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Desmond C, Watt K, Rudgard WE, Sherr L, Cluver L. Whole of government approaches to accelerate adolescent success: efficiency and financing considerations. Health Policy Plan 2024; 39:168-177. [PMID: 38048303 PMCID: PMC11020293 DOI: 10.1093/heapol/czad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 10/10/2023] [Accepted: 11/30/2023] [Indexed: 12/06/2023] Open
Abstract
The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings.
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Affiliation(s)
- Chris Desmond
- School of Economics and Finance, University of the Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg, Gauteng 2000, South Africa
- Centre for Rural Health, University of KwaZulu-Natal, 238 Masizi Kunene Road, Durban, KwaZulu-Natal 4041, South Africa
| | - Kathryn Watt
- Centre for Rural Health, University of KwaZulu-Natal, 238 Masizi Kunene Road, Durban, KwaZulu-Natal 4041, South Africa
| | - William E Rudgard
- Department of Social Policy and Intervention, University of Oxford, 32 Wellington Square, Oxford OX1 2ER, United Kingdom
- Centre for Social Science Research, University of Cape Town, Robert Leslie Social Science Building 12 University Avenue South, University of Rondebosch, Cape Town 7700, South Africa
| | - Lorraine Sherr
- Health Psychology Unit, Institute of Global Health, University College London, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, 32 Wellington Square, Oxford OX1 2ER, United Kingdom
- UK Department of Psychiatry and Mental Health, University of Cape Town, Anzio Road, 1st floor, Neuroscience Institute, Groote Schuur Hospital, Observatory, Cape Town, Western Cape 7925, South Africa
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Hlophe LD, Tamuzi JL, Shumba CS, Nyasulu PS. 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. PLoS One 2023; 18:e0276411. [PMID: 37200399 DOI: 10.1371/journal.pone.0276411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
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.
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Affiliation(s)
- Londiwe D Hlophe
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Environmental Health Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Kingdom of Eswatini
| | - Jacques L Tamuzi
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Peter S Nyasulu
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Koni K, Chaudhuri S, Tarugu J, Udayasree K, Hema K. HIV care policy in India: A review of social security schemes. J Family Med Prim Care 2022; 11:1648-1657. [PMID: 35800572 PMCID: PMC9254757 DOI: 10.4103/jfmpc.jfmpc_1755_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/10/2021] [Accepted: 12/16/2021] [Indexed: 11/25/2022] Open
Abstract
Social protection schemes are available in India to mitigate the various challenges faced by people living with human immunodeficiency virus (PLWH) infection. The availability of the schemes should be uniform across the country and based on the rights of these people. We reviewed the schemes available in the high PLWH-burdened states of the country for the year 2019. We identified 83 social protection schemes for the PLWH in 13 representative states from different zones of India. The number of schemes was as low as two in the states of Mizoram and Telangana and 12 schemes in Rajasthan. Most of the schemes belong to the 'health' category (n = 26, 31.3%), nutrition (n = 14, 16.9%), financial aid (n = 12, 14.5%), insurance (n = 11, 13.5%), employment generation (n = 3, 3.6%), housing (n = 3, 3.6%), and legal support (n = 5, 6.0%). While health-related schemes are present in all the states, the distribution of the other social schemes varies widely across the states. The schemes commonly address the social safety of the children affected by human immunodeficiency virus (HIV), nutritional supplementation, direct financial assistance or subsidized services, and employment generation but vary considerably regarding the type and the number of services. We strongly recommend for evidence-based policy decision to provide uniform social schemes for PLWH.
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Affiliation(s)
- Kiranmayi Koni
- Apollo College of Nursing, Chittoor, Andhra Pradesh, India
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Wilson KS, Mugo C, Katz DA, Manyeki V, Mungwala C, Otiso L, Bukusi D, McClelland RS, Simoni JM, Driver M, Masyuko S, Inwani I, Kohler PK. High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy. AIDS Behav 2022; 26:964-974. [PMID: 34468968 PMCID: PMC8409270 DOI: 10.1007/s10461-021-03451-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/01/2023]
Abstract
Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15-24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA.
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Affiliation(s)
- Kate S Wilson
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA.
| | - Cyrus Mugo
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - David A Katz
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mungwala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - R Scott McClelland
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Matt Driver
- Department of Cardiology, Cedar Sinai Medical Center, Los Angeles, USA
| | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | - Irene Inwani
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K Kohler
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
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Onyango MA, Chergui H, Sabin LL, Messersmith LJ, Sarkisova N, Oyombra J, Akello P, Kwaro DO, Otieno J. School-level Barriers of Antiretroviral Therapy Adherence and Interventions to Overcome them Among Adolescents Living with HIV in Western Kenya: A Qualitative Study. Open AIDS J 2021. [DOI: 10.2174/1874613602115010093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Adolescents in Kenya spend the majority of their time in a school environment. However, research to understand Antiretroviral Therapy (ART) adherence among adolescents living with HIV (ALWHIV) in school settings is sparse.
Objective:
To improve the design of appropriate interventions to better support this vulnerable population, the study aimed to explore school-related barriers to ART adherence experienced by ALWHIV.
Methods:
Qualitative data were utilized from a larger mixed-methods study on ALWHIV conducted at a major teaching and referral hospital in Kisumu, Kenya. Participants encompassed ALWHIV, their caregivers, teachers, and health care providers. Transcripts from a total of 24 in-depth interviews and five focus group discussions were analyzed in NVivo using a thematic approach.
Results:
Four themes emerged as key barriers in a school setting: negative experiences following HIV status self-disclosure, a strong desire for secrecy, restrictive school policies, and health education focused on sexual transmission of HIV. Participants suggested a range of potential interventions to better support ART adherence for ALWHIV, including coaching ALWHIV on disclosure strategies, promoting empathy among teachers and students, transition-preparing for ALWHIV, changing the narrative about HIV transmission in schools, providing water in schools, and introducing adherence support programs in schools, including the use of mobile technology.
Conclusion:
ALWHIV in Kenya experience numerous important challenges while trying to maintain optimal ART adherence in the school environment. Interventions that create supportive school settings are critical for better health outcomes among ALWHIV.
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Audi C, Jahanpour O, Antelman G, Guay L, Rutaihwa M, van de Ven R, Woelk G, Baird SJ. Facilitators and barriers to antiretroviral therapy adherence among HIV-positive adolescents living in Tanzania. BMC Public Health 2021; 21:2274. [PMID: 34903209 PMCID: PMC8670050 DOI: 10.1186/s12889-021-12323-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adolescents living with HIV face substandard outcomes along the continuum of care, including higher rates of poor adherence and virologic failure. Support groups have been identified as a method to improve adherence, but there is insufficient evidence regarding their effectiveness. This study seeks to examine the protective influences for and barriers to antiretroviral therapy (ART) adherence in HIV-positive adolescents living in Tanzania. METHODS This is a qualitative study conducted in Tanzania from January to March 2018. The sample of adolescents aged 10-19 (n = 33) was purposefully selected based on age, gender, and support group attendance to capture a broad range of experiences. Participants completed an in-depth interview, covering topics such as retention in HIV services, support group experiences, and joys and challenges of adolescent life. Interviews were coded and themes related to ART adherence were identified and summarized. RESULTS Support groups helped promote adherence by improving adolescents' knowledge and confidence. Participants associated joining support groups with an improvement in health. Almost every participant described the significant positive influence a treatment supporter had on adherence. Adolescents' daily schedules and emotional state served as a barrier to adherence. Furthermore, adherence was negatively impacted by participants' fear of accidental disclosure. CONCLUSION Logistical and psychosocial factors can hinder adherence. Interventions that provide both education and psychosocial support, such as peer support groups, have the potential to improve health outcomes for this population, but may not address more persistent barriers to adherence rooted in lack of treatment support from family members or friends who have not been disclosed to, or lack of transportation funds/food security.
