Electronic measurement of adherence to pediatric antiretroviral therapy in South Africa

Barriers to viral suppression in children aged 9 years or younger on dolutegravir-based antiretroviral therapy in Malawi, a mixed-methods study

After the transition to pediatric dolutegravir-based regimens, viral load (VL) suppression among children with HIV (CWH) in Malawi has remained suboptimal. This mixed-methods study assessed factors associated with high VL among young CWH on dolutegravir-based antiretroviral therapy (ART) and explored adherence barriers from primary-caregiver and healthcare worker perspectives. Between April-July 2023, we performed an unmatched case-control study at 49 Malawian health facilities. We included CWH aged ≤9 years, on dolutegravir-based ART, with a routine VL test-result that was high (≥1,000 copies/mL) for cases, or suppressed (<200 copies/mL) for controls. Using mixed-effect modified Poisson regression, we determined factors associated with high VL, adjusting for sex, site and district. To assess adherence barriers, we conducted in-depth interviews (IDIs) with randomly selected caregivers of CWH with high VL and with healthcare workers providing pediatric HIV care. Data were analyzed using a hybrid thematic approach that combined deductive and inductive coding strategies. We enrolled 538 CWH: 222 cases, with high VL and 316 controls, with suppressed VL. Duration on ART > 4 years (aRR = 0.86, 95% CI: 0.77-0.95) and ≥2 interruption in treatment episodes (≥28 days late for clinic appointment) in the 12 months before VL sample collection (aRR = 1.47, 95% CI: 1.28-1.68) were significantly associated with high VL. Through 54 IDIs (30-caregivers, 24-healthcare workers), five key adherence challenges were identified and affected the children ≤5 years the most: resistance to daily medication, difficulties taking multiple pills, food insecurity, fear of unintentional disclosure, and inability to attend clinic appointments consistently. This study highlights that behavioral, socio-economic and psychosocial factors influences ART adherence among CWH. Duration on ART and recent interruptions in treatment were associated with high VL, stressing the need for targeted interventions that will require health-system and client-level approaches to improve VL suppression among CWH in Malawi and similar settings.

Pediatric HIV Disclosure Intervention Improves Immunologic Outcome at 48 Weeks: The Sankofa Trial Experience

BACKGROUND

The World Health Organization recommends disclosure of HIV status to children and adolescents living with HIV (CALWH). HIV disclosure improves adherence to antiretroviral therapy and immunologic and virologic outcomes. However, the prevalence of HIV disclosure is low in sub-Saharan Africa. We assessed the longitudinal effect of the Sankofa Pediatric HIV disclosure intervention on immunologic and virologic outcomes among CALWH in Ghana.

METHODS

We conducted a secondary analysis of a two-arm site-randomized clinical trial among CALWH aged 7-18 years. Data were collected at baseline, 24, and 48 weeks. Generalized linear mixed models were used to compare immunologic (CD4) and virologic (viral load) outcomes as both continuous and categorical variables by disclosure status and by intervention group.

RESULTS

Among participants who had their HIV status disclosed during this study, the proportion with CD4 percent >25% increased from 56.5% at baseline to 75.4% at week 48 ( P = 0.03), with a slight increase in the undisclosed group (69.5% vs. 74.3%, P = 0.56). In the intervention arm, there was a steady increase in proportion with CD4 percent >25% from 47.1% at baseline to 67.8% at week 48 ( P = 0.01) while it remained unchanged in the control arm (80.5% vs. 81.3% [ P = 0.89]). Concurrently, declines in detectable viral load were observed in both disclosed (63.3% vs. 51.5%, P = 0.16) and undisclosed (69.9% vs. 62.0%, P = 0.17) groups while the intervention group experienced a meaningful drop from 72.9% to 57.6% at 24 weeks ( P = 0.04), which was maintained at 48 weeks.

CONCLUSIONS

A structured, culturally relevant disclosure intervention can improve clinical outcomes.

Caregivers' psychosocial assessment for identifying HIV-infected infants at risk of poor treatment adherence: an exploratory study in southern Mozambique

Psychosocial support (PSS) to caregivers of HIV-infected infants on antiretroviral treatment (ART) is crucial to ensure ART adherence and sustained long-term viral suppression in children. A specific approach including tools to monitor and understand adherence behavior and risk factors that prevent optimal treatment compliance are urgently needed. This qualitative exploratory study, conducted in southern Mozambique, monitored the infants' viral response trajectories during 18 months follow-up, as a measure of adherence, reviewed the caregiver's PSS session notes and the answers to a study questionnaire, to analyze whether the standard PSS checklist applied to infants' caregivers can identify barriers influencing their adherence. Only 9 of 31 infants had sustained virologic response. Reported factors affecting adherence were: difficulties in drugs administration, shared responsibility to administer treatment; disclosure of child's HIV status to family members but lack of engagement; mother's ART interruption and poor viral response. In conclusion, we found that the standard PSS approach alone, applied to caregivers, was lacking focus on many relevant matters that were identified by the study questionnaire. A comprehensive patient-centered PSS package of care, including an adherence risk factor monitoring tool, tailored to caregivers and their children must be developed.

