"Not Taking it Will Just be Like a Sin": Young People Living with HIV and the Stigmatization of Less-Than-Perfect Adherence to Antiretroviral Therapy

A Call for Youth Voice to Support Engagement in Care for 18- to 29-Year Olds Living with HIV in the US South

Youth with HIV (YWH) face challenges in achieving viral suppression, particularly in the Southern United States, and welcome novel interventions responsive to community needs. The Theory of Planned Behavior (TPB) describes factors that influence behavior change, and the Positive Youth Development (PYD) supports youth-focused program design. We applied TPB and PYD to explore factors supporting care engagement and challenges for YWH in South Texas. We conducted 14 semi-structured interviews with YWH and 7 focus groups with 26 stakeholders informed by TPB, PYD, and themes from a youth advisory board (YAB). The research team and YAB reviewed emerging themes, and feedback-aided iterative revision of interview guides and codebook. Thematic analysis compared code families by respondent type, TPB, and PYD. All study methods were reviewed by the UT Health San Antonio and University Health Institutional Review Boards. Emerging themes associated with care engagement included: varied reactions to HIV diagnosis from acceptance to fear/grief; financial, insurance, and mental health challenges; history of trauma; high self-efficacy; desire for independence; and desire for engagement with clinic staff from their age group. Stakeholders perceived YWH lifestyle, including partying and substance use, as care barriers. In contrast, YWH viewed "partying" as an unwelcome stereotype, and barriers to care included multiple jobs and family responsibilities. Two key themes captured in PYD but not in TPB were the importance of youth voice in program design and structural barriers to care (e.g., insurance, transportation). Based on these findings, we provide critical and relevant guidance for those seeking to design more effective youth-centered HIV care engagement interventions. By considering the perspectives of YWH in program design and incorporating the PYD framework, stakeholders can better align with YWHs' desire for representation and agency. Our findings provide important and relevant guidance for those seeking to design more effective HIV care engagement interventions for YWH.

"What if I got rejected by the girl? I would rather stop the pills": barriers and facilitators of adherence to antiretroviral therapy for emerging adults aged 18-29 living with HIV in Zimbabwe

Emerging adults aged 18-29 have high rates of viral non-suppression, and poorer adherence to ART when compared to older adults. Semi-structured interviews were conducted with 24 emerging adults in Zimbabwe who had a recent history of viral non-suppression, to explore barriers and facilitators of adherence to ART. Interviews were coded using inductive thematic analysis. The mean age of participants was 23, 65% were male, and 79% reported acquiring HIV at birth. Twelve barriers to adherence were identified. Hiding HIV status due to the possible negative consequences of disclosure had a significant impact on adherence to ART. This was particularly important for emerging adults navigating starting intimate relationships. Being away from home, poverty, poor mental health, isolation, significant life events, alcohol, health systems barriers, and stigma were reported as barriers to adherence. Support from peers and family after disclosure of HIV status, phone-based reminders, problem-solving strategies to adhere, knowing others living with HIV, acted as facilitators to adherence to ART. Beliefs about medicines and relationships with health care providers acted as both barriers and facilitators to adherence. Interventions to reduce stigma, foster peer support, and therapy for common mental disorders could facilitate emerging adults aged 18-29 to adhere to ART.

"They test my blood to know how much blood is in my body": the untapped potential of promoting viral load literacy to support adherence and viral suppression among adolescents living with HIV

INTRODUCTION

Achieving sustained HIV viral suppression is a key strategy to optimize the health and wellbeing of those living with HIV. Sub-optimal adherence to antiretroviral therapy (ART) in adolescents and young people living with HIV (AYPLHIV) in Southern Africa, due to a range of social and contextual factors, including poor mental health, has presented a substantial challenge to meeting targets aimed towards improving treatment outcomes and reducing transmission. With the increasing availability of viral load (VL) testing in Southern Africa, there is an opportunity to better understand the relationship between VL literacy, wellbeing and adherence among adolescents.

METHODS

We conducted qualitative interviews with 45 AYPLHIV aged 10-24 years in three districts (urban, peri-urban and rural) in Zimbabwe between March and August 2021. The sample was purposively selected to represent a range of experiences related to HIV status disclosure, gender, marital status and treatment experience. Separate workshops were conducted with 18 healthcare workers (HCWs) and 20 caregivers to better understand existing support mechanisms to AYPLHIV accessing ART. We used thematic analysis to examine adolescent VL literacy, treatment support networks, experiences of clinic interactions, VL testing procedures and barriers to adherence.

RESULTS

VL literacy was consistently under-developed among participants. Comprehension of phrases commonly heard during clinic visits, such as TND (target not detected) and "high" and "low" VL, were better understood by older participants. VL testing was predominantly understood as a clinical procedure that enables HCWs to monitor treatment adherence. Absent throughout the interviews were descriptions of how viral suppression improves health and quality of life, likely fosters wellbeing and enhances self-esteem, enables participation in education and social activities, and eliminates the risk of onward transmission.

CONCLUSIONS

It is imperative that we reconsider how routine VL monitoring is communicated to and understood by AYPLHIV. Reframing ART, including VL test results, in terms of the psychosocial benefits that viral suppression can generate is likely to be crucial to motivating AYPLHIV to maintain optimal treatment engagement and develop self-management approaches as they move into adulthood. Access to accurate information tailored to individual concerns and circumstances can support AYPLHIV to achieve wellbeing.

