Psychosocial needs among older perinatally infected adolescents living with HIV and transitioning to adult care in Kenya

A qualitative analysis of self-management needs of adolescents and young adults living with perinatally acquired HIV in rural, southwestern Uganda

The number of adolescents living with HIV remains high in sub-Saharan Africa with poorer HIV treatment outcomes among adolescents and young adults compared to individuals in other age groups. For adolescents and young adults living with perinatally acquired HIV (AYLPHIV), the transition from pediatric to adult HIV care is a particularly high-risk period. We conducted a qualitative study to understand self-management needs of AYLPHIV in rural, southwestern Uganda as they prepare to transition to adult HIV care in order to inform relevant interventions that can enable AYLPHIV acquire the necessary skills to manage their illness as they age into adulthood. We conducted 60 in-depth interviews with AYLPHIV (n = 30), caregivers (n = 20) and health care providers (n = 10) from the HIV clinic at Mbarara Regional Referral Hospital. We used an interview guide that focused on perceptions about transition to adult HIV care, challenges with transitioning, navigating HIV care, and self-management needs for AYLPHIV (from the perspectives of AYLPHIV, their caregivers, and health care providers). We used thematic analysis to identify themes related to AYLPHIV's self-management skills. We identified several self-management needs that we grouped under two major themes; social support and empowerment for AYLPHIV to assume responsibility for their own health and to navigate adult HIV care independently. The sub-themes under social support were information support, instrumental support, and emotional support as the sub themes while sub-themes under empowerment included self-advocacy skills, interpersonal skills, self-care skills, and disclosure skills. Taken together, these findings indicate that AYLPHIV need to be supported and empowered to maximize their chances of successfully transitioning to adult HIV care. Support comes from peers and caregivers. AYLPHIV require knowledge about their HIV status and empowerment with different skills including: self-advocacy skills, interpersonal skills, self-care skills, and HIV status disclosure skills, in order to assume responsibilities related to independent HIV care.

Views of adolescents living with perinatally acquired HIV on HIV status disclosure in Eswatini

HIV is recognised as a multifaceted chronic disease, bearing psychosocial consequences that potentially impact on the personal and social well-being of those living with it. Adolescents and youth bear a significant proportion of the burden of the HIV epidemic but they have low rates of disclosure of their HIV status. This study aims to determine the views of adolescents living with perinatally acquired HIV on HIV status disclosure among 361 adolescents aged 15-19 in Eswatini. A cross-sectional study was conducted on adolescents who already knew their status, and data were collected using a structured questionnaire. A majority of the participants, 55% (n = 200), were females, and 44% (n = 160) were males. A low number of adolescents (22%) had disclosed their HIV status to anyone. Adolescents who found it difficult to understand disclosure themselves had low levels of onward disclosure (27%) compared to adolescents who better understood the disclosure event. Our results revealed that adolescents' prevalence of HIV status disclosure was low. This raises concerns as some of the adolescents were in relationships with partners who were not aware of their status. However, older adolescents displayed some level of disclosure self-efficacy in that a higher proportion of them disclosed better than younger adolescents.

Qualitative Study on the Voices of Adolescents Living with Perinatally Acquired HIV in Selected Clinics in the Limpopo Province of South Africa

The disclosure of HIV status among adolescents living with perinatally acquired HIV (APHIV) has become one of the core challenges in the management of APHIV. Disclosure is a challenge that undermines positive advances and achievements in HIV management. There is limited literature on the voices of APHIV on disclosure of their status. This study aims to explore the current disclosure process and how it affects APHIV. A qualitative exploratory design was employed to conduct one-on-one in-depth interviews using a semi-structured interview guide. Purposive sampling was used to sample 21 APHIV in 16 selected health facilities in the Vhembe district of Limpopo Province, South Africa. Data were analyzed using Tesch's qualitative data method. The findings of this study reflect the gaps in the current disclosure process and guidelines while acknowledging the importance of disclosure to APHIV. A notable finding in this study is that most APHIV, especially those in early adolescence, did not want to know their HIV status due to the stigma attached to an HIV-positive diagnosis. This study suggests that proper training and support of parents and/or guardians in the disclosure process are needed, as they are the primary caregivers of APHIV. The disclosure of HIV status must be a comprehensive part of the management and care of HIV for APHIV. Furthermore, dedicated support programs should be developed and implemented to improve their lives post-disclosure.