Known HIV status among adolescent women attending antenatal care services in Eswatini, Ethiopia and Mozambique

Background

Antenatal care (ANC) clinics remain important entry points to HIV care for pregnant women living with HIV—including adolescents. Prior knowledge of their HIV status at ANC enrollment is crucial to providing services for prevention of mother-to-child transmission (PMTCT) of HIV. We examined known HIV status of pregnant adolescents and women in other age groups at ANC enrollment.

Methods

A descriptive study of routinely reported PMTCT data from 419 facilities in Eswatini, Ethiopia, and Mozambique, from January through December 2018 was conducted. We assessed knowledge of HIV status by country for three age groups: adolescents aged 15–19 years, young women aged 20–24 years, and older women aged 25–49 years. We report HIV prevalence and proportions of known and newly diagnosed HIV infections in women, by age group and country. The data were summarized by frequencies and proportions, including their 95% confidence intervals.

Results

Among the facilities examined, 52 (12.4%) were in Eswatini, 63 (15.0%) in Ethiopia, and 304 (72.6%) in Mozambique. Across three countries, 488,121 women attended a first ANC visit and 23,917 (4.9%) were HIV-positive. Adolescents constituted 22% of all ANC attendees, whereas young and older women represented 33% and 45%, respectively. HIV prevalence was lowest among adolescents than in other age groups in Eswatini (adolescents 11.9%, young 24.2% and older 47.3%), but comparable to young women in Ethiopia (adolescents 1.6%, young 1.6% and older 2.2%) and Mozambique (adolescents 2.5%, young 2.5% and older 5.8%), However, in each of the three countries, lower proportions of adolescents knew their HIV-positive status before ANC enrollment compared to other age groups: in Eswatini (adolescents 51.3%, young 59.9% and older 79.2%), in Ethiopia (adolescents 42.9%, young 63.7% and older 75.2%), and in Mozambique (adolescents 16.4%, young 33.2% and older 45.6%).

Conclusion

Overall, adolescents made up nearly one-quarter of the women examined and had the least knowledge of their HIV status at ANC enrollment. Their HIV prevalence and known HIV-positive status varied widely across the countries examined. Adolescent-friendly sexual and reproductive health, and PMTCT services, before pregnancy, are needed to improve knowledge of HIV status and support pregnant adolescents and their infants.

Plain English summary

Antenatal care (ANC) clinics are important for HIV testing of pregnant adolescents, who may not know their HIV-positive status at the first ANC visit. We describe data on pregnant adolescents and women in other age groups in ANC services to examine their prior HIV status at ANC enrollment across three African countries.

We examined data from 419 PMTCT sites in Eswatini, Ethiopia, and Mozambique from January-December 2018, to evaluate HIV testing results for adolescents, young and older women aged 15–19, 20–24 and 25–49 years, respectively. We report the number of women living with HIV and the proportions of known and newly identified women living with HIV, by age-group and country.

Across three countries, 488,121 women attended ANC and 23,917 (4.9%) were living with HIV. Adolescents constituted 22% of all ANC attendees, whereas young and older women represented 33% and 45%, respectively. HIV prevalence in each country compared to other age groups was lowest and varied among adolescents from 11.9% in Eswatini, to 1.6% in Ethiopia and to 2.5% in Mozambique. Also, fewer adolescents knew their HIV-positive status before ANC enrollment compared to young and older women from 51.3% in Eswatini, 42.9% in Ethiopia to only 16.4% in Mozambique.

Pregnant adolescents made up nearly one-quarter of all ANC attendees; a majority of them had no previously known HIV-positive status. Adolescent-friendly, sexual and reproductive health services, before pregnancy and in PMTCT services, are needed to support pregnant adolescents and their infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01090-2.

Validation of a self-report adherence measurement tool among a multinational cohort of children living with HIV in Kenya, South Africa and Thailand

INTRODUCTION

There are few data on adherence and low-cost measurement tools for children living with HIV. We collected prospective data on adherence to antiretroviral therapy (ART) among a multinational cohort of children to evaluate an adherence questionnaire.