Let's talk about U=U: seizing a valuable opportunity to better support adolescents living with HIV

The clinical knowledge that people living with HIV who maintain an undetectable viral load and therefore cannot transmit HIV sexually, known as Undetectable equals Untransmittable (U=U), has reached a critical mass of adults, but it is relatively silenced within adolescent HIV care and support. We argue that understanding the full range of opportunities enabled by viral suppression, including the elimination of transmission risk, could transform adolescents' understanding of living with HIV, incentivise optimal treatment engagement and support and sustain their positive mental health. However, the reluctance to discuss U=U with adolescents means that we are not providing them with adequate access to the information and tools that would help them to succeed. We need to recognise, value, and invest in the mediating role of building viral load literacy, illustrated by conveying U=U in ways that are meaningful for adolescents, to accelerate viral suppression. Rather than protect, rationing access to information on U=U only increases their vulnerability and risk to poor HIV and mental health outcomes.

Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa

The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.

Two-year retention in care for adolescents on antiretroviral therapy in Ehlanzeni district, South Africa: a baseline cohort analysis

Adolescents living with HIV (ALHIV) struggle to remain engaged in HIV-related care and adhere to antiretroviral treatment (ART) due to a myriad of physical, psychological and cognitive-developmental challenges. We report on the profile of ALHIV aged 10-19 years on ART and the clinical factors associated with their retention in care. A retrospective cohort analysis was conducted with 16,108 ALHIV, aged 10-19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Anonymised data were obtained from electronic medical records (Tier.net). Trends in retention in care among adolescents on ART was described using Kaplan-Meier survival estimates. Cox proportional analysis was performed to identify factors associated with retention in care over 2 years. More than half (53%) were females, and median duration on ART was 8 months. Retention in care among adolescents at months 6, 12, 18 and 24 was 90.5%, 85.4%, 80.8% and 76.2%, respectively. After controlling for confounders, risk of dying or lost to follow up increased for female adolescents (aHR = 1.28, 95% CI 1.10-1.49); being initiated on ART while pregnant (aHR = 2.72, 95% CI 1.99-3.69); history of TB infection (aHR = 1.71, 95% CI 1.10-2.65); and started ART at age 10-14 years (aHR = 2.45, 95% CI 1.96-3.05), and 15-19 years (aHR = 9.67, 95% CI 7.25-12.89). Retention in care among adolescents on ART over two-year period was considerably lower than the UNAIDS 2030 target of 95%. Of particular concern for intervention is the lower rates of retention in care among females and pregnant adolescents and starting ART between the ages of 10 and 19 years. Family or caregivers and peer support groups centred interventions designed to promote early initiation and retention in care through early case identification are needed.

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]

The end of AIDS? HIV and the new landscape of illness in rural South Africa

The global HIV/AIDS scientific community has begun to hail the dawn of 'the End of AIDS' with widespread anti-retroviral therapy (ART) and dramatic declines in AIDS-related mortality. Drawing on community focus groups and in-depth individual interviews conducted in rural South Africa, we examine the complex unfolding of the end of AIDS in a hard-hit setting. We find that while widespread ART has led to declines in AIDS-related deaths, stigma persists and is now freshly motivated. We argue that the shifting landscape of illness in the community has produced a new interpretive lens through which to view living with HIV and dying from AIDS. Most adults have one or more chronic illnesses, and ART-managed HIV is now considered a preferred diagnosis because it is seen as easier to manage, more responsive to medication, and less dangerous compared to diseases like cancer, hypertension, and diabetes. Viewed through this comparative lens, dying from AIDS elicits stigmatising individual blame. We find that blame persists despite community acknowledgement of structural barriers to ART adherence. Setting the ending of AIDS within its wider health context sheds light on the complexities of the epidemiological and health transitions underway in much of the developing world.

'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.

How older people living with HIV narrate their quality of life: Tensions with quantitative approaches to quality-of-life research

This article draws on life-history interviews with older (aged 50+) people living with HIV in England to uncover the interpretive practices in which they engaged as they evaluated their own quality of life (QoL). Our paper highlights the distinctive insights that biographical and narrative approaches can bring to QoL research. While accounts of subjectively 'poor' QoL were relatively straightforward and unequivocally phrased, accounts of subjectively 'good' and 'OK' QoL were produced using complex interpretive and evaluative practices. These practices involved biographical reflection and contextualization, with participants weighing up and comparing their current lives' 'pros' and 'cons', their own lives with the lives of others, and their present lives with lives they had imagined having at the time of interview. Thus, 'good' and 'OK' QoL were constructed using practical, relational, and interpretive work - features of QoL analytically unavailable in quantitative data gathered through standardised measures (including our own survey data collected from these same participants). Our findings underscore the uneasy fit between QoL's quantitative measurement and its subjective understandings and evaluations, on the one hand, and the interpretive work that goes into achieving these understandings and evaluations, on the other.

Testing for saturation in qualitative evidence syntheses: An update of HIV adherence in Africa

Background

A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant.

Methods

We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as ‘rich’ or ‘sparse’, coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model.

Results

After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory.

Conclusions

Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.

Risk factors for HIV virological non-suppression among adolescents with common mental disorder symptoms in Zimbabwe: a cross-sectional study

INTRODUCTION

Adolescents are at increased risk of HIV virological non-suppression compared to adults and younger children. Common mental disorders such as anxiety and depression are a barrier to adherence and virological suppression. The aim of this study was to identify factors associated with virological non-suppression among adolescents living with HIV (ALWH) in Zimbabwe who had symptoms of common mental disorders.

METHODS

We utilized baseline data from a cluster-randomized controlled trial of a problem-solving therapy intervention to improve mental health and HIV viral suppression of ALWH. Sixty clinics within 10 districts were randomized 1:1 to either the intervention or control arm, with the aim to recruit 14 adolescents aged 10 to 19 per clinic. Adolescents were eligible if they scored ≥7 on the Shona Symptom Questionnaire measuring symptoms of common mental disorders. Multivariable mixed-effects logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for factors associated with non-suppression, defined as viral load ≥1000 copies/mL.

