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Kamau SG, Akatusasira R, Namatovu A, Kibet E, Ssekitto JM, Mamun MA, Kaggwa MM. The level of antiretroviral therapy (ART) adherence among orphan children and adolescents living with HIV/AIDS: A systematic review and meta-analysis. PLoS One 2024; 19:e0295227. [PMID: 38381726 PMCID: PMC10881004 DOI: 10.1371/journal.pone.0295227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/20/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Many children and adolescents living with HIV have ended up as orphans. Due to HIV taking away their parents leaves them deprived of their most important social network and support, which predisposes them to poor adherence to antiretroviral therapy (ART). Various studies have shown poor adherence to ART among orphaned children and adolescents. This systematic review and meta-analysis, therefore, aims to determine the level of ART adherence among orphaned children and adolescents living with HIV/AIDS. METHODS This PROSPERO registered review (CRD42022352867) included studies from PubMed, Google Scholar, Scopus, Web of Science, Africa Journal Online, and selected HIV/AIDS journals from data inception to June 01, 2022. We included articles published in all languages that report the prevalence of adherence to ART among children and adolescent orphans (single parent orphans and/or double orphans) living with HIV/AIDS. We excluded qualitative studies, case studies, opinion papers, and letters to editors. We used the random-effect model to calculate the pooled prevalence of ART adherence based on the highest prevalence provided by the various methods in a particular study. We used the Joanna Briggs Institute Appraisal tool for the prevalence study to evaluate for risk of bias in the included studies. The Egger's test was used to assess small study effects. RESULTS Out of 1087 publications identified from the various databases, six met the selection criteria. The included six studies had a total 2013 orphans living with HIV/AIDS. The pooled prevalence of ART adherence was 78∙0% (95% Confidence Interval: 67.4-87.7; I2 = 82.92%, p<0∙001) and ranged between 7∙6% and >95%, using one of the following methods: pill count, caregiver's self-report, clinical attendance, and nevirapine plasma levels (above three μg/mL). The factors associated with adherence were pill burden, caregiver involvement, stunting, and caregiver relationship. LIMITATION There was a high level of heterogeneity in the finding. CONCLUSION Approximately four fifth of orphan children and adolescents living with HIV/AIDS adhere to ART. Strategies to improve adherence among this group should be prioritized, especially among the double orphaned children and adolescents.
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Affiliation(s)
| | - Rita Akatusasira
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Angella Namatovu
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emmanuel Kibet
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Mohammed A. Mamun
- CHINTA Research Bangladesh, Savar, Dhaka, Bangladesh
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
- Department of Public Health, University of South Asia, Dhaka, Bangladesh
| | - Mark Mohan Kaggwa
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
- Forensic Psychiatry Program, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
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DeLong SM, Xu Y, Genberg BL, Nyambura M, Goodrich S, Tarus C, Ndege S, Hogan JW, Braitstein P. Population-Based Estimates and Predictors of Child and Adolescent Linkage to HIV Care or Death in Western Kenya. J Acquir Immune Defic Syndr 2023; 94:281-289. [PMID: 37643416 PMCID: PMC10609679 DOI: 10.1097/qai.0000000000003288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Population-level estimates of linkage to HIV care among children and adolescents (CAs) can facilitate progress toward 95-95-95 goals. SETTING This study was conducted in Bunyala, Chulaimbo, and Teso North subcounties, Western Kenya. METHODS Linkage to care was defined among CAs diagnosed with HIV through Academic Model Providing Access to Healthcare (AMPATH)'s home-based counseling and testing initiative (HBCT) by merging HBCT and AMPATH Medical Record System data. Using follow-up data from Bunyala, we examined factors associated with linkage or death, using weighted multinomial logistic regression to account for selection bias from double-sampled visits. Based on the estimated model, we imputed the trajectory for each person in 3 subcounties until a simulated linkage or death occurred or until the end of 8 years when an individual was simulated to be censored. RESULTS Of 720 CAs in the analytic sample, 68% were between 0 and 9 years and 59% were female. Probability of linkage among CAs in the combined 3 subcounties was 48%-49% at 2 years and 64%-78% at 8 years while probability of death was 13% at 2 years and 19% at 8 years. Single or double orphanhood predicted linkage (adjusted odds ratio [aOR]: 2.66, 95% confidence interval [CI]: 1.33 to 5.32) and death (aOR: 9.85 [95% CI: 2.21 to 44.01]). Having a mother known to be HIV-positive also predicted linkage (aOR = 1.94, 95% CI: 0.97 to 3.86) and death (aOR: 14.49, 95% CI: 3.32 to 63.19). CONCLUSION HIV testers/counselors should continue to ensure linkage among orphans and CAs with mothers known to be HIV-positive and also to support other CAs to link to HIV care.
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Affiliation(s)
- Stephanie M. DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yizhen Xu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Suzanne Goodrich
- Department of Biostatistics, Brown University School of Public Health, Providence, RI; and
| | - Carren Tarus
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Samson Ndege
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joseph W. Hogan
- Department of Biostatistics, Brown University School of Public Health, Providence, RI; and
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, School of Public Health, Eldoret, Kenya
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Onyango MA, Chergui H, Sabin LL, Messersmith LJ, Sarkisova N, Oyombra J, Akello P, Kwaro DO, Otieno J. School-level Barriers of Antiretroviral Therapy Adherence and Interventions to Overcome them Among Adolescents Living with HIV in Western Kenya: A Qualitative Study. Open AIDS J 2021. [DOI: 10.2174/1874613602115010093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Adolescents in Kenya spend the majority of their time in a school environment. However, research to understand Antiretroviral Therapy (ART) adherence among adolescents living with HIV (ALWHIV) in school settings is sparse.
Objective:
To improve the design of appropriate interventions to better support this vulnerable population, the study aimed to explore school-related barriers to ART adherence experienced by ALWHIV.
Methods:
Qualitative data were utilized from a larger mixed-methods study on ALWHIV conducted at a major teaching and referral hospital in Kisumu, Kenya. Participants encompassed ALWHIV, their caregivers, teachers, and health care providers. Transcripts from a total of 24 in-depth interviews and five focus group discussions were analyzed in NVivo using a thematic approach.
Results:
Four themes emerged as key barriers in a school setting: negative experiences following HIV status self-disclosure, a strong desire for secrecy, restrictive school policies, and health education focused on sexual transmission of HIV. Participants suggested a range of potential interventions to better support ART adherence for ALWHIV, including coaching ALWHIV on disclosure strategies, promoting empathy among teachers and students, transition-preparing for ALWHIV, changing the narrative about HIV transmission in schools, providing water in schools, and introducing adherence support programs in schools, including the use of mobile technology.
Conclusion:
ALWHIV in Kenya experience numerous important challenges while trying to maintain optimal ART adherence in the school environment. Interventions that create supportive school settings are critical for better health outcomes among ALWHIV.
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N Tanyi W, Gachuno O, Odero T, Farquhar C, Kimosop D, Mayi A. Factors affecting adherence to antiretroviral therapy among children and adolescents living with HIV in the Mbita Sub-County Hospital, Homa Bay- Kenya. Afr Health Sci 2021; 21:18-24. [PMID: 34447419 PMCID: PMC8367307 DOI: 10.4314/ahs.v21i1.4s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Adequate adherence to antiretroviral therapy (ART) is key to the successful treatment of children and adolescents living with HIV. Continuous ART Adherence is the key factor for virologic suppression and stability of the immune system and prevents the occurrence of opportunistic infections. Children and adolescents struggle with adherence to ART for various reasons, including a poor psychosocial support system and clinic attendance. OBJECTIVES To describe the uptake of HIV treatment services among children and adolescents in the Mbita Sub-County Hospital, Homa Bay and determine how schooling, clinic attendance, and type of pill/regimen affect adherence to ART and viral suppression. METHODS This retrospective study was conducted at the Mbita Sub-County Hospital. Medical chart data was abstracted from the hospital files of children and adolescents between the ages of 0-19 years on antiretroviral therapy, between the periods of October 2016 and September, 2017. Data was analyzed using measures of central tendency, and cross-tabulations were done to compare schooling, clinic attendance, type of pill/regimen and viral suppression. Univariate and multivariate logistic regression analyses were conducted to determine associations between groups. RESULTS According to patient files reviewed, majority of patients, 244(91.4%) were enrolled into care within 2 weeks of HIV diagnosis according to guidelines, and 193(73.1 %) remained enrolled in care at end of study period. An overall viral suppression of 74.2 %( 132) was recorded. Of all the files reviewed, 121(74.7%) of patients attending school suppressed against 11(68.8 %) out of school, p=0.280. Suppression among Day and boarding reported at 78.6 %( 11) and 74.8 %( 113) of those out of school, respectively, p=0.533. Participants in primary school, 17(85.0%) suppressed better than those in secondary school, 102(73.4%), p=0.263. Keeping clinic appointments among eligible patient files reviewed decreased from 83.1% at 3 months, p=0.016, to 76.6%, p=0.526 at 6 months and to 52.9% at 12 months, p=0.278. Only 3- month clinic appointment return rates and Enhanced Adherence Counseling (EAC) were significant predictors of viral supression χ2 (2) = 0.280, p = 0.869 (> 0.05). CONCLUSION The clinic attendance rate within the first 3 months, and Enhanced Adherence Counseling (EAC) were significant predictors of viral suppression, and therefore adherence to antiretroviral therapy.
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Exavery A, Charles J, Barankena A, Kuhlik E, Mubyazi GM, Tani K, Ally A, Minja E, Koler A, Kikoyo L, Jere E. ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania. BMC Public Health 2020; 20:1251. [PMID: 32807138 PMCID: PMC7433360 DOI: 10.1186/s12889-020-09361-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 08/09/2020] [Indexed: 11/29/2022] Open
Abstract
Background Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. Methods Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. Results In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61–0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15–1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45–0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11–1.83). Caregivers aged 40–49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13–1.41). Conclusions Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.
