Living situation affects adherence to combination antiretroviral therapy in HIV-infected adolescents in Rwanda: a qualitative study

"Successful Living" Among Adolescents With HIV in Sub-Saharan Africa: An Evolutionary Concept Analysis

ABSTRACT

The concept of successful living in the context of adolescents with HIV lacks clarity and is unexplored. Without a common understanding of successful living among adolescents with HIV (AWH) in Sub-Saharan Africa (SSA), health care interventions focusing on this population may continue to fall short, resulting in avoidable morbidity and mortality. Therefore, this analysis used Rodgers Evolutionary Concept Analysis method to identify attributes, antecedents, consequences, and related concepts of successful living among AWH in SSA. Health care interventions are encouraged to promote successful living among AWH to achieve behavioral and clinical outcomes.

Emotion regulation as a potential moderator of the association between HIV stigma and nonadherence to antiretroviral therapy among youth living with HIV

INTRODUCTION

Human immunodeficiency virus (HIV)-related stigma affects adherence to antiretroviral therapy (ART) for youth living with HIV. Emotion regulation strategies such as cognitive reappraisal (reinterpreting adversity to mitigate emotional impact) and expressive suppression (inhibiting emotion-expressive behavior activated by adversity) may moderate the HIV stigma-ART adherence relationship in this group.

METHODS

Using baseline data from 208 youth living with HIV aged 15-24 years enrolled in an mHealth ART-adherence intervention, we performed modified Poisson regressions with robust variance between HIV stigma (internalized, anticipated, enacted) and ART nonadherence. We tested for multiplicative interaction via product terms between HIV stigma and emotion regulation scores, and additive interaction via relative excess risk due to interaction and attributable proportion using dichotomous HIV stigma and emotion regulation variables.

RESULTS

Mean age was 21 years; ≥50% of participants were cisgender male, non-Hispanic Black, and gay-identifying; 18% reported ART nonadherence. Confounder-adjusted regressions showed positive associations between each HIV stigma variable and ART nonadherence. Internalized HIV stigma and cognitive reappraisal negatively, multiplicatively interacted (as internalized HIV stigma increased, ART nonadherence increased for those with low cognitive reappraisal). High internalized HIV stigma positively, additively interacted with low cognitive reappraisal and low expressive suppression (when high internalized HIV stigma and low levels of either emotion regulation strategy were present, ART nonadherence increased dramatically).

CONCLUSION

Cognitive reappraisal and expressive suppression may protect against internalized HIV stigma's harmful association with ART nonadherence. These modifiable emotion regulation strategies may be targeted to potentially buffer the effects of internalized HIV stigma and support ART adherence for youth living with HIV.

Gaps and Opportunities for Strengthening In-School Support for Youth Living With HIV

OBJECTIVES

With optimized antiretroviral treatment youth living with HIV (YLH) now spend most of their time in schools, making schools an important venue to optimize outcomes. We evaluated school support for YLH.

METHODS

We conducted surveys with public secondary/high schools in 3 Kenyan counties (Nairobi, Homa Bay, and Kajiado) to determine policies and training related to HIV. Chi-squared tests and Poisson regression were used to compare policy availability and staff training by county HIV prevalence and school type.

RESULTS

Of 512 schools in the 3 counties, we surveyed 100. The majority (60%) of schools surveyed had boarding facilities. The median student population was 406 (IQR: 200, 775). Only half (49%) of schools had medication use policies; more in boarding than day schools (65% vs 30%, p = .003). While most schools (82%) had clinic attendance policies; policy availability was higher in higher HIV prevalence counties (Homa Bay [100%], Nairobi [82%], Kajiado [56%], p < .05). Overall, 64% had confidentiality policies with higher policy availability in higher HIV prevalence regions (p < .05). Few schools had staff trained in HIV-related topics: HIV prevention (37%), HIV treatment (18%), HIV stigma reduction (36%). Few were trained in confidentiality (41%), psychosocial support (40%), or mental health (26%). Compared to day schools, boarding school were more likely to have staff trained in HIV prevention (prevalence ratio: 2.1 [95% confidence interval 1.0, 4.0], p = .037).

CONCLUSION

In this survey of Kenyan schools, there were notable gaps in HIV care policy availability and training, despite high HIV burden. Development and implementation of national school HIV policies and staff training as well as strengthening clinic and family support may improve outcomes for YLH.

Experiences of Adolescents on Antiretroviral Therapy at Rustenburg Sub-District, Northwest Province, South Africa

BACKGROUND

Antiretroviral therapy (ART) is the treatment of people infected with human immunodeficiency virus (HIV) using anti-HIV drugs. The standard treatment consists of a combination of drugs (often called highly active antiretroviral therapy or HAART) that suppress HIV replication. As a result, people who have been infected live longer while on ART, which was initiated in South Africa in 2004.

AIM

The study aimed to explore the experiences of adolescents on antiretroviral therapy in two primary health care clinics in Rustenburg sub-district Northwest Province.

METHODS

Qualitative, explorative, descriptive, and contextual approaches were adopted. Non-probability 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. Only 13 adolescents between the ages of 15 and 19 years were interviewed. Collected data were analyzed using Tesch's eight steps.

RESULTS

Qualitative themes identified included a description of the experiences of adolescents living HIV to adulthood and challenges experienced from childhood to adolescence period. Each theme had different sub-themes which included the paradoxical experiences of being diagnosed with HIV and being on antiretroviral treatment. Adolescents experienced poor adherence to ART due to treatment side effects such as drowsiness, change in body image, and headaches. Self-stigma resulted in adolescents not disclosing their status to their peers, closest and sexual partners which also made them not to adhere well in treatment.

CONCLUSIONS

The study findings revealed that HIV-positive adolescents encounter various experiences while on ART, which causes them not to adhere to treatment. In the study, adolescents also experienced self-stigma which also affected their treatment adherence and brought fear of losing their loved ones.

Experiences of adolescents and youth with HIV testing and linkage to care through the Red Carpet Program (RCP) in Kenya

Adolescents and youth living with HIV (AYLHIV) experience worse health outcomes compared to adults. We aimed to understand the experiences of AYLHIV in care in the youth-focused Red-Carpet program in Kenya to assess the quality of service provision and identify programmatic areas for optimization. We conducted focus group discussions among 39 AYLHIV (15-24 years) and structured analysis into four thematic areas. Within the HIV testing theme, participants cited fear of positive results, confidentiality and stigma concerns, and suggested engaging the community and youth in HIV testing opportunities. Within the HIV treatment adherence theme, participants cited forgetfulness, stigma, adverse side effects, lack of family support, and treatment illiteracy as barriers to adherence. Most participants reported positive experiences with healthcare providers and peer support. In terms of the HIV status disclosure theme, AYLHIV cited concerns about their future capacity to conceive children and start families and discussed challenges with understanding HIV health implications and sharing their status with friends and partners. Youth voices informing service implementation are essential in strengthening our capacity to optimize the support for AYLHIV within the community, at schools and healthcare facilities.

Adolescent experiences, perceptions, and preferences for the process of HIV status disclosure in Kenya

Introduction

Disclosure of HIV status to adolescents living with HIV has been associated with improved treatment outcomes. However, there are limited data regarding the experiences of, perceptions of, and preferences for the process of disclosure of HIV status among adolescents and young adults living with HIV (AYLH), especially in sub-Saharan Africa.

Methods

Young adults living with HIV from 20 HIV clinics in Kenya who participated in a clinical trial evaluating the effectiveness of a disclosure and transition package completed an anonymous survey in 2019. We described their experiences and preferences using counts and proportions and assessed factors associated with satisfaction with the disclosure process using linear regression, reporting age-adjusted mean differences (aMD), and 95% confidence intervals (95%CIs).