RESULTS

Between 2 January and 21 March 2019 the trial enrolled 842 participants aged 10 to 19 years (55.5% female, 58.8% aged <16). Most participants (N = 613) were taking an NNRTI-based ART regimen (13 PI-based, 216 unknown) and median duration on ART was six years (IQR three to nine years, 240 unknown). Of the 833 with viral load data 292 (35.1%) were non-suppressed. Virological non-suppression was independently associated with male sex (adjusted OR (aOR) = 1.43, 95% CI 1.04 to 1.97), and with not knowing one's own HIV status (aOR = 1.77, 95% CI 1.08 to 2.88), or knowing one's status but not disclosing it to anyone (aOR = 1.99, 95% CI 1.36 to 2.93), compared to adolescents who knew their status and had disclosed it to someone.

CONCLUSIONS

ALWH with symptoms of common mental disorders have high prevalence of virological non-suppression in Zimbabwe, especially if they do not know their status or have not disclosed it. In general adolescents should be informed of their HIV status, with encouragement on the beneficial health and social effects of viral suppression, to incentivise adherence. Efforts to strengthen the operationalization of disclosure guidelines for adolescents should now be prioritized.

Truth, Deception, and Coercion; Communication Strategies Used by Caregivers of Children with Perinatally Acquired HIV During the Pre-Disclosure and Post-Disclosure Period in Rural Communities in South Africa

Typically, children with perinatal HIV (PHIV) receive antiretroviral treatment (ART) for a long time prior to receiving disclosure. Communication with children about HIV and treatment is critical for monitoring adherence and retention in care. However, there is a dearth of information on communication between caregivers and their children. This study examines what and how caregivers tell their their children about their illness and medication in the pre-disclosure and post-disclosure period. A qualitative study using semi-structured one-on-one interviews and focus group discussions was conducted with caregivers recruited via purposive sampling from a rural sub-district in South Africa. The interviews were analyzed using thematic analysis. The sample consisted of 38 caregivers, 24 of whom were the children's biological mothers, 20 had disclosed to the children and 18 had not done so. Caregivers who had disclosed had told their children the truth and named the disease as HIV, but communication about HIV was infrequent and focused on pill taking. Those who had not disclosed had lied, deflected illness-related information, and attributed the children's ill health to co-morbid conditions. To enforce adherence, most caregivers used coercion and threats of the grave consequences of non-adherence as a communication strategy. Those who had not disclosed used deception, deflecting, and coercion as strategies for coping through the pre-disclosure period. There is a need for healthcare workers to prepare, support, and empower caregivers to develop appropriate responses to children's questions and to understand the implications of deception on future full disclosure and children's acceptance of their HIV status.

"I just keep quiet about it and act as if everything is alright" - The cascade from trauma to disengagement among adolescents living with HIV in western Kenya

INTRODUCTION

There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement.

METHODS

We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care.

RESULTS

Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care.

CONCLUSIONS

Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.

Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP

Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of 'being at risk' either by an individual, or healthcare provider. In this paper, we draw on the concept of 'candidacy' to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an 'at risk' population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the 'trust' in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being 'at risk' and query the criteria on which categories of risk and PrEP eligibility are determined.

Acceptability of point-of-care viral load testing to facilitate differentiated care: a qualitative assessment of people living with HIV and nurses in South Africa

Background

Providing viral load (VL) results to people living with HIV (PLHIV) on antiretroviral therapy (ART) remains a challenge in low and middle-income countries. Point-of-care (POC) VL testing could improve ART monitoring and the quality and efficiency of differentiated models of HIV care. We assessed the acceptability of POC VL testing within a differentiated care model that involved task-shifting from professional nurses to less highly-trained enrolled nurses, and an option of collecting treatment from a community-based ART delivery programme.

Methods

We undertook a qualitative sub-study amongst clients on ART and nurses within the STREAM study, a randomized controlled trial of POC VL testing and task-shifting in Durban, South Africa. Between March and August 2018, we conducted 33 semi-structured interviews with clients, professional and enrolled nurses and 4 focus group discussions with clients. Interviews and focus groups were audio recorded, transcribed, translated and thematically analysed.

Results

Amongst 55 clients on ART (median age 31, 56% women) and 8 nurses (median age 39, 75% women), POC VL testing and task-shifting to enrolled nurses was acceptable. Both clients and providers reported that POC VL testing yielded practical benefits for PLHIV by reducing the number of clinic visits, saving time, travel costs and days off work. Receiving same-day POC VL results encouraged adherence amongst clients, by enabling them to see immediately if they were ‘good’ or ‘bad’ adherers and enabled quick referrals to a community-based ART delivery programme for those with viral suppression. However, there was some concern regarding the impact of POC VL testing on clinic flows when implemented in busy public-sector clinics. Regarding task-shifting, nurses felt that, with extra training, enrolled nurses could help decongest healthcare facilities by quickly issuing ART to stable clients. Clients could not easily distinguish enrolled nurses from professional nurses, instead they highlighted the importance of friendliness, respect and good communication between clients and nurses.

Conclusions

POC VL testing combined with task-shifting was acceptable to clients and healthcare providers. Implementation of POC VL testing and task shifting within differentiated care models may help achieve international treatment targets.

Trial registration

NCT03066128, registered 22/02/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05940-w.

Understanding the health-care experiences of people with sickle cell disorder transitioning from paediatric to adult services: This Sickle Cell Life, a longitudinal qualitative study

Background

Transitions from paediatric to adult health-care services cause problems worldwide, particularly for young people with long-term conditions. Sickle cell disorder brings particular challenges needing urgent action.