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Affiliation(s)
| | | | | | - Erica Kuhlik
- Pact, Inc., 1828 L St NW Suite 300, Washington, DC, 20036, USA
| | - Godfrey M Mubyazi
- National Institute for Medical Research (NIMR), P.O Box 9653, Dar es Salaam, Tanzania
| | | | - Amal Ally
- Pact, P.O. Box 6348, Dar es Salaam, Tanzania
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Abstract
OBJECTIVES The objective of this study was to determine the time to, and durability of, viral suppression, among Canadian children living with HIV after initiation of combination antiretroviral therapy (cART). DESIGN Prospective, multicenter Canadian cohort study (Early Pediatric Initiation Canada Child Cure Cohort), using both prospective and retrospectively collected data. METHODS Kaplan-Meir survival estimates with Cox regression were used to determine the time to and risk factors for viral suppression, defined as two consecutive undetectable viral loads (<50 copies/ml) at least 30 days apart after initiation of cART. RESULTS A total of 228 children were enrolled between December 2014 and December 2018. The time to viral suppression was significantly shorter among children initiating cART after 5 ≤ 5 vs. years or less of age [adjusted hazard ratio (aHR) 1.57, 95% confidence interval (CI) 1.13-2.20], among those born after 2010 vs. prior (aHR 1.71, 95% CI 1.04-2.79), and among those without child protection services involvement (aHR 1.44, 95% CI 1.03-2.01). Overall, 27% of children had a viral rebound within 3 years of achieving viral suppression; the risk of viral rebound was significantly lower among children initiating cART after 5 vs. 5 years or less of age [adjusted odds ratio (aOR): 0.32, 95% CI 0.13-0.81], those whose families had not received social assistance (aOR 0.16, 95% CI 0.06-0.46), and females vs. males (aOR 0.51, 95% CI 0.26-0.99). CONCLUSION Only 73% of the children in the Early Pediatric Initiation Canada Child Cure Cohort had maintained viral suppression 3 years after it was first achieved. Age at cART initiation, and socioeconomic factors were predictors of both time to viral suppression and risk of viral rebound in this cohort.
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Nabunya P, Bahar OS, Chen B, Dvalishvili D, Damulira C, Ssewamala FM. The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda. BMC Public Health 2020; 20:340. [PMID: 32183762 PMCID: PMC7077174 DOI: 10.1186/s12889-020-8361-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/17/2020] [Indexed: 01/07/2023] Open
Abstract
Background Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence. Methods Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy. Results The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART. Conclusion Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV. Trial registration This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.
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Affiliation(s)
- Proscovia Nabunya
- Washington University in St. Louis, Brown School of Social Work, One Brookings Drive, St. Louis, MO, 63130, USA.
| | | | - Bin Chen
- Washington University in St. Louis, St. Louis, MO, USA
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Mugusi SF, Mopei N, Minzi O. Adherence to combination antiretroviral therapy among orphaned children in Dar es Salaam, Tanzania. South Afr J HIV Med 2019; 20:954. [PMID: 31534787 PMCID: PMC6739535 DOI: 10.4102/sajhivmed.v20i1.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/05/2019] [Indexed: 11/03/2022] Open
Abstract
Background Adherence to combination antiretroviral therapy (cART) among HIV-infected children is often complicated by various factors including medication formulation, dosing frequency, drug toxicities, age and developmental stage, psychosocial and behavioural characteristics of both children and caregivers and can additionally be complicated by being an orphan. Objectives This study was aimed at determining the factors and the extent of their influence on cART adherence among HIV-infected orphaned children attending Care and Treatment Centres (CTCs) in Dar es Salaam, Tanzania. Methods A cross-sectional study was performed, which assessed adherence in HIV-positive orphaned children aged 2–14 years receiving nevirapine (NVP) based cART for at least 6 months. Data was collected using questionnaires administered to primary caregivers of HIV-infected orphaned children, the review of medical files, and the laboratory measurement of NVP plasma concentrations and CD4 counts. Adherence to cART was determined based on caregivers’ self-report, consistency of clinic attendance and NVP plasma concentrations. Results Among the 216 enrolled orphaned children, adherence to cART was found to be 79.6%, 82.9% and 72.2% respectively based on caregivers’ self-report, clinic attendance and NVP plasma levels. Significant reductions in NVP concentrations (< 3 µg/mL) were seen among children with poor immunological outcomes, poor clinic attendance (p < 0.05) and were suggested by caregivers’ self-reported adherence (p = 0.06). Adherence challenges identified by caregivers included financial constraints (87.5%), lengthy waiting times at clinics (75.5% spent > 2 h at the clinic) and low HIV knowledge among caregivers. Conclusion Significant numbers of HIV-infected orphans have poor adherence to cART ranging between 17% and 28% based on different assessment methods. Inadequate caregiver knowledge of HIV/AIDS, long clinic waiting times and forgetfulness were identified as barriers to cART adherence in these orphans.
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Affiliation(s)
- Sabina F Mugusi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Nassoro Mopei
- Local Government Authority, Dar es Salaam, United Republic of Tanzania
| | - Omary Minzi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Martelli G, Antonucci R, Mukurasi A, Zepherine H, Nöstlinger C. Adherence to antiretroviral treatment among children and adolescents in Tanzania: Comparison between pill count and viral load outcomes in a rural context of Mwanza region. PLoS One 2019; 14:e0214014. [PMID: 30897131 PMCID: PMC6428300 DOI: 10.1371/journal.pone.0214014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/05/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Adherence to antiretroviral treatment is a key challenge for paediatric HIV care. Among children and adolescents living with HIV, lower levels of adherence have been reported compared to adults. Individual, caregiver-, health services-related and sociocultural factors were shown to impact on these outcomes. Study objectives were to assess adherence in a paediatric population in rural Tanzania comparing two measurement methods, and to investigate the association between virologic suppression and demographic, clinical, drug- and family-related factors. METHODS This cross-sectional study was conducted among children and adolescents enrolled in Bukumbi HIV Care and Treatment Clinic (Misungwi district, Mwanza region) in the north of Tanzania, where the HIV prevalence is 7.2%. Adherence was measured through viral load and pill count. Kappa statistics assessed the level of agreement between the methods; bivariate and multivariable analyses identified factors independently associated with virologic suppression. RESULTS N = 72 participants (n = 49 children; n = 23 adolescents) with a median age of eight years were enrolled. 62.5% and 65.3% of the individuals presented an optimal adherence according to viral load and pill count respectively, but among 40% viral load results diverged from the pill count method. In multivariable analysis, living outside Misungwi district and having CD4 counts above 500/μl were significantly associated with optimal adherence. CONCLUSION Children and adolescents living with HIV in Mwanza show high rates of suboptimal adherence. The poor agreement between pill count and viral load results raises concerns about the interpretation of these measurements in clinical practice.
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Affiliation(s)
- Giulia Martelli
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
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Vreeman RC, Ayaya SO, Musick BS, Yiannoutsos CT, Cohen CR, Nash D, Wabwire D, Wools-Kaloustian K, Wiehe SE. Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa. PLoS One 2018; 13:e0191848. [PMID: 29466385 PMCID: PMC5842873 DOI: 10.1371/journal.pone.0191848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/08/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium. METHODS This study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis. RESULTS In East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]). CONCLUSIONS Self-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.
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Affiliation(s)
- Rachel C. Vreeman
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, Inc, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- * E-mail:
| | - Samuel O. Ayaya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Beverly S. Musick
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Constantin T. Yiannoutsos
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- R.M. Fairbanks School of Public Health, Indianapolis, IN, United States of America
| | - Craig R. Cohen
- University of California San Francisco, San Francisco, CA, United States of America
| | - Denis Nash
- City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Deo Wabwire
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Kara Wools-Kaloustian
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, Inc, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sarah E. Wiehe
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, Inc, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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Predictors of Virologic Failure on First-line Antiretroviral Therapy Among Children in a Referral Pediatric Center in Cameroon. Pediatr Infect Dis J 2017; 36:1067-1072. [PMID: 28661967 DOI: 10.1097/inf.0000000000001672] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Suboptimal response to antiretroviral therapy (ART) is common among children living with HIV (CLHIV) in resource-limited settings. We sought to assess virologic failure (VF), time for switching to second-line regimens and factors associated with VF in CLHIV receiving first-line ART in Cameroon. METHODS An observational cohort study was conducted in 375 CLHIV initiating a first-line ART and treated for ≥6 months at the National Social Insurance Fund Hospital in Yaoundé-Cameroon from 2009 to 2013. Using logistic regression, predictors of VF and delayed switch were assessed by univariate and multivariate analysis. P < 0.05 was considered statistically significant. RESULTS Overall, 17% (64/375) CLHIV experienced VF on first-line ART after a median time of 28 (interquartile range: 22-38) months. After VF, median time to switching from first- to second-line ART was 20 (interquartile range: 8-24) months. In multivariate analysis, VF was associated with male gender (adjusted odds ratio: 0.36; 95% confidence interval: 0.19-0.71; P = 0.003), motherless children (adjusted odds ratio: 2.9; 95% confidence interval: 1.3-6.06; P = 0.005) and treatment with stavudine-containing compared with zidovudine-containing regimens (P = 0.022). Overall, male gender, orphanhood (motherless) and treatment with stavudine-containing regimens predicted VF at a rate of 70% (area under curve =0.70). CONCLUSION VF on first-line pediatric ART is common, and switching children failing first-line to second-line ART is considerably delayed. These results suggest performance of pediatric ART program can be improved by targeting orphans, adapting counseling for male children, complete phasing-out of stavudine and ensuring timely switch to second-line regimens.
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Gichane MW, Sullivan KA, Shayo AM, Mmbaga BT, O' Donnell K, Cunningham CK, Dow DE. Caregiver role in HIV medication adherence among HIV-infected orphans in Tanzania. AIDS Care 2017; 30:701-705. [PMID: 29058461 DOI: 10.1080/09540121.2017.1391986] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Youth living with HIV in sub-Saharan Africa face numerous challenges in adhering to HIV treatment. The AIDS epidemic has left many of these youth orphaned due to AIDS-related death of one or both parents. It is imperative to understand the family context of youth living with HIV in order to develop responsive interventions to improve adherence to antiretroviral therapy. We conducted qualitative in-depth interviews with 17 HIV-infected AIDS orphans, ages 13-24 years, screened positive for mental health difficulties according to the Patient Health Questionaire-9 (PHQ-9) or UCLA PTSD Reaction Index (PTSD-RI), and receiving outpatient HIV care at an adolescent medical clinic in Moshi, Tanzania. Treatment-related support varied by orphan status. Paternal orphans cared for by their biological mothers and maternal orphans cared for by grandmothers described adherence support such as assistance taking medication and attending clinic. Double orphans did not report adherence support. Several maternal and double orphans faced direct interference from caregivers and household members when they attempted to take their medications. Caregivers play a significant role in treatment adherence and must be considered in interventions to increase medication adherence in HIV-infected orphans. Findings from this study informed caregiver participation in Sauti ya Vijana (The Voice of Youth), a mental health intervention for youth living with HIV in Tanzania.
