Closing the HIV Treatment Gap for Adolescents in Windhoek, Namibia: A Retrospective Analysis of Predictors of Viral Non-Suppression

Health System Responses to Address Treatment Gaps of Unsuppressed Adolescents on HIV Treatment in Public Primary Health Care Facilities in Windhoek, Namibia

Background

Adolescents living with HIV (ALHIV) face unique challenges that result in persistent gaps in achieving and maintaining suppressed viral load. Although effective evidence-based interventions to address treatment gaps in adolescents are readily available, health systems in resource-constrained, high HIV prevalence settings are challenged to implement them to achieve epidemic control. Here, we describe the health system responses to address the treatment gap of unsuppressed ALHIV on antiretroviral therapy in Windhoek, Namibia.

Methods

We conducted a qualitative descriptive and exploratory study in Windhoek between June and October 2023. Nineteen purposively selected key informants, ranging from pediatric HIV program managers to healthcare providers, were interviewed. In-depth interviews were audio-recorded and transcribed verbatim. The transcripts were uploaded to ATLAS.ti and subjected to thematic analysis.

Results

The four main themes elucidated challenges related to adherence and retention as well as health system responses in the form of interventions and support programs. The predominant adherence and retention challenges faced by ALHIV were mental health issues, behavioral and medication-related challenges, and inadequate care and social support. The health system responses to the identified challenges included providing psychosocial support, peer support, optimization of treatment and care, and the utilization of effective service delivery models. Key health system support elements identified included adequately capacitated human resources, efficient medication supply chain systems, creating and maintaining an enabling environment for optimum care, and robust monitoring systems as essential to program success.

Conclusion

The health system responses to address the remaining treatment gaps of unsuppressed ALHIV in Windhoek are quite varied and, although evidence-based, appear to be siloed. We recommend harmonized, multifaceted guidance, integrating psychosocial, treatment, care, and peer-led support, and strengthening client-centred differentiated service delivery models for unsuppressed adolescents.

Experiences of support by unsuppressed adolescents living with HIV and their caregivers in Windhoek, Namibia: a qualitative study

Background

Adolescents living with HIV (ALHIV) lag behind younger children and adults in the achievement of HIV care and treatment targets for HIV epidemic control. Treatment outcomes for adolescents may be influenced by their experiences with the support provided in HIV programs. We report on the experiences of virally unsuppressed adolescents and their caregivers with the current support in primary healthcare settings in Namibia.

Methods

A qualitative descriptive and exploratory study was conducted in 13 public primary healthcare facilities in Windhoek, Namibia. A total of 25 in-depth interviews were conducted with unsuppressed adolescents (n = 14) and their caregivers (n = 11) between August and September 2023. The audio-recorded interviews were transcribed verbatim, and uploaded into ATLAS.ti software, and subjected to thematic content analysis.

Findings

Three main support domains for the unsuppressed adolescents emerged from our analysis, namely: psychosocial, clinical and care, and socioeconomic support. The psychosocial support was delivered through peer support (teen clubs and treatment supporters) and enhanced adherence counselling mostly. The clinical and care support included implementing adolescent-friendly HIV services, differentiated service delivery approaches, and caregivers and healthcare worker care support for improved ART adherence, clinic attendance and continuous engagement in care. Socioeconomic support was provided for nutritional support, transport to access clinics, and school supplies, as well as income-generating projects.

Conclusion

Psychosocial, clinical and care, and socioeconomic support are key elements in addressing the needs of adolescents challenged with achieving viral suppression. Health systems may benefit from whole-of-society and whole-of-government approaches to meet the needs of ALHIV that are beyond the scope of health service delivery such as nutritional, education and socioeconomic influences on both the health and well-being of ALHIV.

