Falling through the gaps: how should HIV programmes respond to families that persistently deny treatment to children?

Qualitative inquiry into adolescents' experience of ethical challenges during enrollment and adherence to antiretroviral therapy (ART) in Temeke Regional Referral Hospital, Tanzania

Background

Adolescents living with human immunodeficiency virus (HIV) experience challenges, including lack of involvement in their care as well nondisclosure of HIV status, which leads to poor adherence to antiretroviral therapy (ART). Parents have authority over their children, but during adolescence there is an increasing desire for independence. The aim of the study was to explore adolescents’ experience of challenges identified by adolescents ages 10–19 years attending HIV care and treatment at Temeke Regional Referral Hospital in Tanzania.

Methods

An exploratory descriptive qualitative design was employed in the HIV Care and Treatment Centre (CTC) in the Out-Patient Department at the Temeke Regional Referral Hospital in Tanzania with adolescents living with HIV who were 10–19 years of age. A total of 22 adolescents participated in semi-structured face-to-face interviews after parental consent and adolescent assent were obtained. Participants were interviewed about their participation in decisions to be tested for HIV and enrolled in the CTC, concerns surrounding disclosure of their HIV status to the adolescent or to others, stigma and discrimination, and the effect of these challenges on their adherence to medication. All interviews were audio-taped, transcribed verbatim in Swahili, and back-translated to English. Data analysis included both inductive and deductive thematic analysis.

Results

Qualitative themes identified included lack of participation in decisions about HIV testing, challenges to enrollment in care and treatment; issues around disclosure of HIV status, such as delays in disclosure to the adolescent and disclosure to other persons and benefits and harms of such disclosures; and factors supporting and interfering with adherence to ART, such as parental support, organizational (clinic) support and problems, and self-stigmatization and shame.

Conclusion

Lack of adolescents’ involvement in their care decision making and delayed disclosure of HIV status to the adolescent were identified concerns, leading to poor adherence to ART among adolescents. Disclosure to others, especially teachers, helped adolescents at school to take their medication properly. Disclosure to others led to stigma and discrimination for some adolescents. More research is needed to better understand the role of disclosure and its benefits and challenges for HIV-positive adolescents in Tanzania.

The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda

Background

Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence.

Methods

Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy.

Results

The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART.

Conclusion

Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV.

Trial registration

This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

Retention and adherence: global challenges for the long-term care of adolescents and young adults living with HIV

PURPOSE OF REVIEW

Adolescents living with HIV are the only age group with increasing HIV mortality at a time of global scale-up of access to antiretroviral therapy (ART). As a 'treat all' strategy is implemented worldwide, it is critically important to optimize retention and adherence for this vulnerable group.

RECENT FINDINGS

Adolescents and young adults living with HIV have poorer outcomes when compared with adults at each stage of the HIV care cascade, irrespective of income setting. Rates of viral suppression are lowest for adolescents living with HIV, and adherence to ART remains an enormous challenge. High-quality studies of interventions to improve linkage to, and retention in, care on suppressive ART are starkly lacking for adolescents and young adults living with HIV across the globe. However, examples of good practice are beginning to emerge but require large-scale implementation studies with outcome data disaggregated by age, route of infection, and income setting, and include young pregnant women and key populations groups.

SUMMARY

There is an urgent need for evidence-based interventions addressing gaps in the adolescent HIV care cascade, including supporting retention in care and adherence to ART.

Healthcare Workers' Perspectives on the Barriers to Providing HIV Services to Children in Sub-Saharan Africa

Background

In order to accelerate the HIV response to meet the UNAIDS 90-90-90 indicators for children, healthcare workers need to lead a scale-up of HIV services in primary healthcare settings. Such a scale-up will require investigation into existing barriers that prevent healthcare workers from effectively providing those services to children. Furthermore, if the identified barriers are not well understood, designing context-specific and effective public health response programmes may prove difficult.

Objective

This study reviews the current literature pertaining to healthcare workers' perspectives on the barriers to providing HIV services to children in the primary care setting in Sub-Saharan Africa.