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Affiliation(s)
- Margaret W Gichane
- a Center for Health Policy & Inequalities Research, Duke Global Health Institute , Duke University , Durham , USA.,b Department of Health Behavior, Gillings School of Global Public Health , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Kristen A Sullivan
- a Center for Health Policy & Inequalities Research, Duke Global Health Institute , Duke University , Durham , USA.,c Department of Social Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Aisa M Shayo
- e Pediatric and Child Health Department , Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Blandina T Mmbaga
- d Kilimanjaro Christian Medical Centre-Duke Collaboration , Moshi , Tanzania.,e Pediatric and Child Health Department , Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Karen O' Donnell
- a Center for Health Policy & Inequalities Research, Duke Global Health Institute , Duke University , Durham , USA.,f Center for Child & Family Health , Duke University , Durham , USA
| | - Coleen K Cunningham
- g Department of Pediatrics, Division of Pediatric Infectious Diseases , Duke University Medical Center , Durham , USA.,h Duke University Global Health Institute , Durham , USA
| | - Dorothy E Dow
- d Kilimanjaro Christian Medical Centre-Duke Collaboration , Moshi , Tanzania.,g Department of Pediatrics, Division of Pediatric Infectious Diseases , Duke University Medical Center , Durham , USA.,h Duke University Global Health Institute , Durham , USA
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Impact of orphan status on HIV treatment outcomes and retention in care of children and adolescents in Asia. J Virus Erad 2016. [DOI: 10.1016/s2055-6640(20)30875-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Pediatric Access and Continuity of HIV Care Before the Start of Antiretroviral Therapy in Sub-Saharan Africa. Pediatr Infect Dis J 2016; 35:981-6. [PMID: 27187757 DOI: 10.1097/inf.0000000000001213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The number of HIV-infected children starting antiretroviral treatment (ART) has increased in resource-limited settings during the past decades. However, there are still few published data on the characteristics of pediatric patients at program enrolment and on the dynamics of dropping out before the start of ART. METHODS We performed a retrospective cohort study among HIV-infected pediatric patients (age, 5-14 years) not yet started on ART enrolled in 4 HIV sub-Saharan African programs. Descriptive and risk factors for mortality and lost to follow-up (LFU) were investigated using adjusted parametric or Cox proportional hazard models. RESULTS A total of 2244 patients (52.8% girls) were enrolled in HIV care, a median of 2 days [interquartile range (IQR), 0-8 days] after HIV diagnosis. Baseline median CD4 cell count was 409 cells/μL (IQR, 203-478 cells/μL); 43% were in clinical stage 3 or 4, 71% required ART and 76.2% of these patients initiated therapy. Of those eligible not started on ART, 14% died and 59% were LFU. Median pre-ART follow-up was 4.4 months (IQR, 1.3-20 months) and was shorter for eligible patients. Mortality rates were 6.2 of 100 person-years [95% confidence interval (CI), 4.6-8.3] in the 0- to 6-month period and 1.3 of 100 person-years (95% CI, 0.9-2.0) in the 6- to 60-month period. LFU rates were 37.4 of 100 (95% CI, 33.0-42.4) and 8.3 of 100 person-years (95% CI, 7.1-9.8), respectively. Advanced HIV disease at presentation (low body mass index, stage 3 or 4, low CD4 count or tuberculosis diagnosis) was associated with increased mortality and LFU. CONCLUSIONS Late presentation and delays in initiating ART among eligible children were responsible for the large incidence of patient losses during pre-ART follow-up in sub-Saharan Africa.
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COMMUNICATION IN THE CONTEXT OF FAMILY CAREGIVING: AN EXPLORATORY STUDY OF UGANDAN CHILDREN ON ANTIRETROVIRAL THERAPY. J Biosoc Sci 2015; 48:672-93. [PMID: 26507782 DOI: 10.1017/s0021932015000371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
It is important to consider the complexities of family dynamics when deciding when and how to communicate with HIV-infected children about their illness and treatment. Previous research has focused on providers' and caregivers' perspectives on whether, when and how to disclose HIV/AIDS diagnosis and treatment to HIV-infected children. From the perspective of HIV-infected children, communication does not mean just giving information about illness and treatment, but also encompasses emotional and material care. This paper places communication within the broader framework of caregiving in family situations. This exploratory study was conducted in Jinja district, Uganda, between November 2011 and December 2012. Through participant observation and in-depth interviews, communication by, and with, HIV-infected children in the context of family situations was explored from the perspectives of 29 HIV-infected children aged 8-17 years on antiretroviral therapy (ART) using content thematic analysis. Children's communication with caregivers about their illness and treatment varied depending on whom they were living with and the nature of caregiving. Although a mother's care was considered best, children described others who cared 'like a mother'. For some, caregiving was distributed among several relatives and non-relatives, while others felt they had hardly anyone to care for them. Caregiving from the children's perspective involved emotional support, expressed verbally and explicitly in messages of concern, encouragement conveyed in reminders to take medicines, attention when sick and confidential conversations about the challenges of having HIV and taking ART. Caregiving was also communicated implicitly in acts of provision of food/drinks to take with medicines, counting pills to confirm they had taken the medicines and accompanying children to treatment centres. Children's communication about their health and medicines and the care they received was to a large extent shaped by the nature of their relatedness to their caregivers, the extent to which caregiving was dispersed among several people and who else in the household was infected with HIV and on medication.
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Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review. J Int AIDS Soc 2015; 18:20049. [PMID: 26385853 PMCID: PMC4575412 DOI: 10.7448/ias.18.1.20049] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 07/10/2015] [Accepted: 08/12/2015] [Indexed: 12/25/2022] Open
Abstract
Introduction Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour. Methods We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed. Discussion Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV. Conclusions Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.
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Iroha E, Esezobor CI, Ezeaka C, Temiye EO, Akinsulie A. Adherence to antiretroviral therapy among HIV-infected children attending a donor-funded clinic at a tertiary hospital in Nigeria. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 9:25-30. [PMID: 25860410 DOI: 10.2989/16085906.2010.484543] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The success of antiretroviral therapy (ART) depends on a high level of adherence to a life-long regimen of antiretroviral drugs (ARVs). Since the scale-up of access to ARVs in Nigeria, few studies have determined the level of adherence of ART among children. This study was undertaken to determine the level of ART adherence among paediatric patients at an outpatient clinic, the reasons for non-adherence, and the factors associated with adherence, according to caregivers' reports. Out of a total of 212 children, 183 (86%) were adherent in the three days preceding the interview, while 29 (14%) were not adherent. Drug exhaustion at home (16 children), followed by 'child slept through' (7 children) and 'caregiver away' were the most common reasons for a child having missed one or more ARV doses. Independent factors for adherence were male gender (odds ratio [OR] = 2.85; 95% confidence interval [CI]: 1.17-6.92) and attendance at last scheduled clinic appointment (OR = 4.76; 95% CI: 1.73-13.04). The caregiver's highest educational attainment, distance travelled to the clinic, use of medication reminders, formulation of ARVs, duration of HAART usage, age of the child and orphan status were not significantly associated with adherence to drug treatment. The overall level of adherence was high and similar to the rate reported prior to free access to ART services in Nigeria. Among child patients on HAART, there is a need to identify factors affecting clinic attendance and drug exhaustion at home.
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Affiliation(s)
- Edna Iroha
- a Department of Paediatrics, College of Medicine , University of Lagos , PMB 12003 , Lagos , Lagos State , Nigeria
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What makes orphans in Kigali, Rwanda, non-adherent to antiretroviral therapy? Perspectives of their caregivers. J Int AIDS Soc 2014; 17:19310. [PMID: 25477050 PMCID: PMC4256520 DOI: 10.7448/ias.17.1.19310] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 10/04/2014] [Accepted: 10/16/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Every year, approximately 260,000 children are infected with HIV in low- and middle-income countries. The timely initiation and high level of maintenance of antiretroviral therapy (ART) are crucial to reducing the suffering of HIV-positive children. We need to develop a better understanding of the background of children's ART non-adherence because it is not well understood. The purpose of this study is to explore the background related to ART non-adherence, specifically in relation to the orphan status of children in Kigali, Rwanda. METHODS We conducted 19 focus group discussions with a total of 121 caregivers of HIV-positive children in Kigali. The primary data for analysis were verbatim transcripts and socio-demographic data. A content analysis was performed for qualitative data analysis and interpretation. RESULTS The study found several contextual factors that influenced non-adherence: among double orphans, there was psychological distance between the caregivers and children, whereas economic burden was the primary issue among paternal orphans. The factors promoting adherence also were unique to each orphan status, such as the positive attitude about disclosing serostatus to the child by double orphans' caregivers, and feelings of guilt about the child's condition among non-orphaned caregivers. CONCLUSIONS Knowledge of orphan status is essential to elucidate the factors influencing ART adherence among HIV-positive children. In this qualitative study, we identified the orphan-related contextual factors that influenced ART adherence. Understanding the social context is important in dealing with the challenges to ART adherence among HIV-positive children.
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Mutwa PR, Boer KR, Asiimwe-Kateera B, Tuyishimire D, Muganga N, Lange JMA, van de Wijgert J, Asiimwe A, Reiss P, Geelen SPM. Safety and effectiveness of combination antiretroviral therapy during the first year of treatment in HIV-1 infected Rwandan children: a prospective study. PLoS One 2014; 9:e111948. [PMID: 25365302 PMCID: PMC4218827 DOI: 10.1371/journal.pone.0111948] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 10/08/2014] [Indexed: 11/19/2022] Open
Abstract
Background With increased availability of paediatric combination antiretroviral therapy (cART) in resource limited settings, cART outcomes and factors associated with outcomes should be assessed. Methods HIV-infected children <15 years of age, initiating cART in Kigali, Rwanda, were followed for 18 months. Prospective clinical and laboratory assessments included weight-for-age (WAZ) and height-for-age (HAZ) z-scores, complete blood cell count, liver transaminases, creatinine and lipid profiles, CD4 T-cell count/percent, and plasma HIV-1 RNA concentration. Clinical success was defined as WAZ and WAZ >−2, immunological success as CD4 cells ≥500/mm3 and ≥25% for respectively children over 5 years and under 5 years, and virological success as a plasma HIV-1 RNA concentration <40 copies/mL. Results Between March 2008 and December 2009, 123 HIV-infected children were included. The median (interquartile (IQR) age at cART initiation was 7.4 (3.2, 11.5) years; 40% were <5 years and 54% were female. Mean (95% confidence interval (95%CI)) HAZ and WAZ at baseline were −2.01 (−2.23, −1.80) and −1.73 (−1.95, −1.50) respectively and rose to −1.75 (−1.98, −1.51) and −1.17 (−1.38, −0.96) after 12 months of cART. The median (IQR) CD4 T-cell values for children <5 and ≥5 years of age were 20% (13, 28) and 337 (236, 484) cells/mm3respectively, and increased to 36% (28, 41) and 620 (375, 880) cells/mm3. After 12 months of cART, 24% of children had a detectable viral load, including 16% with virological failure (HIV-RNA>1000 c/mL). Older age at cART initiation, poor adherence, and exposure to antiretrovirals around birth were associated with virological failure. A third (33%) of children had side effects (by self-report or clinical assessment), but only 9% experienced a severe side effect requiring a cART regimen change. Conclusions cART in Rwandan HIV-infected children was successful but success might be improved further by initiating cART as early as possible, optimizing adherence and optimizing management of side effects.
