Excellent adherence to antiretrovirals in HIV+ Zambian children is compromised by disrupted routine, HIV nondisclosure, and paradoxical income effects

Pediatric HIV Disclosure Intervention Improves Immunologic Outcome at 48 Weeks: The Sankofa Trial Experience

BACKGROUND

The World Health Organization recommends disclosure of HIV status to children and adolescents living with HIV (CALWH). HIV disclosure improves adherence to antiretroviral therapy and immunologic and virologic outcomes. However, the prevalence of HIV disclosure is low in sub-Saharan Africa. We assessed the longitudinal effect of the Sankofa Pediatric HIV disclosure intervention on immunologic and virologic outcomes among CALWH in Ghana.

METHODS

We conducted a secondary analysis of a two-arm site-randomized clinical trial among CALWH aged 7-18 years. Data were collected at baseline, 24, and 48 weeks. Generalized linear mixed models were used to compare immunologic (CD4) and virologic (viral load) outcomes as both continuous and categorical variables by disclosure status and by intervention group.

RESULTS

Among participants who had their HIV status disclosed during this study, the proportion with CD4 percent >25% increased from 56.5% at baseline to 75.4% at week 48 ( P = 0.03), with a slight increase in the undisclosed group (69.5% vs. 74.3%, P = 0.56). In the intervention arm, there was a steady increase in proportion with CD4 percent >25% from 47.1% at baseline to 67.8% at week 48 ( P = 0.01) while it remained unchanged in the control arm (80.5% vs. 81.3% [ P = 0.89]). Concurrently, declines in detectable viral load were observed in both disclosed (63.3% vs. 51.5%, P = 0.16) and undisclosed (69.9% vs. 62.0%, P = 0.17) groups while the intervention group experienced a meaningful drop from 72.9% to 57.6% at 24 weeks ( P = 0.04), which was maintained at 48 weeks.

CONCLUSIONS

A structured, culturally relevant disclosure intervention can improve clinical outcomes.

Comparing fears about paediatric HIV disclosure to the lived experiences of parents and guardians: a prospective cohort study

OBJECTIVE

We aimed to: (1) follow parents and guardians through the process of paediatric HIV disclosure to understand how often pre-disclosure worries are realised; and (2) estimate the effects of disclosure on child, caregiver, and family well-being.

DESIGN

We conducted a 12-month prospective cohort study in Zimbabwe with 123 primary caregivers of children ages 9 to 15 years who were HIV positive but did not know their serostatus at baseline. By the end of the study period 65 caregivers reported that their child learned his or her HIV-positive status.

MAIN OUTCOME MEASURES

We used three waves of data to compare caregivers' pre-disclosure worries to post-disclosure reports and to characterise associations between disclosure and well-being of the child (Strengths and Difficulties Questionnaire), caregiver (Patient Health Questionnaire-9), and family (Family Relationship Quality) over time.

RESULTS

Caregivers' pre-disclosure worries and fears about how their child would react to disclosure of their HIV status largely went unrealised. Furthermore, we did not find strong evidence of clinically-important increases in problems on average following disclosure.

CONCLUSION

Findings support the call to identify supportive intervention strategies that address caregiver fears at the beginning of the disclosure process.

Disclosure of HIV status and adherence to antiretroviral treatment in children and adolescents from Lomé and Abidjan

Introduction

in Africa, the proportion of minors with AIDS is ever increasing and adherence to treatment protocols is still suboptimal. The study investigated the conditions of HIV status disclosure and adherence to treatment in patients < 19 in two West African cities.

Methods

in 2016, thirteen health professionals and four parents filled out questionnaires to identify problems and solutions relative to disclosure of HIV status and adherence to treatment in 208 children and adolescents seen at University Hospitals in Abidjan (Ivory Coast) and Lomé (Togo).

Results

medians (extrema) of patients´ ages at start and end of status disclosure process were 10 (8-13) and 15 (13-17.5) years. In 61% of cases, disclosure was made individually after preparation sessions. The main difficulties were: parents´ disapproval, skipped visits, and rarity of psychologists. The solutions proposed were: recruiting more full-time psychologists, improving personnel training, and promoting patients´ "clubs". One out of three respondents was not satisfied with patients´ adherence to treatments. The major reasons were: intake frequencies, frequent omissions, school constraints, adverse effects, and lack of perceived effect. Nevertheless, 94% of the respondents confirmed the existence of support groups, interviews with psychologists, and home visits. To improve adherence, the respondents proposed increasing the number of support groups, sustaining reminder phone calls and home visits, and supporting therapeutic mentoring.

Conclusion

despite persisting disclosure and adherence problems, appropriate measures already put into practice still need to be taken further, especially through engaging psychologists, training counsellors, and promoting therapeutic support groups.

Caregivers' psychosocial assessment for identifying HIV-infected infants at risk of poor treatment adherence: an exploratory study in southern Mozambique

Psychosocial support (PSS) to caregivers of HIV-infected infants on antiretroviral treatment (ART) is crucial to ensure ART adherence and sustained long-term viral suppression in children. A specific approach including tools to monitor and understand adherence behavior and risk factors that prevent optimal treatment compliance are urgently needed. This qualitative exploratory study, conducted in southern Mozambique, monitored the infants' viral response trajectories during 18 months follow-up, as a measure of adherence, reviewed the caregiver's PSS session notes and the answers to a study questionnaire, to analyze whether the standard PSS checklist applied to infants' caregivers can identify barriers influencing their adherence. Only 9 of 31 infants had sustained virologic response. Reported factors affecting adherence were: difficulties in drugs administration, shared responsibility to administer treatment; disclosure of child's HIV status to family members but lack of engagement; mother's ART interruption and poor viral response. In conclusion, we found that the standard PSS approach alone, applied to caregivers, was lacking focus on many relevant matters that were identified by the study questionnaire. A comprehensive patient-centered PSS package of care, including an adherence risk factor monitoring tool, tailored to caregivers and their children must be developed.

HIV Status Disclosure to Adolescents Who Are Perinatally Infected in Rustenburg Sub District Northwest Province

Acquired Immune Deficiency Syndrome (AIDS) is a viral disease caused by Human Immunodeficiency Virus (HIV) which affects the immune system of human body. This study sought to explore how adolescents with perinatal HIV infection learn about their status as well as investigate their preferences about the disclosure process. A qualitative exploratory, descriptive, and contextual research design was used to explore the disclosure of an HIV-positive status among adolescents on antiretroviral therapy. Nonprobability purposive sampling was used to select the healthcare facilities, and adolescents were chosen using convenience sampling. In-depth individual interviews were used to collect data from the participants until data saturation was reached. Collected data were analysed using Tesch's eight steps. The results of the study revealed that adolescents have been on ART (antiretroviral therapy) without the knowledge of their own status but taking ART. Delayed disclosure of an HIV-positive status to adolescents lead to adolescent not adhering to ART and wondering why they are on treatment while other adolescents are not. The study further revealed that parents and caregivers struggle to disclose an HIV-positive status of their children, leading them to lie about what the treatment is for, for example, that it is a treatment for cough.

Psychosocial Support Programme Improves Adherence and Health Systems Experiences for Adolescents on Antiretroviral Therapy in Mpumalanga Province, South Africa

(1) Background: Psychosocial support (PSS) plays a significant role in persistent adherence to and retention in antiretroviral therapy (ART) for adolescents living with the human immunodeficiency virus (ALHIV). This paper qualitatively explores the experiences of ALHIV on ART, who participated in a PSS programme in five public primary healthcare facilities in Mpumalanga Province in South Africa during the COVID-19 pandemic. (2) Methods: Data were collected through 24 focus group discussions with 173 ALHIV on ART and subjected to inductive thematic analysis. Informed consent was obtained before all data collection. (3) Results: The PSS programme facilitated the process of full HIV disclosure to these adolescents with the support of parents/guardians while motivating adherence through peer support groups and health education for improved treatment literacy. Participants reported positive health systems experiences, improved healthcare provider-client relations, and prompt access to health services. (4) Conclusions: The PSS programme successfully kept ALHIV engaged in ART care despite the health service disruptions encountered during the COVID-19 pandemic. We recommend rigorous evaluation of the effects of the PSS intervention on adherence to and retention in ART among ALHIV in HIV-endemic settings.

