Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review

'Not taking medications and taking medication, it was the same thing:' perspectives of antiretroviral therapy among people hospitalised with advanced HIV disease

BACKGROUND

Despite HIV's evolution to a chronic disease, the burden of advanced HIV disease (AHD, defined as a CD4 count of < 200 cells/uL or WHO clinical Stage 3 or 4 disease), remains high among People Living with HIV (PLHIV) who have previously been prescribed antiretroviral therapy (ART). As little is known about the experiences of patients hospitalised with AHD, this study sought to discern social forces driving hospitalisation with AHD. Understanding such forces could inform strategies to reduce HIV-related morbidity and mortality.

METHODS

We conducted a qualitative study with patients hospitalised with AHD who had a history of poor adherence. Semi-structured interviews were conducted between October 1 and November 30, 2023. The Patient Health Engagement and socio-ecological theoretical models were used to guide a thematic analysis of interview transcripts.

RESULTS

Twenty individuals participated in the research. Most reported repeated periods of disengagement with HIV services. The major themes identified as driving disengagement included: 1) feeling physically well; 2) life circumstances and relationships; and 3) health system factors, such as clinic staff attitudes and a perceived lack of flexible care. Re-engagement with care was often driven by new physical symptoms but was mediated through life circumstances/relationships and aspects of the health care system.

CONCLUSIONS

Current practices fail to address the challenges to lifelong engagement in HIV care. A bold strategy for holistic care which involves people living with advanced HIV as active members of the health care team (i.e. 'PLHIV as Partners'), could contribute to ensuring health care services are compatible with their lives, reducing periods of disengagement from care.

Factors influencing adherence to antiretroviral therapy among young adults in Limpopo province

BACKGROUND

 South Africa is among the countries with the greatest burden of human immunodeficiency virus (HIV) in the world. The introduction of antiretroviral therapy (ART) has made HIV a manageable chronic health condition with a return to normal life expectancy. Adherence to ART is a prerequisite to realising these benefits.

METHODS

 A qualitative study was conducted using individual semi-structured interviews to understand factors influencing adherence to ART among young adults. The study was conducted at three busy primary care clinics around Mankweng Hospital. Participants aged 18-35 years who had been on ART for more than a year were purposefully selected. Open-ended questions were used to explore factors that influence ART. Recorded interviews were transcribed verbatim and translated. The coded transcripts were thematically analysed.

RESULTS

 Eight major themes were identified to influence ART adherence among young adults: medication-related factors, healthcare system factors, attitudes of healthcare workers, economic factors, disclosure, acceptance, mobile phone reminders and family support.

CONCLUSION

 Adherence to ART is a major problem in our communities, and people living with HIV are still finding it challenging to optimally adhere to their ART medication because of the identified factors that influence ART adherence. Family support is a significant factor that was identified to positively influence ART as it leads to disclosure and acceptance of HIV-positive status, better emotional well-being and subsequently improved ART adherence.Contribution: This study underscores the importance of a family-oriented, patient-centred care approach in managing HIV and ART adherence.

Including the Household: Individual, Community and Household Factors Affecting Antiretroviral Therapy Adherence After ART Initiation in Cape Town, South Africa

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z =  - 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z =  - 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z =  - 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z =  - 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z =  - 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Preliminary Impact of Group-Based Interventions on Stigma and the Mental Health of Caregivers of Adolescents Living with HIV in Uganda

This study examined the preliminary impact of group-cognitive behavioral therapy (G-CBT) and a family-strengthening intervention delivered via multiple family groups (MFG-FS) on HIV stigma, parenting stress, and the mental health of caregivers of adolescents living with HIV. We analyzed data from the Suubi4Stigma study (2020-2022), a two-year pilot randomized clinical trial for adolescents and their caregivers (N = 89 dyads), recruited from nine health clinics in Uganda. Adolescent-caregiver dyads were randomized to three intervention conditions delivered over three months, with data collected at baseline, three and six-months follow-up. We fitted mixed-effects linear regression models to test the effect of the interventions on caregiver outcomes over time. At six months, caregivers randomized to the MFG-FS condition reported lower levels of stigma by association (mean difference = -1.45, 95% CI = -2.52 - -0.38, p = 0.008), and stigma and discrimination attitudes (mean difference = -3.84, 95% CI = -4.63 - -3.05, p < 0.001), compared to Usual care condition. In addition, caregivers of adolescents randomized to the G-CBT condition reported lower levels of stigma and discrimination attitudes at three months (mean difference = -5.18, 95% CI = -9.13 - -1.22, p = 0.010), and at six months (mean difference = -6.70, 95% CI = -9.28 - -4.12, p < 0.001). Caregiver mental health and parenting stress significantly reduced over time regardless of intervention condition. Findings point to the importance of incorporating stigma reduction components within psychosocial interventions targeting adolescents and families impacted by HIV.