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Affiliation(s)
- Cosette Audi
- Elizabeth Glaser Pediatric Aids Foundation, 1140 Connecticut Ave NW, Suite #200, Washington, DC, 20036, USA.
| | - Ola Jahanpour
- Elizabeth Glaser Pediatric Aids Foundation, Dar es Salaam, Tanzania
| | - Gretchen Antelman
- Elizabeth Glaser Pediatric Aids Foundation, 1140 Connecticut Ave NW, Suite #200, Washington, DC, 20036, USA
| | - Laura Guay
- Elizabeth Glaser Pediatric Aids Foundation, 1140 Connecticut Ave NW, Suite #200, Washington, DC, 20036, USA
| | - Mastidia Rutaihwa
- National AIDS Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | | | - Godfrey Woelk
- Elizabeth Glaser Pediatric Aids Foundation, 1140 Connecticut Ave NW, Suite #200, Washington, DC, 20036, USA
| | - Sarah J Baird
- Department of Global Health, George Washington University, Washington, D.C., USA
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Kasimonje B, Shamu T, Mudzviti T, Luethy R. Group counselling for adherence support among young people failing first-line antiretroviral therapy in Zimbabwe. South Afr J HIV Med 2021; 22:1292. [PMID: 34858653 PMCID: PMC8603063 DOI: 10.4102/sajhivmed.v22i1.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background Sub-optimal adherence to antiretroviral therapy (ART) is reportedly worse amongst young people living with HIV (YPLHIV). Group adherence counselling can be useful to improve adherence. Objectives We evaluated an enhanced adherence counselling group intervention (EACGI) amongst YPLHIV failing a non-nucleoside reverse transcriptase (NNRTI)-based first-line ART regimen. Method This was a retrospective cohort study using routinely collected data of YPLHIV failing NNRTI-based first-line ART. Patients with confirmed virological failure were referred for EACGI, a 12-week curriculum of weekly, 1.5-h sessions accommodating 8–15 people per group. It aimed to facilitate readiness to switch to second-line ART and improve adherence through a mental health intervention. Viral loads of HIV were measured pre-EACGI; at baseline; 3, 6 and 12 months post switch. Results Fifty-seven patients aged 13–25 years were invited to EACGI and followed for up to 48 weeks. Thirty-three (58%) patients attended at least four sessions, whilst 24 (42%) attended none. Amongst those who attended none, two (8%) were transferred out, three (13%) were lost to follow-up and two (8%) had died by week 48 of follow-up, whilst all who attended were still in care. By week 48, amongst patients still in care, 29%, 44% and 67% of those who attended no sessions, 4–9 and 10–12 sessions, respectively, had viral loads of < 50 copies/mL. Conclusion An EACGI is a promising intervention for YPLHIV failing ART prior to treatment switch, leading to improved adherence. This study’s findings support the need for further enquiry into rigorous, evidence-based multilevel adherence interventions that are acceptable and effective for YPLHIV.
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Affiliation(s)
| | - Tinei Shamu
- Newlands Clinic, Harare, Zimbabwe.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Graduate School of Health Sciences, University of Bern, Bern, Switzerland
| | - Tinashe Mudzviti
- Newlands Clinic, Harare, Zimbabwe.,Department of Pharmacy and Pharmaceutical Sciences, University of Zimbabwe, Harare, Zimbabwe
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Chang AY, Maswera R, Moorhouse LR, Skovdal M, Nyamukapa C, Gregson S. The determinants and impacts of age-disparate relationships on women in Zimbabwe: A life course perspective. SSM Popul Health 2021; 16:100947. [PMID: 34805475 PMCID: PMC8590073 DOI: 10.1016/j.ssmph.2021.100947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 11/19/2022] Open
Abstract
Age-disparate relationships (ADR) with older men have been studied mostly in the context of HIV and found to be associated with increased HIV prevalence among young women in sub-Saharan Africa. Less is known about the impact of ADR on the broader life course of women. The objectives of this study are to identify the factors associated with being in ADR and estimate the association between ADR and a set of life outcomes in Manicaland, Zimbabwe. We used data from a general population open-cohort survey from 1998 to 2013 in Manicaland. We applied binary logistic regression models to estimate the odds ratios for association between socio-demographic determinants and ADR and multinomial logistic regression models to estimate the association between ADR and women's life outcomes. We found that women with less education, younger age at first sex and first marriage were more likely to be in ADR, and women in ADR have male partners with less education and less skilled employment. In terms of life and relationship outcomes, women in ADR had mostly negative life outcomes compared to women not in ADR. Future policies and research on ADR in women should reflect these complexities and study a wider range of life outcomes, beyond the commonly studied narrower topics such as HIV.
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Affiliation(s)
- Angela Y. Chang
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Louisa R. Moorhouse
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Constance Nyamukapa
- Biomedical Research and Training Institute, Harare, Zimbabwe
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Simon Gregson
- Biomedical Research and Training Institute, Harare, Zimbabwe
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
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Teasdale CA, Brittain K, Zerbe A, Mellins CA, Falcao J, Couto A, Pimentel De Gusmao E, Vitale M, Kapogiannis B, Simione TB, Myer L, Mantell J, Desmond C, Abrams EJ. Characteristics of adolescents aged 15-19 years living with vertically and horizontally acquired HIV in Nampula, Mozambique. PLoS One 2021; 16:e0250218. [PMID: 33901229 PMCID: PMC8075210 DOI: 10.1371/journal.pone.0250218] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/03/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Adolescents living with HIV (ALHIV) 15-19 years of age are a growing proportion of all people living with HIV globally and the population includes adolescents with vertically acquired HIV (AVH) and behaviorally acquired HIV (ABH). METHODS We conducted a survey to measure sociodemographic characteristics, educational status, health history, and antiretroviral therapy (ART) adherence among a convenience sample of ALHIV at three government health facilities in 2019 in Nampula, Mozambique. ALHIV 15-19 years on ART, including females attending antenatal care, were eligible. Routine HIV care data were extracted from medical charts. Classification of ALHIV by mode of transmission was based on medical charts and survey data. ALHIV who initiated ART <15 years or reported no sex were considered AVH; all others ABH. Frequencies were compared by sex, and within sex, by mode of transmission (AVH vs. ABH) using Chi-square, Fishers exact tests and Wilcoxon rank-sum tests. RESULTS Among 208 ALHIV, 143 (69%) were female and median age was 18 years [interquartile range (IQR) 16-19]. Just over half of ALHIV (53%) were in or had completed secondary or higher levels of education; the most common reason for not being in school reported by 36% of females was pregnancy or having a child. Of all ALHIV, 122 (59%) had VL data, 62% of whom were <1000 copies/mL. Almost half (46%) of ALHIV reported missing ARVs ≥ 1 day in the past month (62% of males vs. 39% of females; p = 0.003). Just over half (58%) of ALHIV in relationships had disclosed their HIV status: 13% of males vs. 69% of females (p<0.001). Among sexually active males, 61% reported using a condom at last sex compared to 26% of females (p<0.001). Among female ALHIV, 50 (35%) were AVH and 93 (65%) were ABH, 67% of whom were not in school compared to 16% of ABH, (p<0.001). DISCUSSION Data from our study underscore the high level of deprivation among ALHIV enrolled in HIV care in Mozambique, as well as important disparities by sex and mode of transmission. These data can inform the development of effective interventions for this complex and important population.
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Affiliation(s)
- Chloe A. Teasdale
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health & Health Policy, New York, New York, United States of America
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Claude Ann Mellins
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, United States of America
| | - Joana Falcao
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Aleny Couto
- National STI, HIV/AIDS Control Program, Maputo, Mozambique
| | - Eduarda Pimentel De Gusmao
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Mirriah Vitale
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Bill Kapogiannis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, United States of America
| | | | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanne Mantell
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, United States of America
| | | | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
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Enane LA, Christenson JC. Global emerging resistance in pediatric infections with TB, HIV, and gram-negative pathogens. Paediatr Int Child Health 2021; 41:65-75. [PMID: 33305992 PMCID: PMC8243638 DOI: 10.1080/20469047.2020.1853350] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/13/2020] [Indexed: 12/28/2022]
Abstract
Infants, children and adolescents are at risk of life-threatening, antimicrobial-resistant infections. Global burdens of drug-resistant TB, HIV and gram-negative pathogens have a particular impact on paediatric age groups, necessitating a paediatric-focused agenda to address emerging resistance. Dedicated approaches are needed to find, successfully treat and prevent resistant infections in paediatric populations worldwide. Challenges include the diagnosis and identification of resistant infections, limited access to novel antimicrobials or to paediatric-friendly formulations, limited access to research and clinical trials and implementation challenges related to prevention and successful completion of treatment. In this review, the particular complexities of emerging resistance in TB, HIV and gram-negative pathogens in children, with attention to both clinical and public health challenges, are highlighted. Key principles of a paediatric-focused agenda to address antimicrobial resistance are outlined. They include quality of care, increasing equitable access to key diagnostics, expanding antimicrobial stewardship and infection prevention across global settings, and health system strengthening. Increased access to research studies, including clinical trials, is needed. Further study and implementation of care models and strategies for child- or adolescent-centred management of infections such as HIV and TB can critically improve outcome and avoid development of resistance. As the current global pandemic of a novel coronavirus, SARS-CoV-2, threatens to disrupt health systems and services for vulnerable populations, this is a critical time to mitigate against a potential surge in the incidence of resistant infections.