“The Peer Educator Is the Game-Changer of My Life”: Perceptions of Adolescents Living with HIV in DR Congo on Involving Peer Educators in the Process of HIV Disclosure

Several approaches to the disclosure of HIV status to children and adolescents have been described. Each of these places particular emphasis on the role of parents and health care workers (HCWs) to mitigate the impact of disclosure on the adolescent without exploring the possible roles that other individuals might play in the process of disclosure. This article assesses the perceptions of adolescents living with HIV (ALHIV) about disclosure done by parents, guardians, HCWs, peer educators in the role of peer supporters, accidentally or by self-discovery, and the subsequent effects of disclosure method on their mental health. We used a qualitative study to conduct semi-structured interviews with 73 ALHIV at the Kalembelembe Paediatric Hospital, in DR Congo disclosed to by parents, guardians, HCWs, and/or peer educators, respectively, or disclosed to accidentally or by self-discovery. Microsoft Excel analysis matrix was used to organize the qualitative data. The majority of ALHIV whose disclosure involved a peer educator unanimously acknowledged the important role of the peer in accepting their HIV status, in their ART adherence, and their development of self-esteem. However, most ALHIV disclosed without involving peers declared that they had accepted their situation after a relatively long period followed by contact with the peer and integration in the self-support group. We found that the peer approach is the game-changer of the HIV status disclosure process that would allow ALHIV to accept their HIV status with minimum distress, it builds resilience, and allows them to adhere to treatment.

Adherence challenges and opportunities for optimizing care through enhanced adherence counseling for adolescents with suspected HIV treatment failure in Kenya

Background

Adolescents living with HIV (ALHIV) experience higher mortality and are more likely to have poor antiretroviral therapy (ART) adherence and unsuppressed viral load (VL) compared to adults. Enhanced adherence counseling (EAC) is a client-centered counseling strategy that aims to identify and address barriers to optimal ART use and can be tailored to the unique needs of adolescents. This study aimed to better understand adherence barriers among ALHIV with suspected treatment failure and their experience with EAC to inform future programming.

Methods

A qualitative study was conducted in Homa Bay and Turkana counties, Kenya in 2019 with adolescents and caregivers of children and adolescents living with HIV with suspected treatment failure after ≥6 months on ART and who had received ≥1 EAC sessions. Sixteen focus group discussions (FGDs) were conducted; five FGDs each were held with adolescents 12–14 years (n = 48) and 15–19 years (n = 36). Caregivers (n = 52) participated in six FGDs. Additionally, 17 healthcare workers providing pediatric/adolescent HIV services participated in in-depth interviews. Audio recordings were transcribed and translated from Kiswahili or Dholuo into English and coded using MAXQDA software. Data were thematically analyzed by participant group.

Results

Participants identified adolescents’ fear of being stigmatized due to their HIV status and their relationship with and level of support provided by caregivers. This underpinned and often undermined adolescents’ ART-taking behavior and progress towards more independent medication management. Adolescents were generally satisfied with EAC and perceived it to be important in improving adherence and reducing VL. However, problems were noted with facility-based, individual EAC counseling, including judgmental attitudes of providers and difficulties traveling to and keeping EAC clinic appointments. Participant-suggested improvements to EAC included peer support groups in addition to individual counseling, allowing for greater flexibility in the timing and location of sessions and greater caregiver involvement.

Conclusions

The findings provide opportunities to better tailor EAC interventions to promote improved ALHIV adherence and caregiver-supported disease management. Multi-prong EAC interventions that include peer-led and community approaches and target adolescent and caregiver treatment literacy may improve EAC delivery, address issues contributing to poor adherence, and position adolescents to achieve viral suppression.