Characterizing HIV drug resistance in cases of vertical transmission in the VESTED randomized antiretroviral treatment trial

Introduction

VESTED (NCT03048422) compared the safety and efficacy of three antiretroviral treatment (ART) regimens in pregnant and postpartum women: dolutegravir+emtricitabine/tenofovir alafenamide fumarate; dolutegravir+emtricitabine/tenofovir disoproxil fumarate (TDF); efavirenz/emtricitabine/TDF. Vertical HIV transmission (VT) occurred to 4/617 (0.60%) live-born infants, who were evaluated for HIV drug resistance (HIVDR) and other risk factors.

Setting

In 2018-2020, pregnant (weeks-14-28) women living with HIV and ≤14 days of ART were enrolled at 22 international sites and followed with their infants through 50 weeks postpartum.

Methods

HIV sequences derived by single genome amplification (SGA) from longitudinally collected specimens were assessed from VT Cases for HIVDR in protease, reverse transcriptase, integrase, and the nef 3'polypurine tract (3'PPT).

Results

The four Case mothers were prescribed efavirenz-based-ART for 1-7 days prior to randomization to study ART. Their infants received postnatal nevirapine+/-zidovudine prophylaxis and were breastfed. A total of 833 SGA sequences were derived. The "major" (Stanford HIVDR Score ≥60) non-nucleoside reverse transcriptase inhibitor (NNRTI) mutation (K103N) was detected persistently in one viremic mother, and likely contributed to VT of HIVDR. Major NNRTI HIVDR mutations were detected in all three surviving infants. No integrase, nor high frequencies of 3'PPT mutations conferring dolutegravir HIVDR were detected. The timing of HIV infant diagnosis, plasma HIV RNA levels and HIVDR suggests one in utero, one peripartum, one early, and one late breastfeeding transmission.

Conclusions

VT was rare. New-onset NNRTI HIVDR in Case mothers was likely from efavirenz-ART prescribed prior to study dolutegravir-ART, and in one case appeared transmitted to the infant despite nevirapine prophylaxis.

Gender and stigma in antiretroviral treatment adherence in Mozambique: A qualitative study

Both gender and HIV stigma are known to contribute to poor retention to antiretroviral therapy (ART), but little is known how they interact in decisions about adherence or default by people living with HIV (PLWH). This qualitative study explored HIV stigma and gender interaction in PLWH's care decisions in Mozambique. Transcribed data from semi-structured interviews of 68 men and 71 women living with HIV, were coded and analyzed for themes of HIV stigma, gender norms and treatment continuation and interruption pathways, using both deductive and inductive coding approaches. Stigma experiences were found to be influenced by gender roles. Anticipation of stigma was common across the narratives of PLWH, while women had more experiences of enacted stigma, particularly by their intimate partners. Women's treatment interruptions were influenced by fear of partner's negative reaction. Men's narratives showed internalized stigma and delayed treatment due to anticipated stigma and masculine norm of strength. Severe internalized stigma was found among single mothers, who without economic or moral support defaulted treatment. Women's pathway to adherence was facilitated by their caregiver role and support from partner or kin family. Men's adherence was facilitated by experience of severe symptoms, provider role and by support from their mother or partner. Results indicate that linkage of stigma to gender roles interact in treatment decisions in three main ways. First, HIV stigma and unequal gender norms can work jointly as a barrier to adherence. Secondly, those resisting restrictive gender norms found it easier to manage HIV stigma for the benefit of treatment adherence. Thirdly, some gender norms also facilitated adherence and stigma management. Programs targeted at HIV stigma reduction and improving ART adherence among heterosexual populations should be built on an understanding of the local gender norms and include socially and culturally relevant gender sensitive and transformative activities.

Characterizing the "HIV Care Adherence Journey" for Persons With HIV in the Philippines: Conceptual Foundation for Person-Centered Intervention

ABSTRACT

Promoting adherence to HIV care among persons with HIV (PWH) is a key component to addressing the rising HIV epidemic in the Philippines. HIV care adherence is a complex process that may change throughout an individual's life course or "journey" living with HIV. This qualitative study aimed to explore the HIV care adherence journey of PWH. Maximum variation sampling was used to select 12 PWH and 3 health care providers for in-depth online interviews, which were analyzed using thematic analysis. The four themes that emerged to describe the HIV care adherence journey are integration, relation, navigation, and manifestation. Each theme corresponds to a unique set of activities and goals related to PWH's lived experiences as they initiate, practice, and maintain care adherence. This study provides a preliminary framework to characterize the HIV care adherence journey as a dynamic, complex, and multifaceted phenomenon, which can help to inform holistic interventions to support PWH.