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Affiliation(s)
- Leslie A Enane
- Department of Pediatrics Indiana University School of Medicine, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis, IN, USA
| | - John C Christenson
- Department of Pediatrics Indiana University School of Medicine, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis, IN, USA
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Zuma T, Seeley J, Mdluli S, Chimbindi N, Mcgrath N, Floyd S, Birdthistle I, Harling G, Sherr L, Shahmanesh M. Young people's experiences of sexual and reproductive health interventions in rural KwaZulu-Natal, South Africa. INTERNATIONAL JOURNAL OF ADOLESCENCE AND YOUTH 2020; 25:1058-1075. [PMID: 34177039 PMCID: PMC8224946 DOI: 10.1080/02673843.2020.1831558] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/28/2020] [Indexed: 12/16/2022] Open
Abstract
Despite efforts to address HIV-infection, adolescents and young peoples' (AYP) engagement in interventions remains suboptimal. Guided by a risk protection framework we describe factors that support positive and negative experiences of HIV and SRH interventions among AYP in rural KwaZulu-Natal, South Africa, using data from: community mapping; repeat semi-structured individual interviews (n= 58 in 2017, n=50 in 2018, n=37 in 2019-2020); and group discussions (n=13). AYP who had appropriate and accurate HIV-and SRH-related information were reported to use health care services. Responsive health care workers, good family and peer relationships were seen to be protective through building close connections and improving self-efficacy to access care. In contrast to cross-generational relationships with men, alcohol and drug use and early pregnancy were seen to put AYP at risk. Policies and interventions are needed that promote stable and supportive relationships with caregivers and peers, positive social norms and non-judgemental behaviour within clinical services.
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Affiliation(s)
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sakhile Mdluli
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Natsayi Chimbindi
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, Division of Infection and Immunity, London, UK
| | - Nuala Mcgrath
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of Southampton, Southampton, UK
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, Institute for Global Health, London, UK
| | - Lorraine Sherr
- University College London, Institute for Global Health, London, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, Institute for Global Health, London, UK
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12
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Zombori L, Kirkhope N, Busari T, Tickner N, Weston R, Foster C. Novel Adherence Interventions in Perinatally Acquired HIV: PEG Insertion and Pill Glide. Clin Drug Investig 2020; 40:765-772. [PMID: 32519251 DOI: 10.1007/s40261-020-00918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Children, adolescents and young adults (CAYA) with perinatally acquired human immunodeficiency virus (PaHIV) need lifelong antiretroviral therapy (ART) to suppress viral load (VL), maintain health and prevent onward transmission. Many struggle with adherence despite multidisciplinary input. We assessed ART adherence outcomes following two novel interventions: percutaneous endoscopic gastrostomy (PEG) and Pill Glide®, a fruit-flavoured lubricant spray aiding tablet swallowing. METHODS Retrospective cohort analysis by database and case-note review of PaHIV CAYA aged < 25 years receiving PEG or Pill Glide® between 1995 and 2017 at a single tertiary centre. RESULTS Nineteen PEGs were inserted in 15 CAYA at a median age of 17 (IQR 6-22) years, median CD4 count 40 cells/µL (IQR 10-220). A viral load (VL) < 50 copies/mL was achieved in 93% with PEG ART. At last follow-up all were alive, median age 23 years (IQR 22-28). Nine had PEG removed, after a median of 3.3 years (range 0.5-6.8), with a current VL < 50 copies/mL, median CD4 count 940 cells/µL (IQR 261-1353) sustained post PEG removal median was 5.4 years (range 1.5-17.8) previously. From 2017 seven CAYA received Pill Glide®, median age 10 years (IQR 7-14), median CD4 count 898 cells/µL (range 148-1943), 6/7 with a suppressed VL. All reported increased ease in tablet swallowing and transitioned successfully from crushed tablets/liquids to tablets. At follow-up, all patients had a suppressed VL. CONCLUSIONS Whilst PEG insertion markedly improved rates of viral suppression in CAYA struggling with ART adherence, the use of novel less invasive aids such as Pill Glide® requires further exploration.
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Affiliation(s)
- Luca Zombori
- Department of Paediatrics, Royal London Hospital, Barts Health NHS Trust, 6c ward, Whitechapel Road, Whitechapel, London, E1 1FR, UK.
| | - Natalie Kirkhope
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Temitope Busari
- Department of Paediatrics, Chelsea and Westminster Hospital, Chelsea and Westminster Hospital, NHS Trust, London, UK
| | - Neil Tickner
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Rosy Weston
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Caroline Foster
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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13
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Richterman A, Leandre F, Jerome JG, Tsai AC, Ivers LC. Mortality Over Long-term Follow-up for People With HIV Receiving Longitudinal Care and Antiretroviral Therapy in Rural Haiti. Open Forum Infect Dis 2020; 7:ofaa328. [PMID: 32851109 PMCID: PMC7442269 DOI: 10.1093/ofid/ofaa328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/05/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deaths from HIV have fallen dramatically with the increasing availability of fully suppressive antiretroviral therapy (ART), and yet HIV remains the ninth leading cause of death in low-income countries. As more people with HIV enter care and receive ART, the focus will need to shift from expanding ART to including long-term program effectiveness and outcomes for people with HIV already engaged in care. METHODS We evaluated risk factors for mortality among people with HIV on ART receiving longitudinal care in rural Haiti. We assessed baseline characteristics using a household survey and abstracted clinical characteristics from the electronic record. We used multivariable Cox regression models to identify risk factors for mortality. RESULTS There were 464 people included in this study with a median follow-up (interquartile range [IQR]) of 69 (44-77) months, during which time 37 (8%) were lost to follow-up and 118 (25%) died (median time to death [IQR], 29 [12-53] months). After adjustment, poverty (adjusted hazard ratio [AHR], 1.12 per 10-percentage point increased probability; 95% CI, 1.01-1.24) and single marital status (AHR, 1.59; 95% CI, 1.08-2.36) were associated with increased mortality. Age (AHR, 0.78 per 10-year increase; 95% CI, 0.64-0.94), role function quality of life (AHR, 0.75 per quintile increase; 95% CI, 0.62-0.90), and CD4 count (AHR, 0.66 per 100 cells/μL; 95% CI, 0.58-0.75) were associated with decreased mortality. CONCLUSIONS Poverty, marital status, and quality of life were associated with mortality. Social protection should be evaluated as a strategy to reduce mortality for people with HIV in concert with increasing access to ART.
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Affiliation(s)
- Aaron Richterman
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fernet Leandre
- Zanmi Lasante/Partners In Health, Cange, Haiti
- Division of Global Health Equity, Brigham and Women Hospital, Boston, Massachusetts, USA
| | | | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Louise C Ivers
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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14
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Tuke R, Sikorskii A, Zalwango SK, Webster KD, Ismail A, Pobee RA, Barkin JL, Boivin MJ, Giordani B, Ezeamama AE. Psychosocial Adjustment in Ugandan Children: Coping With Human Immunodeficiency Virus Exposure, Lifetime Adversity, and Importance of Social Support. New Dir Child Adolesc Dev 2020; 2020:55-75. [PMID: 32618425 DOI: 10.1002/cad.20354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cumulative lifetime adversity and social support were investigated as determinants of psychosocial adjustment (esteem, distress, hopefulness, positive outlook/future aspirations, and sense of purpose) over 12 months in 6-10-years-old HIV-infected, HIV-exposed uninfected and HIV-unexposed uninfected children from Uganda. Each determinant and psychosocial adjustment indicator was self-reported using standardized questionnaires administered at baseline, 6, and 12 months. Linear mixed effects models were used to relate time-varying lifetime adversity and social support to psychosocial adjustment over 12 months. Regardless of HIV status, higher adversity predicted lower esteem (coefficient b = -2.98, 95% confidence interval (CI): [-4.62, -1.35]) and increased distress (b =3.96, 95% CI: [1.29, 6.62]) but was not associated with hopefulness, positive outlook or sense of purpose. Low social support predicted higher distress (b =9.05, 95% CI: [7.36, 10.73]), lower positive outlook (b = -10.56, 95% CI: [-2.34, -8.79]) and low sense of purpose (b = -9.90, 95% CI: [-11.44, -8.36]) over 12 months. Pragmatic interventions that enhance coping with adversity and provide emotional/instrumental support should be tested for effectiveness in promoting resilient psychosocial adjustment trajectory in vulnerable children.
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15
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Nwaozuru U, Blackstone S, Obiezu-Umeh C, Conserve DF, Mason S, Uzoaru F, Gbajabiamila T, Ezechi O, Iwelunmor P, Ehiri JE, Iwelunmor J. Psychosocial correlates of safe sex self-efficacy among in-school adolescent girls in Lagos, Nigeria. PLoS One 2020; 15:e0234788. [PMID: 32574187 PMCID: PMC7310695 DOI: 10.1371/journal.pone.0234788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 06/02/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adolescent girls in Nigeria are at heightened risk for HIV and other sexually transmitted infections. However, there are limited studies on psychosocial factors that are associated with safe sex intentions among this population. Self-efficacy has been established as an important correlate of behavioral intentions and the actual behavior. The objective of this research was to examine how key psychosocial factors such as social support, parental monitoring, and future orientation influence perceived safe sex self-efficacy among in-school adolescent girls in Nigeria. Furthermore, we assessed the associations between these psychosocial factors and HIV-related knowledge and safe sex self-efficacy. METHODS A self-administered questionnaire was distributed to 426 adolescent girls attending public and private school systems in Lagos, Nigeria. Multiple linear regression was used to evaluate the influence of psychosocial and demographic factors on safe sex self-efficacy. Further, stratified analysis was conducted to compare the estimates between participants attending public schools (n = 272) and those attending private schools (n = 154). FINDINGS Results from the study show that future orientation (β = 0.17; p < 0.05), participants age (β = 0.14; p < 0.05), and HIV knowledge accuracy (β = 0.17; p < 0.05) were associated with safe sex self-efficacy. Future orientation remained statistically significant in the sub-group analysis among participants attending public (β = 0.13; p < 0.05) and private schools (β = 0.24; p < 0.05). Among participants attending public schools, HIV accuracy (β = 0.2; p < 0.05) remained a significant correlate of safe sex self-efficacy while this association dissipated among private school attendees. CONCLUSIONS These findings point to the importance of including future orientation strategies in interventions developed for in-school adolescent girls in Nigeria. School-based interventions that increase positive future orientation outcomes may be beneficial to improve safe sex intentions among adolescent girls in Nigeria.