Viral Response among Early Treated HIV Perinatally Infected Infants: Description of a Cohort in Southern Mozambique

Early initiation of antiretroviral therapy and adherence to achieve viral load suppression (VLS) are crucial for reducing morbidity and mortality of perinatally HIV-infected infants. In this descriptive cohort study of 39 HIV perinatally infected infants, who started treatment at one month of life in Mozambique, we aimed to describe the viral response over 2 years of follow up. VLS ≤ 400 copies/mL, sustained VLS and viral rebound were described using a Kaplan-Meier estimator. Antiretroviral drug transmitted resistance was assessed for a sub-group of non-VLS infants. In total, 61% of infants reached VLS, and 50% had a rebound. Cumulative probability of VLS was 36%, 51%, and 69% at 6, 12 and 24 months of treatment, respectively. The median duration of VLS was 7.4 months (IQR 12.6) and the cumulative probability of rebound at 6 months was 30%. Two infants had resistance biomarkers to drugs included in their treatment regimen. Our findings point to a low rate of VLS and high rate of viral rebound. More frequent viral response monitoring is advisable to identify infants with rebound and offer timely adherence support. It is urgent to tailor the psychosocial support model of care to this specific age group and offer differentiated service delivery to mother-baby pairs.

Socioeconomic status and other factors associated with HIV status among OVC in Democratic Republic of Congo (DRC)

Background

Orphans and vulnerable children (OVC) are a high-risk group for HIV infection, particularly in Sub-Saharan Africa.

Purpose

This study aims to portray the socioeconomic profile of OVC and examine the association of household and parent/guardian characteristics with the HIV status of OVC.

Methods

For this quantitative retrospective study, we obtained data from ICAP/DRC for a total of 1,624 OVC from households enrolled for social, financial, and clinical services between January 2017 and April 2020 in two provinces of the Democratic Republic of Congo, Haut-Katanga and Kinshasa. We computed descriptive statistics for OVC and their parents' or guardians' characteristics. We used the chi-square test to determine bivariate associations of the predictor variables with the dichotomous dependent variable, HIV positivity status. To analyze the association between these independent variables and the dichotomous dependent variable HIV status after controlling for other covariates, we performed firth's logistic regression.

Results

Of the OVC included in this study, 18% were orphans, and 10.9% were HIV+. The chi-square analysis showed that among parents/guardians that were HIV+, a significantly lower proportion of OVC (11.7%) were HIV+ rather than HIV- (26.3%). In contrast, for parents/guardians with HIV- status, 9.0% of OVC were HIV-negative, and 11.7% of OVC were OVC+. The firth's logistic regression also showed the adjusted odds of HIV+ status were significantly lower for OVC with parents/guardians having HIV+ status themselves (AOR, 0.335; 95% CI, 0.171-0.656) compared with HIV-negative parents/guardians. The adjusted odds of HIV+ status were significantly lower for OVC with a monthly household income of < $30 (AOR, 0.421; 95% CI, 0.202-0.877) compared with OVC with a monthly household income > $30.

Conclusions

Our results suggest that, with the exception of a few household and parent/guardian characteristics, the risk of HIV+ status is prevalent across all groups of OVC within this study, which is consistent with the existing body of evidence showing that OVC are in general vulnerable to HIV infection. With a notable proportion of children who are single or double orphans in DRC, HIV+ OVC constitute a high-risk group that merits customized HIV services. The findings of this study provide data-driven scientific evidence to guide such customization of HIV services.

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

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

Accuracy of measures for antiretroviral adherence in people living with HIV

BACKGROUND

Good patient adherence to antiretroviral (ART) medication determines effective HIV viral suppression, and thus reduces the risk of progression and transmission of HIV. With accurate methods to monitor treatment adherence, we could use simple triage to target adherence support interventions that could help in the community or at health centres in resource-limited settings.

OBJECTIVES

To determine the accuracy of simple measures of ART adherence (including patient self-report, tablet counts, pharmacy records, electronic monitoring, or composite methods) for detecting non-suppressed viral load in people living with HIV and receiving ART treatment.

SEARCH METHODS

The Cochrane Infectious Diseases Group Information Specialists searched CENTRAL, MEDLINE, Embase, LILACS, CINAHL, African-Wide information, and Web of Science up to 22 April 2021. They also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included studies of all designs that evaluated a simple measure of adherence (index test) such as self-report, tablet counts, pharmacy records or secondary database analysis, or both, electronic monitoring or composite measures of any of those tests, in people living with HIV and receiving ART treatment. We used a viral load assay with a limit of detection ranging from 10 copies/mL to 400 copies/mL as the reference standard. We created 2 × 2 tables to calculate sensitivity and specificity.

DATA COLLECTION AND ANALYSIS

We screened studies, extracted data, and assessed risk of bias using QUADAS-2 independently and in duplicate. We assessed the certainty of evidence using the GRADE method. The results of estimated sensitivity and specificity were presented using paired forest plots and tabulated summaries. We encountered a high level of variation among studies which precluded a meaningful meta-analysis or comparison of adherence measures. We explored heterogeneity using pre-defined subgroup analysis.

MAIN RESULTS

We included 51 studies involving children and adults with HIV, mostly living in low- and middle-income settings, conducted between 2003 and 2021. Several studies assessed more than one index test, and the most common measure of adherence to ART was self-report. - Self-report questionnaires (25 studies, 9211 participants; very low-certainty): sensitivity ranged from 10% to 85% and specificity ranged from 10% to 99%. - Self-report using a visual analogue scale (VAS) (11 studies, 4235 participants; very low-certainty): sensitivity ranged from 0% to 58% and specificity ranged from 55% to 100%. - Tablet counts (12 studies, 3466 participants; very low-certainty): sensitivity ranged from 0% to 100% and specificity ranged from 5% to 99%. - Electronic monitoring devices (3 studies, 186 participants; very low-certainty): sensitivity ranged from 60% to 88% and the specificity ranged from 27% to 67%. - Pharmacy records or secondary databases (6 studies, 2254 participants; very low-certainty): sensitivity ranged from 17% to 88% and the specificity ranged from 9% to 95%. - Composite measures (9 studies, 1513 participants; very low-certainty): sensitivity ranged from 10% to 100% and specificity ranged from 49% to 100%. Across all included studies, the ability of adherence measures to detect viral non-suppression showed a large variation in both sensitivity and specificity that could not be explained by subgroup analysis. We assessed the overall certainty of the evidence as very low due to risk of bias, indirectness, inconsistency, and imprecision. The risk of bias and the applicability concerns for patient selection, index test, and reference standard domains were generally low or unclear due to unclear reporting. The main methodological issues identified were related to flow and timing due to high numbers of missing data. For all index tests, we assessed the certainty of the evidence as very low due to limitations in the design and conduct of the studies, applicability concerns and inconsistency of results.

AUTHORS' CONCLUSIONS

We encountered high variability for all index tests, and the overall certainty of evidence in all areas was very low. No measure consistently offered either a sufficiently high sensitivity or specificity to detect viral non-suppression. These concerns limit their value in triaging patients for viral load monitoring or enhanced adherence support interventions.

Clinical characteristics and outcomes after new-onset seizure among Zambian children with HIV during the antiretroviral therapy era

OBJECTIVE

This study describes clinical profiles including human immunodeficiency virus (HIV) disease history and seizure etiology among children living with HIV presenting with new-onset seizure during the era of antiretroviral therapy (ART) in Zambia. 30-day mortality and cause of death are also reported.

METHODS

Children living with HIV (CLWHIV) with new-onset seizures were prospectively evaluated at one large urban teaching hospital and two non-urban healthcare facilities. Interviews with family members, review of medical records, and where needed, verbal autopsies were undertaken. Two clinicians who were not responsible for the patients' care independently reviewed all records and assigned seizure etiology and cause of death with adjudication as needed.

RESULTS

From April 2016 to June 2019, 73 children (49 urban, 24 rural) were identified. Median age was 6 years (IQR 2.2-10.0) and 39 (53%) were male children. Seizures were focal in 36 (49%) and were often severe, with 37% presenting with multiple recurrent seizures in the 24 hours before admission or in status epilepticus. Although 36 (49%) were on ART at enrollment, only 7 of 36 (19%) were virally suppressed. Seizure etiologies were infectious in over half (54%), with HIV encephalitis, bacterial meningitis, and tuberculous meningitis being the most common. Metabolic causes (19%) included renal failure and hypoglycemia. Structural lesions identified on imaging accounted for 10% of etiologies and included stroke and non-accidental trauma. No etiology could be identified in 12 (16%) children, most of whom died before the completion of clinical investigations. Twenty-two (30%) children died within 30 days of the index seizure.