Methods

English articles published between 2010 and April 2018 were searched in electronic databases including Sabinet, MEDLINE, PubMed, and Google Scholar. Key search words used during the search were “healthcare workers' perspectives” and “barriers to providing HIV testing to children” OR “barriers to ART adherence AND children” and “barriers to HIV disclosure AND children.” Results. There are various barriers to provider-initiated counselling and testing (PICT) of children and disclosure of HIV status to children, including the following: lack of child-friendly infrastructure at clinics; lack of consensus on legal age of consent for both HIV testing and disclosure; healthcare worker unfamiliarity with HIV testing and disclosure guidelines; lack of training in child psychology; and confusion around the healthcare worker's role, which most believed was only to provide health education and clinical services and to correct false information, but not to participate in disclosure. Additionally, primary caregivers were reported to be a barrier to care and treatment of children as they continue to refuse HIV testing for their children and delay disclosure.

Conclusion

Training, mentoring, and providing healthcare workers with guidelines on how to provide child-focused HIV care have the potential to address the majority of the barriers to the provision of child-friendly HIV services to children. However, the need to educate primary caregivers on the importance of testing children and disclosing to them is equally important.

Characteristics of adolescents living with HIV receiving care and treatment services in antiretroviral therapy clinics in Cambodia: descriptive findings from a cross-sectional study

Background

Adolescents living with HIV experience worse HIV care outcomes compared to adults, especially during transition from pediatric to adult care. However, data regarding adolescents are limited. This paper describes and compares characteristics of male and female adolescents living with HIV preparing for transition from pediatric to adult care in Cambodia.

Methods

This cross-sectional study was conducted in August 2016 among 328 adolescents aged 15–17, randomly selected from 11 antiretroviral therapy (ART) clinics. Data were collected using a structured questionnaire, and descriptive analyses were conducted to compare characteristics of male and female adolescents.

Results

Of total, 55.2% were male, and 40.8% were living with parents. Majority (82.6%) got HIV infection from their mothers. Overall, adolescents had received ART for an average of 8.4 years, and HIV care for 9.5 years. Additionally, 82.4% were on first line ART regimen. Mean CD4 count from the most recent test was 672 cells/mm³, and viral load was 7686 copies/mL. Overall, 95.6% were adherent to ART on Visual Analogue Scale. About half (50.7%) had never disclosed their HIV status to anyone, while the remaining had disclosed it to their siblings (24.2%), friends (13.0%), schoolteachers (2.4%), or other (5.8%). A fifth reported having had boy or girlfriends, but few (2.1%) had ever had sexual intercourse. Females were more likely to have been engaged in sexual intercourse, and none reported having used a condom in their last intercourse. Few participants reported having ever used tobacco (1.8%), or any kind of illicit drugs (0.9%), but almost a fifth (20.7%) had a history of alcohol use. The majority (82.1%) were aware that they were receiving ART. HIV-related knowledge was suboptimal among the sample.

Conclusions

This study provides a snapshot of immunological, virological, adherence, and disclosure outcomes that should be tracked during and following healthcare transition to evaluate the effectiveness of the transition program. Findings showed high ART adherence, low likelihood of disclosure outside of family circles, sub-optimal condom use, and poor knowledge of HIV. To provide individualized support for healthcare transition, pediatric and adult clinics need to ensure that these characteristics are taken into account.

Social-support needs among adolescents living with HIV in transition from pediatric to adult care in Cambodia: findings from a cross-sectional study

BACKGROUND

Understanding the circumstances of adolescents living with HIV is critical in designing adolescent-friendly services that will facilitate successful transition from pediatric to adult care. This study describes access, utilization and ongoing social support needs among adolescents living with HIV aged 15-17 in transition from pediatric to adult HIV care in Cambodia.

METHODS

A cross-sectional study was conducted among 328 adolescents, randomly selected from 11 antiretroviral therapy (ART) clinics across the country. Descriptive analyses were conducted to summarize their characteristics, access to social support and ongoing support needs among male and female adolescents.

RESULTS

Mean age of the study participants was 15.8 (SD = 0.8) years. Just over half (55.2%) were male. Most had at least one deceased parent (mother 50.9%; father 60.5%), and majority were living with biological parents (40.8%) or relatives (49.3%). A third came from families with an ID poor card, and 21.0% were working for pay. Almost half (46.6%) reported that their family had received social support for their health care, including food support (76.5%), school allowance (62.1%), transport allowance to ART clinics (53.6%), psychosocial counseling (35.3%), vocational training (22.9%) or home visits (11.1%). Several ongoing social support needs were identified, including ongoing inability to cover health expenses unless they are supported by health insurance or health equity fund (55.0%). In addition, adolescents reported having been asked to come back earlier than their scheduled appointment (13.7%), having had to purchase their own drugs (2.7%), experiencing HIV stigma (32.0%), having been denied housing or food due to HIV (8.2%) or failing to attend school within the past month partly because of HIV (16.8%). Two-thirds did not have access to peer support groups.