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Affiliation(s)
- Ucheoma Nwaozuru
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Sarah Blackstone
- Departments of Health Professions and Health Sciences, James Madison University, Harrisonburg, Virginia, United States of America
| | - Chisom Obiezu-Umeh
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Donaldson F. Conserve
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
| | - Stacey Mason
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Florida Uzoaru
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | | | - Oliver Ezechi
- Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Patricia Iwelunmor
- Morning Star Health and Human Development Foundation, Festac Town, Lagos State, Nigeria
| | - John E. Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
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16
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Comins CA, Rucinski KB, Baral S, Abebe SA, Mulu A, Schwartz SR. Vulnerability profiles and prevalence of HIV and other sexually transmitted infections among adolescent girls and young women in Ethiopia: A latent class analysis. PLoS One 2020; 15:e0232598. [PMID: 32407394 PMCID: PMC7224533 DOI: 10.1371/journal.pone.0232598] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 04/17/2020] [Indexed: 12/02/2022] Open
Abstract
Background Adolescent girls and young women (AGYW) aged 15–24 years have among the highest risk for HIV and other sexually transmitted infections (STI) across sub-Saharan Africa. A latent class analysis (LCA) was conducted to identify intersecting social- and structural-level determinants of HIV/STI acquisition among AGYW in Ethiopia. Methods AGYW were recruited from venues using time-location sampling, completing an interviewer-administered behavioral survey and biological testing for HIV, syphilis, and chlamydia. LCA was used to identify distinct groups, defined by social- and structural-level determinants of HIV/STI risk, among AGYW. Prevalence ratios (PR) and 95% confidence intervals (CI) compared differences in HIV/STI prevalence by group. Results A total of 1,501 AGYW were enrolled across Addis Ababa (March–May 2018) and Gambella (June–July 2019). We identified three patterns of vulnerability defined by schooling status, migration history, food insecurity, orphan status, social support, and employment. We labeled these groups as “highly vulnerable” (representing ~21% of the population), “stable, out-of-school, migrated” (~42%), and “stable, in-school, never migrated” (~37%). STI prevalence was nearly two-fold higher among AGYW in the “highly vulnerable” group compared to AGYW in the “stable, in-school, never migrated” group (PR 1.93; 95% CI 1.33, 2.80). Conclusions Characterizing patterns of vulnerability among AGYW that reflect higher-level social and structural factors can help facilitate early identification of AGYW at the highest risk of HIV/STI acquisition, thus differentiating groups of AGYW who may most benefit from targeted HIV prevention interventions during adolescence and early adulthood.
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Affiliation(s)
- Carly A. Comins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
| | - Katherine B. Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | | | - Sheree R. Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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17
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Abstract
: Addressing social determinants of health (SDH) has far greater potential to improve the real-world effectiveness of HIV treatment than expensive, incremental changes in antiretroviral therapy. The ADVANCE study demonstrates that SDH is more impactful than medication regimen on health outcomes. Younger patients and unemployed patients experience heightened precarity, which can have pervasive effects on adherence and suppression. Enhanced adherence counselling can help socioeconomically precarious patients maintain suppression, but in order to improve treatment effectiveness and population health, we should move beyond the short-term solution of helping patients 'cope' with insecurity toward tackling the underlying factors that lead to precarity. Data on intention-to-treat populations are critical to this effort, yet medical researchers and publications continue to obscure the influence of SDH by focusing on per-protocol populations.
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18
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Zuma T, Seeley J, Sibiya LO, Chimbindi N, Birdthistle I, Sherr L, Shahmanesh M. The Changing Landscape of Diverse HIV Treatment and Prevention Interventions: Experiences and Perceptions of Adolescents and Young Adults in Rural KwaZulu-Natal, South Africa. Front Public Health 2019; 7:336. [PMID: 31803703 PMCID: PMC6872529 DOI: 10.3389/fpubh.2019.00336] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/25/2019] [Indexed: 12/24/2022] Open
Abstract
In sub-Saharan Africa, adolescents and young adults aged 15–24 years constitute 36% of an estimated 1. 3 million new HIV infections. Complex biological, social, behavioral and structural factors, as well as cultural norms contribute to whether and how young people perceive, are aware of and experience diverse HIV interventions. This qualitative study explored experiences and perceptions of intervention types among adolescents and young adults, and how different interventions could hinder or facilitate HIV treatment and prevention for adolescents and young adults in rural KwaZulu-Natal, South Africa. Data were collected as part of a DREAMS impact evaluation at the Africa Health Research Institute, KwaZulu-Natal between May 2017–January 2018. We used a combination of rapid community mapping and participant observation in four communities, 58 individual interviews, and 10 group discussions with 61 participants, conducted with both adolescent girls and young women and adolescent boys and young men. Thematic analysis focused on the changing HIV prevention landscape as experienced by adolescents and young adults. Participants reported a mix of new and old biomedical, behavioral, traditional, and locally-developed HIV prevention approaches. The appeal of the newer approaches depended on the extent to which they resonated with existing traditional and longstanding HIV prevention methods and the extent to which they engaged with adolescents and young adults' sexual experiences and with the social and structural factors including gender-related issues. These data demonstrate that in this context, newer methods and approaches can and should synergise with existing methods and beliefs. The HIV prevention landscape is evolving rapidly. Good community links and engagement offer an alternative support structure that could embrace both locally-developed approaches and traditional practices This structure could potentially support feasibility and acceptability of new and old HIV prevention approaches, without creating an impression that new approaches always need to replace the old.
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Affiliation(s)
| | - Janet Seeley
- Africa Health Research Institute, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Lorraine Sherr
- University College London, Institute for Global Health, London, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa.,University College London, Institute for Global Health, London, United Kingdom
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19
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van Wyk BE, Davids LAC. Challenges to HIV treatment adherence amongst adolescents in a low socio-economic setting in Cape Town. South Afr J HIV Med 2019; 20:1002. [PMID: 31745433 PMCID: PMC6852420 DOI: 10.4102/sajhivmed.v20i1.1002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/24/2019] [Indexed: 02/04/2023] Open
Abstract
Background Despite the successful rollout of anti-retroviral therapy (ART) and steep declines in HIV incidence in South Africa, this has not been the case for adolescents (10-19 years). Adolescents on HIV treatment have lower rates of viral load suppression and adherence compared to adults and children. Objectives This article reports on the adherence challenges faced by adolescents receiving ART in a primary health care clinic in a low socio-economic urban setting in Cape Town. Method An exploratory qualitative design was employed where data were collected through four focus group discussions with adolescents (n = 15) who received ART at a primary health care clinic in a low socio-economic urban setting in Cape Town and followed up with eight individual, semi-structured interviews with two adolescents from each focus group. Two key informant interviews were conducted with health workers at the clinic. Audio data were digitally recorded and transcribed verbatim. Data were analysed using content analysis. Results School commitments, strained teacher-learner relationships, negative household dynamics and ill treatment by non-biological caregivers were reported as major barriers to adherence. In addition, poor service delivery, missing or misplaced files and long waiting times came under major criticism. Fear of unintended disclosure of HIV status, stigma and discrimination, treatment fatigue and having unstructured lives negatively influenced adherence. Having a strong social support system and having life goals and ambitions were motivators to remain adherent. Conclusion This study highlighted the complexity of ART adherence in the midst of juggling school, home life and personal life goals and aspirations. Interventions to improve adherence should address psychosocial factors such as treatment fatigue, disclosure and family and household dynamics, in addition to streamlining service delivery between the school and clinic.