Objectives

Understand health-care transitions of young people with sickle cell disorder and how these interact with broader transitions to adulthood to improve services and support.

Methods

We used a longitudinal design in two English cities. Data collection included 80 qualitative interviews with young people (aged 13–21 years) with sickle cell disorder. We conducted 27 one-off interviews and 53 repeat interviews (i.e. interviews conducted two or three times over 18 months) with 48 participants (30 females and 18 males). We additionally interviewed 10 sickle cell disease specialist health-care providers. We used an inductive approach to analysis and co-produced the study with patients and carers.

Results

Key challenges relate to young people’s voices being ignored. Participants reported that their knowledge of sickle cell disorder and their own needs are disregarded in hospital settings, in school and by peers. Outside specialist services, health-care staff refuse to recognise patient expertise, reducing patients’ say in decisions about their own care, particularly during unplanned care in accident and emergency departments and on general hospital wards. Participants told us that in transitioning to adult care they came to realise that sickle cell disorder is poorly understood by non-specialist health-care providers. As a result, participants said that they lack trust in staff’s ability to treat them correctly and that they try to avoid hospital. Participants reported that they try to manage painful episodes at home, knowing that this is risky. Participants described engaging in social silencing (i.e. reluctance to talk about and disclose their condition for fear that others will not listen or will not understand) outside hospital; for instance, they would avoid mentioning cell sickle disorder to explain fatigue. Their self-management tactics include internalising their illness experiences, for instance by concealing pain to protect others from worrying. Participants find that working to stay healthy is difficult to reconcile with developing identities to meet adult life goals. Participants have to engage in relentless self-disciplining when trying to achieve educational goals, yet working hard is incompatible with being a ‘good adult patient’ because it can be risky for health. Participants reported that they struggle to reconcile these conflicting demands.

Limitations

Our findings are derived from interviews with a group of young people in England and reflect what they told us (influenced by how they perceived us). We do not claim to represent all young people with sickle cell disorder.

Conclusions

Our findings reveal poor care for young people with sickle cell disorder outside specialist services. To improve this, it is vital to engage with young people as experts in their own condition, recognise the legitimacy of their voices and train non-specialist hospital staff in sickle cell disorder care. Young people must be supported both in and outside health-care settings to develop identities that can help them to achieve life goals.

Future work

Future work should include research into the understanding and perceptions of sickle cell disease among non-specialist health-care staff to inform future training. Whole-school interventions should be developed and evaluated to increase sickle cell disorder awareness.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 44. See the NIHR Journals Library website for further project information.

"We give them threatening advice…": expectations of adherence to antiretroviral therapy and their consequences among adolescents living with HIV in rural Malawi

INTRODUCTION

Many adolescents living with HIV in sub-Saharan Africa struggle to achieve optimal adherence to antiretroviral therapy (ART), but few studies have investigated how their treatment-taking decisions are influenced by their social interactions with providers, caregivers and community leaders. This study aims to explore the narratives that define expectations of adherence to ART among adolescents living with HIV in a rural Malawian setting.

METHODS

Overall, 45 in-depth interviews were conducted in 2016 with adolescents living with HIV, caregivers, health workers and community leaders, and four group sessions using participatory tools were undertaken with adolescents. Interviews and group sessions were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically.

RESULTS

Adolescents were given strict behavioural codes around optimal treatment adherence, which were often enforced through encouragement, persuasian and threats. In HIV clinics, some staff supported adolescents with broader concerns relating to living with HIV, but other measures to address sub-optimal adherence in HIV clinics were perceived by patients as punitive, including pill-counts and increased frequency of clinic visits. Community leaders felt responsible for young peoples' health, sometimes attempting to influence their treatment-taking by threatening to withdraw services, or to publically "out" those deemed to be non-adherent. At home, discussions with adolescents about HIV were often limited to dose reminders, and some caretakers resorted to physical punishment to ensure adherence. While some adolescents complied with strictly-enforced adherence rules, others demonstrated resistance by hiding missed doses, secretly throwing away drugs, or openly refusing to take them.

CONCLUSIONS

The potential of young people to adhere to their ART may be undermined by restrictive messages and punitive approaches to enforce and control their engagement with treatment at home, in the clinic and in the wider community. Interventions should focus on creating safe spaces for adolescents to speak frankly about the adherence challenges that they face and support for caregivers including home-based interventions.

"Because we all have to grow up": supporting adolescents in Uganda to develop core competencies to transition towards managing their HIV more independently

INTRODUCTION

Sustaining optimal adherence is the major challenge facing adolescents living with HIV (ALHIV), particularly in low-resource settings, where "second-line" is often the last accessible treatment option. We explored the knowledge and skills adolescents need in order to maintain improved adherence behaviours, and the specific ways clinicians and caregivers may support young people to do so more independently.

METHODS

We conducted individual, in-depth interviews with 20 ALHIV aged 10 to 18 years in Uganda in 2017 to 2018. All participants had recently commenced second-line treatment as part of a clinical trial. We used thematic qualitative analysis to examine adherence experiences and challenges while on first-line therapy, as well as specific supports necessary to optimise treatment-taking longer-term.

RESULTS

Adherence difficulties are exacerbated by relatively rapid shifts from caregiver-led approaches during childhood, to an expectation of autonomous treatment-taking with onset of adolescence. For many participants this shift compounded their ongoing struggles managing physical side effects and poor treatment literacy. Switching to second-line typically prompted reversion back to supervised adherence, with positive impacts on self-reported adherence in the immediate term. However, this measure is unlikely to be sustainable for caregivers due to significant caregiver burden (as on first line), and provided little opportunity for clinicians to guide and develop young people's capacity to successfully adopt responsibility for their own treatment-taking.