CONCLUSIONS

Social protection mechanisms are reaching some adolescents in need, while other remain without social support due to discontinuities in health and social care. Multi-sectoral interventions, supporting school attendance, adolescent-friendly clinic scheduling, reductions in child employment, mitigation of HIV-related stigma and strengthening of peer-to-peer support are required to improve coverage of social protection interventions for adolescents in transition.

Familial silence surrounding HIV and non-disclosure of HIV status to older children and adolescents

Increasing numbers of children with HIV are surviving to adolescence and beyond, many of whom are orphaned. Disclosure of childrens' and adolescents' HIV status has been shown to improve adherence and retention in HIV treatment programmes. We investigated caregiving arrangements and intra-familial experience of HIV and its relationship to HIV disclosure to older children and adolescents. Children aged 6–15 years, newly diagnosed with HIV infection or previously diagnosed but not engaged in HIV care, were recruited from seven primary care clinics in Harare, Zimbabwe. Their caregivers responded to a nurse-led questionnaire. Family history of HIV, disclosure of HIV status to the child and reasons for non-disclosure were ascertained. The association between sociodemographics, caregiving, family HIV history and other characteristics and non-disclosure of HIV status to the child was determined using univariate and multivariate logistic regression. We recruited 385 participants, median age = 11 years (IQR: 9–13); 52% were female. Disclosure had occurred in 79% of children aged 11–15 years and 19% of children aged 6–10 years. Age under 11 years (adjusted OR [aOR] = 18.89, 95% confidence interval [CI] = 10.64–33.55; p < 0.001), being male [aOR]= 2.56, 95% CI = 1.49–4.54; p = 0.001, being unaware of the parents’ HIV status [aOR]= 32.42, 95% CI = 13.19–79.71; p < 0.001, and being newly diagnosed [aOR]= 2.52, 95% CI = 1.29–4.91; p = 0.007, were independently associated with non-disclosure. Disclosure outside of the family occurred infrequently and included friends of family (7%), school teacher (8%), school headmaster (4%) and church pastor (6%). High non-disclosure rates were present as well as a lack of discussion about HIV within the family. Disclosure outside of family was low reflecting difficulty in caregivers’ ability to discuss HIV with their child or surrounding community. HIV programmes need to support families in the disclosure process.

Scaling a waterfall: a meta-ethnography of adolescent progression through the stages of HIV care in sub-Saharan Africa

Introduction: Observational studies have shown considerable attrition among adolescents living with HIV across the “cascade” of HIV care in sub-Saharan Africa, leading to higher mortality rates compared to HIV-infected adults or children. We synthesized evidence from qualitative studies on factors that promote or undermine engagement with HIV services among adolescents living with HIV in sub-Saharan Africa.

Methods: We systematically searched five databases for studies published between 2005 and 2016 that met pre-defined inclusion criteria. We used a meta-ethnographic approach to identify first, second and third order constructs from eligible studies, and applied a socio-ecological framework to situate our results across different levels of influence, and in relation to each stage of the HIV cascade.

Results and discussion: We identified 3089 citations, of which 24 articles were eligible for inclusion. Of these, 17 were from Southern Africa while 11 were from Eastern Africa. 6 explored issues related to HIV testing, 11 explored treatment adherence, and 7 covered multiple stages of the cascade. Twelve third-order constructs emerged to explain adolescents’ engagement in HIV care. Stigma was the most salient factor impeding adolescents’ interactions with HIV care over the past decade. Self-efficacy to adapt to life with HIV and support from family or social networks were critical enablers supporting uptake and retention in HIV care and treatment programmes. Provision of adolescent-friendly services and health systems issues, such as the availability of efficient, confidential and comfortable services, were also reported to drive sustained care engagement. Individual-level factors, including past illness experiences, identifying mechanisms to manage pill-taking in social situations, financial (in)stability and the presence/absence of future aspirations also shaped adolescents HIV care engagement.

Conclusions: Adolescents’ initial and ongoing use of HIV care was frequently undermined by individual-level issues; although family, community and health systems factors played important roles. Interventions should prioritise addressing psychosocial issues among adolescents to promote individual-level engagement with HIV care, and ultimately reduce mortality. Further research should explore issues relating to care linkage and ART initiation in different settings, particularly as “test and treat” policies are scaled up.

Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe

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Background:

Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown.

Objective:

To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents.

Methods:

We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models.

Results:

Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively.

Conclusions:

Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.