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Affiliation(s)
- Brian E van Wyk
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Lee-Ann C Davids
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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20
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Gleeson HS, Oliveras Rodriguez CA, Hatane L, Hart D. Ending AIDS by 2030: the importance of an interlinked approach and meaningful youth leadership. J Int AIDS Soc 2019; 21 Suppl 1. [PMID: 29485749 PMCID: PMC5978642 DOI: 10.1002/jia2.25061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/28/2017] [Indexed: 11/12/2022] Open
Abstract
Introduction This commentary by authors from the Adolescent HIV Treatment Coalition calls for action to improve advocacy and service delivery for young people by leveraging the interlinkages between HIV and the broader development agenda. The 2030 Agenda for Sustainable Development includes target 3.3 on ending the AIDS epidemic by 2030, and along with the 2016 Political Declaration on HIV and AIDS, this has led to a global renewal of political commitment to the HIV response. However, young people are still being left behind, and to provide an equitable and sustainable response to HIV we must ensure that we are meeting the needs of the 3.9 million young people living with HIV, and the millions more at risk. Discussion While HIV has its own target within the 2030 Agenda, efforts to end AIDS are inextricable from other goals and targets, such as on poverty eradication, education, gender equality and peace. To tackle HIV we must work beyond target 3.3 and provide a comprehensive response that addresses the underlying structural inequalities that impact adolescents and young people, ensuring that we enable the meaningful engagement of youth and adolescents as partners and leaders of sustainable development and the HIV response. Finally, it is necessary to collect better disaggregated data and evidence on the HIV epidemic among adolescents, as well as on best practices for supporting them. Conclusions Ending the AIDS epidemic among adolescents and young people (aged 10 to 24) by 2030 is possible. However, it requires an integrated, multi‐sectoral response to HIV which pays attention to the social determinants that put adolescents at risk and fuel the epidemic. Positioning efforts to end AIDS among young people within the broader 2030 Agenda and building youth leadership will contribute to building a more healthy, equitable and sustainable society for all.
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Affiliation(s)
- Hayley S Gleeson
- International Planned Parenthood Federation, London, United Kingdom
| | | | - Luann Hatane
- Paediatric-Adolescent Treatment Africa (PATA), Cape Town, South Africa
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21
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Enane LA, Apondi E, Toromo J, Bosma C, Ngeresa A, Nyandiko W, Vreeman RC. "A problem shared is half solved" - a qualitative assessment of barriers and facilitators to adolescent retention in HIV care in western Kenya. AIDS Care 2019; 32:104-112. [PMID: 31554414 DOI: 10.1080/09540121.2019.1668530] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Adolescents living with HIV (ALHIV, ages 10-19) are retained in care at low rates, resulting in poor clinical outcomes. We investigated barriers and facilitators to retention experienced by perinatally infected ALHIV in western Kenya. This qualitative study purposefully sampled hospitalized ALHIV (engaged and not currently engaged in care), ALHIV engaged in outpatient care, and caregivers of ALHIV. In total, 116 ALHIV and caregivers participated in interviews or focus group discussions. Challenges related to the effects of both stigma and poverty at multiple socio-ecological levels pose the greatest barriers to adolescent retention in HIV care. Adolescents with positive relationships with family, clinic, and/or peers with the resources to support their care are facilitated to overcome these barriers. Conversely, adolescents with few of these supports due to orphanhood, caregiver illness, severe poverty, family conflicts, negative relationships with healthcare workers, or isolation, have the greatest challenges staying in care, and maybe at risk of disengagement. Experiences of trauma emerged from narratives of disengagement, and contribute to isolation, mental health challenges, and difficulties engaging in care. Retention of the most vulnerable adolescents will require interventions to mitigate the impacts of stigma, poverty, mental health issues, and limited social support on HIV care engagement.
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Affiliation(s)
- Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Edith Apondi
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Judith Toromo
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | | | - Antony Ngeresa
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone Nyandiko
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Pediatrics, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Rachel C Vreeman
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Pediatrics, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya.,Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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Carbone NB, Njala J, Jackson DJ, Eliya MT, Chilangwa C, Tseka J, Zulu T, Chinkonde JR, Sherman J, Zimba C, Mofolo IA, Herce ME. "I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone": Adapting the Mothers2Mothers Mentor Mother Model for adolescent mothers living with HIV in Malawi. PLoS One 2019; 14:e0217693. [PMID: 31173601 PMCID: PMC6555548 DOI: 10.1371/journal.pone.0217693] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 05/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences. Methods Qualitative researchers conducted 16 focus group discussions (FGDs) in 4 Malawi districts with HIV-infected adolescent mothers ages 15–19 years categorized into two groups: 1) those who had experience with m2m programming (8 FGDs, n = 38); and 2) those who did not (8 FGDs, n = 34). FGD data were analyzed using thematic analysis to assess major and minor themes and to compare findings between groups. Results Median participant age was 17 years (interquartile range: 2 years). Poverty, stigma, food insecurity, lack of transport, and absence of psychosocial support were crosscutting barriers to PMTCT engagement. While most participants highlighted resilience and self-efficacy as motivating factors to remain in care to protect their own health and that of their children, they also indicated a desire for tailored, age-appropriate services. FGD participants indicated preference for support services delivered by adolescent HIV-infected mentor mothers who have successfully navigated the PMTCT cascade themselves. Conclusions HIV-infected adolescent mothers expressed a preference for peer-led, non-judgmental PMTCT support services that bridge communities and facilities to pragmatically address barriers of stigma, poverty, health system complexity, and food insecurity. Future research should evaluate implementation and health outcomes for adolescent mentor mother services featuring these and other client-centered attributes, such as provision of livelihood assistance and peer-led psychosocial support.
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Affiliation(s)
| | - Joseph Njala
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Debra J. Jackson
- UNICEF/New York, New York, New York, United States of America
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Michael T. Eliya
- Department of HIV and AIDS, Ministry of Health, Government of the Republic of Malawi, Lilongwe, Malawi
| | | | - Jennifer Tseka
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Tasila Zulu
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | | | - Chifundo Zimba
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | - Michael E. Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Meinck F, Orkin FM, Cluver L. Does free schooling affect pathways from adverse childhood experiences via mental health distress to HIV risk among adolescent girls in South Africa: a longitudinal moderated pathway model. J Int AIDS Soc 2019; 22:e25262. [PMID: 30869202 PMCID: PMC6416665 DOI: 10.1002/jia2.25262] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 02/20/2019] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Adolescent girls are at high risk of HIV infection in sub-Saharan Africa. Mental health distress, driven by adverse childhood experiences (ACEs) such as abuse, poverty and family HIV, may be an important driver of HIV risk behaviour among adolescent girls, while education may mitigate these risks. This study aimed to develop an empirically based theoretical model between ACEs, mental health distress and HIV risk behaviour among adolescent girls in South Africa and to investigate the potential moderating effects of free schooling provision. METHODS Self-report questionnaires using validated scales were completed by adolescent girls aged 12 to 17 at baseline in two provinces in South Africa in 2011, with a 99% one-year follow-up in 2012 (n = 1498). Sampling included every household in randomly selected census enumeration areas of four deprived health districts. Confirmatory factor analysis was employed to identify measurement models and a structural equation model was developed to test pathways of risk and protection. RESULTS Internalizing and externalizing mental health distress fully mediated the positive relationship between ACEs at baseline and HIV risk behaviour at follow-up among adolescent girls. Internalizing mental health distress was associated with increased sexual risk at follow-up via higher externalizing problems. Free schooling provision at baseline and follow-up eliminated the pathway from internalizing to externalizing mental health distress by moderating the pathway between ACEs and internalizing mental health distress. It also weakened the pathway from externalizing mental health distress to HIV risk behaviour at follow-up through a direct negative effect on externalizing mental health distress. CONCLUSIONS Reducing ACEs and adolescent mental health distress is essential for reducing HIV risk behaviour among girls in South Africa. Free schooling provision may be an important tool for reducing these problems and mitigating negative pathways to HIV risk among vulnerable adolescent girls.
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Affiliation(s)
- Franziska Meinck
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- OPTENTIAFaculty of Health SciencesNorth‐West UniversityVanderbijlparkSouth Africa
| | - FM Orkin
- MRC Developmental Pathways for Health Research UnitSchool of Clinical MedicineUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lucie Cluver
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
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24
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Enane LA, Davies MA, Leroy V, Edmonds A, Apondi E, Adedimeji A, Vreeman RC. Traversing the cascade: urgent research priorities for implementing the 'treat all' strategy for children and adolescents living with HIV in sub-Saharan Africa. J Virus Erad 2018; 4:40-46. [PMID: 30515313 PMCID: PMC6248846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Children and adolescents living with HIV (CALHIV) in sub-Saharan Africa experience significant morbidity and alarmingly high mortality rates due to critical gaps in the HIV care cascade, including late diagnosis and initiation of treatment, as well as poor retention in care and adherence to treatment. Interventions to strengthen the adult HIV care cascade may not be as effective in improving the cascade for CALHIV, for whom specific strategies are needed. Particular attention needs to be paid to the contexts of sub-Saharan Africa, where more than 85% of the world's CALHIV live. Implementing the 'treat all' strategy in sub-Saharan Africa requires dedicated efforts to address the unique diagnosis and care needs of CALHIV, in order to improve paediatric and adolescent outcomes, prevent viral resistance and reduce the number of new HIV infections. We consider the UNAIDS 90-90-90 targets from the perspective of infants, children and adolescents, and discuss the key challenges, knowledge gaps and urgent research priorities for CALHIV in implementation of the 'treat all' strategy in sub-Saharan Africa.