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Affiliation(s)
- Philippe R. Mutwa
- Kigali University Teaching Hospital, Department of Pediatrics, Kigali, Rwanda
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Kimberly R. Boer
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- Biomedical Research, Epidemiology Unit, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Brenda Asiimwe-Kateera
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Diane Tuyishimire
- Outpatients Clinic, Treatment and Research on HIV/AIDS Centre, Kigali, Rwanda
| | - Narcisse Muganga
- Kigali University Teaching Hospital, Department of Pediatrics, Kigali, Rwanda
| | - Joep M. A. Lange
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke van de Wijgert
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United of Kingdom
- Rinda Ubuzima, Kigali, Rwanda
| | | | - Peter Reiss
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Sibyl P. M. Geelen
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
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Cruz MLS, Cardoso CAA, Darmont MQ, Souza E, Andrade SD, D'Al Fabbro MM, Fonseca R, Bellido JG, Monteiro SS, Bastos FI. Viral suppression and adherence among HIV-infected children and adolescents on antiretroviral therapy: results of a multicenter study. J Pediatr (Rio J) 2014; 90:563-71. [PMID: 24953723 DOI: 10.1016/j.jped.2014.04.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/18/2014] [Accepted: 04/03/2014] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate treatment adherence among perinatally-infected pediatric human immunodeficiency virus (HIV) patients followed in pediatric centers in Brazil. METHODS This was a cross-sectional multicenter study. Medical records were reviewed and adherence scale, assessment of caregivers' quality of life (WHOQOL-BREF), anxiety, depression, and alcohol/substances use/abuse were assessed. Outcomes included self-reported 100% adherence in the last three days and HIV viral load (VL)<50 copies/mL. Statistical analyses included contingency tables and respective statistics, and multivariable logistic regression. RESULTS 260 subjects were enrolled: 78% children and 22% adolescents; 93% of caregivers for the children and 77% of adolescents reported 100% adherence; 57% of children and 49% of adolescents had VL<50 copies/mL. In the univariate analyses, HIV diagnosis for screening due to maternal infection, lower caregiver scores for anxiety, and higher scores in physical and psychological domains of WHOQOL-BREF were associated with 100% adherence. Shorter intervals between pharmacy visits were associated with VL<50 copies/mL (p ≤ 0.01). Multivariable regression demonstrated that caregivers who did not abuse alcohol/other drugs (OR=0.49; 95% CI: 0.27-0.89) and median interval between pharmacy visits<33 days (OR=0.97; 95% CI: 0.95-0.98) were independently associated with VL<50 copies/mL; whereas lower caregiver scores for anxiety (OR=2.57; 95% CI: 1.27-5.19) and children's HIV diagnosis for screening due to maternal infection (OR=2.25; 95% CI: 1.12-4.50) were found to be independently associated with 100% adherence. CONCLUSIONS Pediatric HIV programs should perform routine assessment of caregivers' quality of life, and anxiety and depression symptoms. In this setting, pharmacy records are essential to help identify less-than-optimal adherence.
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Affiliation(s)
- Maria L S Cruz
- Escola Nacional de Saúde Pública Sergio Arouca, Rio de Janeiro, RJ, Brazil; Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil.
| | | | - Mariana Q Darmont
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil
| | - Edvaldo Souza
- Instituto de Medicina Integral Prof. Fernando Figueira, Recife, PE, Brazil
| | - Solange D Andrade
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, AM, Brazil
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Viral suppression and adherence among HIV‐infected children and adolescents on antiretroviral therapy: results of a multicenter study. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Kunapareddy CJ, Nyandiko W, Inui T, Ayaya S, Marrero DG, Vreeman R. A qualitative assessment of barriers to antiretroviral therapy adherence among adolescents in western Kenya. JOURNAL OF HIV/AIDS & SOCIAL SERVICES 2014; 13:383-401. [PMID: 28367106 PMCID: PMC5374741 DOI: 10.1080/15381501.2012.754392] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Antiretroviral therapy (ART) requires nearly perfect adherence to be effective. This study aims to identify key factors identified by HIV-infected adolescents on ART as contributing to medication adherence in western Kenya. Using a qualitative study design, three adolescent focus groups discussions were conducted at an urban and rural clinic site in western Kenya. The study population included HIV-infected adolescents receiving ART through the USAID-AMPATH HIV care system. A trained facilitator conducted groups in Kiswahili using a semi-structured interview guide probing multiple aspects of experience of taking medicines. Transcribed focus group dialogues were analyzed using constant comparison, progressive coding, and triangulation. The adolescents described a context of negative societal beliefs about HIV, necessitating a lifestyle of secrecy and minimizing the information shared about HIV or ART. Assessing and addressing adolescents' fears and behaviors regarding medication secrecy and disclosure may enable more accurate monitoring of adherence and development of intervention strategies.
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Affiliation(s)
| | - Winstone Nyandiko
- Moi University School of Medicine, Department of Child Health and Pediatrics, Eldoret, Kenya, and USAID, Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Thomas Inui
- USAID, Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya, Indian University School of Medicine, Department of Medicine, Indianapolis, IN, USA, and Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Samwel Ayaya
- USAID, Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya and Moi University School of Medicine, Department of Child Health and Pediatrics, Eldoret, Kenya
| | - David G Marrero
- Indiana University School of Medicine, Department of Medicine, Indianapolis, United States, and Indiana University School of Medicine, Diabetes Translational Research Center, Indianapolis, IN, USA
| | - Rachel Vreeman
- USAID, Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya, Regenstrief Institute, Inc., Indianapolis, IN, USA, and Indiana University School of Medicine, Children Health Services Research, Indianapolis, IN, USA
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Steady-state pharmacokinetics of nevirapine extended-release tablets in HIV-1-infected children and adolescents: an open-label, multiple-dose, cross-over study. Pediatr Infect Dis J 2014; 33:e173-9. [PMID: 24378938 DOI: 10.1097/inf.0000000000000241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To compare steady-state (ss) pharmacokinetic targets of nevirapine extended-release (NVP-XR) tablets once-daily (QD) with immediate-release (NVP-IR) tablet or oral suspension twice-daily in HIV-1-infected children and adolescents. METHODS Phase I, open-label, multidose, cross-over study with optional extension phase, in 85 patients 3 to <18 years of age, previously on an NVP-IR-based regimen for ≥18 weeks with baseline viral load <50 copies/mL. Patients were stratified by age, treated with NVP-IR twice-daily for 11 days, then NVP-XR QD for 10 days. Cpre,ss (steady-state, predose concentrations) was obtained from all, and 12-hour NVP-IR and 24-hour NVP-XR steady-state pharmacokinetic profiles were obtained in the pharmacokinetic substudy. Viral loads, CD4 counts and adverse events (AEs) were monitored. RESULTS Eighty patients completed the trial. Adjusted geometric mean (gMean) Cpre,ss for NVP-XR and NVP-IR exceeded the target of 3000 ng/mL, and the adjusted gMean NVP-XR:NVP-IR ratio (90% confidence interval) for QD normalized and un-normalized Cpre,ss were 91.2% (83.5-99.6%) and 91.8% (83.7-100.7%). gMean 24-hour area under the curve at steady-state NVP-XR:NVP-IR for un-normalized dose was 90.4% and un-normalized Cpre,ss NVP-XR:NVP-IR were 91.0%, 81.9% and 103.7% for the 3 age groups, 3 to <6, 6 to <12 and 12 to <18 years, respectively. gMean values indicated no exposure to subtherapeutic NVP concentrations and viral suppression was adequate and maintained in all QD groups. Most AEs were mild and similar between age groups. No serious or Division of AIDS Grade 4 AEs or AE related treatment discontinuations occurred. CONCLUSIONS NVP-XR exhibited adequate trough concentrations with equivalent area under the curve at steady-state relative to NVP-IR. NVP-XR was well-tolerated and is a valuable treatment option for HIV-infected children and adolescents.
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Cognitive interviewing for cross-cultural adaptation of pediatric antiretroviral therapy adherence measurement items. Int J Behav Med 2014. [PMID: 23188670 DOI: 10.1007/s12529-012-9283-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND There are 2.3 million children living with HIV worldwide, almost 90 % of whom live in sub-Saharan Africa. Access to antiretroviral therapy (ART) for HIV treatment has dramatically increased in resource-limited settings in recent years and allows more HIV-infected children to survive into adolescence and adulthood. PURPOSE Our objective was to improve the understandability of pediatric antiretroviral adherence measurement items for use in resource-limited settings through cognitive interviewing with pediatric caregivers and HIV-infected adolescents in Kenya. METHODS We compiled adherence measurement items through a systematic literature review and qualitative work. We conducted cognitive interviews assessing the items with caregivers of HIV-infected children enrolled in HIV care in Kenya and conducted group cognitive assessments with HIV-infected adolescents. We used verbal probing and guided "thinking aloud" to evaluate relevance, comprehension, recall, and sensitivity/acceptability. Analysis followed a systematic sequence of review, compiling data by item, and coding responses. RESULTS We interviewed 21 Kenyan parents and guardians and 10 adolescents (mean age 15 years, SD 1.8) on antiretroviral therapy for a mean of 3.6 years. Cognitive interviews optimized item-response options, wording, and content. Some participants demonstrated difficulty with "think aloud" processes, but verbal probes were easily answered. Comprehension problems were found for key language concepts such "missed doses" and "having side effects." Key findings for response options included differences among responses to various recall periods, with preferences for the shortest (one 24-h day) and longest recall periods (1 month); difficulty describing specific drug information; benefits for including normalizing statements before asking for sensitive information; and challenges processing categorical frequency scales. Important content areas for inclusion included dose timing, disclosure, stigma, and food insecurity. CONCLUSIONS Cognitive interviewing is a productive strategy for increasing the face validity and understandability of adherence measurement items, particularly across cultures. Interviews in Kenya suggested adherence measurement modifications of relevance for other resource-limited settings.