METHODS

We enrolled 319 children ages 0 to 16 years on ART in Kenya (n = 110), South Africa (n = 109) or Thailand (n = 100). Children were followed up for six months of adherence monitoring between March 2015 and August 2016 using Medication Event Monitoring Systems (MEMS® ) with at least one viral load measure. At month 3 and 6, children or their caregivers were administered a 10-item adherence questionnaire. Repeated measures analyses were used to compare responses on questionnaire items to external adherence criteria: MEMS® dichotomized adherence (≥90% of doses taken vs. <90%), 48-hour MEMS® treatment interruptions and viral suppression (<1000 copies/mL). Items associated with outcomes (p < 0.10) were coefficient-weighted to calculate a total adherence score, which was tested in multivariate regression against MEMS® and viral suppression outcomes. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Mean child age was 11 years and 54% were female. Children from Thailand (median age 14 years) were significantly older compared to Kenya (10 years) and South Africa (10 years). Prevalence of viral suppression was 97% in Thailand, 81% in South Africa and 69% in Kenya, while the prevalence of MEMS® adherence ≥90% was 57% in Thailand, 58% in South Africa and 40% in Kenya. Across sites, child-reported adherence using the questionnaire was significantly associated with dichotomized MEMS® adherence (OR 1.8, 95% CI 1.4 to 2.4), 48-hour treatment interruptions (OR 0.41, 95% CI 0.3 to 0.6), and viral suppression (OR 3.4, 95% CI 1.7 to 6.7). We did find, however, that different cut-points for the adherence score may be context-specific. For example, MEMS® non-adherent children in Kenya had a lower adherence score (0.98) compared to South Africa (1.77) or Thailand (1.58).

CONCLUSIONS

We found suboptimal adherence to ART was common by multiple measures in this multi-country cohort of children. The short-form questionnaire demonstrated reasonable validity to screen for non-adherence in these diverse settings.

Validation of a Short Adherence Questionnaire for Children Living with HIV on Antiretroviral Therapy in Kenya

Background:

There are few validated tools to measure adherence for children living with HIV. We identified questionnaire items for caregivers of Kenyan children aged <15 years living with HIV.

Methods:

Caregiver–child dyads were followed for 6 months. At monthly visits, the child’s HIV provider administered a 10-item questionnaire to the caregiver. Children were given electronic dose monitors (Medication Event Monitoring Systems [MEMS]). Correlation between questionnaire items and dichotomized MEMS adherence (≥90% doses taken versus <90%) was investigated using logistic regression models.

Results:

In 95 caregiver–child dyads, mean age of children (40% female) was 8.3 years. Items associated with higher odds of MEMS adherence in multivariable analysis included the father giving the child medication, being enrolled in a nutrition program, and the caregiver reporting no difficulties giving the child medication.

Conclusion:

Providers typically ask about missed doses, but asking about caregiver responsibilities and difficulties in giving the child medication may better detect suboptimal adherence.

Comparison of the predictive performance of adherence measures for virologic failure detection in people living with HIV: a systematic review and pairwise meta-analysis

A critical feature of an adherence assessment tool is its ability to predict virologic failure in people living with HIV (PLHIV). We, therefore, aimed to compare the predictive performance of commonly used adherence measures. We systematically searched MEDLINE, Embase and LILACS up to February 2018, to identify relevant observational studies comparing the effects of any two of the following adherence measurements on virologic outcomes: electronic monitoring, pill count, pharmacy refill, self-report and physician assessment. We analyzed data by pairwise meta-analyzes with a random-effects model. The proportion of virologic failures among non-adherent participants in each adherence measure was used to calculate the odds ratio (OR), with 95% Confidence Intervals (95%CI). Heterogeneity was assessed, with potential causes identified by sensitivity and subgroup analysis. We included 38 studies with individual patient data for 18,010 patients. All possible comparisons between pairs of the five adherence measures were considered and a total of nine comparison groups could be established. Meta-analysis suggested that self-report was a better predictor of virologic failure than pill count when the recall period was within one week (OR: 2.35, 95%CI: 1.07-5.18, p = 0.03). Physician assessment had higher odds of predicting virologic failure than did either self-report (OR: 2.63, 95%CI: 1.37-5.26, p < 0.01) or pharmacy refill (OR: 3.57, 95%CI: 1.69-7.14, p < 0.001). There was no difference in the predictive performance between any of the other measures that we were able to compare (p > 0.05). The combination of multiple measures did not increase the predictive value when compared to any of the measures alone. Low-cost and simple adherence measures such as self-report predict virologic failure better than or equally well as objective measures. Our results suggest that there is no need to use expensive or time-consuming adherence measures when the objective is to identify PLHIV at risk of treatment failure.