Results

Of the 375 enrolled AYLH, 265 (71%) had perinatally acquired HIV, of whom 162 (61%) were female. The median age of the enrolled AYLH was 16 years (IQR: 14-19 years), and all of them were on antiretroviral therapy (ART). For over half (55%) of the participants, caregivers disclosed their HIV status, and 57% preferred that their caregivers disclose the status to them. Most (78%) of the participants preferred full disclosure by 12 years of age. The majority (69%) believed the disclosure was planned, and 11% suspected being HIV positive before the disclosure. Overall, 198 (75%) AYLH reported that they were ready for disclosure when it happened, and 86% were satisfied with the process. During both pre-disclosure (67 and 70%, respectively) and post-disclosure (>75% for each), AYLH felt supported by the clinic and caregivers. Factors associated with higher satisfaction with the disclosure process were pre-disclosure clinic support (aMD: 0.19 [95%CI: 0.05-0.33]) and pre-disclosure (aMD: 0.19 [0.06-0.31]) and post-disclosure (aMD: 0.17 [0.03-0.31]) caregiver support. AYLH who suspected they were HIV positive before they were disclosed to tended to have lower satisfaction when compared to those who never suspected (aMD: -0.37 [-0.74-(-0.01)]). Overall, they reported that disclosure positively influenced their ART adherence (78%), clinic attendance (45%), and communication with caregivers (20%), and 40% reported being happier after disclosure.

Conclusion

Young adults living with HIV advocated for an appropriately timed disclosure process with the involvement of caregivers and healthcare workers (HCWs). Support from caregivers and HCWs before and during disclosure is key to improving their disclosure experience.

Structural, Familial, and Psychosocial Factors Affecting Long-Term Antiretroviral Treatment Adherence amongst Adolescents Living with Perinatally Acquired HIV in Limpopo, South Africa

After more than two decades of the expansion of antiretroviral treatment (ART) in adolescents living with perinatal HIV (APHIV) in sub-Saharan Africa, there is still poorly sustained long-term adherence to ART due to multifactorial factors with the consequence of increased mortality and morbidity. There are little data available on the familial and structural factors which affect sustenance to long-term adherence to ART. A qualitative exploratory design was used to conduct in-depth interviews with 21 APHIV attending HIV care and management in the rural health facilities of Vhembe district in Limpopo Province, South Africa. Transcripts were translated verbatim into English, and data were analyzed using Tesch's eight steps of qualitative data analysis. The sample consisted of APHIV 10-19 years old who were aware of their HIV status, and all had received ART for more than 5 years. They lived in extended, disrupted, grandparent- and child-headed households. They experienced food insecurities due to poverty or orphanhood, as well as living in disrupted households, which deterred them from long-term adherence. In addition, dependency on social support grants to sustain their livelihoods affected long-term adherence. APHIV had challenges with structural factors such as inconsistent clinic attendance, clashes between school activities and clinic appointments, and the lack of transport fare to the clinic, which affected adherence. Although APHIV were on one-pill fixed-dose ART, they were not able to sustain long-term adherence due to various familial, structural, and psychosocial challenges. In addition to institution-based interventions, there is a need for family, community-based, and multi-sectorial interventions to support long-term ART adherence among APHIV.

Navigating antiretroviral adherence in boarding secondary schools in Nairobi, Kenya: A qualitative study of adolescents living with HIV, their caregivers and school nurses

In Kenya, adolescents spend much of their formative years in boarding secondary schools, which presents a challenging environment for antiretroviral (ART) adherence support among adolescents living with HIV (ALHIV). We examined the experiences of ALHIV, caregivers of adolescents, and school nurses regarding navigating ART adherence in boarding secondary schools. Between July and November 2022, we conducted focus group discussions (FGDs) among ALHIV attending boarding schools in Nairobi, Kenya, and caregivers of ALHIV, and in-depth interviews (IDIs) with school nurses. Clinic records were used to identify ALHIV and caregivers, who were invited to participate based on their availability. We categorized boarding schools into national, county, and sub-county levels and selected two schools from each category. We obtained permission from head teachers and invited school nurses to take part in virtual IDIs. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. We conducted two FGDs with 11 caregivers, two FGDs with 18 adolescents, and 7 IDIs with school nurses. Most of the ALHIV reported having disclosed their HIV status to a school nurse or teacher during admission. School nurse friendliness, being understanding, fair, and confidential were qualities associated with ALHIV willingness to confide in them. Strategies ALHIV used to adhere to medication included: waiting until students were engaged in other activities, waking up early, stepping away from others, and stating their drugs were for different ailments. Caregivers were nervous about school-based adherence counseling, fearing it could lead to inadvertent disclosure of adolescents' HIV status and stigmatization by fellow students. All school nurses reported lacking appropriate training in HIV adherence counseling for adolescents. ALHIV have devised innovative strategies to navigate pill-taking and enlist quiet support while operating in stigmatized school environments. Establishment of a strong school nurse-adolescent rapport and building nurses' skills are key to improving school-based support for ALHIV.

Studies on HIV/AIDS Among Students: Bibliometric Analysis

BACKGROUND

In recent years, HIV infection in students has been an ongoing concern worldwide. A large number of articles have been published; however, statistical analysis of the data presented in these publications is lacking.

OBJECTIVE

This study aimed to detect and analyze emerging trends and collaborative networks in research on HIV/AIDS among students.

METHODS

Research publications on HIV/AIDS among students from 1985 to 2022 were collected from the Web of Science Core Collection. A topic search was used for this study, and articles in English were included. CiteSpace was used to generate visual networks of countries/regions, institutions, references, and keywords. Citation analysis was used to discover milestones in the field and trace the roots of the knowledge base. Keyword analysis was used to detect research hotspots and predict future trends.

RESULTS

A total of 2726 publications met the inclusion criteria. Over the past 38 years, the number of publications annually has been on the rise overall. The United States had the highest number of publications (n=1303) and the highest centrality (0.91). The University of California system was the core institution. The main target population of studies on HIV/AIDS among students were medical and university students. These studies focused on students' knowledge, attitudes, risk behaviors, and education about HIV/AIDS. The recent bursting keywords (gay, sexual health, adherence, barriers, mental health, HIV testing, stigma, and antiretroviral therapy) revealed research trends and public interest on this topic.

CONCLUSIONS

This study identified countries/regions and institutions contributing to the research area of HIV/AIDS among students and revealed research hotspots and emerging trends. The field of research on HIV/AIDS among students was growing rapidly. The United States was at the center, and the University of California system was the core institution. However, academic collaboration should be strengthened. Future research may focus on exploring gay students, sexual health, adherence, barriers, mental health, HIV testing, stigma, and antiretroviral therapy.

Intrapersonal predictors of internalized stigma among school going adolescents living with HIV in southwestern Uganda

We assessed the association between internalized HIV stigma, resilience, health locus of control, coping self-efficacy and empowerment among adolescents living with HIV in Uganda. We conducted a cross-sectional study between August and October 2020 among 173 adolescents aged 13-18 years attending Mbarara Regional Referral Hospital's HIV clinic. We used linear regression to determine the association between HIV stigma and intrapersonal factors adjusting for sociodemographic characteristics. The median age of the participants was 16 (IQR 3) years. There was a negative correlation between HIV stigma and resilience (β= -0.03, p < 0.001), internal health locus of control (β= -0.095, p < 0.001) and coping self-efficacy (β= -0.02, p < 0.001), while empowerment was positively correlated (β = 0.07, p < 0.001) with HIV stigma. After adjusting for the intrapersonal factors (resilience, health locus of control, coping self-efficacy and empowerment) and socio-demographic characteristics (education level and boarding school), only internal health locus of control (β=-0.044, p = 0.016) and coping self-efficacy (β=-0.015, p < 0.001) remained significantly correlated with HIV stigma. The findings suggest that interventions focusing on intrapersonal factors such as internal locus of control, empowerment and resilience may contribute towards reduction of HIV stigma among adolescents in boarding schools.

Emotional distress among adolescents living with perinatal HIV in India: examining predictors and their mediating and moderating effects

BACKGROUND

Development of emotional distress (ED) among adolescents living with perinatally acquired HIV (ALPHIV) affects their adherence behaviour and social and psychological functioning. Data on stressors among ALPHIV demonstrates the gap on the predictors of ED experienced by 'perinatally infected ALHIV' in the Indian socio-cultural milieu. This study aimed to identify the predictors of ED and examine their mediating and moderating role in the development of ED among Indian ALPHIV.