SIGNIFICANCE

Despite widespread ART roll out in Zambia, new-onset seizure in CLWHIV occurs in the setting of advanced, active HIV disease. Seizure severity/burden is high as is early mortality. Enhanced programs to assure early ART initiation, improve adherence, and address ART failure are needed to reduce the burden of neurological injury and premature death in CLWHIV.

Determinants of Disclosure, Adherence and Viral Suppression in Children and Adolescents Living With HIV in Ecuador: A Cross-Sectional Study

BACKGROUND

Studies on HIV disclosure and adherence among children performed in Latin America are anecdotal. We aimed to assess the factors associated with HIV disclosure, adherence and viral suppression among Ecuadorian children and compare the psychologic consequences and the impact on adherence and viral suppression of early against late disclosure age.

METHODS

Cross-sectional study using a questionnaire and collected data on medical records of HIV-infected children between 6 and 21 years of age in Ecuador.

RESULTS

In 250 children included, HIV diagnosis was revealed at a median age of 11 years (p25-p75 9-12). Children 12 years old or older (P < 0.0001), 10 or more years since HIV diagnosis (P = 0.001), antiretroviral initiation above 3 years of age (P = 0.018) and decease of the mother (P = 0.048) were significantly associated with total disclosure in multivariate analysis. Profound sadness or anxiety was significantly more common when diagnosis was disclosed after 12 years of age (28.4%) than before (15.4%, P = 0.047). According to the simplified medication adherence questionnaire, 194 children (78.2%) were adherent to antiretroviral therapy and HIV-RNA viral load was undetectable in 168 (67.7%). In multivariate analysis, variables associated with nonadherence were age ≥14 years (P < 0.001), taking ≥3 daily antiretroviral pills (P = 0.013) and the presence of adverse effects (P < 0.001), whereas nonadherence (P = 0.001) was the only variable significantly associated with an unsuppressed HIV-RNA viral load.

CONCLUSIONS

Although we failed to show that an earlier disclosure age is followed by better adherence outcomes, psychological outcomes did seem to improve, supporting disclosure before 12 years of age.

Attendance of psychosocial teen clubs and self-reported antiretroviral medication adherence: a cross section study of adolescents with perinatal HIV in the Kingdom of Lesotho

Background

To address the problem of poor adherence among adolescents with perinatal HIV (PHIV), all clinics in Lesotho offer adolescent-friendly services and psychosocial support to improve their overall health outcomes and adherence. As a result, most adolescents with PHIV attend Teen Clubs as part of the package of youth-friendly HIV services. This study set out to determine whether attending Teen Clubs facilitates treatment adherence among adolescents with PHIV.

Methods

In this cross-sectional study, data were collected from 130 adolescents aged 10–19 years who were aware of their HIV status and had attended three or more Teen Club sessions in selected clinics in rural district in Lesotho. Adherence was measured through self-report of last pills missed, based on the 7-days recall of pills taken. Descriptive statistics were used to analyse the data.

Results

The median age of adolescents was 15 years, 56% were female, 37.7% were orphans, 41% were being cared for by their grandparents, 6.9% were living with siblings with no adult figure, and two were living on their own. The majority (93%) reported optimal adherence, 92% had not missed a clinic appointment in the past 30 days, and 74.4% knew that if they skipped doses, the viral load would increase and they would get sick. Over half (56%) had been reminded by their caregivers to take their medication and 96% talked to their caregivers regularly about their medication.

Conclusion

A supportive environment provided through the Teen Clubs and in the home were the main facilitators for adherence. Strategies to improve adherence among adolescents should consider the importance of the involvement of caregivers in the adolescents' visits to their clinic.

Sexual experiences of adolescents and young adults living with HIV attending a specialized clinic in Accra, Ghana

Background

We assessed sexual experiences among adolescent and young adults living with HIV (AYALHIV) attending the adolescent HIV care clinic in Korle Bu Teaching Hospital (KBTH).

Design

Cross-sectional study conducted in 2015.

Setting

HIV clinic at KBTH.

Participants

AYALHIV who attended the adolescent HIV care clinic.

Interventions

AYALHIV were interviewed with a structured questionnaire to obtain data on their socio-demographic characteristics and sexual experiences. The data was analyzed with STATA version 13.

Main outcome measures

sexual experiences of adolescents and young people living with HIV.

Results

Of 101 participants, 60.4% (61/101) were males. The mean age of respondents was (18±3.2) years with an average age at sexual debut (16.2±4.2) years. A third of the respondents (34/101) had had sex before and out of them 76.5% (26/34) were males. Seventeen percent (4/23) had multiple sexual partners and 38.1% (8/21) of sexually active use condom at last sexual intercourse. Eighty-six percent (87/101) of respondents knew their HIV status, 66.7% (58/87) of them were males. There was a significant association (p<0.05) between being male and knowledge of HIV positive status. Knowledge of a respondents' HIV positive status was found to be positively associated with ever using condom.

Conclusion

Sexual experience prevalence is high among AYALHIV. More males were sexually active, not using condom and had multiple sexual partners. Safer sexual practices such as consistent use of condoms, need to be intensified especially during counselling sessions. This could contribute to the reduction in prevalence of HIV among the adolescents in the country.

Funding

This work was funded by the authors.

Determinants of antiretroviral therapy adherence among older adolescents living with HIV in Kenya during the transition to adult care; An observational study

INTRODUCTION

Lower levels of adherence to antiretroviral therapy (ART) among older adolescents as compared to adults are influenced by individual, psychosocial, and treatment-related factors. Successful transition of older adolescents into HIV adult care from paediatric & adolescent focused care requires an understanding of barriers to ART adherence. This study aimed at determining individual factors affecting ART adherence among older HIV positive adolescents transitioning to adult care.

METHODS

Between December 2018 and January 2019, we conducted a cross-sectional study among 82 perinatally infected adolescents aged 16-19 years in an HIV care and treatment clinic in Nairobi, Kenya. We used completed structured questionnaires and abstracted data from clinical charts. We performed multivariate logistic regression to identify factors independently associated >95% self-reported ART adherence (7-day recall).

RESULTS

The study participants had a median age of 17 (IQR 16,18) on ART for a median duration of 11 years (IQR 7,13). Sixty-four per cent (52) of the adolescents reported optimal adherence was of >95%, and 15% reported missing doses for three or more months. Self -reported adherence had a high correlation with viral loads of <1000 copies ml (Kappa= 0.087). Adolescents with high self-efficacy were eight times more likely to report adherence of >95% [OR 8.1, 95% CI (2.31- 28.18)]. Once a day, dosing was also independently associated with adherence [OR 1.58, 95 %CI [0.62-4.08].

CONCLUSIONS

The reduction of ART pill burden and the inclusion of assessment of ART self -efficacy may contribute to transition preparedness among adolescents.

Factors affecting adherence to treatment in children living with HIV

Background:

With the successful introduction of ART, the life expectancy of children living with HIV (CLHIV) is substantially increased. However, strict compliance is a necessary step to begin with as noncompliance is again associated with its own demerits of incomplete suppression and decreasing the overall survival of the patients.

Aims:

The aim of this study was to measure factors associated with adherence to ART among CLHIV.

Materials and Methods:

This is a 1-year follow-up study conducted from November 2012 to December 2013. A total of 171 children between 18 months and 15 years living with HIV and on ART attending the two ART centers of Delhi were enrolled in the study. Adherence and factors affecting adherence were obtained from the study participants using a semi-structured interview schedule.

Statistical Analysis Used:

Collected data were transformed into variables and analyzed into SPSS. All observations were in terms of mean, median, standard deviations, percentages, and proportions. Tests of significance such as Chi-square test and t-test were applied wherever required.

Results:

In nearly 89% of the study participants, adherence to ART was ≥95% at the end of the study. The most common reason for nonadherence was forgetfulness (59%), and 57% of the parents/caretakers were facing monetary problems. Long distance, greater duration to reach center, and unavailability of the parents/caretakers were also quoted as problems.

Conclusion:

Adherence is genesis to successful treatment outcome and is strongly associated with availability of support by their parents/caretakers. Professional help along with guidance and encouragement is required not only at the caretaker level but also to the family as a whole.