Prevalence and factors associated with viral non-suppression in people living with HIV receiving antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis

Despite advances in HIV treatment, the burden of viral non-suppression (VNS) remains a treatment success concern, particularly in Sub-Saharan African (SSA) countries. We determined the prevalence and factors associated with VNS for people living with HIV (PLHIV) receiving antiretroviral therapy (ART). This review, registered with PROSPERO (CRD42023470234), conducted an extensive search for evidence, focusing on PLHIV living in SSA on ART from the year 2000 to 19th October 2023, across databases including PubMed/MEDLINE, Embase, Web of Science, and Scopus. A total of 2357 articles were screened, from which 32 studies met the criteria for the final analysis, involving 756,620 PLHIV of all ages. The pooled prevalance for VNS was found to be 20.0% (95% CI: 15.43%-25.52%, I2 = 100%, p-value <0.01) Children and adolescents demonstrated the highest prevalence of VNS (viral load ≥1000 copies/mL) at 27.98% (95% CI: 21.91%-34.97%, I2 = 94%, p-value <0.01). The study revealed various factors associated with increased odds (risk) of VNS, p-value <0.05. These factors encompassed socio-demographics such as sex, age, education level, and marital status. Additionally, aspects related to HIV care, such as the facility attended, HIV status disclosure and adherence exhibited higher odds of VNS. Suboptimal ART adherence, longer duration on ART, socio-economic factors, lack of family and social support, presence of co-morbidities, advanced WHO HIV clinical stage, ART regimens, lower CD4+ count, abnormal body mass index, history of treatment interruptions, and progression of HIV illness were associated with VNS. Furthermore, behavioural/psychological factors including depression, substance use, negative perceptions towards ART, experiences of abuse, alcohol use, stigma, and certain patterns of sexual behaviour were also identified as factors for VNS. The occurrence of two VNS to every ten PLHIV on ART poses a threat to the progress made towards reaching the third 95% UNAIDS target in SSA. Additionally, these findings highlight the intricate interplay of various factors, encompassing patient characteristics, behavioural patterns, sociocultural influences, and pharmacological factors, all impacting VNS among PLHIV. Recognising its multifaceted nature, we recommend designing and implementing high impact interventions to effectively address VNS in SSA.

Policy and Programming Towards Addressing Treatment Gaps in Adolescents Living with HIV: A Content Analysis of Policy and Programme Documents in Namibia

Adolescents living with HIV (ALHIV) face unique challenges resulting in persistent treatment gaps, particularly viral non-suppression. Country programs adopt policies, guidelines, and innovations, based on WHO recommendations and best practices from elsewhere. However, it is unclear to what extent these tools address the management of adolescents with viral non-suppression. We report on a review of guidelines for the provision of HIV services to ALHIV in Namibia. We conducted a systematic document review using Content Analysis and Thematic Analysis methodology, and the READ approach. We identified seven relevant policy documents, four of which somewhat addressed viral non-suppression (treatment gap) in ALHIV and outlined interventions to improve treatment outcomes in adolescents considering their lived experience and unique challenges. The persistent treatment gap may reflect policy implementation gaps in specifically addressing viral non-suppression. It may be worthwhile to leverage existing documents to develop specific operational guidance for ALHIV with unsuppressed viral loads.

Growing Up with HIV: Experiences of Transition from Adolescence to Adulthood at Selected Primary Health Facilities in Limpopo Province, South Africa

BACKGROUND

Many children who contracted Human Immunodeficiency Virus (HIV) through vertical transmission are now in their adolescent and early adult years. The aim was to explore the experiences of adolescents living with HIV (ALWHIV) during the transition from childhood to adulthood.

METHODS AND MATERIAL

The study was conducted at selected primary healthcare facilities in the Mopani and Vhembe districts in July 2021. A qualitative research approach that included contextual, descriptive, and exploratory designs was used. The population comprised 27 ALWHIV who were purposively sampled and enrolled for ART care. Data were collected using in-depth interviews, and the question was "How is it for you as you live with a virus and transit from adolescent to adulthood". The open coding approach was used to analyse the data. Measures to ensure trustworthiness articulated in Lincoln and Guba's criteria and ethical considerations were adhered to.

FINDINGS

The findings revealed four themes: poor understanding of the disease condition, improved physical health when adhering to ARV treatments, challenges related to sexual maturity and intimate relationships, and parents not disclosing their children's HIV status.

CONCLUSION

Parents' delayed and non-disclosure of adolescents' positive HIV status led to a lack of awareness about the course of the disease, non-adherence to ART, and unsafe sex practices that could increase the risk of HIV transmission and re-infection. To address these multiple obstacles associated with ALWHIV, a comprehensive, multi-sectoral approach that is teenager-friendly should be undertaken.