METHODS

Utilizing the sequential exploratory mixed-methods design, 43 qualitative interviews were conducted with ALPHIV, parents/guardians, and health care providers, followed by the cross-sectional survey among 100 ALPHIV (10-19 years). The distress subscale of the Weinberger Adjustment Inventory was used to measure ED. Qualitative data, analyzed using grounded theory were utilized to develop a survey tool. Bivariate and regression analyses were conducted to identify predictors of ED. Mediation and moderation models were tested to examine underlying mechanisms associated with ED. The study was approved by the institutional ethics committee.

RESULTS

Strong parental control, compulsive asexuality, perceived negatively different from peers, and anger toward parents were the major themes emerging from the qualitative component which eventually led to survey tool domains viz., HIV awareness, parental control, hypervigilance, adolescent-parent relationship, adolescent-parent communication, body image and perceived negatively different from peers (PNDP). Quantitative analysis indicated high ED among ALPHIV and ED was significantly associated with PNDP, anger, body image, and hypervigilance. The relationship between PNDP and ED was significantly mediated by anger, and moderated by body image and hypervigilance.

CONCLUSIONS

The study stresses the need for early mental health interventions for Indian ALPHIV before an ALPHIV develops ED. Focused counseling on anger assessment, body image issues, and self-perception is critical for leading a 'normal' life by ALPHIV. Besides, skill building of primary caregivers is recommended to draw a line between protection and overprotection.

Barriers and facilitators to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review and meta-analysis

BACKGROUND

Human Immunodeficiency Virus (HIV) significantly affects adolescents globally, with the sub-Saharan Africa (SSA) reporting a high burden of the disease. HIV testing, treatment, and retention to care are low among adolescents. We conducted a mixed-method systematic review to assess anti-retroviral therapy (ART) adherence; barriers and facilitators to ART adherence and ART outcomes among adolescents living with HIV and on ART in sub-Saharan Africa.

METHODS

We conducted searches in four scientific databases for studies conducted between 2010 and March 2022 to identify relevant primary studies. Studies were screened against inclusion criteria and assessed for quality, and data was extracted. Meta-analysis of rates and odd ratios was used to plot the quantitative studies and meta-synthesis summarized the evidence from qualitative studies.

RESULTS

A total of 10 431 studies were identified and screened against the inclusion/ exclusion criteria. Sixty-six studies met the inclusion criteria (41 quantitative, 16 qualitative, and 9 mixed-methods study designs). Fifty-three thousand two hundred and seventeen (53 217) adolescents (52 319 in quantitative studies and 899 in qualitative studies) were included in the review. Thirteen support focused interventions for improved ART adherence were identified from quantitative studies. The plotted results from the meta-analysis found an ART adherence rate of 65% (95%CI 56-74), viral load suppression was 55% (95%CI 46-64), un-suppressed viral load rate of 41% (95%CI 32-50), and loss to follow up of 17% (95%CI 10-24) among adolescents. Meta-synthesis found six themes of barriers to ART (social, patient-based, economic, health system-based, therapy-based, and cultural barriers) in both the qualitative and quantitative studies, and three themes of facilitators to ART were also identified (social support, counselling, and ART education and secrecy or confidentiality) from qualitative studies.

CONCLUSION

ART adherence remains low among adolescents in SSA despite multiple interventions implemented to improve ART adherence. The low adherence rate may hinder the attainment of the UNAIDS 2030 targets. Additionally, various barriers to ART adherence due to lack of support have been reported among this age group. However, interventions aimed at improving social support, educating, and counselling adolescents may improve and sustain ART adherence.

TRIAL REGISTRATION

Systematic review registration: PROSPERO CRD42021284891.

Factors Associated with Retention in HIV Care Among HIV-Positive Adolescents in Public Antiretroviral Therapy Clinics in Ibanda District, Rural South Western Uganda

Background

Retention in antiretroviral therapy (ART) care is a key indicator of Human Immunodeficiency Virus (HIV) treatment success as it improves adherence, critical for better treatment outcomes and prevention of drug resistance. HIV treatment among adolescents living with HIV (ALHIV) is characterized by loss to follow-up, poor ART adherence, and eventual death. This study assessed retention in ART care and the associated factors among ALHIV in Ibanda district, rural South Western Uganda.

Methods

This was a retrospective cohort study using clinical data from ALHIV enrolled from 2019 to 2020 in eight health facilities in Ibanda district. Data from the Electronic Medical Record (EMR) system was extracted to assess the associated factors and participants' status two years after enrollment. Data were analyzed using EPIdata version 3.1 in which Univariate and multivariate cox proportional hazard regression analyses were determined. A hazard ratio (HR) at a 95% confidence interval was obtained, and a P-value <0.05 was considered statistically significant.

Results

Eighty-four ALHIV comprising 86.9% (N = 73) females were enrolled. The majority 63.1% (N = 53) resided in semi/peri-urban, and 44.0% (N = 37) stayed less than 5 km from the facility. Only 35.7% (N = 30) were active on ART, while 17 (20.2%) and 36 (42.9%) were lost to follow-up and transfer-outs, respectively. Factors associated with low retention were: ALHIV that moved 5-10Km (HR = 5.371; 95% CI: 1.227-23.5050, p = 0.026), used differential service delivery model was Facility-Based Group (FBG) (HR = 12.419; 95% CI: 4.034-38.236, p < 0.001) and those enrolled on the Young Adolescent Program Support (YAPs) (HR = 4.868; 95CI:1.851-12.803; p = 0.001). Retention reduced with increasing ART duration, ALHIV on (TDF/3TC/EFV) (p < 0.001), lived more than 10Km (p = 0.043) and did not benefit from any intervention (p < 0.001).

Conclusion

Results showed low retention in care and the urgent need to strengthen individual case management strategies for ALHIV, thus interventions focusing on peer support are desired.

Impact of Family-Based Economic Empowerment Intervention, Suubi+Adherence (2012-2018) on Multidimensional Poverty for Adolescents Living with HIV (ALWHIV) in Uganda

Children growing up in poverty are disproportionately affected by diseases, including HIV. In this study, we use data from Suubi+Adherence, a longitudinal randomized control trial (2012-2018) with 702 adolescents living with HIV (ALWHIV), to examine the effectiveness of a family-based multifaceted economic empowerment (EE) intervention in addressing economic instability and multidimensional poverty among ALWHIV in Southern Uganda. We constructed a Multidimensional Poverty Index of individual and household indicators, including health, assets, housing and family dynamics. We computed the proportion of multidimensionally poor children (H), estimated poverty intensity (A) and adjusted headcount ratio (M₀). Using repeated measures at five-time points (baseline, years 1, 2, 3 and 4-post baseline) across two study arms: treatment (receiving the EE intervention) vs. control arm (not receiving EE), we find that both the incidence and proportion of multidimensional poverty decreased in the treatment arm vs. the control arm. Given that there is a direct link between economic instability and poor health outcomes, these findings are informative. They point to the potential for family EE interventions to decrease multidimensional poverty among vulnerable children, including ALWHIV, impacting their overall wellbeing and ability to meet their treatment needs and improve HIV care continuum outcomes.

Adolescent Girls and Young Women's Experiences of Living with HIV in the Context of Patriarchal Culture in Sub-Saharan Africa: A Scoping Review

Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by the human immunodeficiency virus (HIV) due to socio-cultural gender, power, and economic disparities. This scoping review examined the literature to explore what is known about AGYW's everyday personal, relational, and social experiences of HIV to help shape future protective HIV policy and practice. Six databases were searched: Medline, CINAHL, Scopus, ASSIA, Google Scholar, and ProQuest, resulting in a total of 12,581 articles. Of these, 40 articles were included in the review. Key themes generated from the thematic analysis were relational and psychosocial challenges, inhibiting sexual expression, poverty, stigma, and discrimination; managing health in everyday life; agency and resilience; and personal space and social support. In conclusion, the review found a lack of understanding of AGYW's everyday experiences of living with HIV from their own perspectives. There was also little consideration of the role of patriarchal culture and how this constrains AGYW's ability to negotiate their relationships. Further research is needed to reveal AGYW's perspectives on living with HIV in sub-Saharan Africa.