Perceived Stigma and Fear of Unintended Disclosure are Barriers in Medication Adherence in Adolescents with Perinatal HIV in Botswana: A Qualitative Study

Background

Maintaining optimal adherence to antiretroviral treatment (ART) is a challenge for adolescents with perinatally HIV (ALPHIV), and there is little consensus on what factors contribute to adherence in this population. This study assessed self-reported medication adherence among ALPHIV and explored structural factors that hinder or motivate them to adhere.

Methods

This qualitative study used in-depth interviews with ALPHIV at the infectious disease control centre of a teaching hospital in Botswana. Thirty adolescents aged 12–19 years who were aware of their HIV status were recruited purposively. Transcribed interviews were analysed using the thematic approach and NVivo data analysis software.

Findings

Nonadherence was a problem across age groups and gender. Perceived stigma was a major barrier to ART adherence. The fear of stigma and unintended disclosure were more pronounced in those attending boarding school. The adolescents were not willing to take medication in front of roommates and outside of the home. They opted for hiding and taking medication in privacy which led to missed doses. The heightened fear of being seen collecting ART medication affected keeping appointments for clinic visits. Fear of stigma also influenced the choice of action when there was a clash between school activities, dosing times, and scheduled clinic appointments for ART refill. The home environment was the main facilitator for adherence. Support was the strongest motivator for adolescents to adhere and keep up with clinic visits. On a personal level, the desire to be healthy and live long was a major motivator to adhere.

Conclusions

The fear of stigma shaped the adolescents' adherence behaviour. Perceived stigma affected the time and place to take medication, the visit to the clinic for ART refill, and self-disclosure of HIV status. There is need to encourage adolescents to self-disclose their HIV status to friends since the fear of unintended disclosure fuelled perceived stigma. Planning of clinic appointments should also be consistent with realistic daily activities of adolescents.

Courage and confidence to stop lying: caregiver perspectives on a video to support paediatric HIV disclosure in Kampala, Uganda

The World Health Organization (WHO) recommends that HIV-positive children are told their diagnosis by age 12 years. However, most perinatally-infected children reach adolescence without being told their HIV status. Effective strategies are needed to promote disclosure, and optimise children's health outcomes as they transition to adolescence and adulthood. This qualitative study explored how caregivers of HIV-positive children aged 7-12 years perceived and related to a video used as part of a larger behavioural intervention to promote full disclosure to children by age 12 years. Eight semi-structured interviews and 3 group reflection sessions with 28 caregivers were analysed thematically. Five themes were generated: courage and confidence; reasoning and empathy; child- caregiver relationship; foreign but relatable; and not reaching everyone. The video was found acceptable and appropriate for fostering readiness to disclose. Through watching it, participants reported they could see people similar to themselves prevail despite challenges, which gave them courage.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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.

Communication with children and adolescents about the diagnosis of their own life-threatening condition

When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.

The Association of Material Hardship with Medication Adherence and Perceived Stress Among People Living with HIV in Rural Zambia

The intersection of poverty and HIV/AIDS has exacerbated socioeconomic inequalities in Zambia. For example, the downstream consequences of HIV/AIDS are likely to be severe among the poor. Current research has relied on multidimensional indicators of poverty, which encompass various forms of deprivation, including material. Although comprehensive measures help us understand what constitutes poverty and deprivation, their complexity and scope may hinder the development of appropriate and feasible interventions. These limitations prompted us to examine whether material hardship, a more practicable, modifiable aspect of poverty, is associated with medication adherence and perceived stress among people living with HIV (PLHIV) in Zambia. We used cross-sectional data from 101 PLHIV in Lundazi District, Eastern Province. Data were collected using a questionnaire and hospital records. Material hardship was measured using a five-item scale. Perceived stress was measured using the ten-item perceived stress scale. Adherence was a binary variable measured using a visual analog scale and medication possession ratio (MPR) obtained from pharmacy data. We analyzed the data with multivariable linear and logistic regressions using multiply imputed datasets. Results indicated that greater material hardship was significantly associated with MPR nonadherence (odds ratio = 0.83) and higher levels of perceived mental distress (β = 0.34). Our findings provide one of the first evidence on the association of material hardship with treatment and mental health outcomes among PLHIV. The findings also draw attention to the importance of economic opportunities for PLHIV and their implications for reducing material hardship and improving adherence and mental health status.

The Supporting Adolescent Adherence in Vietnam (SAAV) study: study protocol for a randomized controlled trial assessing an mHealth approach to improving adherence for adolescents living with HIV in Vietnam

BACKGROUND

The overall goal of the Supporting Adolescent Adherence in Vietnam (SAAV) study is to improve understanding of an adherence feedback mHealth intervention designed to help adolescents living with HIV (ALHIV) maintain high adherence to antiretroviral therapy (ART), critical to effective treatment. Specifically, we aim to: (1) conduct formative research with Vietnamese ALHIV and their caregivers to better understand adherence challenges and refine the personalized mHealth intervention package; and (2) assess the feasibility, acceptability, and efficacy of the intervention to improve ART adherence by implementing a randomized controlled trial (RCT).

METHODS

The study will utilize mixed methods. The formative phase will include 40 in-depth interviews (IDIs) with 20 adolescent (12-17 years)/caregiver dyads and eight focus group discussions with adolescents, caregivers, and clinicians at the National Hospital for Pediatrics (NHP) in Hanoi, Vietnam. We will also conduct 20 IDIs with older adolescents (18-21 years) who have transitioned to adult care at outpatient clinics in Hanoi. We will then implement a seven-month RCT at NHP. We will recruit 80 adolescents on ART, monitor their adherence for one month to establish baseline adherence using a wireless pill container (WPC), and then randomize participants to intervention versus control within optimal (≥ 95% on-time doses) versus suboptimal (< 95% on-time doses) baseline adherence strata. Intervention participants will receive a reminder of their choice (cellphone text message/call or bottle-based flash/alarm), triggered when they miss a dose, and engage in monthly counseling informed by their adherence data. Comparison participants will receive usual care and offer of counseling at routine monthly clinic visits. After six months, we will compare ART adherence, CD4 count, and HIV viral suppression between arms, in addition to acceptability and feasibility of the intervention.

DISCUSSION

Findings will contribute valuable information on perceived barriers and facilitators affecting adolescents' ART adherence, mHealth approaches as adherence support tools for ALHIV, and factors affecting adolescents' ART adherence. This information will be useful to researchers, medical personnel, and policy-makers as they develop and implement adherence programs for ALHIV, with potential relevance to other chronic diseases during transition from adolescent to adult care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03031197 . Registered on 21 January 2017.

Challenges and support for quality of life of youths living with HIV/AIDS in schools and larger community in East Africa: a systematic review

BACKGROUND

Youths living with HIV/AIDS (YLWHA) experience innumerable challenges within schools and the larger community. Nonetheless, these environments are potential sources of support for such youths. This review provides a synthesis of evidence about these challenges and support available for YLWHA to inform the design and implementation of interventions that support the wellbeing of youths living with HIV/AIDS in an East African context.

METHODS

We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane central registry of systematic reviews and randomized control trials for studies conducted in East Africa and published in English in the last 10 years (March 2007 to March 2017). We also searched Google Scholar and reference lists of all included studies. We purposed to include both qualitative and quantitative data but no quantitative data merited inclusion. We analyzed qualitative data using a framework thematic analysis.

RESULTS

We included 16 primary studies conducted in clinic and community settings that used qualitative or mixed methods. Three overarching themes-psychosocial wellbeing, treatment and health, and disclosure of HIV status together with a sub-theme of stigma that was important across the three overarching themes-were the basis for analysis. In each overarching theme, a duality of challenges versus support was reported. Psychosocial wellbeing included subthemes of challenges in schools and larger community, financial challenges, domestic violence, sexual and reproductive health challenges, and psychosocial support.

CONCLUSION

YLWHA experience numerous challenges and support needs, some of which occur in schools and affect their QoL. The effects of these challenges are poor health and educational outcomes as well as school dropout. The schools in which youths spend most of their formative years have not provided adequate support for YLWHA. This review identified that although most of the challenges that studies identified arose from within schools and that a few supportive approaches were available, none of the studies explored how these supportive approaches would work in schools. It was additionally identified that stigma complicates challenges of living with HIV/AIDS necessitating interventions for the wellbeing of YLWHA to understand and address HIV-stigma and its ramifications. Such interventions ought to be sustainable in schools, culturally appropriate, and multidisciplinary in order to promote the general health of all students.