High prevalence of non-adherence to antiretroviral therapy among undisclosed HIV-infected children in Ghana

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7-18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0%-100.0%). However, only 47.5% of children had ≥95% adherence ("good adherence") using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29-6.56), p = 0.010) or elementary education only (aOR, 2.20, CI, 1.24-3.88, p = 0.007) were more likely to have "good adherence" (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).

Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa

OBJECTIVE

To describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium.

METHODS

This study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis.

RESULTS

In East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]).

CONCLUSIONS

Self-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.

Patterns of HIV Treatment Adherence do not Differ Between Male and Female Adolescents in Botswana

We hypothesized that longer and more frequent dosing gaps among boys in Botswana taking antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection compared to girls could account for previously seen gender-specific differences in outcomes. We monitored 154 male and 134 female adolescents for 2 years with medication event monitoring systems (MEMS). Median adherence was 95.6 % for males and 95.7 % for females (p = 0.40). There were no significant gender differences in the number of ≥7 day (p = 0.55) and ≥14 day (p = 0.48) dosing gaps. The median maximal gap was 7.7 days for males and 8.0 days for females (p = 0.47). These findings are not consistent with clinically meaningful gender differences in adherence.

A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.

Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review

Introduction

Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour.

Methods

We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed.

Discussion

Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV.

Conclusions

Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.

Comprehensive evaluation of caregiver-reported antiretroviral therapy adherence for HIV-infected children

For HIV-infected children, adherence to antiretroviral therapy (ART) is often assessed by caregiver report but there are few data on their validity. We conducted prospective evaluations with 191 children ages 0-14 years and their caregivers over 6 months in western Kenya to identify questionnaire items that best predicted adherence to ART. Medication Event Monitoring Systems(®) (MEMS, MWV/AARDEX Ltd., Switzerland) electronic dose monitors were used as external criterion for adherence. We employed a novel variable selection tool using the LASSO technique with logistic regression to identify items best correlated with dichotomized MEMS adherence (≥90 or <90 % doses taken). Nine of 48 adherence items were identified as the best predictors of adherence, including missed or late doses in the past 7 days, problems giving the child medicines, and caregiver-level factors like not being present at medication taking. These items could be included in adherence assessment tools for pediatric patients.

Evaluation of adherence measures of antiretroviral prophylaxis in HIV exposed infants in the first 6 weeks of life

BACKGROUND

Adherence to an antiretroviral regimen is imperative for treatment success in both HIV infected adults and children. Likewise, adherence to antiretroviral prophylaxis is critical in HIV prevention. Studies on pediatric adherence are limited, particularly the prophylactic use of antiretroviral drugs and treatment adherence in very young infants. The HIV Prevention Trials Network (HPTN) 046 study (Clinical Trial Registration NCT00074412) determined the safety and efficacy of an extended regimen of nevirapine suspension in infants born to HIV-1 infected women for the prevention of vertical HIV transmission during breastfeeding. As per protocol, adherence to nevirapine prophylaxis was measured by maternal verbal reports. In addition, the pharmacy assessed the unused returned suspension. The aim of this sub-study was to determine the reliability of maternal verbal reports in measuring adherence to antiretroviral prophylaxis in infants in the first 6 weeks of life and evaluating the unused returned nevirapine as an alternative method of measuring adherence.

METHODS

Maternal verbal reports and pharmacy returns indicative of "missed < 2 doses" were evaluated against a plasma nevirapine concentration of >100 ng/ml in a subgroup of infants at 2, 5 and 6 weeks of age. Plasma nevirapine concentration of >100 ng/ml was used as a marker of adherence (10 times the in vitro IC50 against HIV).

RESULTS

Adherence was 87.7% (maternal verbal report) and 71.3% (unused returned medication), as compared to 85.6% by plasma nevirapine concentration. Evaluated against plasma nevirapine concentration <100 ng/ml, the sensitivity and specificity of maternal verbal reports to detect a missed dose in the last 3 days were 75% and 78% (p = 0.03) respectively. Overall, among infants who were classified as adherent based on missed doses by maternal verbal reports and unused returned medication, 88.4% and 87.4% of infants attained a nevirapine concentration above 100 ng/ml respectively.