Trial registration

ClinicalTrials.gov: NCT04915469.

"I have never talked to anyone to free my mind" - challenges surrounding status disclosure to adolescents contribute to their disengagement from HIV care: a qualitative study in western Kenya

Introduction

Adolescents living with HIV (ALHIV, ages 10–19) experience complex barriers to care engagement. Challenges surrounding HIV status disclosure or non-disclosure to adolescents may contribute to adolescent disengagement from HIV care or non-adherence to ART. We performed a qualitative study to investigate the contribution of disclosure challenges to adolescent disengagement from HIV care.

Methods

This was a qualitative study performed with disengaged ALHIV and their caregivers, and with healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Inclusion criteria for ALHIV were ≥1 visit within the 18 months prior to data collection at one of two clinical sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Analysis was conducted by multiple independent coders, and narratives of disclosure and care disengagement were closely interrogated. Overarching themes were elucidated and summarized.

Results

Interviews were conducted with 42 disengaged ALHIV, 32 caregivers, and 28 HCW. ALHIV were average age 17.0 (range 12.9–20.9), and 95% indicated awareness of their HIV diagnosis. Issues surrounding disclosure to ALHIV presented important barriers to HIV care engagement. Themes centered on delays in HIV status disclosure; hesitancy and reluctance among caregivers to disclose; struggles for adolescents to cope with feelings of having been deceived prior to full disclosure; pervasive HIV stigma internalized in school and community settings prior to disclosure; and inadequate and unstructured support after disclosure, including for adolescent mental health burdens and for adolescent-caregiver relationships and communication. Both HCW and caregivers described feeling inadequately prepared to optimally handle disclosure and to manage challenges that may arise after disclosure.

Conclusions

Complex challenges surrounding HIV status disclosure to adolescents contribute to care disengagement. There is need to enhance training and resources for HCW, and to empower caregivers to support children and adolescents before, during, and after HIV status disclosure. This should include counseling caregivers on how to provide children with developmentally-appropriate and accurate information about their health from an early age, and to support adolescent-caregiver communication and relationships. Optimally integrating peer support can further promote ALHIV wellbeing and retention in care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13519-9.

Transitioning from paediatric to HIV adult care services for adolescents and young people living with HIV in the African region: a scoping review protocol

INTRODUCTION

The number of children living with HIV is increasing worldwide and is a major public health concern as they grow into adolescence and young adulthood with increasing access to antiretroviral therapy (ART) especially in the African region. There is a pressing need to transfer them from paediatric to adult care which has implications for their well-being. The objective of this scoping review is to systematically review published and unpublished literature to understand the extent and type of evidence in relation to the transition of adolescents to adult HIV clinics in the African region.

METHODS AND ANALYSIS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Review) guidelines for conducting a scoping review, we will systematically search online bibliographic databases including PubMed, EMBASE, Google Scholar and bibliographies of pertinent articles. This will be supplemented by searches in grey literature databases. Two reviewers will independently review all articles to determine if they meet eligibility criteria. Any conflicts will be resolved after discussion with a third reviewer to ensure accurate and reliable data collection. Both quantitative and qualitative results will be extracted from all included articles and synthesised in a narrative form in response to the review questions.

ETHICS AND DISSEMINATION

The scoping review does not require ethics approval as we will collect and review existing literature and materials. The results will be disseminated through a peer-reviewed publication, conference presentations and stakeholder meetings to support clinicians, health experts and policy makers develop guidelines and evidence-based transition protocols favourable for the populations in the African region to minimise challenges associated with the transition process.

