We collected parent-rated information regarding youth functional impairment on four different measures and administered a cognitive battery to youth to determine cognitive impairment, 203 HIV-infected youth and 44 HIV-uninfected controls. Degree of cognitive impairment correlated strongly with decreased function: CBCL, r = -.17, p = .01; VABS2, r = -.28, p < .001; repeated-grades, r = .26, p < .001. Presence of cognitive impairment was associated with increased risk of functional impairment: 3.47 (CIS); 1.71 (CBCL); 2.17 (VABS2); 2.97 (repeated-grades). Repeated-grades strongly associated with cognitive impairment and functional impairment. We found strong associations between HIV-infected youth functional impairment on CBCL, VABS2 and repeated-grades with degree of cognitive impairment; and that when cognitive impairment was present youth had higher risk of experiencing functional impairment as well. Asking whether youth have repeated a grade at school could be a helpful screening question for assessing potential functional impairment and provide clinicians with an indication as to whether a further in-depth assessment is required.

Factors Associated With Nonadherence to Antiretroviral Therapy Among Young People Living With Perinatally Acquired HIV in England

Young people living with perinatally acquired HIV may be at risk of poor adherence to antiretroviral therapy; identification of predictors, using a conceptual framework approach proposed previously by others, is important to identify those at higher risk. In 261 young people with perinatally acquired HIV in England, 70 (27%) reported 3-day nonadherence, 82 (31%) last month nonadherence, and 106 (41%) nonadherence on either measure. Of those reporting nonadherence on both measures, 52% (23/44) had viral load of <50 copies/ml, compared with 88% (127/145) of those reported being fully adherent. In multivariable analysis, young person and medication theme factors were associated with nonadherence. The main predictors of 3-day nonadherence were antiretroviral therapy containing a boosted protease inhibitor and poorer quality of life. Predictors of last month nonadherence were having told more people about one's HIV status, worse self-perception about having HIV, and boosted protease inhibitor-based regimens. The consistency of individual young person and medication factors in predicting nonadherence gives insight into where interventions may best be targeted to improve adherence.

Hospitalization in South African Adolescents With Perinatally Acquired HIV on Antiretroviral Therapy

BACKGROUND

Little is known about hospitalization in African adolescents with perinatally acquired HIV (PHIV+ adolescents). We described the incidence and causes of hospitalization in participants enrolled in the Cape Town Adolescent Antiretroviral Cohort in South Africa.

METHODS

Data collected from July 2013 to October 2018 from PHIV+ and HIV- adolescents were analyzed. Participants were assessed every 6 months and data on intercurrent hospitalization were abstracted. Causes of hospitalizations were classified according to ICD-10 codes. Descriptive statistics, time-to-event analysis and Poisson regression were used to describe causes and incidence and to determine incidence rate ratios for factors associated with hospitalization.

RESULTS

Five hundred fifteen PHIV+ and 109 HIV- participants had a median follow-up of 4.1 years [interquartile range (IQR): 3.7-4.6]. At enrollment HIV+ participants had a median duration of ART of 7.6 years (IQR: 4.6-9.2), median CD4 count of 713 cells/mm (IQR: 561.0-957.5) and 387 (75%) had a viral load <50 copies/mL. There were 149 hospital admissions over 64 months. Crude incidence rates for hospitalization were 6.6 [95% confidence interval (CI): 5.7-7.8] and 2.2 (95% CI: 1.2-4.3) per 100-person-years (P = <0.01) in HIV + and HIV-, respectively. Ninety of 149 (60%) admissions in HIV+ participants were classified as non-infectious, 36/149 (24%) were infectious and 23/149 (16%) were "other HIV-related" or "unknown." Older age (15-19 years) and maintaining a CD4 >500 cells/cm were associated with decreased risk of hospitalization: adjusted incidence rate ratios of 0.61 (CI: 0.44-0.86, P = <0.01) and 0.68 (CI: 0.49-0.94, P = 0.02), respectively.

CONCLUSIONS

PHIV+ adolescents had a high incidence of hospitalization despite ART. Strategies addressing infectious and non-infectious morbidity must be strengthened.