Assessing methods of measuring medication adherence in chronically ill children-a narrative review

Nonadherence in children who use long-term medication is a serious problem and assessing adherence is an important step to provide solutions to this problem. Medication adherence can be measured by several methods, including (a) self-report questionnaires or structured interviews, (b) therapeutic drug monitoring (TDM), (c) electronic devices, and (d) pick-up/refill rates. The objective of this narrative review is to provide an overview of the literature about methods for the measurement of medication adherence in chronically ill children and adolescents. Therefore, we conducted a literature search by using multiple databases. Four methods of monitoring medication adherence are presented for the most described chronic diseases: asthma, HIV/AIDS, epilepsy, diabetes mellitus and ADHD. First, 10 commonly used self-report questionnaires and structured interviews are described, including the main characteristics, (dis)advantages and their validation studies. Second, the use of TDM in pediatric trials for medication adherence measurement is discussed. New sampling methods (e.g. dried blood spot) and sampling matrices (e.g. hair, saliva and urine) have shown their benefits for TDM in children. Third, electronic devices to measure medication adherence in children are presented, being developed for several drug administration routes. Fourth, the analyses, advantages and disadvantages of pharmacy data are discussed. The usage of this data requires specific calculations and interpretations to assess adherence. As presented in this review, every adherence method has specific (dis)advantages. When deciding which adherence method is applicable, validity and generalizability should be taken into account. Combining multiple methods seems to offer the best solution in the daily clinical practice.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Pattern of paediatric HIV status disclosure in coastal Karnataka

Background & objectives:

Karnataka is a high HIV prevalent State in India. Although benefits have been shown by disclosing the HIV status to the child, information regarding HIV status disclosure in Karnataka is limited. Hence, this study was conducted to estimate the proportion of children who had been disclosed of their HIV status and its pattern among those who visited the district antiretroviral therapy (ART) centre in coastal Karnataka.

Methods:

A cross-sectional study was conducted in an ART centre in a district hospital in coastal Karnataka between October 2014 and July 2015. Caregivers of paediatric HIV patients were approached and willing participants were administered a pre-formed, pre-tested semi-structured questionnaire developed for the study.

Results:

A total of 185 caregivers of the HIV-positive children were interviewed. Mean age of the children was 11±4 years. Only 107 (57.8%) children were aware of their HIV status. Of these, 95 were disclosed fully. Counsellors in rehabilitation centres were the most probable person to disclose and planned events. Children were told of their HIV status for their knowledge and were more likely to be disclosed if they were around 11-15 yr of age and staying in rehabilitation centres.

Interpretation & conclusions:

Older children were more likely to be disclosed of their HIV status by counsellors. Steps need to be taken to counsel and encourage caregivers to fully disclose the HIV status to the children at least when they attain the age more than 11 years.

High prevalence of non-adherence to antiretroviral therapy among undisclosed HIV-infected children in Ghana

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7-18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0%-100.0%). However, only 47.5% of children had ≥95% adherence ("good adherence") using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29-6.56), p = 0.010) or elementary education only (aOR, 2.20, CI, 1.24-3.88, p = 0.007) were more likely to have "good adherence" (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).

Disclosure to HIV-seropositive children in rural Zambia

Background

Care of children living with HIV comprises various issues, some considered challenging. One of the challenging areas is the serostatus disclosure to HIV-positive children. This study describes the current situation of HIV disclosure among rural children in Zambia and examines the socio-demographic factors promoting disclosure.

Methods

We used a mixed method approach applying both quantitative and qualitative methods to obtain comprehensive picture of HIV serostatus disclosure for children. Data were collected in Mumbwa district, Zambia (2010–2012), included 57 clinical records of children older than 5 years old. We examined children’s age, gender, and cohabitation status with their parents, caregivers’ level of education and income, and the relation between children and caregivers. Logistic regression model was applied to examine associations between disclosure and socio-demographic characteristics. Semi-structured interviews with 50 caregivers and 22 HIV-positive children were conducted to qualitatively investigate attitude towards disclosure and support needed.

Results

Full disclosure was completed in 17 out of 57 (29.8%) patients. Median ages of patients in disclosed group and non-disclosed group were 10 and 9, respectively (IQR 8.0–13.0, 7.0–11.25). In univariate analyses, older age and male gender has positive relation to the completion of serostatus disclosure. In logistic regression models, cohabitation status with patients’ mothers showed positive correlation to the completion of serostatus disclosure. In the interviews with caregivers, all caregivers said that disclosure of serostatus is a necessary process and good for their children, while actual serostatus disclosure rate was low.

Conclusion

Serostatus disclosure to HIV-seropositive children is not prevalent in Rural Zambia. Although further researches would be desirable, increased support to caregivers would be beneficial.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1252-2) contains supplementary material, which is available to authorized users.

Impact of a massive earthquake on adherence to antiretroviral therapy, mental health, and treatment failure among people living with HIV in Nepal

INTRODUCTION

The April 2015 Nepal earthquake resulted in more than 8,700 deaths and 22,000 casualties including damage to health facilities. The impact of this situation on chronic conditions such as human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) may become a long-lasting public health threat. Therefore, the objectives of this study were i) to assess the association of antiretroviral therapy (ART) adherence with mental health problems, and social behaviors, ii) to examine factors affecting treatment failure, and iii) to investigate changes in ART adherence and post-traumatic stress disorder (PTSD) among people living with HIV 6 and 12 months after the disaster.

METHODS

Study was conducted 6 months after the earthquake in 2015 with a sample size of 305 earthquake victims with HIV and followed after 12 months of the earthquake. A logistic regression analysis was used to examine relationships, while a paired t-test analysis was conducted to assess changes in adherence to ART and PTSD level at 6 months and 12 months after earthquake.

RESULTS

In the earthquake, 5.2% of the participants lost their family member. Approximately 44% of participants had earthquake-PTSD symptoms and 50% experienced HIV stigma. PTSD and HIV status disclosure were significantly associated with adherence to ART, while HIV stigma and religion were associated with treatment failure. PTSD and adherence levels to ART were significantly improved over the 6-month period.

CONCLUSION

Awareness programs for general public to eliminate HIV stigma; promote psychosocial counseling to earthquake victims living with HIV in order to reduce PTSD will contribute to maintaining optimal ART adherence and to prevent treatment failure.

Socioeconomic correlates of dietary diversity and its association with adherence and psychosocial functioning of people living with HIV in rural Zambia

BACKGROUND

The intersection of nutrition and HIV underscores the importance of adequate food and a diverse diet. In communities with high prevalence of food insecurity and HIV, there is a substantial co-occurrence of low dietary diversity, undernutrition, and adverse health outcomes.

AIM

The aim of this study was to identify correlates of individual dietary diversity (IDD) and its association with health outcomes for people living with HIV (PLHIV) in rural Zambia.

METHODS

The study used a cross-sectional design using data from 101 PLHIV. We calculated IDD using a composite score based on dietary diversity, food frequency, and the relative nutritional importance of different food groups. Adherence was measured using the visual analog scale. Psychosocial functioning was measured using the Structural Barriers to Medication-taking Scale and the Perceived Stress Scale. Data were analyzed using linear and logistic regressions. Multiple imputation was conducted to address missing data.

RESULTS

Staples were the most commonly consumed food group. Income and household size were negatively associated with IDD scores. Assets were positively associated with IDD scores. Residing in Lundazi and having a poor or fair self-rated health were associated with lower IDD scores. IDD was also associated, albeit not significant, with desirable health outcomes, including adherence and lower levels of perceived barriers to pill taking and stress.

CONCLUSIONS

Findings suggest a heterogeneous effect of socioeconomic variables on IDD. Understanding this heterogeneity is important for the design of interventions. Interventions that combine opportunities to generate economic resources with food and nutrition coaching may be appropriate and effective.

Pretreatment HIV drug resistance results in virological failure and accumulation of additional resistance mutations in Ugandan children

Background

Pretreatment HIV drug resistance (PDR) can impair virological response to ART, jeopardizing effective treatment for children.

Methods

Children aged ≤12 years initiated first-line ART in Uganda during 2010-11. Baseline and 6 monthly viral load (VL) and genotypic resistance testing if VL >1000 copies/mL was done. The 2015 IAS-USA mutation list and Stanford algorithm were used to score drug resistance mutations (DRMs) and susceptibility. Virological failure (VF) was defined as two consecutive VLs >1000 copies/mL or death after 6 months of ART. Factors associated with failure and acquired drug resistance (ADR) were assessed in a logistic regression analysis.