The Association of Perceived, Internalized, and Enacted HIV Stigma With Medication Adherence, Barriers to Adherence, and Mental Health Among Young People Living With HIV in Zambia

Few studies have examined the independent effects of different manifestations of HIV stigma experiences on health outcomes among youth living with HIV in low- and middle-income countries. We examined the association of internalized, enacted, and perceived HIV stigmas with medication adherence, self-esteem, depression, and barriers to adherence. Young people living with HIV aged 18-21 years (N = 120) were purposively sampled from two health facilities in Eastern Province, Zambia, and completed self-report measures. Results indicated heterogeneous associations. Internalized HIV stigma was positively associated with depression and negatively associated with adherence, adherence motivation, behavioral adherence skills, and self-esteem. Perceived stigma was negatively associated with self-esteem. No significant association was observed between enacted stigma and health outcomes. The complexity of HIV stigma requires a precise explication of the associations among different HIV stigma experiences and outcomes, which can inform the development of stigma reduction interventions targeting one or more stigma experiences.

A Multilevel Integrated Intervention to Reduce the Impact of HIV Stigma on HIV Treatment Outcomes Among Adolescents Living With HIV in Uganda: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.

OBJECTIVE

The proposed intervention-Multilevel Suubi (MSuubi)-has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants' experiences with HIV stigma, HIV treatment adherence, and intervention and educators' attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.

METHODS

MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.

RESULTS

This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.

CONCLUSIONS

MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40101.

'They can stigmatize you': a qualitative assessment of the influence of school factors on engagement in care and medication adherence among adolescents with HIV in Western Kenya

School-related factors may influence retention in care and adherence to antiretroviral therapy (ART) among adolescents with human immunodeficiency virus (HIV). We analyzed data from in-depth interviews with 40 adolescents with HIV (aged 14 -19 years), 40 caregivers of adolescents with HIV, and 4 focus group discussions with healthcare workers to evaluate contextual factors affecting adherence to ART and clinic attendance among adolescents, with a focus on the school environment. Informed by Anderson's Model of Health Services Utilization, transcripts were systematically coded and synthesized to identify school-related themes. All groups identified the school environment as a critical barrier to engagement in HIV care and medication adherence for adolescents with HIV. Adolescent participants reported inflexible school schedules and disclosure to school staff as the biggest challenges adhering to clinic appointments and ART. Adolescents described experiencing stigma and discrimination by peers and school staff and would adjust when, where and how often they took ART to avoid inadvertent disclosure. Boarding school students faced challenges because they had limited private space or time. Caregivers were often instrumental in navigating school permissions, including identifying a treatment supporter among school staff. Additional research engaging school staff may guide interventions for schools to reduce stigma and improve adherence and retention.

Storyboarding HIV Infected Young People's Adherence to Antiretroviral Therapy in Lower- to Upper Middle-Income Countries: A New-Materialist Qualitative Evidence Synthesis

Young people living with perinatal infections of Human Immunodeficiency Virus (YLPHIV) face a chronic disease, with treatment including adherence to lifelong antiretroviral treatment (ART). The aim of this QES was to explore adherence to ART for YLPHIV as an assemblage within the framework of the biopsychosocial model with a new materialist perspective. We searched up to November 2021 and followed the ENTREQ and Cochrane guidelines for QES. All screening, data extraction, and critical appraisal were done in duplicate. We analysed and interpreted the findings innovatively by creating images of meaning, a storyboard, and storylines. We then reported the findings in a first-person narrative story. We included 47 studies and identified 9 storylines. We found that treatment adherence has less to do with humans' preferences, motivations, needs, and dispositions and more to do with how bodies, viruses, things, ideas, institutions, environments, social processes, and social structures assemble. This QES highlights that adherence to ART for YLPHIV is a multisensorial experience in a multi-agentic world. Future research into rethinking the linear and casual inferences we are accustomed to in evidence-based health care is needed if we are to adopt multidisciplinary approaches to address pressing issues such as adherence to ART.

Health-related needs reported by adolescents living with HIV and receiving antiretroviral therapy in sub-Saharan Africa: a systematic literature review

Introduction

Adolescents living with HIV (ALHIV) on antiretroviral therapy (ART) have specific health needs that can be challenging to deliver. Sub‐Saharan Africa (SSA) is home to 84% of the global population of ALHIV, of whom about 59% receive ART. Several studies in SSA have demonstrated health service gaps due to lack of synchronized healthcare for ALHIV receiving ART. We conducted a systematic review of health‐related needs among ALHIV on ART in SSA to inform decisions and policies on care.

Methods

We searched MEDLINE, Web of Science, EMBASE, PsycINFO, Cochrane library and grey literature for studies reporting health‐related needs among ALHIV receiving ART in SSA, between January 2003 and May 2020.

Results and discussion

Of the 2333 potentially eligible articles identified, 32 were eligible. Eligible studies were published between 2008 and 2019, in 11 countries: Zambia (7), Uganda (6), Tanzania (4), South Africa (4), Kenya (3), Ghana (2), Zimbabwe (2), Rwanda (1), Malawi (1), Botswana (1) and Democratic Republic of Congo (1). Seven categories of health needs among ALHIV were identified. In descending order of occurrence, these were: psychosocial needs (stigma reduction, disclosure and privacy support, and difficulty accepting diagnosis); dependency of care (need for family and provider support, and desire for autonomy); self‐management needs (desire for better coping strategies, medication adherence support and reduced ART side effects); non‐responsive health services (non‐adolescent friendly facility services and non‐compatible school system); need for food, financial and material support; inadequate information about HIV (desire for more knowledge to fight misinformation and misconception); and developmental and growth needs (desire to experience sex, parenthood and love). Ecological analysis identified different priority needs between ALHIV, their caregivers and healthcare providers, including psychosocial needs, financial challenges and non‐responsive health services, respectively.

Conclusions

To respond effectively to the health needs of ALHIV and improve ART adherence, interventions should focus on stigma reduction, disclosure challenges and innovative coping mechanisms for ART. Interventions that address the health needs of ALHIV from the perspective of carers and providers, such as financial support schemes and adolescent‐friendly healthcare strategies, should supplement efforts to improve adolescent ART adherence outcomes.

"I was still very young": agency, stigma and HIV care strategies at school, baseline results of a qualitative study among youth in rural Kenya and Uganda

INTRODUCTION

Adolescents and young adults living with HIV (AYAH) have the lowest rates of retention in HIV care and antiretroviral therapy (ART) adherence, partly due to the demands of school associated with this life stage, to HIV-related stigma and to fears of serostatus disclosure. We explore the implications of school-based stigma and disclosure on the development of agency during a critical life stage in rural Kenya and Uganda.

METHODS

We conducted a qualitative study in the baseline year of the SEARCH Youth study, a combination intervention using a life-stage approach among youth (15-24 years old) living with HIV in western Kenya and southwestern Uganda to improve viral load suppression and health outcomes. We conducted in-depth, semi-structured interviews in 2019 with three cohorts of purposively selected study participants (youth [n = 83], balanced for sex, life stage and HIV care status; recommended family members of youth [n = 33]; and providers [n = 20]). Inductive analysis exploring contextual factors affecting HIV care engagement revealed the high salience of schooling environments.

RESULTS

Stigma within school settings, elicited by non-consensual serostatus disclosure, medication schedules and clinic appointments, exerts a constraining factor around which AYAH must navigate to identify and pursue opportunities available to them as young people. HIV status can affect cross-generational support and cohort formation, as AYAH differ from non-AYAH peers because of care-related demands affecting schooling, exams and graduation. However, adolescents demonstrate a capacity to overcome anticipated stigma and protect themselves by selectively disclosing HIV status to trusted peers and caregivers, as they develop a sense of agency concomitant with this life stage. Older adolescents showed greater ability to seek out supportive relationships than younger ones who relied on adult caregivers to facilitate this support.