CONCLUSIONS

As ALHIV in sub-Saharan Africa are attributed increasing responsibility for treatment adherence and HIV management, they must be equipped with the core knowledge and skills required for successful, self-directed care. Young people need to be relationally supported to develop necessary "adherence competencies" within the supportive framework of a gradual "transition" period. Clinic conversations during this period should be adolescent-focussed and collaborative, and treatment-taking strategies situated within the context of their lived environments and support networks, to facilitate sustained adherence. The disclosure of adherence difficulties must be encouraged so that issues can be identified and addressed prior to treatment failure.

Scaling up peer-led community-based differentiated support for adolescents living with HIV: keeping the needs of youth peer supporters in mind to sustain success

INTRODUCTION

Low rates of viral suppression among adolescents living with HIV (ALHIV) indicate that more effective support is urgently required at scale. The provision of peer support has generated considerable enthusiasm because it has the potential to ameliorate the complex social and relational challenges which underpin suboptimal adherence. Little is known about the impact on young peer supporters themselves, which is the focus of this paper.

METHODS

We present qualitative findings from the Zvandiri trial investigating the impact of a peer support intervention on the viral load for beneficiaries (ALHIV, aged 13 to 19 years) in Zimbabwe. The Zvandiri peer supporters aged 18 to 24 years, known as community adolescent treatment supporters (CATS), are themselves living with HIV. Individual in-depth interviews were conducted in late 2018 with 17 CATS exploring their experiences of delivering peer support and their own support needs. Interviews were analysed iteratively using thematic analysis.

RESULTS

The CATS reported that being peer supporters improved their own adherence behaviour and contributed to an improved sense of self-worth. The social connections between the CATS were a source of comfort and enabled them to develop skills to manage the challenging aspects of their work. Two substantial challenges were identified. First, their work may reveal their HIV status. Second, managing the emotional labour of this caring work; given how commonly the complexity of the beneficiaries' needs mirrored the circumstances of their own difficult lives. Both challenges were ameliorated by the support the CATS provided to each other and ongoing supervision from the adult mentor. There was variation in whether they felt their roles were appropriately valued through the remuneration they received and within the health system. There was a consensus that their experience meant that they would graduate from being a CATS with transferable skills that could enhance their employability.

CONCLUSIONS

Their experiences illustrate the advantages and opportunities of being a CATS. To minimize potential harms, it is vital to ensure that they feel valued in their role, which can be demonstrated by the provision of appropriate remuneration, recognition and respect, and that there is continued investment in ongoing support through ongoing training and mentoring.

Point-of-care viral load testing among adolescents and youth living with HIV in Haiti: a protocol for a randomised trial to evaluate implementation and effect

INTRODUCTION

Adolescents living with HIV have poor antiretroviral therapy (ART) adherence and viral suppression outcomes. Viral load (VL) monitoring could reinforce adherence but standard VL testing requires strong laboratory capacity often only available in large central laboratories. Thus, coordinated transport of samples and results between the clinic and laboratory is required, presenting opportunities for delayed or misplaced results. Newly available point-of-care (POC) VL testing systems return test results the same day and could simplify VL monitoring so that adolescents receive test results faster which could strengthen adherence counselling and improve ART adherence and viral suppression.

METHODS AND ANALYSIS

This non-blinded randomised clinical trial is designed to evaluate the implementation and effectiveness of POC VL testing compared with standard laboratory-based VL testing among adolescents and youth living with HIV in Haiti. A total of 150 participants ages 10-24 who have been on ART for >6 months are randomised 1:1 to intervention or standard arms. Intervention arm participants receive a POC VL test (Cepheid Xpert HIV-1 Viral Load system) with same-day result and immediate ART adherence counselling. Standard care participants receive a laboratory-based VL test (Abbott m2000sp/m2000rt) with the result available 1 month later, at which time they receive ART adherence counselling. VL testing is repeated 6 months later for both arms. The primary objective is to describe the implementation of POC VL testing compared with standard laboratory-based VL testing. The secondary objective is to evaluate the effect of POC VL testing on VL suppression at 6 months and participant comprehension of the correlation between VL and ART adherence.

ETHICS AND DISSEMINATION

This study is approved by GHESKIO, Weill Cornell Medicine and Columbia University ethics committees. This trial will provide critical data to understand if and how POC VL testing may impact adolescent ART adherence and viral suppression. If effective, POC VL testing could routinely supplement standard laboratory-based VL testing among high-risk populations living with HIV.

TRIAL REGISTRATION NUMBER

NCT03288246.

A qualitative enquiry into the meaning and experiences of wellbeing among young people living with and without HIV in KwaZulu-Natal, South Africa

Young people in sub-Saharan Africa encounter health and livelihood challenges which may compromise their wellbeing. Understanding how young people's wellbeing is defined could strengthen wellbeing policies. We investigated perceptions and experiences of young people's wellbeing, and whether these aligned with Ryff's psychological wellbeing (PWB) model. Data were collected between January-August 2018 through focus-group discussions (n = 12) and in-depth interviews (n = 16) with young people living with and without HIV, selected purposively from South African healthcare facilities. Key informant interviews (n = 14) were conducted with healthcare workers and subject-matter experts. Using a framework approach, we situated our analysis around dimensions of Ryff's PWB model: autonomy, self-acceptance, purpose in life, environmental mastery, positive relationships, personal growth. Young people's wellbeing was rooted in family and peer relationships. Acceptance and belongingness received from these networks fostered social integration. HIV-related stigma, crime and violence reduced their perceived control and social trust. For males, fulfilling gendered roles made them feel socially valued. Self-perceived failure to uphold sexual norms undermined women's social contribution and autonomy. Social integration and contribution framed young people's wellbeing. However, these dimensions were not fully captured by Ryff's PWB model. Models that consider relationality across socio-ecological levels may be relevant for understanding young people's wellbeing.