Results

Among 317 children enrolled, median age was 4.9 years and 91.5% received NNRTI-based regimens. PDR was detected in 47/278 (16.9%) children, of whom 22 (7.9%) had resistance against their first-line regimen and were therefore on a partially active regimen. After 24 months of follow-up, 92/287 (32.1%) had experienced VF. Children with PDR had a higher risk of VF (OR 15.25, P < 0.001) and ADR (OR 3.58, P = 0.01).

Conclusions

Almost one-third of children experienced VF within 24 months of NNRTI-based first-line treatment. PDR was the strongest predictor of VF and ADR, and therefore presents a major threat in children. There is a need for ART regimens that maximize effectiveness of first-line therapy for long-term treatment success in the presence of PDR or incorporation of routine VL testing to detect VF and change treatment in time, in order to prevent clinical deterioration and accumulation of additional drug resistance. Children ≤3 years should be initiated on a PI-based regimen as per WHO guidelines.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evidence of reduced treatment adherence among HIV infected paediatric and adolescent populations in Nairobi at the onset of the UNAIDS Universal Test and Treat Program

OBJECTIVE

We conducted a retrospective cohort study to evaluate the efficacy of the World Health Organization (WHO) "Universal Test and Treat" (UTT) policy, initiated in Kenya in September 2016. Under this policy, every human immunodeficiency virus (HIV)-infected person should be initiated on antiretroviral therapy (ART). We compared intra- and inter-group viral suppression and ART adherence rates for pre-UTT (initiated on ART in March-August 2016) and UTT groups (initiated in September 2016). The study was conducted in a community outreach Program in Nairobi with 3500 HIV-infected children enrolled.

RESULTS

122 children and adolescents were initiated on first-line ART pre-UTT, and 197 during the UTT period. The 6 month viral suppression rate was 79.7% pre-UTT versus 76.6% UTT (P < 0.05). Suboptimal adherence was higher in the UTT than pre-UTT period (88 of 197, 44.7% and 44 of 122, 34%; P < 0.001). The decrease in adherence was greater among orphans (91.7% pre-UTT and 87.2% UTT, P = 0.001) and children 11-18 years. Our results show that successful implementation of the UTT policy in Africa is challenged by an increased risk of suboptimal adherence. There is a need to develop extra strategies to support adherence, especially among orphans and teenagers.

Psychological well-being and adherence to antiretroviral therapy among adolescents living with HIV in Zambia

Physical and psychosocial changes during adolescence could influence the psychological well-being and adherence to antiretroviral therapy (ART) of adolescents living with HIV. However, few studies have assessed these two important issues in Zambia. This study aimed at addressing this gap by examining adolescents' depressive symptoms and ART adherence. This was a mixed-methods study conducted from April to July 2014. We recruited 200 adolescents, ages 15 to 19, who were already aware of their HIV status. We measured depressive symptoms using the short form of the Center for Epidemiologic Studies Depression Scale, and self-reported three-day adherence to ART. We performed logistic regression analysis to identify factors associated with depressive symptoms and non-adherence to ART. For qualitative data, we examined challenges over ART adherence using thematic analysis. Out of 190 adolescents, 25.3% showed high scores of depressive symptoms. Factors associated with depressive symptoms were unsatisfactory relationships with family (Adjusted Odds Ratio [AOR] 3.01; 95% Confidence Interval [CI] 1.20-7.56); unsatisfactory relationships with health workers (AOR 2.68; 95% CI 1.04-6.93); and experience of stigma (AOR 2.99; 95% CI 1.07-8.41). Of all participants, 94.2% were taking ART, but 28.3% were non-adherent. Factors associated with non-adherence to ART were loss of a mother (AOR 3.00; 95% CI 1.05-8.58) and lack of basic knowledge about HIV (AOR 3.25; 95% CI 1.43-7.40). Qualitative data identified the following challenges to ART adherence: management of medication, physical reactions to medicine, and psychosocial distress. The evidence suggests that depressive symptoms and non-adherence to ART were priority issues in late adolescence in Zambia. Health workers should be aware of these issues, and the care and treatment services should be tailored to respond to age-specific needs.

Adolescents' Experiences and Their Suggestions for HIV Serostatus Disclosure in Zambia: A Mixed-Methods Study

Background

HIV serostatus disclosure is an immense challenge for adolescents living with HIV, their caregivers, and health workers. In Zambia, however, little guidance is available from the adolescents’ point of view on the HIV disclosure process.

Objective

This study aimed to examine the setting of HIV serostatus disclosure for adolescents, its impacts on them, and their suggestions on the best practice of HIV disclosure.

Methods

We conducted a mixed-methods study at the University Teaching Hospital in Zambia from April to July 2014. We recruited 200 adolescents living with HIV, aged 15–19 years. We collected data using a structured questionnaire including two open-ended questions. We excluded two adolescents due to withdrawal during the survey, and eight from the data set due to out-of-eligibility criteria in age. Eventually, we included 190 in the analysis. We performed descriptive analysis to calculate the distributions of basic characteristics of the adolescents, their experience and preference on HIV serostatus disclosure, its emotional and behavioral impacts, and health education topics they had ever learned at hospital. We performed thematic analysis with open-ended data to explain first impressions upon disclosure in detail and to determine perceived advantages of HIV serostatus disclosure.

Results

The majority of adolescents recommended the age of 12 as appropriate for adolescents to learn about their HIV serostatus and preferred disclosure by both parents. Out of 190 adolescents, 73.2% had negative or mixed feelings about HIV serostatus disclosure, while 86.2% reported that disclosure was beneficial. Thematic analyses showed that the adolescents reacted emotionally due to an unexpected disclosure and a belief of imminent death from HIV. However, they improved adherence to treatment (84.7%), limited self-disclosure of their HIV serostatus to others (81.1%), and felt more comfortable in talking about HIV with their caregivers (54.2%). Thematic analysis identified perceived benefits of disclosure as follows: better understanding of their sickness and treatment, and improved self-care and treatment adherence. Lower percentage of the adolescents have learned about psychosocial well-being, compared to facts about HIV and treatment.

Conclusion

Despite initial emotional distress experienced after the disclosure, knowing one’s own HIV serostatus was found to be a crucial turning point for adolescents to improve motivation for self-care. HIV serostatus disclosure to adolescents requires follow-up support involving parents/primary caregivers, health workers, and peers.

Diagnosis disclosure to adolescents living with HIV in rural Kenya improves antiretroviral therapy adherence and immunologic outcomes: A retrospective cohort study

Background & aims

Emphasis on adolescent HIV has increased worldwide as antiretroviral treatment has greatly extended life expectancies of HIV-positive children. Few evidence-based guidelines exist on the optimal time to disclose to an adolescent living with HIV (ALHIV); little is known about the medical effects of disclosure. This study looked to determine whether disclosure is associated with improved medical outcomes in ALHIV. Prior work has tended to be qualitative, cross-sectional, and with an emphasis on psychosocial outcomes. This paper addresses the adolescent cohort retrospectively (longitudinally), building upon what is already known about disclosure.

Methods

Retrospective, longitudinal clinical record reviews of ALHIV seen at Kericho District Hospital between April 2004 and November 2012 were performed. Patient demographics and clinical outcomes were systematically extracted. The student’s t-test was used to calculate changes in mean CD4 count, antiretroviral therapy (ART), and cotrimoxazole adherence pre- vs. post-disclosure. Linear regression modelling assessed for trends in those clinical outcomes associated with age of disclosure.

Results

Ninety-six ALHIV (54 female, 42 male) were included; most (73%) entered care through the outpatient department. Nearly half were cared for by parents, and 20% experienced a change in their primary caregiver. The mean time in the study was 2.47 years; mean number of visits 10.97 per patient over the mean time in the study. Mean disclosure age was 12.34 years. An increase in mean ART adherence percentage was found with disclosure (0.802 vs. 0.917; p = 0.0015). Younger disclosure age was associated with significantly higher mean CD4 counts over the course of the study (p = 0.001), and a nonsignificant trend toward a higher mean ART adherence percentage (p = 0.055).

Conclusion

ART adherence and improved immunologic status are both associated with disclosure of HIV infection to adolescent patients. Disclosure of an HIV diagnosis to an adolescent is an important means to improve HIV care.