CONCLUSIONS

School is a potential site of HIV stigma and also a setting for learning how to resist such stigma. School-going adolescents should be supported to identify helpful peers and selectively disclose serostatus as they master decision making about when and where to take medications, and who should know. Stigma is avoided by fewer visits to the clinic; providers should consider longer refills, discreet packaging and long-acting, injectable ART for students.

'So hurt and broken': A qualitative study of experiences of violence and HIV outcomes among Zambian youth living with HIV

Emerging data show associations between violence victimisation and negative HIV outcomes among youth in sub-Saharan Africa. We conducted in-depth interviews with adolescents and young adults living with HIV (aged 15-24 years) in Ndola, Zambia, to better understand this relationship. We purposively selected 41 youth (24 females, 17 males) with varied experiences of violence and virologic results. Analysis used thematic coding. Two-thirds of participants said violence affected their medication adherence, clinic attendance, and/or virologic results. They focused on the negative effects of psychological abuse from family members in homes and peers at schools, which were the most salient forms of violence raised, and sexual violence against females. In contrast, they typically depicted physical violence from caregivers and teachers as a standard discipline practice, with few impacts. Youth wanted HIV clinic settings to address verbal abuse and emotional maltreatment, alongside physical and sexual violence, including through peer mentoring. Violence - especially verbal and emotional forms - must be recognised as a potential barrier to HIV self-management among youth living with HIV in the region. Further testing of clinic, home, and school-based interventions may be critical to reducing levels of violence and improving HIV outcomes in this vulnerable but resilient population.Trial registration: ClinicalTrials.gov identifier: NCT04115813.

Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment

In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.

Mobile technology access and use among youth in Nairobi, Kenya: implications for mobile health intervention design

BACKGROUND

Social media can be used to support the health of underserved youth beyond clinical settings. Young people are avid users of social media, but estimates of smartphone access among youth in sub-Saharan Africa are lacking, making it difficult to determine context-appropriateness of online and social media interventions.

METHODS

We conducted a cross-sectional observational survey assessing technology access and use among youth aged 14-24 receiving general outpatient or human immunodeficiency virus (HIV) care in three hospitals in Nairobi, Kenya. Correlates of smartphone access and social media use were evaluated by Poisson regression.

RESULTS

Of 600 youth, 301 were receiving general outpatient care and 299 HIV care. Median age was 18 years. Overall, 416 (69%) had access to a mobile phone and 288 (48%) to a smartphone. Of those with smartphones, 260 (90%) used social media. Smartphone access varied by facility (40% at the sub-county hospital vs. 55% at the national referral hospital, P=0.004) and was associated with older age [65% in 20-24-year-old vs. 37% in 14-19-year-old, adjusted prevalence ratio (aPR) 1.58, 95% CI: 1.30-1.92], secondary vs. primary education (aPR 2.59, 95% CI: 1.76-3.81), and HIV vs. general outpatient care (aPR 1.18, 95% CI: 1.01-1.38). Social media use was similarly associated with facility, older age, higher education, and male gender.

CONCLUSIONS

These data suggest that smartphone-based and social media interventions are accessible in Nairobi, Kenya, in the general population and youth living with HIV, and most appropriate for older youth. Intervention developers and policymakers should consider smartphone and social media interventions as candidates for youth health programs, while noting that heterogeneity of access between and within communities requires tailoring to the specific intervention context to avoid excluding the most vulnerable youth.

Supporting adolescents living with HIV within boarding schools in Kenya

Adolescents and youth living with HIV (AYLHIV) are a uniquely vulnerable population facing challenges around adherence, disclosure of HIV status and stigma. Providing school-based support for AYLHIV offers an opportunity to optimize their health and wellbeing. The purpose of this study was to evaluate the feasibility of school-based supportive interventions for AYLHIV in Kenya. From 2016-2019, with funding from ViiV Healthcare, the Elizabeth Glaser Pediatric AIDS Foundation implemented the innovative Red Carpet Program (RCP) for AYLHIV in participating public healthcare facilities and boarding schools in Homa Bay and Turkana Counties in Kenya. In this analysis, we report the implementation of the school-based interventions for AYLHIV in schools, which included: a) capacity building for overall in-school HIV, stigma and sexual and reproductive health education; b) HIV care and treatment support; c) bi-directional linkages with healthcare facilities; and d) psychosocial support (PSS). Overall, 561 school staff and 476 school adolescent health advocates received training to facilitate supportive environments for AYLHIV and school-wide education on HIV, stigma, and sexual and reproductive health. All 87 boarding schools inter-linked to 66 regional healthcare facilities to support care and treatment of AYLHIV. Across all RCP schools, 546 AYLHIV had their HIV status disclosed to school staff and received supportive care within schools, including treatment literacy and adherence counselling, confidential storage and access to HIV medications. School-based interventions to optimize care and treatment support for AYLHIV are feasible and contribute to advancing sexual and reproductive health within schools.

Antiretroviral Therapy and Retention in Care Experiences and Needs of Adolescents Living with HIV in Southern Ethiopia

Background

Adolescents with HIV are faced with challenges when taking care of their medication, which affects their treatment adherence. Therefore, this study aimed to explore the experiences and needs of adolescents living with HIV regarding their antiretroviral therapy adherence and retention in care in southern Ethiopia.

Methods

An inductive qualitative study design was applied to explore adolescents’ experiences and needs regarding antiretroviral treatment adherence and retention in care in southern Ethiopia. Eighteen adolescents were selected from five HIV care and treatment facilities by purposive sampling. The interviews followed an interview guide, translated into the participants’ national language. The interviews were transcribed verbatim and the first author developed a coding frame for the analysis by using NVivo software including meaning units and codes, which were discussed by all authors. Then, sub-themes and themes were identified and analyzed by qualitative content analysis.

Results

The results were described in two themes: barriers and facilitators for treatment adherence and retention in care. Barriers were described in seven subthemes and facilitators in three subthemes. Forgetting to take medication, hiding information, or non-disclosure of HIV status, being afraid to collect treatment drugs, being in an orphanage, and school activities were described as barriers while support from health care workers, families, personal motivation to cope with medication-related problems were described as facilitators for antiretroviral therapy adherence and retention in care.

Conclusion

Adherence is a major challenge among adolescents living with HIV in Ethiopia, with barriers that are unique to this age group and their living conditions. Therefore, interventions should be targeted to address privacy barriers, stigma, and lack of support.

Association of experienced and internalized stigma with self-disclosure of HIV status by youth living with HIV

We examined patterns of disclosure among youth living with HIV (YLHIV) in Kenya, and the association between self-disclosure and antiretroviral therapy adherence, stigma, depression, resilience, and social support. Of 96 YLHIV, 78% were female, 33% were ages 14-18, and 40% acquired HIV perinatally. Sixty-three (66%) YLHIV had self-disclosed their HIV status; 67% to family and 43% to non-family members. Older YLHIV were 75% more likely to have self-disclosed than those 14-18 years. Of the 68 either married or ever sexually active, 45 (66%) did not disclose to their partners. Those who had self-disclosed were more likely to report internalized stigma (50% vs. 21%, prevalence ratio [PR] 2.3, 1.1-4.6), experienced stigma (26% vs. 3%, PR 11.0, 1.4-86), and elevated depressive symptoms (57% vs. 30%, PR 1.8, 1.0-3.1). The association with stigma was stronger with self-disclosure to family than non-family. Support should be provided to YLHIV during self-disclosure to mitigate psychosocial harms.