Secrets and Silence: Agency of Young Women Managing HIV Disclosure

Drawing on a 12-month ethnography with young women living with HIV in Zambia, we explore their everyday strategies to avoid unintentional disclosure of their HIV status. Young women practiced secrecy with sexual partners, through hiding their antiretroviral therapy and using veiled language around HIV. Whilst remaining silent about their HIV status enabled them to maintain identities beyond HIV, this secrecy triggered feelings of guilt and anxiety, suggesting that their agency was "bounded" by the context of persistent stigma. These strategies to hide their HIV status question public health narratives urging disclosure, and support disclosure-counseling approaches that champions choice.

Informing the measurement of wellbeing among young people living with HIV in sub-Saharan Africa for policy evaluations: a mixed-methods systematic review

Young people living with HIV (YPLHIV) in sub-Saharan Africa (SSA) are at high risk of having a poor quality of life. Addressing wellbeing explicitly within HIV/AIDS policies could assist mitigation efforts. However, guidance on wellbeing measures to evaluate policies for YPLHIV is scarce. The aims of this mixed-methods review were to identify: i) key dimensions of wellbeing and ii) wellbeing measures that align to these dimensions among YPLHIV (15-24 years) in SSA. We searched six social science and medical databases, including grey literature. We included studies that examined correlates and lived experiences of wellbeing, among YPLHIV in SSA, from January 2000 to May 2019. Two reviewers independently screened abstracts and full texts and assessed methodological quality of included articles. We analysed quantitative and qualitative data using descriptive and meta-ethnographic approaches, respectively. Thereafter, we integrated findings using a framework approach. We identified 6527 citations. Of these, 10 quantitative and 30 qualitative studies were included. Being male, higher educational status, less stigma and more social support were likely correlates of wellbeing. Themes that shaped experiences suggestive of wellbeing were: 1) acceptance and belonging- stigma, social support; 2) coping; 3) standard of living. Our final synthesis found that the following dimensions potentially characterise wellbeing: self-acceptance, belonging, autonomy; positive relations, environmental mastery, purpose in life. Wellbeing for YPLHIV is multi-dimensional and relational. Relevant measures include the Personal Wellbeing Index, Ryff's Psychological Wellbeing Scale and Mental Health Continuum Short Form. However, psychometric evaluations of these scales among YPLHIV in SSA are needed.

Experiences and effects of HIV-related stigma among youth living with HIV/AIDS in Western Uganda: A photovoice study

HIV-related stigma has been identified as a significant stressor affecting Quality of Life of Youth Living With HIV/AIDS (YLWHA). Gaining a contextualized understanding of how this stigma is experienced by YLWHA in Western Uganda is crucial in addressing it in this group and setting. In this study, we explored the lived experiences of YLWHA with HIV-related stigma. Photovoice was used to gain insight into the lived experiences of HIV-related stigma in 11 YLWHA (15–19 years), purposively selected from a hospital-based peer support group. Group interview transcripts, notes and photographs were subjected to phenomenological hermeneutic analysis. Encounters with enacted, anticipated and internalized stigmas and their myriad sequels were prevalent in the photos and narratives of participants. Our findings were categorized and presented in 5 main themes that were identified through the analysis: being devalued, experiencing fear, experiencing injustices, feeling lonely, and lacking future perspectives. HIV-related stigmas were experienced in various socio-ecological domains but predominantly in homes and schools that ought to be supportive surroundings for youths. A multilevel approach, targeting the entire society where the root causes of stigma can be found and specific contexts like schools and homes where youth are confronted with stigma on a daily basis is proposed for a wholistic intervention.

Coming of age with HIV: a temporal understanding of young women's experiences in Zambia

Young perinatally-infected women living with HIV in Zambia grew up alongside antiretroviral therapy (ART) roll-out and expanding prevention programmes. We used Bonnington's temporal framework to understand how HIV impacted the experiences of these women over time. Data were drawn from two sequential studies with a cohort of young women living with HIV: a qualitative study in 2014-16 and an ethnographic study in 2017-18. Data from workshops, in-depth interviews, participant observation and diaries were analysed thematically, guided by three temporalities within the framework: everyday, biographical and epochal time. In everyday time, repetitive daily treatment-taking reminded young women of their HIV status, affecting relationships and leading to secrecy with ART. In biographical time, past events including HIV disclosure, experiences of illness, and loss shaped present experiences and future aspirations. Lastly, in epochal time, the women's HIV infection and their survival were intimately interlinked with the history of ART availability. The epochal temporal understanding leads us to extend Reynolds Whyte's notion of "biogeneration" to conceptualise these women, whose experiences of living with HIV are enmeshed with their biosocial environment. Support groups for young women living with HIV should help them to process biographical events, as well as supporting their everyday needs.

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.

A Failed Method? Reflections on Using Audio Diaries in Uganda With Young People Growing Up With HIV in the BREATHER Trial

In this article, we present a case study in which we consider our use of the audio diary method with young people (aged 10-24) living with HIV in Uganda in a longitudinal qualitative study conducted in a clinical randomized control trial. Despite initial enthusiasm for the method among participants to capture accounts of participants' experiences outside of the confines of the HIV clinic, the constraints the young people encountered in accessing sufficient privacy to confidently make recordings meant that no one elected to use them again in the study. Despite the insights the use of the method generated, the lack of acceptability led to its relative failure. This demonstrates that despite the call for innovation, there is an unwavering necessity when selecting methods that they align with the needs and preferences of our participants and with an attentive assessment of the local context in which illness narratives are produced.