Social networks and HIV treatment adherence among people with HIV initiating treatment in rural Uganda and peri-urban South Africa

Timely initiation of and adherence to antiretroviral therapy (ART) is critical for improving HIV outcomes and reducing HIV transmissibility. Social networks, or the social relationships individuals have with each other, have been linked with positive health outcomes, but less is known about the extent to which social network composition and structure are associated with improved ART adherence among people living with HIV (PLWH). We conducted an ego-centric network study among 828 previously ART-naïve PLWH presenting for ART initiation at 11 clinics in Mbarara, Uganda (rural population) and Gugulethu, South Africa (peri-urban population). We collected social network data using name generator and name interpreter questions. ART adherence was monitored over 12 months using wireless monitors (Wisepill). Our primary outcome of interest was ART adherence during the 12-month follow-up period. We used generalized linear models to estimate the associations between network measures and ART adherence. PLWH at the Uganda site (compared with the South Africa site) were less isolated, had larger social networks, and had more social ties providing sufficient social support; they were also more likely to bridge different social groups whereby not all social ties were connected to each other. In Uganda, social isolation was associated with a 5.5 percentage point reduction in ART adherence (95% confidence interval [CI] -9.95 to -1.13; p = 0.014), while having more same gender social ties was associated with higher ART adherence (b = 0.13, 95% CI 0.02-0.25, p = 0.025). In South Africa, there was no association between social isolation and ART adherence, and having more friendship ties (vs. family ties) was associated with lower ART adherence (b = -2.20, 95% CI -3.56 to -0.84; p = 0.002). Identifying and supporting PLWH who are isolated may facilitate optimal adherence, but understanding how networks differentially affect ART adherence by country context is important.

Managing household income and antiretroviral therapy adherence among people living with HIV in a low-income setting: a qualitative data from the HPTN 071 (PopART) trial in South Africa

BACKGROUND

South Africa is reported to have the highest burden of HIV with an estimated 8.2 million people living with HIV (PLHIV) in 2021- despite adopting the World Health Organisation (WHO) universal HIV test and treat (UTT) recommendations in 2016. As of 2021, only an estimated 67% (5.5 million) of all PLHIV were accessing antiretroviral therapy (ART), as per recorded clinic appointments attendance. Studies in sub-Saharan Africa show that people living in low-income households experience multiple livelihood-related barriers to either accessing or adhering to HIV treatment including lack of resources to attend to facilities and food insecurity. We describe the interactions between managing household income and ART adherence for PLHIV in low-income urban and semi-urban settings in the Western Cape, South Africa.

METHODS

We draw on qualitative data collected as part of the HPTN 071 (PopART) HIV prevention trial (2016 - 2018) to provide a detailed description of the interactions between household income and self-reported ART adherence (including accessing ART and the ability to consistently take ART as prescribed) for PLHIV in the Western Cape, South Africa. We included data from 21 PLHIV (10 men and 11 women aged between 18 and 70 years old) from 13 households. As part of the qualitative component, we submitted an amendment to the ethics to recruit and interview community members across age ranges. We purposefully sampled for diversity in terms of age, gender, and household composition.

RESULTS

We found that the management of household income interacted with people's experiences of accessing and adhering to ART in diverse ways. Participants reported that ART adherence was not a linear process as it was influenced by income stability, changing household composition, and other financial considerations. Participants reported that they did not have a fixed way of managing income and that subsequently caused inconsistency in their ART adherence. Participants reported that they experienced disruptions in ART access and adherence due to competing household priorities. These included difficulties balancing between accessing care and/or going to work, as well as struggling to cover HIV care-related costs above other basic needs.

CONCLUSION

Our analysis explored links between managing household income and ART adherence practices. We showed that these are complex and change over the course of treatment duration. We argued that mitigating negative impacts of income fluctuation and managing complex trade-offs in households be included in ART adherence support programmes.