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Alvarez-Uria G, Naik PK, Midde M, Pakam R. Mortality and Loss to Follow up Before Initiation of Antiretroviral Therapy Among HIV-Infected Children Eligible for HIV Treatment. Infect Dis Rep 2014; 6:5167. [PMID: 25002959 PMCID: PMC4083298 DOI: 10.4081/idr.2014.5167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/12/2013] [Accepted: 12/20/2013] [Indexed: 11/23/2022] Open
Abstract
Data on attrition due to mortality or loss to follow-up (LTFU) from antiretroviral therapy (ART) eligibility to ART initiation of HIV-infected children are scarce. The aim of this study is to describe attrition before ART initiation of 247 children who were eligible for ART in a cohort study in India. Multivariable analysis was performed using competing risk regression. The cumulative incidence of attrition was 12.6% (95% confidence interval, 8.7-17.3) after five years of follow-up, and the attrition rate was higher during the first months after ART eligibility. Older children (>9 years) had a lower mortality risk before ART initiation than those aged <2 years. Female children had a lower risk of LTFU before ART initiation than males. Children who belonged to scheduled tribes had a higher risk of delayed ART initiation and LTFU. Orphan children had a higher risk of delayed ART initiation and mortality. Children who were >3 months in care before ART eligibility were less likely to be LTFU. The 12-month risk of AIDS, which was calculated using the absolute CD4 cell count and age, was strongly associated with mortality. A substantial proportion of ART-eligible children died or were LTFU before the initiation of ART. These findings can be used in HIV programmes to design actions aimed at reducing the attrition of ART-eligible children in India.
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Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital , Bathalapalli, AP, India
| | - Praveen Kumar Naik
- Department of Infectious Diseases, Rural Development Trust Hospital , Bathalapalli, AP, India
| | - Manoranjan Midde
- Department of Infectious Diseases, Rural Development Trust Hospital , Bathalapalli, AP, India
| | - Raghavakalyan Pakam
- Department of Infectious Diseases, Rural Development Trust Hospital , Bathalapalli, AP, India
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Sudjaritruk T, Maleesatharn A, Prasitsuebsai W, Fong SM, Le NO, Le TTT, Lumbiganon P, Kumarasamy N, Kurniati N, Hansudewechakul R, Yusoff NKN, Razali KAM, Kariminia A, Sohn AH, Sirisanthana, on behalf of the TREA V. Prevalence, characteristics, management, and outcome of pulmonary tuberculosis in HIV-infected children in the TREAT Asia pediatric HIV Observational Database (TApHOD). AIDS Patient Care STDS 2013; 27:649-56. [PMID: 24206012 DOI: 10.1089/apc.2013.0236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A multicenter, retrospective, observational study was conducted to determine prevalence, characteristics, management, and outcome of pulmonary tuberculosis (PTB) in Asian HIV-infected children in the TREAT Asia Pediatric HIV Observational Database (TApHOD). Data on PTB episodes diagnosed during the period between 12 months before antiretroviral therapy (ART) initiation and December 31, 2009 were extracted. A total of 2678 HIV-infected children were included in TApHOD over a 13-year period; 457 developed PTB, giving a period prevalence of 17.1% (range 5.7-33.0% per country). There were a total of 484 PTB episodes; 27 children had 2 episodes each. There were 21 deaths (4.3%). One third of episodes (n=175/484) occurred after ART initiation at a median of 14.1 months (interquartile range [IQR] 2.5-28.8 months). The median (IQR) CD4+ values were 9.0% (3.0-16.0%) and 183.5 (37.8-525.0) cells/mm(3) when PTB was diagnosed. Most episodes (n=424/436, 97.3%) had abnormal radiographic findings compatible with PTB, whereas half (n=267/484, 55.2%) presented with clinical characteristics of PTB. One third of those tested (n=42/122, 34.4%) had bacteriological evidence of PTB. Of the 156 episodes (32.2%) that were accompanied with extrapulmonary TB, pleuritis was the most common manifestation (81.4%). After treatment completion, most episodes (n=396/484, 81.9%) were recorded as having positive outcomes (cured, treatment completed and child well, and improvement). The prevalence of PTB among Asian HIV-infected children in our cohort was high. Children with persistent immunosuppression remain vulnerable to PTB even after ART initiation.
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Affiliation(s)
- Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Wasana Prasitsuebsai
- HIV-Netherlands, Australia, Thaliand HIV-NAT/Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Ngoc Oanh Le
- Worldwide Orphans Foundation, Ho Chi Minh City, Vietnam
| | | | | | | | - Nia Kurniati
- Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | - Azar Kariminia
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Annette H. Sohn
- TREAT Asia, amfAR—The Foundation for AIDS Research, Bangkok, Thailand
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Anaemia and zidovudine-containing antiretroviral therapy in paediatric antiretroviral programmes in the IeDEA Paediatric West African Database to evaluate AIDS. J Int AIDS Soc 2013; 16:18024. [PMID: 24047928 PMCID: PMC3776924 DOI: 10.7448/ias.16.1.18024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 08/09/2013] [Accepted: 08/19/2013] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION There is a risk of anaemia among HIV-infected children on antiretroviral therapy (ART) containing zidovudine (ZDV) recommended in first-line regimens in the WHO guidelines. We estimated the risk of severe anaemia after initiation of a ZDV-containing regimen in HIV-infected children included in the IeDEA West African database. METHODS Standardized collection of data from HIV-infected children (positive PCR<18 months or positive serology ≥ 18 months) followed up in HIV programmes was included in the regional IeDEA West Africa collaboration. Ten clinical centres from seven countries contributed (Benin, Burkina Faso, Côte d'Ivoire, Gambia, Ghana, Mali and Senegal) to this collection. Inclusion criteria were age <16 years and starting ART. We explored the data quality of haemoglobin documentation over time and the incidence and predictors of severe anaemia (Hb<7 g/dL) per 100 child-years of follow-up over the duration of first-line antiretroviral therapy. RESULTS As of December 2009, among the 2933 children included in the collaboration, 45% were girls, median age was five years; median CD4 cell percentage was 13%; median weight-for-age z-score was-2.7; and 1772 (60.4%) had a first-line ZDV-containing regimen. At baseline, 70% of the children with a first-line ZDV-containing regimen had a haemoglobin measure available versus 76% in those not on ZDV (p ≤ 0.01): the prevalence of severe anaemia was 3.0% (n=38) in the ZDV group versus 10.2% (n=89) in those without (p<0. 01). Over the first-line follow-up, 58.9% of the children had ≥ 1 measure of haemoglobin available in those exposed to ZDV versus 60.4% of those not (p=0.45). Severe anaemia occurred in 92 children with an incidence of 2.47 per 100 child-years of follow-up in those on a ZDV-containing regimen versus 4.25 in those not (p ≤ 0.01). Adjusted for age at ART initiation and first-line regimen, a weight-for-age z-score ≤-3 was a strong predictor associated with a 5.59 times risk of severe anaemia (p<0.01). CONCLUSIONS Severe anaemia is frequent at baseline and guides the first-line ART prescription, but its incidence seems rare among children on ART. Severe malnutrition at baseline is a strong predictor for development of severe anaemia, and interventions to address this should form an integral component of clinical care.
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Nonadherence to Clinic Appointments Among HIV-Infected Children in an Ambulatory Care Program in Western Kenya. J Acquir Immune Defic Syndr 2013; 63:e49-55. [DOI: 10.1097/qai.0b013e31828e1e2c] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bhattacharya M, Saxena R. Outcome of anti-retroviral treatment in HIV-infected orphans and non-orphans at an ART centre in North India. Paediatr Int Child Health 2013; 32:228-32. [PMID: 23164297 DOI: 10.1179/2046905512y.0000000035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Few Indian studies have reported the long-term efficacy of anti-retroviral treatment (ART) in children and in orphaned, HIV-infected children in particular. AIM To study differences in outcome of ART in HIV-infected orphans compared with non-orphans. METHODS A retrospective study of 87 HIV-infected children who commenced ART in the period January 2006 to August 2007. The main measures were orphan status, absolute CD4 count and weight-for-height (WHZ) and height-for-age (HAZ) Z-scores. RESULTS Median follow-up was 33 months. Forty (45·9%) children were orphaned. Orphans and non-orphans had similar baseline median WHZ and HAZ (-2·48 vs -2·63, P = 0·65 and -2·78 vs -2·91, P = 0·77, respectively). The two groups were similar in terms of WHO clinical stage and frequency of severe immunosuppression at presentation (P = 0·88 and 0·25, respectively). After ART initiation, the median absolute CD4 count increased progressively in both groups. Median WHZ and HAZ increased throughout the study period in the orphans and reached -1 at 27 and 39 months of ART, respectively. In the non-orphans, WHZ remained below that of the orphan group, the difference becoming statistically significant from 18 months of ART. The increment in HAZ in the non-orphan group was at par with the orphan group until 12 months of follow-up, after which it fell between 18 and 30 months. Subsequently, HAZ rose but remained below that of the orphan group. Both WHZ and HAZ failed to reach -1 in the non-orphan group. In both groups, 85% reported 100% adherence to ART. CONCLUSION The outcome of ART is not affected by orphan status with the extended family adequately supporting orphaned children. Growth of children whose parents are HIV-infected may be constrained despite ART if there is inadequate family support.