"Pain Special Issue" "Stakeholders' perspectives and requirements on pain self-management for adolescents living with HIV/AIDS in Malawi: a cross-sectional qualitative study"

Malawi has one of the highest HIV prevalence rates (8.9%), and data suggest 27% pain prevalence among adolescents living with HIV (ALHIV) in Malawi. Pain among ALHIV is often under-reported and pain management is suboptimal. We aimed to explore stakeholders' perspectives and experiences on pain self-management for ALHIV and chronic pain in Malawi. We conducted cross-sectional in-depth qualitative interviews with adolescents/caregiver dyads and healthcare professionals working in HIV clinics. Data were audio-recorded, transcribed verbatim and translated (where applicable) then imported into NVivo version 12 software for framework analysis. We identified three main themes: (1) Experiencing "total pain": adolescents experienced physical, psychosocial, and spiritual pain which impacted their daily life activities. (2) Current self-management approaches: participants prefer group-based self-management approaches facilitated by healthcare professionals or peers at the clinic focussing on self-management of physical, psychosocial, and spiritual pain. (3) Current pain strategies: participants used prescribed drugs, traditional medicine, and non-pharmacological interventions, such as exercises to manage pain. A person-centred care approach to self-management of chronic pain among ALHIV is needed to mitigate the impact of pain on their daily activities. There is a need to integrate self-management approaches within the existing structures such as teen clubs in primary care.

Prevalence and Factors Associated With Virological Treatment Failure Among Children and Adolescents on Antiretroviral Therapy Attending HIV/AIDS Care and Treatment Clinics in Dodoma Municipality, Central Tanzania

BACKGROUND

As the World Health Organization (WHO) and its joint partners such as USAIDS target achieving 90% sustained virological suppression among children and adolescents living with Human Immunodeficience Virus (HIV)/AIDS, it is imperative to elucidate the current prevalence and factors associated with virological treatment failure for formulation of appropriate strategies. This study was conducted determine the prevalence and factors associated with virological treatment failure among children and adolescents with HIV/AIDS on antiretroviral therapy (ART) attending HIV/AIDS care clinics in Dodoma, Central Tanzania.

METHODS

This was a cross-sectional study of children aged 1-19 years attending 3 HIV/AIDS care clinics in Dodoma (central Tanzania) from November 2018 to February 2019. Sociodemographic and clinical factors were documented, HIV viral load and CD4+ T lymphocytes were evaluated for children on ART for ≥6 months. The primary outcomes were the prevalence and factors associated with viralogic treatment failure.

RESULTS

Of 300 children enrolled, 102 (34%) had virological treatment failure. Poor adherence to ART (adjusted odds ratio [AOR] = 3.221; 95% confidence interval [CI], 1.867-5.558; P = .032), nevirapine regimen (AOR = 3.185; 95% CI, 1.473-6.886; P ≤ .001), not using cotrimoxazole prophylaxis (AOR = 25.56; 95% CI, 3.15-27.55; P = .002) and nondisclosure of HIV status to others (AOR = 7.741; 95% CI, 2.351-25.489; P = .001) were independently associated with virological treatment failure.

CONCLUSIONS

Current prevalence of virological treatment failure among children and adolescents living with HIV on ART remain high. Factors such as ART adherence, nevirapine based regimen, HIV status disclosure to those caring for the child need to be addressed to achieve sustained virological suppression.

Influence of boarding secondary school environment on HIV positive students in South Western Uganda

Background

The number of human immunodeficiency virus (HIV) positive adolescents in secondary school has increased over the years. Little is known on how the students cope to the pressures and demands of their academic and health lives in the boarding secondary schools. This study explored the factors surrounding their anti-retroviral therapy adherence as well as their experiences.

Methods

We did a qualitative study that employed in-depth interviews amongst purposively selected 19 HIV positive adolescent students in boarding secondary school and seven key informants. Key informants were members of boarding secondary school staff directly taking care of the adolescents living with human immune virus and had spent at least two academic terms in that school.

The study participants were recruited from four health facilities in Bushenyi district, southwestern Uganda, and key informants from five boarding secondary schools in Bushenyi. These were engaged in in-depth interviews using an interview guide. Data was transcribed, coded and the content analyzed thematically.

Results

Adolescents living with human immunodeficiency virus in boarding secondary school face challenges similar to adolescents outside boarding school settings. However, some challenges are unique to them. Students faced numerous barriers which made it difficult to adhere to their medication. Stigmatization in its different forms was also a major challenge amongst students. Willingness disclosure of serostatus was beneficial to the students since it guaranteed support while at school; facilitating adherence and better living. However, students were uneasy to disclose their status. Some students adopted negative coping mechanisms such as telling lies, escaping from school, and class to access medication.

Conclusions

Adolescents in boarding secondary schools face similar challenges as compared to their counterparts with some being unique to them. Few school mechanisms help these students to cope while at school. Limited disclosure has proven useful but some adolescents have opted not to disclose their status and hence used negative coping mechanisms. These challenges need to be addressed and a safe environment to encourage limited disclosure should be made.

Understanding how young people become motivated to take their human immunodeficiency virus medication (antiretroviral therapy) and how the need for adherence is communicated

Background

Antiretroviral therapy (ART), the only effective treatment for human immunodeficiency virus (HIV), requires excellent long-term compliance. Poor levels of adherence to ART, especially amongst adolescents and young adults in South Africa, have been reported.

Aim

This study aimed to explore how young people become motivated to take their HIV medication (ART) and how the need for adherence is communicated.

Setting

The study was conducted in a peri-urban township in the Western Cape, South Africa.

Methods

A qualitative grounded theory approach was employed. Eighty young people were purposively recruited. Participant observation, focus groups and semi-structured interviews were utilised to explore how effective ART adherence messages are in motivating adherence amongst young people and how they would like ART adherence to be communicated to them. All interviews and focus groups were transcribed and analysed by using cross-comparison analysis. Measures to ensure trustworthiness were established and ethical considerations were adhered to.

Results

Young people’s adherence motivation was an outcome of reconnecting to one or more trusted significant other(s) from within their belonging group, who accepted and supported them, which in turn affirmed their prior belonging identities of son, daughter, other family member or close friend. This facilitated reconnection to their present and future hopes, which in turn increased their motivation to live and to adhere to treatment.

Conclusion

The findings highlight the need for the development of more effective communication strategies, which facilitate and support young people’s reconnection to trusted members of their belonging groups, and also help belonging group members to accept, affirm and support adherence.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in HIV Treatment Adherence Before and After HIV Status Disclosure to Adolescents in Botswana

PURPOSE

This study aimed to determine if disclosure of HIV status to adolescents impacted their medication adherence and how medication autonomy might explain observed effects.

METHODS

Three hundred adolescents on HIV treatment using electronic medication monitors were followed for 24 months while undergoing routine care. One hundred six of the adolescents were HIV disclosure-naïve and HIV status disclosure in this group was assessed quarterly. Analyses included data from the 75 adolescents who experienced disclosure during the study providing adherence and autonomy data both predisclosure and postdisclosure. Segmented generalized estimating equations were used to examine the trend of adherence and autonomy predisclosure and postdisclosure. Covariates assessed include age at disclosure, sex, and orphan status.

RESULTS

Median age at study entry was 12.2 years (interquartile range 11.6-12.9). Incident disclosure occurred in 75 (71%) of the adolescents at a median age of 13.1 years (interquartile range 12.5-13.9). Adherence decreased by 11% (95% confidence interval [CI] 7-15, p < .001) during the predisclosure period and by 22% (95% CI 9-36, p = .001) during the postdisclosure period. Adolescents' autonomy over their medication-taking increased over time, but disclosure did not impact the rate of increase in measured medication-taking autonomy. On a scale of 1-4 assessing autonomy (1 = receiving directly observed therapy and 4 = taking medicines mostly without supervision), autonomy increased by an average of .03 units/month (95% CI .02-.03, p < .001) predisclosure and by .05 units/month (95% CI -.01 to .11, p = .42) postdisclosure.

CONCLUSIONS

The findings suggest that, among perinatally HIV infected adolescents, HIV status disclosure may adversely impact treatment adherence. Postdisclosure support to HIV infected adolescents should be intensified.