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

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

Attitudes and perceptions towards novel objective measures of ARV-based vaginal ring use: Results from a global stakeholder survey

Results of recent microbicide and pre-exposure prophylaxis clinical trials have shown adherence to be a significant challenge with new HIV prevention technologies. As the vaginal ring containing dapivirine moves into two open label follow-on studies (HOPE/MTN-025 and DREAM) and other antiretroviral-based and multi-purpose prevention technology ring products advance through the development pipeline, there is a need for more accurate and reliable measures of adherence to microbicide ring products. We previously conducted a comprehensive landscape analysis to identify new technologies that could be applied to adherence measurement of vaginal rings containing antiretrovirals. To explore attitudes and perceptions towards the approaches that we identified, we conducted a survey of stakeholders with experience and expertise in microbicide and HIV prevention clinical trials. From May to July 2015 an electronic survey was distributed via email to 894 stakeholders; a total of 206 eligible individuals responded to at least one question and were included in the data analysis. Survey respondents were presented with various objective measures and asked about their perceived acceptability to trial participants, feasibility of implementation by study staff, usefulness for measuring adherence and ethical concerns. Methods that require no additional input from the participant and require no modifications to the existing ring product (i.e., measurement of residual drug or excipient, or a vaginal analyte that enters the ring) were viewed as being more acceptable to trial participants and more feasible to implement in the field. Respondents saw value in using objective measures to provide real-time feedback on adherence. However, approaches that involve unannounced home visits for sample collection or spot checks of ring use, which could provide significant value to adherence feedback efforts, were met with skepticism. Additional research on the acceptability of these methods to potential trial participants and trial staff is recommended.

A cross-sectional study to evaluate second line virological failure and elevated bilirubin as a surrogate for adherence to atazanavir/ritonavir in two urban HIV clinics in Lilongwe, Malawi

Background

Malawi’s national antiretroviral therapy program provides atazanavir/ritonavir–based second line regimens which cause concentration-dependent rise in indirect bilirubin. We sought to determine if elevated bilirubin, as a surrogate of atazanavir/ritonavir adherence, can aid in the evaluation of second line virological failure in Malawi.

Methods

We conducted a cross-sectional study of HIV-infected patients ≥15 years who were on boosted protease inhibitor-based second line antiretroviral therapy for at least 6 months in two urban HIV clinics in Lilongwe, Malawi. Antiretroviral therapy history and adherence data were extracted from the electronic medical records and blood was drawn for viral load, complete blood count, total bilirubin, and CD4 cell count at a clinic visit. Factors associated with virological failure were assessed using multivariate logistic regression model.

Results

Out of 376 patients on second line antiretroviral therapy evaluated, 372 (98.9%) were on atazanavir/ritonavir-based therapy and 142 (37.8%) were male. Mean age was 40.9 years (SD ± 10.1), mean duration on second line antiretroviral therapy was 41.9 months (SD ± 27.6) and 256 patients (68.1%) had elevated bilirubin >1.3 mg/dL. Overall, 35 (9.3%) patients had viral load >1000 copies/ml (virological failure). Among the virologically failing vs. non-failing patients, bilirubin was elevated in 34.3% vs. 72.0% respectively (p < 0.001), although adherence by pill count was similar (62.9% vs. 60.7%, p = 0.804). The odds of virological failure were higher for adults aged 25–40 years (adjusted odds ratio (aOR) 2.5, p = 0.048), those with CD4 cell count <100 (aOR 17.5, p < 0.001), and those with normal bilirubin levels (aOR 5.4, p < 0.001); but were lower for the overweight/obese patients (aOR 0.3, p = 0.026). Poor pill count adherence (aOR 0.7, p = 0.4) and male gender (aOR 1.2, p = 0.698) were not associated with second line virological failure.

Conclusions

Among patients receiving atazanavir/ritonavir-based second line antiretroviral therapy, bilirubin levels better predicted virological failure than pill count adherence. Therefore, strategic use of bilirubin and viral load testing to target adherence counseling and support may be cost-effective in monitoring second line antiretroviral therapy adherence and virological failure. Drug resistance testing targeted for patients with virological failure despite elevated bilirubin levels would facilitate timely switch to third line antiretroviral regimens whenever available.

Pediatric HIV Disclosure Intervention Improves Knowledge and Clinical Outcomes in HIV-Infected Children in Namibia

Objectives:

Using routinely collected data, we evaluated a nationally implemented intervention to assist health care workers and caregivers with HIV disclosure to children. We assessed the impact of the intervention on child's knowledge and health outcomes.

Methods:

Data were abstracted from national databases and patient charts for HIV-infected children aged 7–15 years attending 4 high-volume HIV clinics in Namibia. Disclosure rates, time to disclosure, and HIV knowledge in 314 children participating in the intervention were analyzed. Logistic regression was used to identify correlates of partial vs. full disclosure. Paired t-tests and McNemar tests were used to compare adherence and viral load (VL) before versus after intervention enrollment.

Results:

Among children who participated in the disclosure intervention, 11% knew their HIV status at enrollment and an additional 38% reached full disclosure after enrollment. The average time to full disclosure was 2.5 years (interquartile range: 1.2–3 years). Children who achieved full disclosure were more likely to be older, have lower VLs, and have been enrolled in the intervention longer. Among children who reported incorrect knowledge regarding why they take their medicine, 83% showed improved knowledge after the intervention, defined as knowledge of HIV status or adopting intervention-specific language. On comparing 0–12 months before vs. 12–24 months after enrollment in the intervention, VL decreased by 0.5 log₁₀ copies per milliliter (N = 42, P = 0.004), whereas mean adherence scores increased by 10% (N = 88, P value < 0.001).

Conclusions:

This HIV disclosure intervention demonstrated improved viral suppression, adherence, and HIV knowledge and should be considered for translation to other settings.

Disclosure of HIV status and its impact on the loss in the follow-up of HIV-infected patients on potent anti-retroviral therapy programs in a (post-) conflict setting: A retrospective cohort study from Goma, Democratic Republic of Congo

BACKGROUND

The study aimed to identify the impact of non-disclosure of HIV status on the loss to follow-up (LTFU) of patients receiving anti-retroviral therapy.

METHODOLOGY

A historic cohort of HIV patients from 2 major hospitals in Goma, Democratic Republic of Congo was followed from 2004 to 2012. LTFU was defined as not taking an ART refill for a period of 3 months or longer since the last attendance, and had not yet been classified as 'dead' or 'transferred-out'. Kaplan-Meier plots were used to determine the probability of LTFU as a function of time as inclusive of the cohort. The log-rank test was used to compare survival curves based on determinants. Cox proportional hazard modeling was used to measure predictors of LTFU from the time of treatment induction until December 15th, 2012 (the end-point).

RESULTS

The median follow-up time was 3.99 years (IQR = 2.33 to 5.59). Seventy percent of patients had shared their HIV status with others (95% CI: 66.3-73.1). The proportion of LTFU was 12% (95%CI: 9.6-14.4). Patients who did not share their HIV status (Adjusted HR 2.28, 95% CI 1.46-2.29), patients who did not live in the city of Goma (Adjusted HR 1.97, 95% CI 1.02-3.77), and those who attained secondary or higher education level (Adjusted HR 1.60, 95% CI 1.02-2.53) had a higher hazard of being LTFU.

CONCLUSION

This study shows the relationship between the non-disclosure HIV status and LTFU. Healthcare workers in similar settings should pay more attention to clients who have not disclosed their HIV status, and to those living far from health settings where they receive medication.

Improved Adherence to Antiretroviral Therapy Observed Among HIV-Infected Children Whose Caregivers had Positive Beliefs in Medicine in Sub-Saharan Africa

A high level of adherence to antiretroviral treatment is essential for optimal clinical outcomes in HIV infection, but measuring adherence is difficult. We investigated whether responses to a questionnaire eliciting caregiver beliefs in medicines were associated with adherence of their child (median age 2.8 years), and whether this in turn was associated with viral suppression. We used the validated beliefs in medicine questionnaire (BMQ) to measure caregiver beliefs, and medication event monitoring system caps to measure adherence. We found significant associations between BMQ scores and adherence, and between adherence and viral suppression. Among children initiating Antiretroviral therapy (ART), we also found significant associations between BMQ ‘necessity’ scores, and BMQ ‘necessity-concerns’ scores, and later viral suppression. This suggests that the BMQ may be a valuable tool when used alongside other adherence measures, and that it remains important to keep caregivers well informed about the long-term necessity of their child’s ART.