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Mutwa PR, Van Nuil JI, Asiimwe-Kateera B, Kestelyn E, Vyankandondera J, Pool R, Ruhirimbura J, Kanakuze C, Reiss P, Geelen S, van de Wijgert J, Boer KR. Living situation affects adherence to combination antiretroviral therapy in HIV-infected adolescents in Rwanda: a qualitative study. PLoS One 2013; 8:e60073. [PMID: 23573232 PMCID: PMC3616046 DOI: 10.1371/journal.pone.0060073] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 02/21/2013] [Indexed: 12/22/2022] Open
Abstract
Introduction Adherence to combination antiretroviral therapy (cART) is vital for HIV-infected adolescents for survival and quality of life. However, this age group faces many challenges to remain adherent. We used multiple data sources (role-play, focus group discussions (FGD), and in-depth interviews (IDI)) to better understand adherence barriers for Rwandan adolescents. Forty-two HIV positive adolescents (ages 12–21) and a selection of their primary caregivers were interviewed. All were perinatally-infected and received (cART) for ≥12 months. Topics discussed during FGDs and IDIs included learning HIV status, disclosure and stigma, care and treatment issues, cART adherence barriers. Results Median age was 17 years, 45% female, 45% orphaned, and 48% in boarding schools. We identified three overarching but inter-related themes that appeared to influence adherence. Stigma, perceived and experienced, and inadvertent disclosure of HIV status hampered adolescents from obtaining and taking their drugs, attending clinic visits, carrying their cARTs with them in public. The second major theme was the need for better support, in particular for adolescents with different living situations, (orphanages, foster-care, and boarding schools). Lack of privacy to keep and take medication came out as major barrier for adolescents living in congested households, as well the institutionalization of boarding schools where privacy is almost non-existent. The third important theme was the desire to be ‘normal’ and not be recognized as an HIV-infected individual, and to have a normal life not perturbed by taking a regimen of medications or being forced to disclose where others would treat them differently. Conclusions We propose better management of HIV-infected adolescents integrated into boarding school, orphanages, and foster care; training of school-faculty on how to support students and allow them privacy for taking their medications. To provide better care and support, HIV programs should stimulate caregivers of HIV-infected adolescents to join them for their clinic visits.
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Affiliation(s)
- Philippe R Mutwa
- Kigali University Teaching Hospital/Department of Pediatrics, Kigali, Rwanda.
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Thompson RT, Meslin EM, Braitstein PKA, Nyandiko WM, Ayaya SO, Vreeman RC. The vulnerabilities of orphaned children participating in research: a critical review and factors for consideration for participation in biomedical and behavioral research. J Empir Res Hum Res Ethics 2013; 7:56-66. [PMID: 23086048 DOI: 10.1525/jer.2012.7.4.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orphans are a subpopulation with a unique set of additional vulnerabilities. Increasing focus on children's rights, pediatric global health, and pediatric research makes it imperative to recognize and address unique vulnerabilities of orphaned children. This paper describes the unique vulnerabilities of the orphaned pediatric population and offers a structured set of factors that require consideration when including orphans in biomedical research. Pediatric orphans are particularly vulnerable due to decreased economic resources, psychosocial instability, increased risk of abuse, and delayed/decreased access to healthcare. These vulnerabilities are significant. By carefully considering each issue in a population in a culturally specific and study-specific manner, researchers can make valuable contributions to the overall health and well-being of this uniquely vulnerable population.
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Scanlon ML, Vreeman RC. Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings. HIV AIDS (Auckl) 2013; 5:1-17. [PMID: 23326204 PMCID: PMC3544393 DOI: 10.2147/hiv.s28912] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.
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Affiliation(s)
- Michael L Scanlon
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Rachel C Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
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Musiime V, Kayiwa J, Kiconco M, Tamale W, Alima H, Mugerwa H, Abwola M, Apilli E, Ahimbisibwe F, Kizito H, Abongomera G, Namusoke A, Makabayi A, Kiweewa F, Ssali F, Kityo C, Colebunders R, Mugyenyi P. Response to antiretroviral therapy of HIV type 1-infected children in urban and rural settings of Uganda. AIDS Res Hum Retroviruses 2012; 28:1647-57. [PMID: 22545751 DOI: 10.1089/aid.2011.0313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
From 2006 to 2011, a cohort study was conducted among 1000 children resident in urban and rural settings of Uganda to ascertain and compare the response to antiretroviral therapy (ART) among urban versus rural children and the factors associated with this response. Clinical, immunological, and virological parameters were ascertained at baseline and weeks 24, 48, 96, and 144 after ART initiation. Adherence to ART was assessed at enrollment by self-report (SR) and pill counts (PC). Overall, 499/948 (52.6%) children were resident in rural areas, 504/948 (53.1%) were male, and their mean age was 11.9±4.4 years (urban children) and 11.4±4.1 years (rural children). The urban children were more likely to switch to second-line ART at a rate of 39.9 per 1000 person-years (95% CI: 28.2-56.4) versus 14.9 per 1000 person-years (95% CI: 8.7-25.7), p=0.0038, develop any new WHO 3/4 events at 127/414 (30.7%) versus 108/466 (23.2%), p=0.012, and have a higher cumulative incidence of hospitalization of 54/449 (12.0%) versus 32/499 (6.4%), p=0.003, when compared to rural children. No differences were observed in mean changes in weight, height, CD4 count and percentage, and hemoglobin and viral load between urban and rural children. Adherence of ≥95% was observed in 88.2% of urban versus 91.3% of rural children by SR (p=0.130), and in 78.8% of urban versus 88.8% of rural children by PC (p<0.0001). In this study rural children had more favorable clinical outcomes and were more likely to adhere optimally to ART than urban children.
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Affiliation(s)
- Victor Musiime
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Joshua Kayiwa
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Mary Kiconco
- Joint Clinical Research Centre, Fort-Portal Regional Centre of Excellence, Fort-Portal, Uganda
| | - William Tamale
- Joint Clinical Research Centre, Kakira Regional Centre of Excellence, Jinja, Uganda
| | - Hillary Alima
- Joint Clinical Research Centre, Kabale Regional Centre of Excellence, Kabale, Uganda
| | - Henry Mugerwa
- Joint Clinical Research Centre, Mbarara Regional Centre of Excellence, Mbarara, Uganda
| | - Mary Abwola
- Joint Clinical Research Centre, Mbale Regional Centre of Excellence, Mbale, Uganda
| | | | | | - Hilda Kizito
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - George Abongomera
- Joint Clinical Research Centre, Gulu Regional Centre of Excellence, Gulu, Uganda
| | - Asia Namusoke
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Agnes Makabayi
- Joint Clinical Research Centre, Mbale Regional Centre of Excellence, Mbale, Uganda
| | - Francis Kiweewa
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Francis Ssali
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | - Cissy Kityo
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
| | | | - Peter Mugyenyi
- Joint Clinical Research Centre, Headquarters, Kampala, Uganda
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Ushie BA, Jegede AS. The paradox of family support: concerns of tuberculosis-infected HIV patients about involving family and friends in their treatment. AIDS Patient Care STDS 2012; 26:674-80. [PMID: 23072439 DOI: 10.1089/apc.2011.0304] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite the widely documented evidence that family support improves adherence to HIV treatment, some studies have reported no benefit or even a negative association between family support and adherence. This study reexamined the role of family support in treatment adherence to find out the circumstances under which family support for HIV and tuberculosis coinfected patients promotes or hinders treatment adherence in Cross River State, Nigeria. We conducted eight focus group discussions (FGDs) and four case histories with coinfected patients. In addition, 21 in-depth interviews (IDIs) were conducted with: 8 family members, 6 friends, and 7 care providers. Data were analyzed in a thematic format with the aid of NVIVO software. Overall, family support promotes adherence in coinfected patients. Family support may, however, have a negative effect on adherence when the recipient perceives that the support is given with ulterior motives (e.g., gossiping about them and becoming indebted to the support givers) and when the recipient is the primary breadwinner and feels that this role is being undermined. Family support is useful as a tool for scaling up adherence but the usefulness is context-specific and mediated by the patient's subjective interpretation of the support givers' motives.
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Okomo U, Togun T, Oko F, Peterson K, Jaye A. Mortality and loss to programme before antiretroviral therapy among HIV-infected children eligible for treatment in The Gambia, West Africa. AIDS Res Ther 2012; 9:28. [PMID: 23031736 PMCID: PMC3505473 DOI: 10.1186/1742-6405-9-28] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 09/28/2012] [Indexed: 11/25/2022] Open
Abstract
Background HIV infection among children, particularly those under 24 months of age, is often rapidly progressive; as a result guidelines recommend earlier access to combination antiretroviral therapy (cART) for HIV infected children. Losses to follow-up (LTFU) and death in the interval between diagnosis and initiation of ART profoundly limit this strategy. This study explores correlates of LTFU and death prior to ART initiation among children. Methods The study is based on 337 HIV-infected children enrolled into care at an urban centre in The Gambia, including those alive and in care when antiretroviral therapy became available and those who enrolled later. Children were followed until they started ART, died, transferred to another facility, or were LTFU. Cox proportional hazards regression models were used to determine the hazard of death or LTFU according to the baseline characteristics of the children. Results Overall, 223 children were assessed as eligible for ART based on their clinical and/or immunological status among whom 73 (32.7%) started treatment, 15 (6.7%) requested transfer to another health facility, 105 (47.1%) and 30 (13.5%) were lost to follow-up and died respectively without starting ART. The median survival following eligibility for children who died without starting treatment was 2.8 months (IQR: 0.9 - 5.8) with over half (60%) of all deaths occurring at home. ART-eligible children less than 2 years of age and those in WHO stage 3 or 4 were significantly more likely to be LTFU when compared with their respective comparison groups. The overall pre-treatment mortality rate was 25.7 per 100 child-years of follow-up (95% CI 19.9 - 36.8) and the loss to programme rate was 115.7 per 100 child-years of follow-up (95% CI 98.8 - 137). In the multivariable Cox proportional hazard model, significant independent predictors of loss to programme were being less than 2 years of age and WHO stage 3 or 4. The Adjusted Hazard Ratio (AHR) for loss to programme was 2.06 (95% CI 1.12 – 3.83) for being aged less than 2 years relative to being 5 years of age or older and 1.92 (95% CI 1.05 - 3.53) for being in WHO stage 3 or 4 relative to WHO stage 1 or 2. Conclusions Earlier enrolment into HIV care is key to achieving better outcomes for HIV infected children in developing countries. Developing strategies to ensure early diagnosis, elimination of obstacles to prompt initiation of therapy and instituting measures to reduce losses to follow-up, will improve the overall outcomes of HIV-infected children.