Patterns of detectable viral load in a cohort of HIV-positive adolescents on antiretroviral therapy in South Africa

INTRODUCTION

Despite improved treatment and access to care, adolescent AIDS deaths are decreasing more slowly than in any other age group. There is lack of longitudinal data around adolescent adherence and the dynamics of viraemia over time. We aimed to describe patterns of detectable viral load (VL) in a cohort of adolescents attending an ARV clinic in Cape Town, South Africa.

METHODS

We conducted a retrospective cohort study of all patients on antiretroviral therapy aged 10 to 19 years. Participants were included if they underwent at least two VL measurements and remained in care at the Groote Schuur Hospital HIV Clinic for at least 24 months between 2002 and 2016. The primary outcome was two consecutive HIV VL >100 copies/mL, in line with the lower limit of detection of assays in use over the follow-up period.

RESULTS AND DISCUSSION

Of the 482 screened participants, 327 met inclusion criteria. Most participants had perinatally acquired HIV (n = 314; 96%), and 170 (52%) were males. Overall, there were 203 episodes of confirmed detectable VL involving 159 (49% (95% CI 43% to 54%)) participants during the follow-up period. Six participants had genotyped resistance to protease inhibitors. Four of these never suppressed, while two suppressed on salvage regimens. Total follow-up time was 1723 person years (PY), of which 880 (51%) were contributed by the 159 participants who experienced detectable VL. Overall time with detectable VL was 370 PY. This comprised 22% of total follow-up time, and 42% of the follow-up time contributed by those who experienced detectable VL. The rate of detectable VL was 11.8 (95% CI 10.3 to 13.5) episodes per 100 PY. The risk increased by 24% for each year of increasing age (Relative Risk 1.24 (95% CI 1.17 to 1.31); p < 0.0001). There was no sex difference with respect to duration (p = 0.4), prevalence (p = 0.46) and rate (p = 0.608) of detectable VL.

CONCLUSIONS

Clinicians need to be alert to the high prevalence of detectable VL during adolescence so as to pre-empt it and act swiftly once it is diagnosed. This study helps to highlight the risk of detectable VL that is associated with increase in age as well the high proportion of time that poorly adherent adolescents spend in this state.

Urban-rural disparity in sociodemographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women and their perspectives on their male sexual partners: A cross-sectional study in Zimbabwe

We conducted a cross sectional survey in Zimbabwe to describe urban-rural disparity in socio-demographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women (AGYW) and their male sexual partners. Between September and November 2016, we interviewed 360 sexually active HIV positive AGYW, aged 15––24 years attending ART and PMTCT clinics in urban and rural health facilities in Harare and Mazowe district respectively. HIV positive AGYW in rural areas as compared to those in urban areas were older, less educated, more frequently married or cohabiting, had lower number of male sexual partners in their lifetime and in the last 12 months preceding the survey. They were mostly heterosexually infected, more likely to disclose their status to a family member and to be more adherent to ART (OR = 2.5–95% CI = 1.1–5.5). Most recent male sexual partners of HIV positive AGYW in urban areas as compared to those from rural areas were mainly current or former boyfriends, single, more educated, less likely to have a child with them and to engage in couple voluntary counseling and testing (CVCT). They were more likely to patronize dancing and drinking venues and involved in transactional sex (OR = 2.2–95% CI: 1.2–4). They were also more likely to be circumcised (OR = 2.3–95% CI: 1.3–4.1) and to use condom more consistently in the last 12 months preceding the survey. Our study findings called for the strengthening of HIV prevention interventions in urban areas among HIV positive AGYW who had more than one partner in their lifetime or are patronizing dancing and drinking venues. In Zimbabwe, promotion of CVCT, index testing, male circumcision and condom use should be sustained to engage male sexual partners of both urban and rural HIV positive AGYW in HIV prevention.