CONCLUSION

Maternal verbal reports are a reliable measure of adherence to infant antiretroviral prophylaxis in the first 6 weeks of life and could be useful in assessing adherence to antiretroviral treatment in infants younger than 6 weeks. In the absence of resources or expertise to determine plasma drug concentration, we would recommend random assessments of unused returned medication.

Relationship between viral load and behavioral measures of adherence to antiretroviral therapy in children living with human immunodeficiency virus in Latin America

Few studies have examined antiretroviral therapy adherence in Latin American children. Standardized behavioral measures were applied to a large cohort of human immunodeficiency virus-infected children in Brazil, Mexico, and Peru to assess adherence to prescribed antiretroviral therapy doses during the three days prior to study visits, assess timing of last missed dose, and evaluate the ability of the adherence measures to predict viral suppression. Time trends in adherence were modeled using a generalized estimating equations approach to account for possible correlations in outcomes measured repeatedly in the same participants. Associations of adherence with human immunodeficiency virus viral load were examined using linear regression. Mean enrollment age of the 380 participants was 5 years; 57.6% had undetectable’ viral load (<400 copies/mL). At enrollment, 90.8% of participants were perfectly (100%) adherent, compared to 87.6% at the 6-month and 92.0% at the 12-month visit; the proportion with perfect adherence did not differ over time (p = 0.1). Perfect adherence was associated with a higher probability of undetectable viral load at the 12-month visit (odds ratio = 4.1, 95% confidence interval: 1.8–9.1; p < 0.001), but not at enrollment or the 6-month visit (p > 0.3). Last time missed any antiretroviral therapy dose was reported as “never” for 52.0% at enrollment, increasing to 60.7% and 65.9% at the 6- and 12-month visits, respectively (p < 0.001 for test of trend). The proportion with undetectable viral load was higher among those who never missed a dose at enrollment and the 12-month visit (p ≤ 0.005), but not at the 6-month visit (p = 0.2). While antiretroviral therapy adherence measures utilized in this study showed some association with viral load for these Latin American children, they may not be adequate for reliably identifying non-adherence and consequently children at risk for viral resistance. Other strategies are needed to improve the evaluation of adherence in this population.

Cognitive interviewing for cross-cultural adaptation of pediatric antiretroviral therapy adherence measurement items

BACKGROUND

There are 2.3 million children living with HIV worldwide, almost 90 % of whom live in sub-Saharan Africa. Access to antiretroviral therapy (ART) for HIV treatment has dramatically increased in resource-limited settings in recent years and allows more HIV-infected children to survive into adolescence and adulthood.

PURPOSE

Our objective was to improve the understandability of pediatric antiretroviral adherence measurement items for use in resource-limited settings through cognitive interviewing with pediatric caregivers and HIV-infected adolescents in Kenya.

METHODS

We compiled adherence measurement items through a systematic literature review and qualitative work. We conducted cognitive interviews assessing the items with caregivers of HIV-infected children enrolled in HIV care in Kenya and conducted group cognitive assessments with HIV-infected adolescents. We used verbal probing and guided "thinking aloud" to evaluate relevance, comprehension, recall, and sensitivity/acceptability. Analysis followed a systematic sequence of review, compiling data by item, and coding responses.

RESULTS

We interviewed 21 Kenyan parents and guardians and 10 adolescents (mean age 15 years, SD 1.8) on antiretroviral therapy for a mean of 3.6 years. Cognitive interviews optimized item-response options, wording, and content. Some participants demonstrated difficulty with "think aloud" processes, but verbal probes were easily answered. Comprehension problems were found for key language concepts such "missed doses" and "having side effects." Key findings for response options included differences among responses to various recall periods, with preferences for the shortest (one 24-h day) and longest recall periods (1 month); difficulty describing specific drug information; benefits for including normalizing statements before asking for sensitive information; and challenges processing categorical frequency scales. Important content areas for inclusion included dose timing, disclosure, stigma, and food insecurity.

CONCLUSIONS

Cognitive interviewing is a productive strategy for increasing the face validity and understandability of adherence measurement items, particularly across cultures. Interviews in Kenya suggested adherence measurement modifications of relevance for other resource-limited settings.