Development and Validation of a New Comprehensive Assessment Scale of HIV-Related Psychological Distress in China: A Methodological Study

ABSTRACT

Instruments evaluating HIV-related psychological distress (HRPD) in people living with HIV may lack sensitivity to capture patients' psychological burden. We developed a comprehensive scale measuring HRPD and evaluated its psychometric properties. A mixed-method study was conducted from July 2021 to April 2022; it involved a literature review, semistructured interviews (n = 15), three rounds of panel discussions, two rounds of Delphi studies (n = 20), a pilot test (n = 20) to generate new scale items, and a cross-sectional survey (n = 659) to evaluate the psychometric properties of the HIV-related psychological distress scale. The scale contains 22 items across 4 subscales (i.e., disease-related distress, treatment adherence distress, identity distress, and disclosure distress). The confirmatory factor analysis revealed high goodness of fit (χ2/df = 2.412, comparative fit index = 0.916, incremental fit index = 0.917, and Tucker‒Lewis index = 0.902), showing that the HIV-related psychological distress scale is a reliable (Cronbach's α = 0.871 overall) and valid scale for evaluating HRPD in China and can be used to dynamically evaluate and monitor HRPD levels during patient follow-up.

Examining the Relationship Between Psychosocial Factors with Knowledge of HIV-Positive Status and Antiretroviral Therapy Exposure Among Adolescent Girls and Young Women Living with HIV in South Africa

Adolescent girls and young women (AGYW) living with HIV have poor antiretroviral therapy (ART) outcomes. We examined the relationship between psychosocial factors with knowledge of HIV-positive status and antiretroviral therapy exposure among AGYW living with HIV in South Africa. Participants 15-24 years responded to a survey including socio-demographics, psychosocial factors, and HIV testing. Blood was collected to determine HIV status and ART exposure. Multivariable analyses were conducted using R. Of 568 participants with HIV, 356 had knowledge of their HIV-positive status. Social support from family [aOR 1.14 (95% CI 1.04-1.24)] or from a special person [aOR 1.12 (95% CI 1.02-1.23)] was associated with knowledge of HIV-positive status. Resilience [aOR 1.05 (95% CI 1.01-1.08)] was the only psychosocial factor associated with a higher odds of ART exposure. Social support and resilience may increase knowledge of HIV-positive status and ART exposure among South African AGYW.

"It was protected, except, it wasn't [with] a condom": a mixed-methods study of BBVs/STIs protective practices among International University Students in Sydney, Australia

BACKGROUND

A number of previous sex-related studies among international students in Australia and other Western societies may be limited by conflating students from conservative and non-conservative sexual backgrounds. Such conflation leads to situations where nuances and complexities around sex-related experiences are lost or, at most, tangentially investigated. To address this research problem, this study used a mixed-methods design to examine protective practices against blood-borne viruses and sexually transmissible infections (BBVs/STIs) among Sydney-based East Asian and sub-Saharan African international students.

METHODS

This mixed-methods study generated quantitative data using anonymous online survey (n = 149), and qualitative data through in-depth interviews (n = 20). The main recruitment strategy involved advertising the study through paper and electronic flyers. Quantitative data were analysed using logistic regression, while interviews data were analysed using reflexive thematic analysis.

RESULTS

Self-reported BBVs/STIs protective practices in the last 12 months include abstinence (28.7%), consistent condom use (19.9%), occasional condom use (18.7%), single partner fidelity (25.1%), other strategies (1.8%), and nothing (5.8%). Further, findings from the bivariate analysis showed higher BBVs/STIs prevention knowledge, lower acculturation into Australian sexual culture, greater access to sexual health information, less conservative sexual norms, greater emotional social support and older age were significantly associated with increased protective practices. Variables significant at bivariate level were entered into a logistic regression. The model was statistically significant, (X²(6) = 31.33, p < 0.01) and explained 33.1% of the variance in BBVs/STIs protective practices. However, only acculturation to sexual norms in Australia (OR = 0.883, 95% CI = 0.820-0.952) was found to be independent predictor of BBVs/STIs protective practices. The results of the study based on the quantitative data, indicated condom use (consistent and occasional) was the most reported BBVs/STIs protective behaviour among sexually active participants. Therefore, interviews data was used to explore condom-use motives and practices. The interviews results showed participants primary concern as regards condom use was around pregnancy and not BBVs/STIs. Thus, some participants described safe sex largely as contraception, with BBVs/STIs constituting a secondary concern or no concern at all.

CONCLUSIONS

Based on the results of this study, tailored sexual health interventions for international students; which incorporate strategies for modifying perceived sexual norms in Australia, are advocated. In addition, this study recommends sexual health interventions that promote dual protection of condoms for both contraception and BBVs/STIs.

Medication Non-Adherence in Rheumatology, Oncology and Cardiology: A Review of the Literature of Risk Factors and Potential Interventions

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project's objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors' level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors' opinion. Information and education are essential to improve adherence in all patients.