Interventions to Improve Antiretroviral Therapy Adherence Among Adolescents and Youth in Low- and Middle-Income Countries: A Systematic Review 2015-2019

Adolescents and youth living with HIV have poorer antiretroviral treatment (ART) adherence and viral suppression outcomes than all other age groups. Effective interventions promoting adherence are urgently needed. We reviewed and synthesized recent literature on interventions to improve ART adherence among this vulnerable population. We focus on studies conducted in low- and middle-income countries (LMIC) where the adolescent and youth HIV burden is greatest. Articles published between September 2015 and January 2019 were identified through PubMed. Inclusion criteria were: [1] included participants ages 10-24 years; [2] assessed the efficacy of an intervention to improve ART adherence; [3] reported an ART adherence measurement or viral load; [4] conducted in a LMIC. Articles were reviewed for study population characteristics, intervention type, study design, outcomes measured, and intervention effect. Strength of each study's evidence was evaluated according to an adapted World Health Organization GRADE system. Articles meeting all inclusion criteria except being conducted in an LMIC were reviewed for results and potential transportability to a LMIC setting. Of 108 articles identified, 7 met criteria for inclusion. Three evaluated patient-level interventions and four evaluated health services interventions. Of the patient-level interventions, two were experimental designs and one was a retrospective cohort study. None of these interventions improved ART adherence or viral suppression. Of the four health services interventions, two targeted stable patients and reduced the amount of time spent in the clinic or grouped patients together for bi-monthly meetings, and two targeted patients newly diagnosed with HIV or not yet deemed clinically stable and augmented clinical care with home-based case-management. The two studies targeting stable patients used retrospective cohort designs and found that adolescents and youth were less likely to maintain viral suppression than children or adults. The two studies targeting patients not yet deemed clinically stable included one experimental and one retrospective cohort design and showed improved ART adherence and viral suppression outcomes. ART adherence and viral suppression outcomes remain a major challenge among adolescents and youth. Intensive home-based case management models of care hold promise for improving outcomes in this population and warrant further research.

Longitudinal evaluation of adherence, retention, and transition patterns of adolescents living with HIV in Nigeria

Introduction

Adherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic.

Setting

The Jos University Teaching Hospital, United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria.

Methods

We conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ≥95% MPR and the proportion with virologic suppression (viral load ≤400 copies/mL) within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed.

Results

A total of 476 patients received at least one dose of ART as an adolescent (ages 10–19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ≥95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%–64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression.

Conclusions

Our evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ≥95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals.

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.

Youth living with HIV/AIDS in secondary schools: perspectives of peer educators and patron teachers in Western Uganda on stressors and supports

As Youth Living With HIV/AIDS (YLWHA) continue to survive and live with HIV chronically due to effective Antiretroviral Therapy (ART), it is paramount to work toward maximising their psychosocial wellbeing. The school where these YLWHA are expected to spend most of their time is an excellent environment to investigate this. In this study, we explore perspectives of Peer Educators (PEs) in secondary schools of one district in Western Uganda on how YLWHA are perceived in school, on their daily stressors and their way of coping with their HIV-positive serostatus given the support of the schools. We conducted eight focus groups with a total of 59 students who were members of Peer Educators Clubs (PECs) as well as 8 in-depth interviews with patron teachers of PECs in eight secondary schools of Kabarole district, selected through a stratified random sampling method. Focus groups and interviews were tape-recorded, transcribed and analysed thematically both inductively and deductively. Stressors and support in schools, as identified by the PEs were categorised into three interrelated thematic domains; psychological wellbeing of YLWHA, disclosure of HIV status by YLWHA, and health and treatment adherence. Stigma was found to be a key stressor and an intermediary in all the three thematic domains Stressors affecting psychological wellbeing were fear of death and uncertainty of the future compounded by financial and academic challenges. Stressors affecting disclosure centred around lack of privacy, confidentiality and fear of loss of friends. Stressors affecting treatment adherence included lack of privacy while taking drugs, unintended disclosure while obtaining drugs or seeking permission to attend clinic appointments and fear of drug adverse effects due to poor nutrition. A supportive school environment involved the availability of a school nurse, counselling services and PECs. We conclude that the school environment brings more stressors than supports for YLWHA. The daily stressors related to HIV stigma, uncertainty, disclosure, privacy and confidentiality render schooling a hassle for YLWHA. Interventions that promote resilient school communities are necessary to foster disclosure in a non-discriminatory and stigma-free environment. This calls for concerted efforts from all school stakeholders.

Secrets and Silence: Agency of Young Women Managing HIV Disclosure

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

A Longitudinal Study of Behavioral Risk, Adherence, and Virologic Control in Adolescents Living With HIV in Asia

BACKGROUND

Adolescents living with HIV (ALHIV) have poorer adherence and clinical outcomes than adults. We conducted a study to assess behavioral risks and antiretroviral therapy outcomes among ALHIV in Asia.

METHODS

A prospective cohort study among ALHIV and matched HIV-uninfected controls aged 12-18 years was conducted at 9 sites in Malaysia, Thailand, and Vietnam from July 2013 to March 2017. Participants completed an audio computer-assisted self-interview at weeks 0, 48, 96, and 144. Virologic failure (VF) was defined as ≥1 viral load (VL) measurement >1000 copies/mL. Generalized estimating equations were used to identify predictors for VF.

RESULTS

Of 250 ALHIV and 59 HIV-uninfected controls, 58% were Thai and 51% females. The median age was 14 years at enrollment; 93% of ALHIV were perinatally infected. At week 144, 66% of ALHIV were orphans vs. 28% of controls (P < 0.01); similar proportions of ALHIV and controls drank alcohol (58% vs. 65%), used inhalants (1% vs. 2%), had been sexually active (31% vs. 21%), and consistently used condoms (42% vs. 44%). Of the 73% of ALHIV with week 144 VL testing, median log VL was 1.60 (interquartile range 1.30-1.70) and 19% had VF. Over 70% of ALHIV had not disclosed their HIV status. Self-reported adherence ≥95% was 60% at week 144. Smoking cigarettes, >1 sexual partner, and living with nonparent relatives, a partner or alone, were associated with VF at any time.

CONCLUSIONS

The subset of ALHIV with poorer adherence and VF require comprehensive interventions that address sexual risk, substance use, and HIV-status disclosure.

Experiences and perceptions of youth living with HIV in Western Uganda on school attendance: barriers and facilitators

BACKGROUND

The globally recognized socio-economic benefits of education have stirred many countries in Sub-Saharan Africa like Uganda to promote universal access to schooling by removing fiscal barricades for those in primary and secondary schools. However, the proportion of Youth Living With HIV/AIDS (YLWHA) missing school, studying with difficulties and dropping out of school in Uganda has been observed to be higher than that of other youth. This study aimed at understanding the barriers and facilitators for YLWHA in Uganda to attend school.

METHODS

We conducted a qualitative inquiry with 35 purposively selected YLWHA aged 12 to 19 years, including 16 females at three accredited Antiretroviral Therapy (ART) treatment centres in Kabarole district in Western Uganda. Individual semi-structured interviews were tape-recorded, transcribed verbatim and subjected to thematic inductive analysis.

RESULTS

We identified five main themes in which barriers to attend school were reported and four main themes in which facilitators were reported by participants. The main themes for barriers were: 1) management of ART and illnesses, 2) fear, negative thoughts and self-devaluation, 3) lack of meaningful and supportive relationships, 4) reactionary attitudes and behaviours from others at school, 5) financial challenges. The main themes for facilitators were: 1) practical support at school, home and community, 2) counselling, encouragement and spirituality, 3) individual coping strategies, 4) hopes, dreams and opportunities for the future.

CONCLUSION

Most of the barriers reported arose from HIV-related stigma and financial challenges whose genesis transcends school boundaries. While YLWHA reported measures to cope, and support from other people, these were non-sustainable and on a limited scale due to disclosure apprehension at school and the indiscretion of those who learnt about their status. To promote supportive school environments for YLWHA, integrated curricular and extracurricular interventions are necessary to increase HIV knowledge, dispel misconceptions about HIV and consequently transform the school community from a stigmatizing one to a supportive one.

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.

Understanding health-related behavior among adolescents living with HIV in Lima, Peru

Background

The global HIV burden among adolescents ages 10–19 is growing. This population concurrently confronts the multifaceted challenges of adolescence and living with HIV. With the goal of informing future interventions tailored to this group, we assessed sexual activity, HIV diagnosis disclosure, combination antiretroviral therapy (cART) adherence, and drug use among adolescents living with HIV (ALHIV) in Lima, Peru.