Long-term outcomes in perinatally HIV-infected adolescents and young adults on antiretroviral therapy: a review of South African and global literature

Paediatric antiretroviral programmes have been implemented globally for more than a decade, yet information on long-term treatment outcomes in perinatally HIV-infected adolescents is limited. Published literature on long-term treatment outcomes was reviewed, including virologic, immunologic and growth outcomes, as well as drug resistance and factors associated with drug resistance. Outcomes were compared between high-income countries and low- and middle-income countries (LMIC), with additional focus on South Africa, the country with the biggest HIV epidemic in the world and the largest treatment programme. Treatment outcomes varied but viral suppression results globally were generally concerning. No studies from LMIC have reported on outcomes after >10 years follow-up, demonstrating that further studies are needed.

Screening for HIV-associated neurocognitive disorders in perinatally infected adolescents: youth-International HIV Dementia Scale validation

CONTEXT

Perinatal HIV infection has adverse cognitive consequences into adolescence. However, there are no screening tools that assess risk for HIV-associated neurocognitive disorders in adolescent populations. Such screening tools are needed urgently for clinical care in resource-poor settings with a high prevalence of HIV.

OBJECTIVE

To investigate the performance of the International HIV Dementia Scale (IHDS) as a screening tool for HIV-associated neurocognitive disorders in perinatally adolescents.

DESIGN

The current study is a quantitative, quasiexperimental design.

METHODS

Perinatally HIV-infected adolescents aged 9-12 years were recruited from community health clinics into the Cape Town Adolescent Antiretroviral Cohort; matched HIV-negative controls from the same communities were enrolled. Each participant completed the IHDS and a comprehensive neuropsychological battery. The adult version of the IHDS was performed, except for two minor modifications. We evaluated the diagnostic validity of this modified instrument, the youth-IHDS (y-IHDS), using a four-step process that included sensitivity and specificity calculations, and generating receiver operating characteristic curves. Validity was measured against the youth HIV-associated diagnostic criteria.

RESULTS

At a cut-off score of 10 or less, the y-IHDS demonstrated good sensitivity (94%) but poor specificity (24%) for detecting all forms of neurocognitive disorders, with an acceptable area under the curve value of 0.695.

CONCLUSION

The y-IHDS requires minimal resources and is based on a screening tool for adult HIV-associated cognitive disorders that is already widely used globally. Hence, this brief, cost-efficient, and valid screening tool may be a useful addition for clinicians working in resource-poor contexts in which adolescent HIV is highly prevalent.

Behavioural health risks during early adolescence among perinatally HIV-infected South African adolescents and same-age, HIV-uninfected peers

Behavioural health risks, including substance use, early sexual debut, bullying and suicidality, are common during adolescence, but may be complicated among perinatally HIV-infected adolescents. However, there are few data exploring these behaviours in sub-Saharan Africa. We compared behavioural health risks (any self-report of substance use, sexual activity, bullying others or suicidality, or a positive urine toxicology screen) among perinatally-infected adolescents ages 9-14 years to that of an HIV-uninfected comparator group; and explored the effect of behavioural health risks on adolescent and caregiver report of adolescent suboptimal adherence (missed antiretroviral therapy dose(s) on ≥1 day during the preceding 30 days) and elevated HIV viral load (≥50 and ≥1000 copies/mL in sensitivity analyses) in multivariable logistic regression models. Among 506 HIV-infected and 110 HIV-uninfected adolescents (median age overall: 12 years), 15% and 25% reported any behavioural health risk (p = 0.018), respectively. Tobacco and other drug use was uncommon, while alcohol use was reported by 8% of HIV-infected versus 12% of HIV-uninfected adolescents (p = 0.185). One HIV-infected (0.2%) and 3 HIV-uninfected adolescents (3%) reported any sexual activity (p = 0.019). Among HIV-infected adolescents, report of any behavioural health risk was more common among male adolescents [adjusted odds ratio (aOR): 1.78; 95% confidence interval (CI): 1.08-2.95] and was associated with adolescent report of suboptimal adherence (aOR: 1.66; 95% CI: 0.99-2.78) but not with caregiver report of suboptimal adherence or with elevated viral load. In this group of perinatally-infected youth entering early adolescence, the prevalence of behavioural health risks was lower than that among same-age, HIV-uninfected peers. Longitudinal data are needed to explore the reasons underlying these differences, for example the possibility of more protective caregiving and supportive family environments, or of emotional and physical immaturity, as well as the emergence of risk behaviours over time in this population.