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Affiliation(s)
- Leslie A Enane
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, IN,
USA,Corresponding author:
Leslie Enane, 1044 W Walnut Street, Room 402A,
Indianapolis,
Indiana,
46202,
USA
| | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, University of Cape Town,
South Africa
| | - Valériane Leroy
- Inserm (French Institute of Health and Medical Research), UMR 1027, Université Toulouse 3,
France
| | - Andrew Edmonds
- Department of Epidemiology, University of North Carolina at Chapel Hill,
NC,
USA
| | - Edith Apondi
- Moi Teaching and Referral Hospital,
Eldoret,
Kenya
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine,
Bronx, NY,
USA
| | - Rachel C Vreeman
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, IN,
USA
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25
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Enane LA, Davies MA, Leroy V, Edmonds A, Apondi E, Adedimeji A, Vreeman RC. Traversing the cascade: urgent research priorities for implementing the ‘treat all’ strategy for children and adolescents living with HIV in sub-Saharan Africa. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30344-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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26
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Zgambo M, Kalembo FW, Mbakaya BC. Risky behaviours and their correlates among adolescents living with HIV in sub-Saharan Africa: a systematic review. Reprod Health 2018; 15:180. [PMID: 30355344 PMCID: PMC6201550 DOI: 10.1186/s12978-018-0614-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 09/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Adolescents living with HIV (ALWHIV) in sub-Saharan Africa encounter multiple health problems that are often unrecognised by the public and the healthcare workforce. The aim of this systematic review was to identify risky health behaviours and their associated factors among ALWHIV in sub-Saharan Africa. METHODS We systematically searched for articles in Medline, SCOPUS, Directory of Open Access Journals, Science Direct, ProQuest, Psych-info, Web of science, WHO Global Index Medicus library, Cochrane, and Google Scholar. Studies were included in this review if: they were original studies; participants were aged from 10 to 19 years; participants were ALWHIV or they had data from different key informants focusing on ALWHIV within the age group; they had health behaviours as an outcome; they were conducted in sub-Saharan Africa and were published before December 2016. Data were extracted and the quality of the studies was appraised using the Mixed Method Appraisal Tool (MMAT). RESULTS Thirty-six studies met the eligibility criteria. Nineteen studies scored 100% (indicating high quality), sixteen studies scored 75% (indicating moderate quality) and one study scored 50% (indicating low quality) on the MMAT scale. Adherence to antiretroviral therapy among ALWHIV was suboptimal and was negatively affected by forgetfulness, opportunistic infection, long distance to clinics, and fear of unplanned disclosure. Many adolescents were sexually active, but the majority did not disclose their HIV status to sexual partners, despite knowing their diagnosis (range 76-100% across available studies) and some did not use protection (condoms) to prevent transmission of HIV and other sexually transmitted diseases (range 35-55%). Disclosure to and from adolescents was low across the studies and was associated with fear of disclosure aftermaths including stigma and discrimination (range 40-57%). CONCLUSION A considerable proportion of ALWHIV in sub-Saharan Africa engage in multiple risky health behaviours, which have a substantial negative impact on their wellbeing and cause significant risk and burden to their families, sexual partners and societies.
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Affiliation(s)
- Maggie Zgambo
- St John’s College of Nursing and Midwifery, P.O Box 18, Mzuzu, Malawi
| | - Fatch Welcome Kalembo
- Faculty of Health Sciences, Mzuzu University, Private Bag 201, Luwinga, Mzuzu 2, Malawi
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27
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Rudgard WE, Carter DJ, Scuffell J, Cluver LD, Fraser-Hurt N, Boccia D. Cash transfers to enhance TB control: lessons from the HIV response. BMC Public Health 2018; 18:1052. [PMID: 30134870 PMCID: PMC6106939 DOI: 10.1186/s12889-018-5962-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 08/14/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The World Health Organization prioritises a more holistic global response to end the tuberculosis (TB) epidemic by 2030. Based on experiences in the HIV response, social protection, and in particular cash transfers, show promise for contributing to this. Currently, individual-level evidence for the potential of cash transfers to prevent TB by addressing the structural social determinants of disease is lacking. To identify priority actions for the TB research agenda, we appraised efforts by the HIV response to establish the role of cash transfers in preventing HIV infection. MAIN BODY The HIV response has evaluated the effects of cash transfers on risky sexual behaviours and HIV incidence. Work has also evaluated the added effects of supplementing cash transfers with psychosocial support. The HIV response has focused research on populations with disproportionate HIV risk, and used a mix of explanatory evaluations, which use ideal conditions, and pragmatic evaluations, which use operational conditions, to generate evidence that is both causally valid and applicable to the real world. It has always collaborated with multiple stakeholders in funding and evaluating projects. Learning from the HIV response, priority actions for the TB response should be to investigate the effect of cash transfers on intermediary social determinants of active TB disease, and TB incidence, as well as the added effects of supplementing cash transfers with psychosocial support. Work should be focused on key groups in high burden settings, and look to build a combination of explanatory and pragmatic evidence to inform policy decisions in this field. To achieve this, there is an urgent need to facilitate collaborations between groups interested in evaluating the impact of cash transfers on TB risk. CONCLUSIONS The HIV response highlights several priority actions necessary for the TB response to establish the potential of cash transfers to prevent TB by addresing the structural social determinants of disease.
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Affiliation(s)
- William E. Rudgard
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Daniel J. Carter
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - James Scuffell
- Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - Lucie D. Cluver
- Department of Social Policy & Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Delia Boccia
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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28
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Nimkar S, Valvi C, Kadam D, Rewari BB, Kinikar A, Gupte N, Suryavanshi N, Deluca A, Shankar A, Golub J, Bollinger R, Gupta A, Marbaniang I, Mave V. Loss to follow-up and mortality among HIV-infected adolescents receiving antiretroviral therapy in Pune, India. HIV Med 2018; 19:395-402. [PMID: 29573312 DOI: 10.1111/hiv.12605] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES India has the highest number of HIV-infected adolescents in Asia, but little is known about their treatment outcomes. We assessed rates and factors associated with loss to follow-up (LTFU) and mortality among Indian adolescents. METHODS The analysis included adolescents (10-19 years old) starting antiretroviral therapy (ART) between 2005 and 2014 at BJ Government Medical College, Pune, India. LTFU was defined as missing more than three consecutive monthly visits. The competing-risks method was used to calculate subdistribution hazard ratios (SHRs) of predictors for LTFU, with death as the competing risk. Cox proportional hazard models were used to identify predictors of mortality. RESULTS Of 717 adolescents starting ART, 402 with complete data were included in the analysis. Of these, 61% were male and 80% were perinatally infected, and the median baseline CD4 count was 174 cells/μL. LTFU and mortality rates were 4.4 and 4.9/100-person years, respectively. Cumulative LTFU incidence increased from 6% to 15% over 6 years. Age ≥ 15 years [adjusted SHR (aSHR) 2.44; 95% confidence interval (CI) 1.18-5.02] was a risk factor for LTFU. Cumulative mortality increased from 9.5% to 17.9% over 6 years. World Health Organization (WHO) stages III and IV [adjusted hazard ratio (aHR) 2.26; 95% CI: 1.14-4.48] and an increase in CD4 count by 100 cells/μL (aHR: 0.59; 95% CI: 0.43-0.83) were associated with mortality. CONCLUSIONS A third of adolescents had been lost to follow-up or died by follow-up year 6. Older age was a risk factor for LTFU and advanced clinical disease for death. Strategies to improve retention counselling for older adolescents and closer clinical monitoring of all adolescents must be considered.
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Affiliation(s)
- S Nimkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - C Valvi
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - D Kadam
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - B B Rewari
- National AIDS Control Organization, New Delhi, India
| | - A Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - N Gupte
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N Suryavanshi
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - A Deluca
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A Shankar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Golub
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - R Bollinger
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Gupta
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - I Marbaniang
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - V Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
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29
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Multicentre analysis of second-line antiretroviral treatment in HIV-infected children: adolescents at high risk of failure. J Int AIDS Soc 2018; 20:21930. [PMID: 28953325 PMCID: PMC5640308 DOI: 10.7448/ias.20.1.21930] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Introduction: The number of HIV-infected children and adolescents requiring second-line antiretroviral treatment (ART) is increasing in low- and middle-income countries (LMIC). However, the effectiveness of paediatric second-line ART and potential risk factors for virologic failure are poorly characterized. We performed an aggregate analysis of second-line ART outcomes for children and assessed the need for paediatric third-line ART. Methods: We performed a multicentre analysis by systematically reviewing the literature to identify cohorts of children and adolescents receiving second-line ART in LMIC, contacting the corresponding study groups and including patient-level data on virologic and clinical outcomes. Kaplan–Meier survival estimates and Cox proportional hazard models were used to describe cumulative rates and predictors of virologic failure. Virologic failure was defined as two consecutive viral load measurements >1000 copies/ml after at least six months of second-line treatment. Results: We included 12 cohorts representing 928 children on second-line protease inhibitor (PI)-based ART in 14 countries in Asia and sub-Saharan Africa. After 24 months, 16.4% (95% confidence interval (CI): 13.9–19.4) of children experienced virologic failure. Adolescents (10–18 years) had failure rates of 14.5 (95% CI 11.9–17.6) per 100 person-years compared to 4.5 (95% CI 3.4–5.8) for younger children (3–9 years). Risk factors for virologic failure were adolescence (adjusted hazard ratio [aHR] 3.93, p < 0.001) and short duration of first-line ART before treatment switch (aHR 0.64 and 0.53, p = 0.008, for 24–48 months and >48 months, respectively, compared to <24 months). Conclusions: In LMIC, paediatric PI-based second-line ART was associated with relatively low virologic failure rates. However, adolescents showed exceptionally poor virologic outcomes in LMIC, and optimizing their HIV care requires urgent attention. In addition, 16% of children and adolescents failed PI-based treatment and will require integrase inhibitors to construct salvage regimens. These drugs are currently not available in LMIC.