Factors Associated with Transition of HIV Care Readiness Among Adolescents and Youth from a Specialty Pediatric HIV Clinic in the United States

Transitioning from pediatric to adult services is known to be associated with worsening of health outcomes and decreased retention in care among adolescents and youth living with HIV (AYLHIV). We aimed to identify factors associated with HIV care transition readiness among AYLHIV in care at a pediatric HIV clinic in Washington, DC. This retrospective cohort study from June 2019 through January 2021 collected demographic and clinical characteristics from the clinic database. We adapted the Transition Readiness Assessment Questionnaire (TRAQ; scored 1-4; 1 being the lowest level of preparedness) to evaluate transition readiness over time. We analyzed data using two-sided unadjusted two-sample and paired t-tests and adjusted analysis of variance (ANOVA). We included 103 AYLHIV (50.49% female; 100% non-Hispanic Black/African American; mean age = 19.54 ± 2.78 years; 81.55% virally suppressed). Mean baseline TRAQ score (2.32 ± 0.78) was associated with age (p < 0.0001), gender (p = 0.033), mode of HIV transmission (p = 0.0005), viral suppression (p = 0.0033), and duration of HIV diagnosis (p = 0.012). AYLHIV diagnosed with HIV within the prior year experienced significantly greater mean improvement in transition readiness compared with those living with HIV for >10 years (p = 0.013). Adjusted for covariates, older age (p < 0.0001), undetectable viral load (p = 0.0008), and presence of mental health condition(s) (p = 0.020) were associated with higher TRAQ scores. Lower improvement in transition readiness among youth with a longer history of HIV suggests that AYLHIV with perinatally acquired HIV might require additional support than those with horizontally acquired HIV.

Uncovering ART adherence inconsistencies: An assessment of sustained adherence among adolescents in South Africa

Introduction

Antiretroviral treatment (ART) adherence rates are lower among adolescents living with HIV (ALHIV) than among adults and children, but more evidence is needed on long‐term sustained ART adherence among ALHIV. This study assesses rates of sustained ART adherence in a cohort of adolescents in South Africa.

Methods

A prospective cohort of adolescents (10‐19 years) living with HIV (baseline sample N = 1 046, 55% female, mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline (2014‐15) and followed‐up twice (2015‐16, 2017–18). All adolescents ever initiated on treatment in 52 government health facilities were traced (with 90% uptake, 94% retention at Wave 2, and 97% retention at Wave 3, 3.4% mortality) and their clinic records were extracted where available. We investigate sustained ART adherence among adolescents interviewed at all three waves of data collection (N = 933). To quantify adherence at each study wave, we used self‐reported past‐week adherence (including weekdays and weekends). Self‐reported adherence was validated using HIV‐1 RNA viral load (>50 copies/mL cut‐off) reported in clinic records, in a random‐intercept logistic regression.

Results and discussion

At baseline, approximately 66% (N = 615) of adolescents reported past‐week ART adherence, and of these 45.3% reported adherence at both baseline and follow‐up. Only 37.1% of the sample reported sustained past‐week ART adherence over the three waves of the study. Most adolescents (N = 587, 62.9%) report inconsistent adherence across time (including 6.4% disengaged from care). Older (P = 0.007) and adolescents with horizontally acquired HIV (P = 0.002) were more likely to report inconsistent adherence across time. Controlling for socio‐demographic characteristics, past‐week adherence was associated with non‐detectable viral load (aOR 1.72, 95%CI 1.14‐2.59, P = 0.009). Overall, of the adolescents with viral load measurements at study Wave 1 and Wave 2, 50.6% maintained undetectable viral load for the preceding year.

Conclusions

Adolescents living with HIV reported very low rates of sustained ART adherence. Adherence reported at a single time may mask high rates of variability in adherence over time. These findings highlight the urgent need for enhanced and effective interventions to assist ALHIV with ART adherence through the challenging years of adolescence.

Examining healthcare transition experiences among youth living with HIV in Atlanta, Georgia, USA: a longitudinal qualitative study

INTRODUCTION

Virtually all youth living with HIV in paediatric/adolescent care must eventually transition to adult-oriented HIV care settings. To date, there is limited evidence examining the perspectives of youth living with HIV longitudinally through the healthcare transition process. The objective of our study was to examine attitudes and experiences of youth living with HIV regarding healthcare transition, including potential change in attitudes and experiences over time.