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

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

Assessing Adherence to Antiretroviral Therapy in a Rural Paediatric Cohort in KwaZulu-Natal, South Africa

Achieving optimal adherence to ARV's in a rural paediatric population is challenging. Monitoring adherence by frequent viral load assay is not always feasible or sustainable in rural communities. A relatively cheaper, reliable, valid and sustainable measure of adherence for children is required for routine management. This study retrospectively assessed adherence outcomes using monthly pill count and viral load data, including reasons reported for non-adherence, in a paediatric cohort in rural KwaZulu-Natal, South Africa. Between 2008 and 2013, 78 children, mean age of 7.1 years, were enrolled in the CAPRISA 052 AIDS Treatment Programme. Monthly treatment adherence by pill count was categorized as either high (≥95 %) or low (<95 %). Overall median monthly adherence to treatment by pill count was 87.8 % at month 6, 88.9 % at month 12 and 90.8 % at month 24. However, the proportion of children with an undetectable viral load (<400 copies/ml) was 84.0 % (63/74), 86.6 % (58/67), and 84.5 % (49/58) at the three time points respectively. Agreement between pill count and viral load showed that only 33.9, 36. 3 and 30.6 % of children were truly adherent by pill count at months 6, 12 and 24 respectively. In conclusion, this treatment programme demonstrated that adherence of >95 % by pill count is not an ideal indicator of virological suppression in children aged 6 months to 13 years. Viral load assessment remains the gold standard for assessing treatment success in this age group.

Why Tell Children: A Synthesis of the Global Literature on Reasons for Disclosing or Not Disclosing an HIV Diagnosis to Children 12 and under

While the psychological and health benefits of knowing one's HIV diagnosis have been documented for adults and adolescents, practice is still in development for younger children. Moderating conditions for whether or not to tell a child he/she has HIV vary by region and local context. They include accessibility of treatment, consideration of HIV as a stigmatizing condition, prevalence of HIV, and an accompanying presumption that any illness is HIV-related, parent or caregiver concerns about child reactions, child's worsening health, assumptions about childhood and child readiness to know a diagnosis, and lack of policies such as those that would prevent bullying of affected children in schools. In this systematic review of the global literature, we summarize the reasons caregivers give for telling or not telling children 12 and under their HIV diagnosis. We also include articles in which children reflect on their desires for being told. While a broad number of reasons are given for telling a child - e.g., to aid in prevention, adaptation to illness (e.g., primarily to promote treatment adherence), understanding social reactions, and maintaining the child-adult relationship - a narrower range of reasons, often related to immediate child or caregiver well-being or discomfort, are given for not telling. Recommendations are made to improve the context for disclosure by providing supports before, during, and after disclosure and to advance the research agenda by broadening samples and refining approaches.

Age Matters: Increased Risk of Inconsistent HIV Care and Viremia Among Adolescents and Young Adults on Antiretroviral Therapy in Nigeria

PURPOSE

Interruptions in HIV care are a major cause of morbidity and mortality, particularly in resource-limited settings. We compared engagement in care and virologic outcomes between HIV-infected adolescents and young adults (AYA) and older adults (OA) one year after starting antiretroviral therapy (ART) in Nigeria.

METHODS

We conducted a retrospective cohort study of AYA (15-24 years) and OA (>24 years) who initiated ART from 2009-2011. We used negative binomial regression to model the risk of inconsistent care and viremia (HIV RNA >1,000 copies/mL) among AYA and OA in the first year on ART. Regular care included monthly ART pickup and 3-monthly clinical visits. Patients with ≤3 months between consecutive visits were considered in care. Those with inconsistent care had >3 months between consecutive visits.

RESULTS

The cohort included 354 AYA and 2,140 OA. More AYA than OA were female (89% vs. 65%, p < .001). Median baseline CD4 was 252/μL in AYA and 204/μL in OA (p = .002). More AYA had inconsistent care than OA (55% vs. 47%, p = .001). Adjusting for sex, baseline CD4, and education, AYA had a greater risk of inconsistent care than OA (Relative Risk [RR]: 1.15, p = .008). Among those in care after one year on ART, viremia was more common in AYA than OA (40% vs. 26% p = .003, RR: 1.53, p = .002).

CONCLUSIONS

In a Nigerian cohort, AYA were at increased risk for inconsistent HIV care. Of patients remaining in care, youth was the only independent predictor of viremia at 1 year. Youth-friendly models of HIV care are needed to optimize health outcomes.

Non-Uptake of HIV Testing in Children at Risk in Two Urban and Rural Settings in Zambia: A Mixed-Methods Study

This article investigates reasons why children who were considered at risk of HIV were not taken for HIV testing by their caregivers. Qualitative and quantitative data collected in Zambia from 2010–11 revealed that twelve percent of caregivers who stated that they had been suspecting an HIV infection in a child in their custody had not had the child tested. Fears of negative reactions from the family were the most often stated reason for not testing a child. Experience of pre-existing conflicts between the couple or within the family (aOR 1.35, 95% CI 1.00–1.82) and observed stigmatisation of seropositive children in one’s own neighbourhood (aOR 1.69, 95% CI1.20–2.39) showed significant associations for not testing a child perceived at risk of HIV. Although services for HIV testing and treatment of children have been made available through national policies and programmes, some women and children were denied access leading to delayed diagnosis and treatment–not on the side of the health system, but on the household level. Social norms, such as assigning the male household head the power to decide over the use of healthcare services by his wife and children, jeopardize women’s bargaining power to claim their rights to healthcare, especially in a conflict-affected relationship. Social norms and customary and statutory regulations that disadvantage women and their children must be addressed at every level–including the community and household–in order to effectively decrease barriers to HIV related care.

Parental concerns on disclosure of HIV status to children living with HIV: children's perspective

Disclosure is an important component of comprehensive management of children living with HIV infection (CLHIV). Many parental concerns are barriers for disclosure in children and only few studies addresses children's perspective on these concerns. Our study aims to understand children's perspective on parental concerns for disclosure and assess the knowledge of HIV. A questionnaire-based cross-sectional study involving CLHIV between 10 and 18 years attending HIV clinic in southern India, was conducted. Data were collected by directly interviewing only the children after obtaining consent from parents/caregivers. Initial open-ended questions were asked to assess the disclosure status and only fully disclosed children were included. Out of 362 enrolled eligible children, the prevalence of full and partial disclosure was 36.7% and 24%, respectively. The mean age of disclosure was 10.4 years (SD ± 2.6) and non-parental family members in an informal setting were the most common source of disclosure (38.3%). Forty-six percentages of parents were unaware of their child's disclosure status. Only 2% had disclosed their status to others who were not part of their care. Among disclosed children, 33.8% became upset or sad upon knowing their status, 12% faced discrimination and 41.4% had complete knowledge about their illness. Though the prevalence of disclosure among CLHIV was high, a majority of them had incomplete knowledge about HIV infection. The parental concerns as reported in literature like the child is too young to disclose, concerns about coping, fear of stigma and discrimination and child disclosing to others were not expressed by children.

Delays in Initiation of Antiretroviral Therapy Among HIV-infected Children in Rural Zambia

BACKGROUND

Although care and treatment are available to many HIV-infected children, barriers remain that delay initiation of antiretroviral therapy (ART). Minimizing these barriers is critical to starting ART at earlier ages.

METHODS

Reasons for delay were evaluated among 200 children younger than 15 years of age initiating treatment in an HIV clinic in rural Zambia from 2011 to 2013.

RESULTS

The median age of children at ART eligibility was 2.9 years, and 49% were male. After being determined eligible, 60% of children delayed ART initiation for a median of 28 days (interquartile range: 14, 75). Primary reasons for delay included waiting for test results, adherence issues and concurrent treatment for tuberculosis. When reasons for delay were categorized by type, 36% of children had family-related delays, 32% had delays because of clinic logistics, 27% had health-related delays and 6% had other or no identified reasons for delay. The median time between eligibility and ART initiation was shortest for children with delays because of clinic logistics (median: 18 days; interquartile range: 14, 35). Children with family-related delays tended to be older and orphaned, whereas children with delays because of clinic logistics tended to be younger, and children with health-related delays tended to have more advanced disease. In the first year of ART, no association was found between adherence and type of delay. CD4 T-cell percentages and weight-for-age Z scores were lower for children with health-related delays.

CONCLUSIONS

Strategies to reduce delays in ART initiation will need to address a diverse set of issues, so children can benefit from earlier treatment.