Social Support for Improved ART Adherence and Retention in Care among Older People Living with HIV in Urban South Africa: A Complex Balance between Disclosure and Stigma

The number of older people living with HIV (OPLWH) (aged 50-plus) in South Africa is increasing as people age with HIV or are newly infected. OPLWH are potentially vulnerable because of the intersection of age-related and HIV stigmas, co-morbidities, and lack of social support. Evidence from younger populations suggests that social support can improve ART adherence and retention in care. Further, HIV status disclosure plays a role in mediating social support and may reduce stigma by facilitating access to social support. This paper draws on qualitative research with OPLWH to explore the complex associations between disclosure, social support, and HIV stigma among OPLWH in urban Western Cape. The findings demonstrate that OPLWH receive most of their support from their family and this support can facilitate adherence to ART and retention in care. However, social support is facilitated by participants' disclosure, thus, when perceived stigma limits disclosure, social support is less accessible. Gender, age, and pre-existing vulnerability also affect disclosure to and support from kin and community. Given that social support, particularly from family members, amplifies HIV care access and ART adherence, encouraging disclosure stimulating household HIV competency is likely to both address anticipated stigma and support improved OPLWH's health outcomes.

Stay-at-Home: The Impact of the COVID-19 Lockdown on Household Functioning and ART Adherence for People Living with HIV in Three Sub-districts of Cape Town, South Africa

In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV's (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019-March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June-July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

The Situated Information, Motivation, and Behavioral Skills Model of HIV Antiretroviral Therapy Adherence Among Persons Living With HIV in Haiti: A Qualitative Study Incorporating Culture and Context

ABSTRACT

To inform a clinic-based adherence-promotion intervention, this qualitative study applied the Situated Information, Motivation, and Behavioral Skills Model of Care Initiation and Maintenance to elucidate cultural and contextual factors affecting antiretroviral therapy adherence in Haiti. From the 23 focus group discussions with patients (n = 58) and health care workers (n = 57), culturally specific themes emerged relating to Information (e.g., conflicts with allopathic medicine and heuristics about how treatment failure occurs), Motivation (e.g., protecting family members, health and physical appearance, material advantages, and relationships with health workers), and Behavioral Skills (e.g., managing food intake and side effects, navigating health services utilization, accessing medication, and advocating for care needs). Recommendations include: provide therapeutic education on HIV drug resistance; promote the concept of "undetectable = untransmittable"; develop treatment buddy relationships; invest in training and enforcement of patient privacy, transparency, and fairness in access to services and resources; and provide patient-centered behavioral skills counseling.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

Predicting the individualized risk of poor adherence to ART medication among adolescents living with HIV in Uganda: the Suubi+Adherence study

INTRODUCTION

Achieving optimal adherence to antiretroviral therapy (ART) among adolescents living with HIV (ALWHIV) is challenging, especially in low-resource settings. To help accurately determine who is at risk of poor adherence, we developed and internally validated models comprising multi-level factors that can help to predict the individualized risk of poor adherence among ALWHIV in a resource-limited setting such as Uganda.

METHODS

We used data from a sample of 637 ALWHIV in Uganda who participated in a longitudinal study, "Suubi+Adherence" (2012 to 2018). The model was developed using the Least Absolute Shrinkage and Selection Operator (LASSO) penalized regression to select the best subset of multi-level predictors (individual, household, community or economic-related factors) of poor adherence in one year's time using 10-fold cross-validation. Seventeen potential predictors included in the model were assessed at 36 months of follow-up, whereas adherence was assessed at 48 months of follow-up. Model performance was evaluated using discrimination and calibration measures.

RESULTS

For the model predicting poor adherence, five of the 17 predictors (adherence history, adherence self-efficacy, family cohesion, child poverty and group assignment) were retained. Its ability to discriminate between individuals with and without poor adherence was acceptable; area under the curve (AUC) = 69.9; 95% CI: 62.7, 72.8. There was no evidence of possible areas of miscalibration (test statistic = 1.20; p = 0.273). The overall performance of the model was good.

CONCLUSIONS

Our findings support prediction modelling as a useful tool that can be leveraged to improve outcomes across the HIV care continuum. Utilizing information from multiple sources, the risk prediction score tool applied here can be refined further with the ultimate goal of being used in a screening tool by practitioners working with ALWHIV. Specifically, the tool could help identify and provide early interventions to adolescents at the highest risk of poor adherence and/or viral non-suppression. However, further fine-tuning and external validation may be required before wide-scale implementation.