Methods

Adolescents at risk or with a history of suboptimal cART adherence completed a self-administered, health behaviors survey and participated in support group sessions, which were audio recorded and used as a qualitative data source. Additionally, we conducted in-depth interviews with caregivers and care providers of ALHIV. Thematic content analysis was performed on the group transcripts and in-depth interviews and integrated with data from the survey to describe adolescents’ health related behaviors.

Results

We enrolled 34 ALHIV, of which 32 (14 male, 18 female, median age 14.5 years) completed the health behavior survey. Nine (28%) adolescents reported prior sexual intercourse, a minority of whom (44%) reported using a condom. cART adherence was highest in the 10–12 age group with 89% reporting ≤2 missed doses in the last month, compared to 36% in adolescents 13 years or older. Over 80% of adolescents had never disclosed their HIV status to a friend or romantic partner. Adolescents, caregivers, and health service providers described sexual health misinformation and difficulty having conversations about sexual health and HIV.

Conclusions

In this group of ALHIV, adherence to cART declined with age and condom use among sexually active adolescents was low. Multifactorial interventions addressing sexual health, gaps in HIV-related knowledge, and management of disclosure and romantic relationships are urgently needed for this population.

High Medication Possession Ratios Associated With Greater Risk of Virologic Failure Among Youth Compared With Adults in a Nigerian Cohort

BACKGROUND

Medication possession ratio (MPR) is widely used as a measure of adherence to antiretroviral therapy (ART). Many adolescents and young adults (AYA) experience ART adherence challenges. Our objective was to determine whether the relationship between MPR and virologic failure (VF) is consistent between AYA and older adults in Nigeria.

METHODS

We conducted a retrospective study of AYA (aged 15-25 years) and adults (aged >25 years) who initiated ART between January 2009 and December 2012 at 10 university-affiliated HIV clinics in Nigeria. We used multivariate generalized linear models to assess the relationship between age, MPR (ART doses dispensed)/(days since ART initiation), and risk of VF (HIV RNA >1000 copies/mL) in the 1st year on ART.

RESULTS

The cohort included 1508 AYA and 11,376 older adults. VF was more common in AYA than older adults (30% vs. 24% P < 0.01). Overall, 74% of patients had optimal, 16% suboptimal, and 9% poor adherence (MPR >94%, 80%-94%, and <80%, respectively). AYA attended fewer pharmacy-only visits than older adults (5 vs. 6, P < 0.001). Higher MPR was associated with decreased rate of VF (80%-94%, accounting rate of return 0.57; >94% accounting rate of return 0.43, P < 0.001 vs. MPR <80%). Among those with optimal adherence by MPR, 26% of AYA had VF, a risk that was 20% higher than for older adults with optimal adherence (P < 0.001).

CONCLUSIONS

In this Nigerian cohort, MPRs were high overall, and there was a strong association between low MPR and risk of VF. Nonetheless, 26% of AYA with high MPRs still had VF. Understanding the discrepancy between MPR and viral suppression in AYA is an important priority.

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.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

BACKGROUND

Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

METHODS

We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

RESULTS

We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

CONCLUSION

This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

BACKGROUND

Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

METHODS

We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

RESULTS

We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

CONCLUSION

This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

"How am I going to live?": exploring barriers to ART adherence among adolescents and young adults living with HIV in Uganda

Background

Studies from sub-Saharan Africa (SSA) document how barriers to ART adherence present additional complications among adolescents and young adults living with HIV. We qualitatively explored barriers to ART adherence in Uganda among individuals age 14–24 to understand the unique challenges faced by this age group.

Methods

We conducted focus group (FG) discussions with Community Advisory Board members (n = 1), health care providers (n = 2), and male and female groups of adolescents age 14–17 (n = 2) and youth age 18–24 (n = 2) in Kampala, Uganda. FGs were transcribed verbatim and translated from Luganda into English. Two investigators independently reviewed all transcripts, developed a detailed codebook, achieved a pooled Cohen’s Kappa of 0.79 and 0.80, and used a directed content analysis to identify key themes.

Results

Four barriers to ART adherence emerged: 1) poverty limited adolescents’ ability to buy food and undercut efforts to become economically independent in their transition from adolescence to adulthood; 2) school attendance limited their privacy, further disrupting ART adherence; 3) family support was unreliable, and youth often struggled with a constant change in guardianship because they had lost their biological parents to HIV. In contrast peer influence, especially among HIV-positive youth, was strong and created an important network to support ART adherence; 4) the burden of taking multiple medications daily frustrated youth, often leading to so-called ‘drug holidays.’ Adolescent and youth-specific issues around disclosure emerged across three of the four barriers.

Conclusions

To be effective, programs and policies to improve ART adherence among youth in Uganda must address the special challenges that adolescents and young adults confront in achieving optimal adherence. For example, training on budgeting and savings practices could help promote their transition to financial independence. School staff could develop strategies to help students take their medications consistently and confidentially. While challenging to extend the range of services provided by HIV clinics, successful efforts will require engaging the family, peers, and larger community of health and educational providers to support adolescents and young adults living with HIV to live longer and healthier lives.

Trial registration

ClinicalTrials.gov Identifier: NCT02514356. Registered August 3, 2015.

Primary caregivers, healthcare workers, teachers and community leaders' perceptions and experiences of their involvement, practice and challenges of disclosure of HIV status to children living with HIV in Malawi: a qualitative study

Background

The World Health Organisation has recommended that healthcare workers, teachers and community leaders work with parents to support children living with HIV. The aim of this study was to assess the perceptions and experiences of primary caregivers and other care providers such as healthcare workers, teachers, and community leaders regarding their involvement, practice and challenges of HIV disclosure to children aged between 6 and 12 years living with HIV in Malawi.

Methods

Twelve focus group discussions and 19 one-on-one interviews involving a total of 106 participants were conducted in all three administrative regions of Malawi. The interviews and focus group discussions explored perceptions and experiences regarding involvement, practice and challenges of disclosure of HIV status to children. Data were analysed using thematic analysis.

Results

Primary caregivers, healthcare workers, teachers, and community leaders all reported that the disclosure of HIV status to children was not well coordinated because each of the groups of participants was working in isolation instead of working as a team. A “working together” model emerged from the data analysis where participants expressed the need for them to work as a team in order to promote safe and effective HIV status disclosure through talking about HIV, sharing responsibility and open communication. Participants reported that by working together, the team members would ensure that the prevalence of HIV disclosure to young children increases and that there would be a reduction in any negative impact of disclosure.

Conclusion

Global resources are required to better support children living with HIV and their families. Healthcare workers and teachers would benefit greatly from training in working together with families living with HIV and, specifically, training in the disclosure process. Resources, in the form of books and other educational materials, would help them explain HIV and its effective management to children and families.

Facilitators and Barriers Affecting Adherence Among People Living With HIV/AIDS: A Qualitative Perspective

Background:

It is widely accepted that for HIV-positive persons on highly active antiretroviral treatment, high levels of adherence to treatment regimens are essential for promoting viral suppression and preventing drug resistance.

Objectives:

This qualitative study examines factors affecting the adherence to HIV/AIDS treatment among patients with HIV/AIDS at a local hospital in Malaysia.

Methods:

The data from purposefully selected patients were collected by in-depth interviews using a pretested interview guide. Saturation was reached at the 13th interview. All interviews were audio-taped and transcribed verbatim for analysis using thematic content analysis.

Results:

Fear and stigma of perceived negative image of HIV diagnosis, lack of disease understating, poor support from the community, and perceived severity or the treatment side effects were among the reasons of nonadherence. Appropriate education and motivation from the doctors and reduction in pill burden were suggested to improve adherence.

Conclusion:

Educational interventions, self-management, and peer and community supports were among the factors suggested to improve adherence. This necessitates uncovering efficient ways to boost doctor–patient communication and recognizing the role of support group for the social and psychological well-being of the patients.