Reflections on the Use of Audio Diaries to Access Young People's Lived Experiences of HIV in Zimbabwe

This methodological article reflects on the contribution audio diaries can make to accessing important, and commonly silenced, dimensions of the lived experience of growing up with HIV and their acceptability to children. Audio diaries were used by 12 young people, aged 11 to 13 years, as part of a longitudinal qualitative study embedded within the Anti-Retroviral Research for Watoto (ARROW) clinical trial. The method provided an alternative means for young people to express detailed reflections on their day-to-day encounters, as well as ordinarily silenced topics, including hidden and suppressed emotions regarding the circumstance surrounding their perinatal infection. Although the audio diary has great potential as method, its efficacy rests on young people's understanding of how to use it. There are ethical challenges around maintaining confidentiality while participants are in possession of the diaries and provision of appropriate support. The technology used in the study was in many ways cumbersome compared with opportunities increasingly available.

"I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini

"Treat-all" programmes aim to improve clinical outcomes and to reduce HIV transmission through regular HIV testing and immediate offer of antiretroviral therapy (ART) for those diagnosed HIV-positive, irrespective of immunological status and symptoms of disease. Global narratives on the benefits of Treat-all anticipate reduced HIV-related stigma and increased "normalisation" of HIV with Treat-all implementation, whereby HIV is remoulded as a manageable, chronic condition where stigmatising symptoms can be concealed. Drawing on Goffman's stigma work, we aimed to investigate how stigma may influence the engagement of clinically asymptomatic people living with HIV (PLHIV) with Treat-all HIV care in Shiselweni, Eswatini (formerly Swaziland). This longitudinal research comprised 106 interviews conducted from August 2016 to September 2017, including repeated interviews with 30 PLHIV, and one-off interviews with 20 healthcare workers. Data were analysed thematically using NVivo 11, drawing upon principles of grounded theory to generate findings inductively from participants' accounts. Stigma was pervasive within the narratives of PLHIV, framing their engagement with treatment and care. Many asymptomatic PLHIV were motivated to initiate ART in order to maintain a "discreditable" status, by preventing the development of visible and exposing symptoms. However, engagement with treatment and care services could itself be exposing. PLHIV described the ways in which these "invisibilising" benefits and exposing risks of ART were continually assessed and navigated over time. Where the risk of exposure was deemed too great, this could lead to intermittent treatment-taking, and disengagement from care. Addressing HIV related stigma is crucial to the success of Treat-all, and should thus be a core component of HIV responses.

Treatment adherence in HIV stigmatized environments in South Africa: stigma avoidance and medication management

Stigmatization of HIV infection undermines antiretroviral therapy (ART) adherence. The current study examined strategies that people living with HIV employ to manage their ART in stigmatized environments. We conducted an anonymous survey with 439 patients receiving ART at a community clinic in Cape Town, South Africa. Measures included demographic and health characteristics, ART adherence, stigma experiences, efforts to conceal ART to avoid stigma (stigma-medication management strategies), and beliefs that ART nonadherence itself is stigmatizing. One in four participants had forgone taking their ART in social settings to avoid stigmatization, a behavior associated with younger age, experiencing greater stigma, and poorer ART adherence. Regression models found stigma-medication management strategies significantly predicted ART nonadherence over and above age, gender, alcohol use, and HIV stigma experiences. We also found that a significant majority of participants believed that having unsuppressed HIV and ART nonadherence are irresponsible and should be reprimanded by clinicians. Results show that the behavioral effects of stigma directly impede ART adherence. The behaviors that patients may employ to avoid stigma are amenable to interventions to directly improve ART adherence while managing stigma concerns.

Qualitative research on community experiences in large HIV research trials: what have we learned?

INTRODUCTION

Very few pragmatic and community-level effectiveness trials integrate the use of qualitative research over all stages of the trial, to inform trial design, implementation optimization, results interpretation and post-trial policy recommendations. This is despite the growing demand for mixed methods research from funding agencies and awareness of the vital importance of qualitative and mixed methods research for understanding trial successes and challenges.

DISCUSSION

We offer examples from work we have been involved in to illustrate how qualitative research conducted within trials can reveal vital contextual factors that influence implementation and outcomes, can enable an informed adaptation of trials as they are being conducted and can lead to the formulation of theory regarding the social and behavioural pathways of intervention, while also enabling community engagement in trial design and implementation. These examples are based on published findings from qualitative studies embedded within two ongoing large-scale studies demonstrating the population-level impacts of universal HIV testing and treatment strategies in southern and eastern Africa, and a qualitative study conducted alongside a clinical trial testing the adaptation, acceptability and experience of short-cycle therapy in children and adolescents living with HIV.

CONCLUSIONS

We advocate for the integration of qualitative with clinical and survey research methods in pragmatic clinical and community-level trials and implementation studies, and for increasing visibility of qualitative and mixed methods research in medical journals. Qualitative research from trials ideally should be published along with clinical outcome data, either integrated into the "main" trial papers or published concurrently in the same journal issue. Integration of qualitative research within trials can help not only to understand the why behind success or failure of interventions in different contexts, but also inform the adaptation of interventions that can facilitate their success, and lead to new alternative strategies and to policy changes that may be vital for achieving public health goals, including the end of AIDS.

"My mother told me that I should not": a qualitative study exploring the restrictions placed on adolescent girls living with HIV in Zambia

Introduction

Adolescent girls in sub‐Saharan Africa are disproportionately affected by HIV due to a range of social and structural factors. As they transition to adulthood, they are recipients of increasing blame for HIV infection and ‘improper’ sex, as well as increasing scrutiny, restrictions and surveillance. This study used a qualitative and participatory approach to explore the messaging and restrictions imposed on adolescent girls living with HIV in Zambia.