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30
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Tolley EE, Taylor J, Pack A, Greene E, Stanton J, Shelus V, Dunner R, Hodge T, Branson B, El-Sadr WM, Gamble T. The Role of Financial Incentives Along the Antiretroviral Therapy Adherence Continuum: A Qualitative Sub-study of the HPTN 065 (TLC-Plus) Study. AIDS Behav 2018; 22:245-257. [PMID: 28612215 PMCID: PMC5758676 DOI: 10.1007/s10461-017-1821-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The stages of change (SOC) theory suggests individuals adapt incrementally to behaviors like adherence, requiring different strategies over the behavior change continuum. Offering financial incentives (FIs) is one strategy to motivate adherence. This qualitative sub-study examined adherence barriers and the role of FIs to increase viral suppression (VS) among HIV Prevention Trials Network (HPTN) 065 study participants categorized into SOC-related adherence stages based on changes from baseline to follow-up viral load tests. Of 73 participants, most were in Maintenance stage (n = 31), defined as having achieved VS throughout HPTN 065, or in Action stage (n = 29), defined as moving from virally unsuppressed to suppressed in 50% or more of tests. Only 13 were Low Adherers, having achieved VS in fewer than 50% of tests. The latter group faced substantial social and structural adherence barriers. Participants in the Action stage made positive changes to adherence routines to achieve VS. Those in Maintenance were less incentivized by FIs, as they were already committed. Results from this sub-study suggest FI effectiveness may vary across the SOC continuum, with greatest impact for those initiating antiretroviral or without explicit adherence routines. FIs may be insufficient to overcome strong social or structural barriers, and unnecessary for those intrinsically committed to remaining adherent.
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Affiliation(s)
- Elizabeth E Tolley
- Behavioral, Epidemiological & Clinical Sciences Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA.
| | - Jamilah Taylor
- Behavioral, Epidemiological & Clinical Sciences Division, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Allison Pack
- Health Behavior Department, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth Greene
- Science Facilitation, FHI 360, 359 Blackwell St, Durham, NC, USA
| | - Jill Stanton
- Science Facilitation, FHI 360, 359 Blackwell St, Durham, NC, USA
| | - Victoria Shelus
- Institute for Reproductive Health, Georgetown University, Washington, DC, USA
| | | | | | | | | | - Theresa Gamble
- Science Facilitation, FHI 360, 359 Blackwell St, Durham, NC, USA
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31
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Sherr L, Tomlinson M, Macedo A, Skeen S, Hensels IS, Cluver LD. Can cash break the cycle of educational risks for young children in high HIV-affected communities? A cross-sectional study in South Africa and Malawi. J Glob Health 2017; 7:020409. [PMID: 29302316 PMCID: PMC5735773 DOI: 10.7189/jogh.07.020409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Household cash grants are associated with beneficial outcomes; enhanced if provided in combination with care. OBJECTIVES This study describes the impact of cash grants and parenting quality on 854 children aged 5-15 (South African and Malawi) on educational outcomes including enrolment, regular attendance, correct class for age and school progress (controlling for cognitive performance). Consecutive attenders at randomly selected Community based organisations were recruited. The effects of cash plus good parenting, HIV status and gender were examined. RESULTS Overall 73.1% received a grant - significantly less children with HIV (57.3% vs 75.6% (χ2 = 17.21, P < 0.001). Controlling for cognitive ability, grant receipt was associated with higher odds of being in the correct grade (odds ratio (OR) = 2.00; 95% confidence interval (CI) = 1.36, 2.95), higher odds of attending school regularly (OR = 3.62; 95% CI = 1.77, 7.40), and much higher odds of having missed less than a week of school recently (OR = 8.95; 95% CI = 2.27, 35.23). Grant receipt was not associated with how well children performed in school compared to their classmates or with school enrolment. Linear regression revealed that grant receipt was associated with a significant reduction in educational risk (B = -0.32, t(420) = 2.84, P = 0.005) for girls. CONCLUSION Cash plus good parenting affected some educational outcomes in a stepwise manner, but did not provide additive protection.
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Affiliation(s)
- Lorraine Sherr
- Research Department of Global Health, University College London, London, United Kingdom
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Ana Macedo
- Research Department of Global Health, University College London, London, United Kingdom
| | - Sarah Skeen
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape town, South Africa
| | - Imca Sifra Hensels
- Department of Psychology, University of Manchester, Manchester, United Kingdom
| | - Lucie Dale Cluver
- Department of Psychiatry and Mental Health, University of Cape Town, Cape town, South Africa
- Centre for Evidence–Based Intervention, Department of Social Policy & Social Intervention, University of Oxford, Oxford, United Kingdom
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32
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Cluver LD, Toska E, Orkin FM, Meinck F, Hodes R, Yakubovich AR, Sherr L. Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa? AIDS Care 2017; 28 Suppl 2:73-82. [PMID: 27392002 PMCID: PMC4991216 DOI: 10.1080/09540121.2016.1179008] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews find no effective adolescent adherence-promoting interventions. Social protection has demonstrated benefits for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10–19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa’s Eastern Cape were traced and interviewed in 2014–2015 (n = 1175 eligible). About 90% of the eligible sample was included (n = 1059). Social protection provisions were “cash/cash in kind”: government cash transfers, food security, school fees/materials, school feeding, clothing; and “care”: HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p = .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1–3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42–.76, p < .001); HIV support group attendance (aOR .60, CI .40–.91, p < .02), and high parental/caregiver supervision (aOR .56, CI .43–.73, p < .001). Combination social protection showed additive benefits. With no social protection, non-adherence was 54%, with any one protection 39–41%, with any two social protections, 27–28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of “cash plus care”, may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents.
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Affiliation(s)
- L D Cluver
- a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.,b Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - E Toska
- a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.,c AIDS and Society Research Unit, Centre for Social Science Research , University of Cape Town , Cape Town , South Africa
| | - F M Orkin
- d DPHRU, School of Clinical Medicine, and DST-NRF Centre of Excellence in Human Development , University of the Witwatersrand , Johannesburg , South Africa
| | - F Meinck
- a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK
| | - R Hodes
- a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.,c AIDS and Society Research Unit, Centre for Social Science Research , University of Cape Town , Cape Town , South Africa
| | - A R Yakubovich
- a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK
| | - L Sherr
- e Health Psychology Unit, Research Department of Infection & Population Health, University College London , London , UK
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Toska E, Cluver LD, Boyes ME, Isaacsohn M, Hodes R, Sherr L. School, Supervision and Adolescent-Sensitive Clinic Care: Combination Social Protection and Reduced Unprotected Sex Among HIV-Positive Adolescents in South Africa. AIDS Behav 2017; 21:2746-2759. [PMID: 27631367 PMCID: PMC5565649 DOI: 10.1007/s10461-016-1539-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine 'cash/cash-in-kind' and 'care' provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33-0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33-0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25-0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1-2 provisions 13-38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.
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Interventions to improve treatment, retention and survival outcomes for adolescents with perinatal HIV-1 transitioning to adult care: moving on up. Curr Opin HIV AIDS 2017; 11:477-486. [PMID: 27272537 DOI: 10.1097/coh.0000000000000302] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW There is an increasing number of deaths among adult survivors of perinatal HIV. Multiple and complex factors drive this mortality, including problems with retention in care and adherence during adolescence, coupled with the critical period of transition from paediatric to adult care, increasing their risk of treatment failure and severe immunosuppression. We reviewed studies that evaluated the impact of service delivery interventions to improve the health of perinatally infected adolescents living with HIV (P-ALHIV) to gain insight into what might help them survive the vulnerable period of adolescence. RECENT FINDINGS Youth-focused health services and individual-level interventions may improve P-ALHIV adherence and retention in care. However, there have been few studies, many with small sample sizes and with short durations of follow-up that end before the transition period. Studies from other childhood-onset chronic diseases are similarly limited. SUMMARY Further studies are urgently needed to identify optimal intervention strategies to reduce mortality and poor outcomes as the adolescent population expands and ages into adult care. Until we have a more robust evidence base, programmes can develop transition plans based on best practice recommendations to optimize the health and longevity of ALHIV in adulthood.