The importance of caregivers in the outcome of pediatric HIV management, Mombasa, Kenya

We assessed programmatic gaps that prevent the optimal treatment of pediatric HIV infection despite free antiretroviral care in Kenya. Of 626 HIV-infected Kenyan children, the median age was five years, 54% were male and the mortality rate was 3.2 per 100 person-years. A total of 380 (61%) children initiated antiretroviral therapy (ART) during the study period. Among the 246 children who never started ART, 129 (52%) met the criteria for ART initiation. Immunologic failure occurred in 20% of children who received ART for >24 weeks. In multivariate analysis, immunological failure was associated with having nonimmediate relative or unrelated caregivers accompanying the child to clinic (AOR = 69.16, p = 0.008). Having ≥ 3 types of accompanying caregivers was also associated with virologic failure in multivariate analysis (AOR = 3.84, p = 0.03). The lost to follow-up rate was 8.7/100 persons-years for the entire cohort, and significantly higher (17.7/100 persons-years) among children not on ART (p < 0.001). Among children who do initiate ART, those with the best treatment outcomes were those who had a limited number of close relatives as caregivers and good adherence to ART. Focus on early ART initiation and education of the right caregiver will likely improve retention and quality of pediatric HIV care in Kenya.

Cost of behavioral interventions utilizing electronic drug monitoring for antiretroviral therapy adherence

OBJECTIVE

To provide data on the actual costs associated with behavioral ART adherence interventions and electronic drug monitoring used in a clinical trial to inform their implementation in future studies and real-world practice.

METHODS

Direct and time costs were calculated from a multisite 3-arm randomized controlled ART adherence trial. HIV-positive participants (n = 204) were randomized to standard care, enhanced counseling (EC), or EC and modified directly observed therapy (mDOT) interventions. Electronic drug monitoring (EDM) was used. Costs were calculated for various components of the 24-week adherence intervention. This economic evaluation was conducted from the perspective of an agency that may wish to implement these strategies. Sensitivity analyses were conducted to examine costs and savings associated with different scenarios.

RESULTS

Total direct costs were $126,068 ($618 per patient). Initial time costs were $53,590 ($262 per patient). Base cost of labor was $0.36/min. EC costs for 134 patients were $18,427 ($137 per patient) and mDOT for 64 patients cost $18,638 ($291 per patient). Total per patient costs were as follows: standard care = $880, EC = $1018, EC/mDOT = $1309. Removing driving costs evidenced the most variable impact on savings between the 3 study arms. The tornado diagram (sensitivity analysis) showed a graphical representation of how each sensitivity assumption reduced costs compared with each other and the resulting comparative costs for each group.

CONCLUSIONS

This novel economic analysis provides valuable cost information to guide treatment implementation and research design decisions.

Adherence and viral suppression among infants and young children initiating protease inhibitor-based antiretroviral therapy

BACKGROUND

High levels of adherence to antiretroviral therapy are considered necessary to achieve viral suppression. We analyzed data from a cohort of HIV-infected children who were <2 years of age receiving protease inhibitor-based antiretroviral therapy to investigate associations between viral suppression and adherence ascertained using different methods.

METHODS

Data were from the prerandomization phase of a clinical trial in South Africa of HIV-infected children initiating either ritonavir-boosted lopinavir (LPV/r) or ritonavir-based antiretroviral therapy. At scheduled visits during the first 24 weeks of enrollment, study pharmacists measured quantities of medications returned to the clinic. Caregivers answered questionnaires on missed doses and adherence barriers. Associations between adherence and viral suppression (HIV-1 RNA <400 copies/mL) were investigated by regimen.

RESULTS

By 24 weeks, 197 of the 269 (73%) children achieved viral suppression. There was no association between viral suppression and caregiver reported missed doses or adherence barriers. For children receiving the LPV/r-based regimen, medication return adherence to each of the 3 drugs in the regimen (LPV/r, lamivudine or stavudine) individually or together was associated with viral suppression at different adherence thresholds. For example, <85% adherence to any of the 3 medications significantly increased odds of lack of viral suppression (odds ratio: 2.30, 95% confidence interval: 1.30-4.07, P = 0.004). In contrast, for children receiving the ritonavir-based regimen, there was no consistent pattern of association between medication return and viral suppression.

CONCLUSIONS

Caregiver reports of missed doses did not predict virologic response to treatment. Pharmacist medication reconciliation correlated strongly with virologic response for children taking a LPV/r-based regimen and appears to be a valid method for measuring pediatric adherence.