Methods

Thirty‐four in‐depth interviews and four participatory workshops were carried out with 24 adolescent girls aged 15 to 19 years old living with HIV in Lusaka, Zambia. Key themes explored included experiences living with HIV, finding out about HIV status, disclosure, experiences with antiretroviral treatment, and support needs. Data were organized, coded and analysed using a grounded theory approach to thematic analysis. This analysis uses data on participants’ experiences of living with HIV and their interactions with their parents, guardians and healthcare providers.

Results

Family and healthcare providers, partly in a quest to protect both the health of adolescent girls living with HIV and also to protect them from blaming discourse, imposed restrictions on their behaviour around three main topics: don't disclose your HIV status, don't have sex, and don't miss your medicines. These restrictions were often delivered using tactics of fear, and usually disconnected from other options. Participants responded to these messages in several ways, including internalizing the messages, changing their behaviour either to comply with or resist the restrictions, by remaining silent and anxious when restrictions were broken, and developing concerns around their own health and sexual and reproductive aspirations. Participants also sometimes experiencing stigma when restrictions could not be maintained.

Conclusions

Restrictive messages were delivered to adolescent girls living with HIV through the broader social discourses of stigma, religion, and global and local narratives about HIV. Programmes aiming to support adolescent girls living with HIV need to work together with parents and healthcare providers to reflect on the impact of sanctioning messages, and to encourage more enabling and empowering messaging for adolescent girls living with HIV.

Being an 'adolescent': The consequences of gendered risks for young people in rural Uganda

The behaviour of adolescents is recognised increasingly as having substantial and long-term consequences for their health. We examined the meaning of 'adolescence' in southern Uganda with HIV-positive young people aged 11-24 years. Adolescent girls and boys are described differently in the local language (Luganda). Adolescence is described as a behavioural rather than a life course category and an inherently dangerous one. The practices, risks and consequences of 'adolescent' behaviour are highly gendered. Local understandings of adolescence are likely to have a significant impact on the efficacy of interventions designed to minimise their 'risky behaviour'.

"How Do We Start? And How Will They React?" Disclosing to Young People with Perinatally Acquired HIV in Uganda

Despite great advances in pediatric HIV care, rates and the extent of full disclosure of HIV status to infected children remain low especially in resource-constrained setting. The World Health Organisation recommends that, by the age of 10–12 years old, children should be made fully aware of their HIV-positive status. However, this awareness is often delayed until much later in their adolescence. Few studies have been conducted to investigate what influences caregivers’ decision-making process in this regard in low-income settings. In this article, we present an analysis of care dyads of caregivers and HIV-positive young people in Kampala, Uganda, as part of the findings of a longitudinal qualitative study about young people’s adherence to antiretroviral therapy embedded in an international clinical trial (BREATHER). Repeat in-depth interviews were conducted with 26 young people living with HIV throughout the course of the trial, and once-off interviews with 16 of their caregivers were also carried out toward the end of the trial. In this article, we examine why and how caregivers decide to disclose a young person’s HIV status to them and explore their feelings and dilemmas toward disclosure, as well as how young people reacted and the influence it had on their relationships with and attitudes toward their caregivers. Caregivers feared the consequences of disclosing the young person’s positive status to them and disclosure commonly occurred hurriedly in response to a crisis, rather than as part of an anticipated and planned process. A key impediment to disclosure was that caregivers feared that disclosing would damage their relationships with the young people and commonly used this as a reason to continue to postpone disclosure. However, young people did not report prolonged feelings of blame or anger toward their caregivers about their own infection, but they did express frustration at the delay and obfuscation surrounding the disclosure process. Our findings can inform the ways in which mainstream HIV services support caregivers through the disclosure process. This includes providing positive encouragement to disclose fully and to be more confident in initiating and sustaining the timely process of disclosure.

Qualitative study of the BREATHER trial (Short Cycle antiretroviral therapy): is it acceptable to young people living with HIV?

OBJECTIVES

A qualitative study of the BREATHER (PENTA 16) randomised clinical trial, which compared virological control of Short Cycle Therapy (SCT) (5 days on: 2 days off) with continuous efavirenz (EFV)-based antiretroviral therapy (CT) in children and young people (aged 8-24) living with HIV with viral load <50 c/mL to examine adaptation, acceptability and experience of SCT to inform intervention development.

SETTING

Paediatric HIV clinics in the UK (2), Ireland (1), the USA (1) and Uganda (1).

PARTICIPANTS

All BREATHER trial participants who were over the age of 10 and aware of their HIV diagnosis were invited to participate. 49 young people from both arms of the BREATHER trial (31 females and 18 males; 40% of the total trial population in the respective sites; age range 11-24) gave additional consent to participate in the qualitative study.

RESULTS

Young people from both trial arms had initial concerns about the impact of SCT on their health and adherence, but these decreased over the early months in the trial. Young people randomised to SCT reported preference for SCT compared with CT pre-trial. Attitudes to SCT did not vary greatly by gender or country. Once short-term adaptation challenges were overcome, SCT was positively described as reducing impact of side effects, easing the pressure to carry and remember medication and enabling more weekend social activities. Young people on both arms reported frequent medication side effects and occasional missed doses that they had rarely voiced to clinical staff. Participants liked SCT by trial end but were concerned that peers who had most problems adhering could find SCT disruptive and difficult to manage.

CONCLUSIONS

To realise the potential of SCT (and mitigate possible risks of longer interruptions), careful dissemination and communication post-trial is needed. SCT should be provided alongside a package of monitoring, support and education over 3 months to allow adaptation.

TRIAL REGISTRATION NUMBER

NCT 01641016.