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Sherr L, Macedo A, Tomlinson M, Skeen S, Cluver LD. Could cash and good parenting affect child cognitive development? A cross-sectional study in South Africa and Malawi. BMC Pediatr 2017; 17:123. [PMID: 28499423 PMCID: PMC5427556 DOI: 10.1186/s12887-017-0883-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 05/08/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Social protection interventions, including cash grants and care provision have been shown to effectively reduce some negative impacts of the HIV epidemic on adolescents and families. Less is known about the role of social protection on younger HIV affected populations. This study explored the impact of cash grants on children's cognitive development. Additionally, we examined whether combined cash and care (operationalised as good parenting) was associated with improved cognitive outcomes. METHODS The sample included 854 children, aged 5 - 15, participating in community-based organisation (CBO) programmes for children affected by HIV in South Africa and Malawi. Data on child cognitive functioning were gathered by a combination of caregiver report and observer administered tests. Primary caregivers also reported on the economic situation of the family, cash receipt into the home, child and household HIV status. Parenting was measured on a 10 item scale with good parenting defined as a score of 8 or above. RESULTS About half of families received cash (55%, n = 473), only 6% (n = 51) reported good parenting above the cut-off point but no cash, 18% (n = 151) received combined cash support and reported good parenting, and 21% (n = 179) had neither. Findings show that cash receipt was associated with enhanced child cognitive outcomes in a number of domains including verbal working memory, general cognitive functioning, and learning. Furthermore, cash plus good parenting provided an additive effect. Child HIV status had a moderating effect on the association between cash or/plus good parenting and cognitive outcomes. The association between cash and good parenting and child cognitive outcomes remained significant among both HIV positive and negative children, but overall the HIV negative group benefited more. CONCLUSIONS This study shows the importance of cash transfers and good parenting on cognitive development of young children living in HIV affected environments. Our data clearly indicate that combined provision (cash plus good parenting) have added value.
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Affiliation(s)
- Lorraine Sherr
- Research Department of Global Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Ana Macedo
- Research Department of Global Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Sarah Skeen
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Lucie Dale Cluver
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Department of Social Policy & Social Intervention, Centre for Evidence-Based Intervention, University of Oxford, Oxford, UK
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Embleton L, Nyandat J, Ayuku D, Sang E, Kamanda A, Ayaya S, Nyandiko W, Gisore P, Vreeman R, Atwoli L, Galarraga O, Ott MA, Braitstein P. Sexual Behavior Among Orphaned Adolescents in Western Kenya: A Comparison of Institutional- and Family-Based Care Settings. J Adolesc Health 2017; 60:417-424. [PMID: 28110864 PMCID: PMC5389113 DOI: 10.1016/j.jadohealth.2016.11.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/28/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE This study sought to assess whether risky sexual behaviors and sexual exploitation of orphaned adolescents differed between family-based and institutional care environments in Uasin Gishu County, Kenya. METHODS We analyzed baseline data from a cohort of orphaned adolescents aged 10-18 years living in 300 randomly selected households and 19 charitable children's institutions. The primary outcomes were having ever had consensual sex, number of sex partners, transactional sex, and forced sex. Multivariate logistic regression compared these between participants in institutional care and family-based care while adjusting for age, sex, orphan status, importance of religion, caregiver support and supervision, school attendance, and alcohol and drug use. RESULTS This analysis included 1,365 participants aged ≥10 years: 712 (52%) living in institutional environments and 653 (48%) in family-based care. Participants in institutional care were significantly less likely to report engaging in transactional sex (adjusted odds ratio, .46; 95% confidence interval, .3-.72) or to have experienced forced sex (adjusted odds ratio, .57; 95% confidence interval, .38-.88) when controlling for age, sex, and orphan status. These associations remained when adjusting for additional variables. CONCLUSIONS Orphaned adolescents living in family-based care in Uasin Gishu, Kenya, may be at increased risk of transactional sex and sexual violence compared to those in institutional care. Institutional care may reduce vulnerabilities through the provision of basic material needs and adequate standards of living that influence adolescents' sexual risk-taking behaviors. The use of single items to assess outcomes and nonexplicit definition of sex suggest the findings should be interpreted with caution.
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Affiliation(s)
- Lonnie Embleton
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto Canada
| | | | - David Ayuku
- Department of Behavioral Sciences, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Edwin Sang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Samuel Ayaya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya,Department of Child Health and Paediatrics, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Winstone Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya,Department of Child Health and Paediatrics, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Peter Gisore
- Department of Child Health and Paediatrics, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Rachel Vreeman
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya,Department of Child Health and Paediatrics, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya,Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, USA,Indiana University School of Medicine, Department of Pediatrics, Indianapolis, IN, USA
| | - Lukoye Atwoli
- Department of Mental Health, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Omar Galarraga
- Department of Health Policy, Services, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Mary A. Ott
- Indiana University School of Medicine, Department of Pediatrics, Indianapolis, IN, USA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya; Department of Medicine, College of Health Sciences, School of Medicine, Eldoret, Kenya; Regenstrief Institute, Inc, Indianapolis, Indiana; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Ahonkhai AA, Banigbe B, Adeola J, Adegoke AB, Regan S, Bassett IV, Idigbe I, Losina E, Okonkwo P, Freedberg KA. Age Matters: Increased Risk of Inconsistent HIV Care and Viremia Among Adolescents and Young Adults on Antiretroviral Therapy in Nigeria. J Adolesc Health 2016; 59:298-304. [PMID: 27329680 PMCID: PMC5022362 DOI: 10.1016/j.jadohealth.2016.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/28/2016] [Accepted: 05/03/2016] [Indexed: 01/24/2023]
Abstract
PURPOSE Interruptions in HIV care are a major cause of morbidity and mortality, particularly in resource-limited settings. We compared engagement in care and virologic outcomes between HIV-infected adolescents and young adults (AYA) and older adults (OA) one year after starting antiretroviral therapy (ART) in Nigeria. METHODS We conducted a retrospective cohort study of AYA (15-24 years) and OA (>24 years) who initiated ART from 2009-2011. We used negative binomial regression to model the risk of inconsistent care and viremia (HIV RNA >1,000 copies/mL) among AYA and OA in the first year on ART. Regular care included monthly ART pickup and 3-monthly clinical visits. Patients with ≤3 months between consecutive visits were considered in care. Those with inconsistent care had >3 months between consecutive visits. RESULTS The cohort included 354 AYA and 2,140 OA. More AYA than OA were female (89% vs. 65%, p < .001). Median baseline CD4 was 252/μL in AYA and 204/μL in OA (p = .002). More AYA had inconsistent care than OA (55% vs. 47%, p = .001). Adjusting for sex, baseline CD4, and education, AYA had a greater risk of inconsistent care than OA (Relative Risk [RR]: 1.15, p = .008). Among those in care after one year on ART, viremia was more common in AYA than OA (40% vs. 26% p = .003, RR: 1.53, p = .002). CONCLUSIONS In a Nigerian cohort, AYA were at increased risk for inconsistent HIV care. Of patients remaining in care, youth was the only independent predictor of viremia at 1 year. Youth-friendly models of HIV care are needed to optimize health outcomes.
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Affiliation(s)
- Aimalohi A Ahonkhai
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Bolanle Banigbe
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria
| | - Juliet Adeola
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria
| | - Abdulkabir B Adegoke
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Susan Regan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts
| | - Ingrid V Bassett
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts
| | - Ifeoma Idigbe
- Nigerian Institute for Medical Research, Lagos, Nigeria
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | | | - Kenneth A Freedberg
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Toska E, Gittings L, Hodes R, Cluver LD, Govender K, Chademana KE, Gutiérrez VE. Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2016; 15:123-40. [PMID: 27399042 PMCID: PMC5558245 DOI: 10.2989/16085906.2016.1194299] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with "care" and "capability" among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.
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Affiliation(s)
- Elona Toska
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, 4.26 Leslie Social Sciences Building,12 University Avenue, Rondebosch, Cape Town, 7701, Western Cape, South Africa
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford Barnett House, 32 Wellington Square, Oxford, OX1 2ER, UK
| | - Lesley Gittings
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, 4.26 Leslie Social Sciences Building,12 University Avenue, Rondebosch, Cape Town, 7701, Western Cape, South Africa
- School of Public Health and Family Medicine, Division of Social and Behavioural Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Rebecca Hodes
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, 4.26 Leslie Social Sciences Building,12 University Avenue, Rondebosch, Cape Town, 7701, Western Cape, South Africa
| | - Lucie D. Cluver
- School of Public Health and Family Medicine, Division of Social and Behavioural Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa
| | - KE Chademana
- School of Public Health, University of the Western Cape, Private Bag X17 Bellville, Cape Town, South Africa
| | - Vincent Evans Gutiérrez
- School of Public Health and Family Medicine, Division of Social and Behavioural Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
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Affiliation(s)
- Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Jorge Pinto
- Department of Pediatrics, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
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