A meta-analysis of adherence to antiretroviral therapy and virologic responses in HIV-infected children, adolescents, and young adults

The relationship between adherence to antiretroviral therapy (ART) and virologic outcomes in HIV+ children, adolescents, and young adults has been notably understudied, with much of the extant research focused on specific sub-literatures, such as resource-limited regions, specific clinical outcomes and time frames. The authors sought to better characterize the relationship between adherence to ART and virologic functioning along various sample and methodological factors. The authors conducted a meta-analysis of thirty-seven studies and utilized a random effects model to generate weighted mean effect sizes. In addition, the authors conducted meta-ANOVAs to examine potential factors influencing the relationship between adherence and three categories of clinical outcomes, specifically Viral Load (VL) <100, VL < 400, and continuously measured VL. The analyses included 5,344 HIV+ children, adolescents, and young adults. The relationship between adherence behaviors and virologic outcomes varied across different methods of measurement and analysis. The relationship between adherence and continuously measured VL was significantly larger than for dichotomously-coded VL < 400 at Qb (20.69(1), p < .0005). Caregiver self-report indices elicited very small to small magnitude effects across both VL < 100 and VL < 400 outcomes and combined informant reporting (youth/adolescent and parent) produced significantly larger effects than caregiver report alone with adherence and VL < 400 outcomes at Qb (9.28(1), p < .005). More recently published trials reported smaller relationships between adherence and categorical clinical outcomes, such that year of publication significantly negatively correlated with VL < 100 (r = -.71(14), p < .005) and VL < 400 (r = -.43(26), p < .02). The data suggest that the magnitude of the relationship between ART adherence and virologic outcomes among heterogeneous samples of HIV+ children, adolescents and young adults varies across virologic outcomes and may be affected by moderating sample and methodological factors. Methodological and research recommendations for the interpretation of the current findings as well as for future HIV adherence related research are presented.

Adherence to antiretroviral therapy in HIV-positive adolescents in Uganda assessed by multiple methods: a prospective cohort study

BACKGROUND

The effectiveness of traditional adherence measurements used in adolescent populations is difficult to assess. Antiretroviral (ARV) adherence research among adolescents living with HIV in resource-constrained countries is particularly challenging and little evidence is available.

OBJECTIVES

The primary objective of this study was to determine the feasibility of a large-scale, long-term study using electronic adherence monitoring in Uganda. The secondary objective was to compare accuracy of pill count (PC) and self-report (SR) adherence with electronic medication vials (eCAPs™).

METHODS

Adolescents receiving ARV therapy at the Joint Clinical Research Centre in Kampala, Uganda, were recruited. ARVs were dispensed in eCAPs™ for 1 year. Person-pill-days (PPDs) [1 day where adherence was measured for one medication in one patient] were calculated and a weighted paired t-test was used to compare the levels of adherence among subjects for three different adherence measurement methods.

RESULTS

Fifteen patients were included: 40% were female, mean age was 14 years, mean baseline CD4+ cell count was 244 cells/μL, and average treatment duration was 9 months at study entry. Overall, 4721 PPDs were observed. Some eCAPs™ required replacement during the study resulting in some data loss. Consent rate was high (94%) but was slow due to age limit cut-points. Overall adherence for SR was 99%, PC was 97% and eCAP™ was 88% (p<0.05 for all comparisons). 93%, 67% and 23% of patients had an adherence of greater than 95% as measured by SR, PC and eCAP™ methods, respectively.

CONCLUSIONS

A large-scale adherence study in Uganda would be feasible using a more robust electronic monitoring system. Adherence measurements produced by PCs and self-reporting methods appear to overestimate adherence measured electronically.

Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel

DESCRIPTION

After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV.

METHODS

A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation.

RECOMMENDATIONS

Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.

Multiple measures reveal antiretroviral adherence successes and challenges in HIV-infected Ugandan children

BACKGROUND

Adherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood.