Determinants and rates of retention in HIV care among adolescents receiving antiretroviral therapy in Windhoek, Namibia: a baseline cohort analysis

BACKGROUND

Long-term engagement in HIV care is essential to achieving and maintaining viral suppression. Adolescents living with HIV (ALHIV) experience many barriers to remaining engaged in care and treatment programs. Higher attrition among adolescents compared to adults remains a huge concern due to unique psychosocial and health systems challenges adolescents face, and recently the COVID-19 pandemic effects. We report on determinants and rates of retention in care in adolescents aged 10-19 years enrolled on antiretroviral therapy (ART) in Windhoek, Namibia.

METHODS

A retrospective cohort analysis of routine clinical data of 695 adolescents aged 10-19 years enrolled for ART at 13 Windhoek district public healthcare facilities, between January 2019 and December 2021 was conducted. Anonymized patient data were extracted from an electronic database and registers. Bivariate and Cox proportional hazards analysis were performed to determine factors associated with retention in care among ALHIV at 6, 12, 18, 24 and 36 months. Retention in care trends were also described using the Kaplan-Meier survival analysis.

RESULTS

The retention in care rates at 6, 12, 18, 24 and 36 months were 97.7%, 94.1%, 92.4%, 90.2%, and 84.6%, respectively. Our study population had predominantly treatment-experienced adolescents, who initiated ART between birth and 9 years (73.5%), were on treatment for > 24 months (85.0%), and on first-line ART (93.1%). After controlling for confounders, the risk of dropping out of care was increased for older adolescents aged 15-19 years (aHR = 1.964, 95% CI 1.033-3.735); adolescents on switched ART regimens (Second line + Third line regimen) (aHR = 4.024, 95% CI 2.021-8.012); adolescents who initiated ART at 15-19 years (aHR = 2.179, 95%CI 1.100-4.316); and male adolescents receiving ART at a PHC clinic (aHR = 4.322, 1.332-14.024). Conversely, the risk of ALHIV dropping out of care decreased for adolescents whose TB screen results were negative (aHR = 0.215, 95% CI 0.095-0.489).

CONCLUSION

Retention in care rates among ALHIV in Windhoek do not meet the UNAIDS revised target of 95%. Gender-specific interventions are needed to keep male and older adolescents motivated and engaged in long-term care, and to promote adherence amongst those adolescents who were initiated on ART in late adolescence (15-19 years).

Sexual Behaviour and Attitudes towards Safe Sex of Youth Receiving Antiretroviral Care at Public Health Facilities in Palapye District, Botswana

BACKGROUND

Sexual behaviour of HIV-infected youths is very important in determining the direction of the HIV epidemic, as these youths are reservoirs of HIV and can propagate its transmission if they engage in risky sexual behaviours. However, support structures for secondary prevention are weak even in healthcare settings. There is a need to understand the sexual behaviour of these youths and, in turn, tailor appropriate secondary prevention strategies, hence the current study was designed to assess sexual behaviour and attitudes towards safe sex of youth receiving antiretroviral care at public health facilities in Palapye district, Botswana.

METHOD

This quantitative, descriptive cross-sectional survey was used to describe the sexual behaviour and attitudes towards safe sex and identify factors associated with risky sexual behaviours among HIV-infected youths aged between 15 and 19 years receiving antiretroviral therapy (ART) care from public healthcare facilities in Palapye District, Botswana.

RESULTS

A total of 188 youths participated in this study, 56% being females while 44% were males. We reported that 15.4% had ever had sex. At their last sexual encounter, more than half of the youths (51.7%) had not used condoms. More than a third of the participants were under the influence of alcohol during their last sexual experience. Generally, the youths had good attitudes towards safe sex, as most youths said they would prioritise protecting their sexual partners and themselves from HIV and STIs. Alcohol use, substance use and not considering religion as important were strongly associated with having ever had sex.

CONCLUSIONS

A significant proportion of HIV-infected youths are sexually active, whereas their preventive practices such as condom use are poor despite good attitudes towards safe sex. Alcohol use, substance use and not perceiving religion as important were associated with risky sexual behaviours.