METHODS

We conducted a longitudinal qualitative interview study within a large, comprehensive HIV care centre in Atlanta, Georgia, USA between August 2016 and October 2019.We interviewed 28 youth living with HIV as part of a longitudinal observational cohort study of youth undergoing healthcare transition. We conducted qualitative interviews both immediately prior to, and one year following the transition from paediatric to adult-oriented care.

RESULTS

Six distinct themes emerged from interviews conducted with youth living with HIV pre-transition: (1) reluctance to transition; (2) paediatric spaces as welcoming, and adult spaces as unwelcoming; (3) varying levels of preparation for transition; and (4) expectation of autonomy in the adult clinic. Analysis of post-transition interviews with the same youth demonstrated: (1) inconsistencies in the transition experience; (2) fear and anxiety about transition quelled by experience; (3) varying reactions to newfound autonomy and (4) communication as the most valuable facilitator of successful transition.

CONCLUSIONS

This study's longitudinal perspective on the healthcare transition experience yields insights that can be incorporated into programming targeting this critically important population. Although our study was conducted in a USA-based clinic with co-located paediatric and adult care services, many of our findings are likely to have relevance in other settings as well. Interventions aiming to improve HIV care engagement through transition should seek to enhance patient-provider communication in both paediatric and adult clinics, improve preparation of patients in paediatric clinics and ease patients gradually into autonomous disease management.

The Consequences of Delaying Telling Children with Perinatal HIV About Their Diagnosis as Perceived by Healthcare Workers in the Eastern Cape; A Qualitative Study

Although the benefits of disclosure are considerable, informing children with perinatal HIV of their own HIV status is often delayed to late adolescence. This study examined the social and contextual challenges that influence delaying disclosure to children and assessed the outcomes of delayed disclosure on the psychosocial health of children as perceived by the healthcare workers (HCWs) providing care to these children. Data were collected from HCWs via focus group discussions. Nurses, lay counsellors, social workers, and dieticians were selected from facilities in a rural South African health district. Thematic analysis was performed. The caregivers’ social context was the main barrier against informing children timely about their HIV diagnosis. The extent of the internalised HIV stigma influenced the delay in disclosing to the children. Delaying disclosure contributes to children’s refusing to take their medication, leads to the accidental disclosure of HIV, give rise to anger and resentment towards the caregiver, increase the risk of secondary transmitting of HIV, and poor health outcomes. It is essential to train HCWs to support caregivers and children through the disclosure process to ensure that caregivers realise the benefits of disclosure. Strategies to encourage caregivers to disclose early should be sensitive to their concerns about the negative impacts of disclosure.

Pain, Anger, and the Fear of Being Discovered Persist Long after the Disclosure of HIV Serostatus among Adolescents with Perinatal HIV in Rural Communities in South Africa

Informing adolescents of their HIV serostatus forms part of their HIV care and is a critical step in the transition to adult clinical care services. This article describes the experiences of adolescents with perinatal HIV in regard to disclosure, and examines the impact disclosure has on their emotional health and behaviors. We used a qualitative design to conduct interviews with 21 adolescents aged 12-19 years recruited from a rural district in South Africa. NVivo 10 computer software was used for thematic analyses. All adolescents were aware of their HIV-serostatus. The findings show that delayed disclosure, was a one-time event, and was unplanned. Disclosure occurred at the clinic rather than the adolescent's home. For most adolescents, feelings of anger, pain, sadness, negative perceptions of self, internalized stigma, and denial persisted long after disclosure occurred. They lived in constant fear of having their serostatus being discovered, and they developed a sense of fear of self-disclosure. Their negative emotions undermined treatment adherence. In contrast, other adolescents that described disclosure as a positive event, had accepted their HIV status, and lived similar to other adolescents. The prolonged negative reactions underscore the importance of ongoing post-disclosure interventions for adolescents in rural settings where psychosocial support services are insufficient to address their emotional wellbeing.