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Kikuchi K, Poudel KC, Muganda J, Majyambere A, Otsuka K, Sato T, Mutabazi V, Nyonsenga SP, Muhayimpundu R, Jimba M, Yasuoka J. High risk of ART non-adherence and delay of ART initiation among HIV positive double orphans in Kigali, Rwanda. PLoS One 2012; 7:e41998. [PMID: 22860043 PMCID: PMC3408396 DOI: 10.1371/journal.pone.0041998] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 06/28/2012] [Indexed: 12/15/2022] Open
Abstract
Background To reduce HIV/AIDS related mortality of children, adherence to antiretroviral treatment (ART) is critical in the treatment of HIV positive children. However, little is known about the association between ART adherence and different orphan status. The aims of this study were to assess the ART adherence and identify whether different orphan status was associated with the child’s adherence. Methods A total of 717 HIV positive children and the same number of caregivers participated in this cross-sectional study. Children’s adherence rate was measured using a pill count method and those who took 85% or more of the prescribed doses were defined as adherent. To collect data about adherence related factors, we also interviewed caregivers using a structured questionnaire. Results Of all children (N = 717), participants from each orphan category (double orphan, maternal orphan, paternal orphan, non-orphan) were 346, 89, 169, and 113, respectively. ART non-adherence rate of each orphan category was 59.3%, 44.9%, 46.7%, and 49.7%, respectively. The multivariate analysis indicated that maternal orphans (AOR 0.31, 95% CI 0.12–0.80), paternal orphans (AOR 0.35, 95% CI 0.14–0.89), and non-orphans (AOR 0.45, 95% CI 0.21–0.99) were less likely to be non-adherent compared to double orphans. Double orphans who had a sibling as a caregiver were more likely to be non-adherent. The first mean CD4 count prior to initiating treatment was 520, 601, 599, and 844 (cells/ml), respectively (p<0.001). Their mean age at sero-status detection was 5.9, 5.3, 4.8, and 3.9 (year old), respectively (p<0.001). Conclusions Double orphans were at highest risk of ART non-adherence and especially those who had a sibling as a caregiver had high risk. They were also in danger of initiating ART at an older age and at a later stage of HIV/AIDS compared with other orphan categories. Double orphans need more attention to the promote child’s adherence to ART.
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Affiliation(s)
- Kimiyo Kikuchi
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Krishna C. Poudel
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - John Muganda
- Division of Obstetrics and Gynecology, King Faisal Hospital, Kigali, Rwanda
| | - Adolphe Majyambere
- HIV/AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Keiko Otsuka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoko Sato
- Department of Psychology, The Meiji Gakuin University, Tokyo, Japan
| | - Vincent Mutabazi
- HIV/AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Simon Pierre Nyonsenga
- HIV/AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Ribakare Muhayimpundu
- HIV/AIDS, STIs and Other Blood Borne Infections Division, Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- * E-mail:
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Long-term impact of the Kenya postelection crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya. J Acquir Immune Defic Syndr 2012; 59:199-206. [PMID: 22027872 DOI: 10.1097/qai.0b013e31823b4448] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Kenya experienced a political and humanitarian crisis after presidential elections on December 27, 2007. We sought to describe both the immediate and long-term impact of this conflict for HIV-infected children in western Kenya. METHODS We conducted a retrospective study of a cohort of these children for 3 periods: period 1, before the election (October 26, 2007, to December 25, 2007); period 2, immediately after the election (December 26, 2007, to April 15, 2008); and period 3, long-term postelection (April 16, 2008, to December 31, 2008). Two outcome variables of loss-to-follow-up (LTFU) were assessed: initial LTFU and complete LTFU. We assessed clinic adherence by evaluating the difference between actual visits and expected visits. Among children on antiretroviral therapy (ART), we assessed overall medication adherence and changes in medication adherence. RESULTS Two thousand five hundred forty-nine HIV-infected children <14 years were seen in period 1. Children on ART had less initial LTFU (3.0% compared with 5.1%, P < 0.01) and less complete LTFU (2.6% compared with 6.8%, P < 0.001) than children not on ART. For children not on ART, clinic adherence improved in period 3 compared with period 2. For children on ART with a more strict measure of clinic adherence, clinic adherence declined over time. Orphans had better clinic adherence than nonorphans. Among children on ART, there were few demographic differences when comparing medication adherence between time. CONCLUSIONS HIV-infected children are at risk for disruptions in clinic follow-up and medication adherence after a humanitarian crisis. Individual and contextual factors moderate the effects of these disruptions.
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Bhattacharya M, Dubey AP. Adherence to antiretroviral therapy and its correlates among HIV-infected children at an HIV clinic in New Delhi. ACTA ACUST UNITED AC 2012; 31:331-7. [PMID: 22041467 DOI: 10.1179/1465328111y.0000000031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND With the introduction of antiretroviral therapy (ART), the mortality and morbidity of HIV/AIDS have decreased markedly. However, high adherence to ART (>95%) is necessary for a good therapeutic outcome. There is a paucity of data on paediatric adherence to ART and its correlates from developing countries, particularly India. AIM To determine the rate of adherence to ART in HIV-infected Indian children and the factors associated with adherence. METHODS A cross-sectional study was conducted at an ART clinic in New Delhi, north India. Caregivers of 90 children were interviewed using a pre-designed, structured questionnaire and checklist. The primary measure of adherence was 4-day caregiver's recall. Adherence rates were correlated with 3-monthly CD4 counts. RESULTS Mean (SD, range) adherence was 91·4% (12·3, 75-100%). Adherence was low (<95%) in 31 (34·4%) patients. On multivariate logistic regression analysis, increasing time since ART initiation (OR 1·08, 95% CI 1·02-1·13), low caregiver educational status (OR 4·19, 95% CI 1·37-10·88), orphanhood (OR 3·57, 95% CI 1·13-9·25), efavirenz-based ART regimens (OR 3·65, 95% CI 1·05-10·69) and female gender (OR 3·15, 95% CI 1·03-7·68) were associated with lower adherence. The rise in CD4 count after ART initiation was more marked in the high adherence group, with the difference in the two groups becoming statistically significant after 6 months of ART (median CD4 count 698 vs 355, p=0·016). CONCLUSIONS It is possible to achieve high adherence to ART in a resource-limited setting. Caregiver recall is a reliable and inexpensive tool for measuring adherence. Paediatric adherence to ART is influenced by numerous factors and larger studies are needed to address the issue in India.
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Affiliation(s)
- M Bhattacharya
- Department of Paediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.
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Jaspan HB, Mueller AD, Myer L, Bekker LG, Orrell C. Effect of caregivers' depression and alcohol use on child antiretroviral adherence in South Africa. AIDS Patient Care STDS 2011; 25:595-600. [PMID: 21470047 DOI: 10.1089/apc.2010.0323] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pediatric antiretroviral adherence is difficult to assess, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. We enrolled 56 child-caregiver dyads from Cape Town, South Africa and followed their adherence over 1 month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess these factors and their affect on pediatric adherence. The median age of the children was 4 years, and median time on antiretrovirals was 20 months. Increased time on ART was associated with poorer adherence via 3-day recall (3DR; p=0.03). Ethanol use was inversely associated with adherence by both subjective measures, 3DR and visual analogue scale (VAS) (both p<0.01), and with Medication Event Monitoring System (MEMS) adherence as a continuous variable. In a multivariate analysis predicting MEMS adherence greater than 95%, including variables that were associated with adherence in univariate analyses, having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with adherence (odds ratio [OR] 19.2; 95% confidence interval [CI] 1.1-327 and 0.9; 95% CI 0.9-0.99). Pediatric adherence is affected by caregiver alcohol use, but caregiver relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
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Affiliation(s)
- Heather B. Jaspan
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Seattle Childrens' Hospital, University of Washington Pediatric Infectious Diseases, Seattle, Washington
| | - Alexandra D. Mueller
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Network Dynamics Group, Max Planck Institute for Dynamics and Self-Organization, Göttingen, Germany
| | - Landon Myer
- Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Ahoua L, Guenther G, Rouzioux C, Pinoges L, Anguzu P, Taburet AM, Balkan S, Olson DM, Olaro C, Pujades-Rodríguez M. Immunovirological response to combined antiretroviral therapy and drug resistance patterns in children: 1- and 2-year outcomes in rural Uganda. BMC Pediatr 2011; 11:67. [PMID: 21791095 PMCID: PMC3176156 DOI: 10.1186/1471-2431-11-67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 07/26/2011] [Indexed: 02/05/2023] Open
Abstract
Background Children living with HIV continue to be in urgent need of combined antiretroviral therapy (ART). Strategies to scale up and improve pediatric HIV care in resource-poor regions, especially in sub-Saharan Africa, require further research from these settings. We describe treatment outcomes in children treated in rural Uganda after 1 and 2 years of ART start. Methods Cross-sectional assessment of all children treated with ART for 12 (M12) and 24 (M24) months was performed. CD4 counts, HIV RNA levels, antiretroviral resistance patterns, and non-nucleoside reverse transcriptase inhibitor (NNRTI) plasma concentrations were determined. Patient adherence and antiretroviral-related toxicity were assessed. Results Cohort probabilities of retention in care were 0.86 at both M12 and M24. At survey, 71 (83%, M12) and 32 (78%, M24) children remained on therapy, and 84% participated in the survey. At ART start, 39 (45%) were female; median age was 5 years. Median initial CD4 percent was 11% [IQR 9-15] in children < 5 years old (n = 12); CD4 count was 151 cells/mm3 [IQR 38-188] in those ≥ 5 years old (n = 26). At M12, median CD4 gains were 11% [IQR 10-14] in patients < 5 years old, and 206 cells/mm3 [IQR 98-348] in ≥ 5 years old. At M24, median CD4 gains were 11% [IQR 5-17] and 132 cells/mm3 [IQR 87-443], respectively. Viral suppression (< 400 copies/mL) was achieved in 59% (M12) and 33% (M24) of children. Antiretroviral resistance was found in 25% (M12) and 62% (M24) of children. Overall, 29% of patients had subtherapeutic NNRTI plasma concentrations. Conclusions After one year of therapy, satisfactory survival and immunological responses were observed, but nearly 1 in 4 children developed viral resistance and/or subtherapeutic plasma antiretroviral drug levels. Regular weight-adjustment dosing and strategies to reinforce and maintain ART adherence are essential to maximize duration of first-line therapy in children in resource-limited countries.
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Estimating the impact of expanded access to antiretroviral therapy on maternal, paternal and double orphans in sub-Saharan Africa, 2009-2020. AIDS Res Ther 2011; 8:13. [PMID: 21385370 PMCID: PMC3063201 DOI: 10.1186/1742-6405-8-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 03/07/2011] [Indexed: 11/17/2022] Open
Abstract
Background HIV/AIDS has orphaned 11.6 million children in sub-Saharan Africa. Expanded antiretroviral therapy (ART) use may reduce AIDS orphanhood by decreasing adult mortality and population-level HIV transmission. Methods We modeled two scenarios to measure the impact of adult ART use on the incidence of orphanhood in 10 sub-Saharan African countries, from 2009 to 2020. Demographic model data inputs were obtained from cohort studies, UNAIDS, UN Population Division, WHO and the US Census Bureau. Results Compared to current rates of ART uptake, universal ART access averted 4.37 million more AIDS orphans by year 2020, including 3.15 million maternal, 1.89 million paternal and 0.75 million double orphans. The number of AIDS orphans averted was highest in South Africa (901.71 thousand) and Nigeria (839.01 thousand), and lowest in Zimbabwe (86.96 thousand) and Côte d'Ivoire (109.12 thousand). Conclusion Universal ART use may significantly reduce orphanhood in sub-Saharan Africa.
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Vreeman RC, Nyandiko WM, Ayaya SO, Walumbe EG, Marrero DG, Inui TS. The perceived impact of disclosure of pediatric HIV status on pediatric antiretroviral therapy adherence, child well-being, and social relationships in a resource-limited setting. AIDS Patient Care STDS 2010; 24:639-49. [PMID: 20836704 DOI: 10.1089/apc.2010.0079] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In resource-limited settings, beliefs about disclosing a child's HIV status and the subsequent impacts of disclosure have not been well studied. We sought to describe how parents and guardians of HIV-infected children view the impact of disclosing a child's HIV status, particularly for children's antiretroviral therapy (ART) adherence. A qualitative study was conducted using involving focus groups and interviews with parents and guardians of HIV-infected children receiving ART in western Kenya. Interviews covered multiple aspects of the experience of having children take medicines. Transcribed interview dialogues were coded for analysis. Data were collected from 120 parents and guardians caring for children 0–14 years (mean 6.8 years, standard deviation [SD] 6.4); 118 of 120 had not told the children they had HIV. Children's caregivers (parents and guardians) described their views on disclosure to children and to others, including how this information-sharing impacted pediatric ART adherence, children's well-being, and their social relationships. Caregivers believed that disclosure might have benefits such as improved ART adherence, especially for older children, and better engagement of a helping social network. They also feared, however, that disclosure might have both negative psychological effects for children and negative social effects for their families, including discrimination. In western Kenya, caregivers' views on the risks and benefits to disclosing children's HIV status emerged a key theme related to a family's experience with HIV medications, even for families who had not disclosed the child's status. Assessing caregivers' views of disclosure is important to understanding and monitoring pediatric ART.
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Affiliation(s)
- Rachel C. Vreeman
- Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- The Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Winstone M. Nyandiko
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Samwel O. Ayaya
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Eunice G. Walumbe
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - David G. Marrero
- Diabetes Translational Research Center, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas S. Inui
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- The Regenstrief Institute, Inc., Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Early mortality and loss to follow-up in HIV-infected children starting antiretroviral therapy in Southern Africa. J Acquir Immune Defic Syndr 2010; 54:524-32. [PMID: 20588185 DOI: 10.1097/qai.0b013e3181e0c4cf] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many HIV-infected children in Southern Africa have been started on antiretroviral therapy (ART), but loss to follow up (LTFU) can be substantial. We analyzed mortality in children retained in care and in all children starting ART, taking LTFU into account. PATIENTS AND METHODS Children who started ART before the age of 16 years in 10 ART programs in South Africa, Malawi, Mozambique, and Zimbabwe were included. Risk factors for death in the first year of ART were identified in Weibull models. A meta-analytic approach was used to estimate cumulative mortality at 1 year. RESULTS Eight thousand two hundred twenty-five children (median age 49 months, median CD4 cell percent 11.6%) were included; 391 (4.8%) died and 523 (7.0%) were LTFU in the first year. Mortality at 1 year was 4.5% [95% confidence interval (CI): 2.8% to 7.4%] in children remaining in care, but 8.7% (5.4% to 12.1%) at the program level, after taking mortality in children and LTFU into account. Factors associated with mortality in children remaining in care included age [adjusted hazard ratio (HR) 0.37; 95% CI: 0.25 to 0.54 comparing > or =120 months with <18 months], CD4 cell percent (HR: 0.56; 95% CI: 0.39 to 0.78 comparing > or =20% with <10%), and clinical stage (HR: 0.12; 95% CI: 0.03 to 0.45 comparing World Health Organization stage I with III/IV). CONCLUSIONS In children starting ART and remaining in care in Southern Africa mortality at 1 year is <5% but almost twice as high at the program level, when taking LTFU into account. Age, CD4 percentage, and clinical stage are important predictors of mortality at the individual level.
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Abstract
BACKGROUND Fathers are intricately bound up in all aspects of family life. This review examines fathers in the presence of HIV: from desire for a child, through conception issues, to a summary of the knowledge base on fathers within families affected by HIV. METHODS A mixed-methods approach is used, given the scarcity of literature. A review is provided on paternal and male factors in relation to the desire for a child, HIV testing in pregnancy, fatherhood and conception, fatherhood and drug use, paternal support and disengagement, fatherhood and men who have sex with men (MSM), and paternal effects on child development in the presence of HIV. Literature-based reviews and systematic review techniques are used to access available data Primary data are reported on the issue of parenting for men who have sex with men. RESULTS Men with HIV desire fatherhood. This is established in studies from numerous countries, although fatherhood desires may be lower for HIV-positive men than HIV-negative men. Couples do not always agree, and in some studies, male desires for a child are greater than those of their female partners. Despite reduced fertility, support and services, many proceed to parenting, whether in seroconcordant or serodiscordant relationships. There is growing knowledge about fertility options to reduce transmission risk to uninfected partners and to offspring.Within the HIV field, there is limited research on fathering and fatherhood desires in a number of difficult-to-reach groups. There are, however, specific considerations for men who have sex with men and those affected by drug use. Conception in the presence of HIV needs to be managed and informed to reduce the risk of infection to partners and children. Further, paternal support plays a role in maternal management. CONCLUSIONS Strategies to improve HIV testing of fathers are needed. Paternal death has a negative impact on child development and paternal survival is protective. It is important to understand fathers and fathering and to approach childbirth from a family perspective.
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Affiliation(s)
- Lorraine Sherr
- University College London, Research Department of Infection and Population Health, London, UK.
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Abstract
More than 2 million children are infected with HIV globally. Pediatric antiretroviral therapy (ART) adherence is complex, and current levels are often suboptimal. As established treatment programs in developed settings struggle with chronic therapy and nascent treatment programs in resource-limited settings expand, the importance and challenges of good adherence to ART are becoming ever more clear. Adherence behavior is influenced by many factors, which may be categorized as characteristics of the child, the caregiver(s) and family, the regimen, and society and culture. Many of these influences complicate measurement of pediatric adherence, and there is no gold standard. This article provides a conceptual framework and evidence-based look at the factors influencing ART adherence in children and aims to identify areas for intervention for this vulnerable population in need.
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Vreeman RC, Nyandiko WM, Ayaya SO, Walumbe EG, Marrero DG, Inui TS. Factors sustaining pediatric adherence to antiretroviral therapy in western Kenya. QUALITATIVE HEALTH RESEARCH 2009; 19:1716-1729. [PMID: 19949221 DOI: 10.1177/1049732309353047] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Antiretroviral therapy (ART) requires nearly perfect adherence to be effective. Although 90% of HIV-infected children live in Africa, there are limited data on pediatric adherence from this multicultural continent.We conducted a qualitative study to identify key factors contributing to pediatric ART adherence. Ten focus group discussions (N = 85) and 35 individual interviews were conducted with parents and guardians of HIV-infected children receiving ART in western Kenya. Interviews covered multiple aspects of the experience of having children take ART and factors that inhibited or facilitated medication adherence. Constant comparison, progressive coding, and triangulation methods were used to arrive at a culturally contextualized, conceptual model for pediatric ART adherence derived from the descriptions of the lived experience in this resource-limited setting. Child care, including sustained ART adherence, depends on interacting cultural and environmental determinants at the levels of the individual child, parent/caregiver, household, community, health care system, and society.
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Affiliation(s)
- Rachel C Vreeman
- Indiana University School of Medicine, Department of Pediatrics, Children's Health Services Research, Indianapolis, Indiana 46202, USA.
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van Dijk JH, Sutcliffe CG, Munsanje B, Hamangaba F, Thuma PE, Moss WJ. Barriers to the care of HIV-infected children in rural Zambia: a cross-sectional analysis. BMC Infect Dis 2009; 9:169. [PMID: 19835604 PMCID: PMC2767351 DOI: 10.1186/1471-2334-9-169] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 10/16/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful antiretroviral treatment programs in rural sub-Saharan Africa may face different challenges than programs in urban areas. The objective of this study was to identify patient characteristics, barriers to care, and treatment responses of HIV-infected children seeking care in rural Zambia. METHODS Cross-sectional analysis of HIV-infected children seeking care at Macha Hospital in rural southern Zambia. Information was collected from caretakers and medical records. RESULTS 192 HIV-infected children were enrolled from September 2007 through September 2008, 28% of whom were receiving antiretroviral therapy (ART) at enrollment. The median age was 3.3 years for children not receiving ART (IQR 1.8, 6.7) and 4.5 years for children receiving ART (IQR 2.7, 8.6). 91% travelled more than one hour to the clinic and 26% travelled more than 5 hours. Most participants (73%) reported difficulties accessing the clinic, including insufficient money (60%), lack of transportation (54%) and roads in poor condition (32%). The 54 children who were receiving ART at study enrollment had been on ART a median of 8.6 months (IQR: 2.7, 19.5). The median percentage of CD4+ T cells was 12.4 (IQR: 9.2, 18.6) at the start of ART, and increased to 28.6 (IQR: 23.5, 36.1) at the initial study visit. However, the proportion of children who were underweight decreased only slightly, from 70% at initiation of ART to 61% at the initial study visit. CONCLUSION HIV-infected children in rural southern Zambia have long travel times to access care and may have poorer weight gain on ART than children in urban areas. Despite these barriers, these children had a substantial rise in CD4+ T cell counts in the first year of ART although longer follow-up may indicate these gains are not sustained.
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Affiliation(s)
| | - Catherine G Sutcliffe
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Philip E Thuma
- Medical/Malaria Institute at Macha, Macha Hospital, Choma, Zambia
| | - William J Moss
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Vreeman RC, Nyandiko WM, Sang E, Musick BS, Braitstein P, Wiehe SE. Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya. Confl Health 2009; 3:5. [PMID: 19344523 PMCID: PMC2670263 DOI: 10.1186/1752-1505-3-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 04/04/2009] [Indexed: 11/10/2022] Open
Abstract
Background Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation. Results Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness. Conclusion During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.
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Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
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