METHODOLOGY/PRINCIPAL FINDINGS

To understand the level, distribution, and correlates of ART adherence behavior, we prospectively determined monthly ART adherence through multiple measures and six-monthly HIV RNA levels among 121 Ugandan children aged 2-10 years for one year. Median adherence levels were 100% by three-day recall, 97.4% by 30-day visual analog scale, 97.3% by unannounced pill count/liquid formulation weights, and 96.3% by medication event monitors (MEMS). Interruptions in MEMS adherence of ≥ 48 hours were seen in 57.0% of children; 36.3% had detectable HIV RNA at one year. Only MEMS correlated significantly with HIV RNA levels (r = -0.25, p = 0.04). Multivariable regression found the following to be associated with <90% MEMS adherence: hospitalization of child (adjusted odds ratio [AOR] 3.0, 95% confidence interval [CI] 1.6-5.5; p = 0.001), liquid formulation use (AOR 1.4, 95%CI 1.0-2.0; p = 0.04), and caregiver's alcohol use (AOR 3.1, 95%CI 1.8-5.2; p<0.0001). Child's use of co-trimoxazole (AOR 0.5, 95%CI 0.4-0.9; p = 0.009), caregiver's use of ART (AOR 0.6, 95%CI 0.4-0.9; p = 0.03), possible caregiver depression (AOR 0.6, 95%CI 0.4-0.8; p = 0.001), and caregiver feeling ashamed of child's HIV status (AOR 0.5, 95%CI 0.3-0.6; p<0.0001) were protective against <90% MEMS adherence. Change in drug manufacturer (AOR 4.1, 95%CI 1.5-11.5; p = 0.009) and caregiver's alcohol use (AOR 5.5, 95%CI 2.8-10.7; p<0.0001) were associated with ≥ 48-hour interruptions by MEMS, while second-line ART (AOR 0.3, 95%CI 0.1-0.99; p = 0.049) and increasing assets (AOR 0.7, 95%CI 0.6-0.9; p = 0.0007) were protective against these interruptions.

CONCLUSIONS/SIGNIFICANCE

Adherence success depends on a well-established medication taking routine, including caregiver support and adequate education on medication changes. Caregiver-reported depression and shame may reflect fear of poor outcomes, functioning as motivation for the child to adhere. Further research is needed to better understand and build on these key influential factors for adherence intervention development.

Do automated text messages increase adherence to acne therapy? Results of a randomized, controlled trial

BACKGROUND

Acne is a common skin condition often requiring complex therapeutic regimens. Patient nonadherence to prescribed medication regimens is a factor in treatment failure.

OBJECTIVE

The goal of this study was to determine if daily automated text messages would result in increased adherence to recommended use of topical acne medication and consequently greater improvement in acne.

METHODS

Forty patients with mild to moderate acne were prescribed clindamycin/benzoyl peroxide 1%/5% gel in the mornings and adapalene 0.3% gel in the evenings for 12 weeks. Each medication tube was fitted with an electronic Medication Event Monitoring System cap (MEMS, Aardex Group, Sion, Switzerland) (to record the date and time of every opening/closing of the tube). Twenty patients were randomly assigned to receive customized twice-daily text messages instructing them to apply their morning and evening medication. The remainder of patients (N = 20), who did not receive text messages, served as control subjects.

RESULTS

Mean adherence rates for the correct application of both medications on a daily basis over 12 weeks was 33.9% for patients in the reminder group and 36.5% for patients in the control group (P = .75). Patients in both groups had similar clinical improvement of their acne.

LIMITATIONS

The small sample size may limit the ability to detect differences between the study groups.

CONCLUSIONS

Electronic reminders in the form of daily, customized text messages were not associated with significant differences in adherence to topical medications in patients with mild to moderate acne and had no significant effect on therapeutic response.

Adherence to tablet and liquid formulations of antiretroviral medication for paediatric HIV treatment at an urban clinic in Uganda

BACKGROUND

Major obstacles remain in scaling up paediatric HIV treatment, including limited paediatric anti-retroviral drug options for resource-limited settings, challenges with adherence to liquid formulations and treatment fatigue with lifelong therapy.

AIM

To determine levels of adherence to HAART in HIV-infected children at 12, 24, 36 and 48 weeks of follow-up and to compare adherence levels before and after switching from syrup to fixed-dose combination (FDC)-tablet anti-retroviral formulations.

METHODS

HIV-infected children aged between 6 months and 12 years were initiated on anti-retroviral therapy at Makerere University-Johns Hopkins University Care Clinic, Kampala. Good adherence to HAART was defined as taking ≥95% of prescribed medications. Adherence levels were measured using pharmacy refill data, quarterly unannounced home-visit pill counts and caregiver self-reports. Data were analysed using STATA(®) version 10.0.

RESULTS

A total of 129 HIV-infected children were initiated on HAART with 14.7% on syrups and 85.3% on tablet formulations at enrollment. According to caregiver self-reporting, 99.2%, 100%, 100% and 99.2% achieved ≥95% adherence at 12, 24, 36 and 48 weeks, respectively. Using pharmacy refill data, the proportions were 89.9%, 95.4%, 93.8% and 93.0% and for unannounced home visits were 89.8%, 92.4%, 88.9% and 86.2%, respectively. Median adherence to syrup formulations (97%, IQR 93-98) was significantly lower than for tablets (100%, IQR 97-100, p = 0.012, n = 28) using pharmacy refill data. Viral suppression correlated with home visit and pharmacy refill adherence data.

CONCLUSION

The majority of children initiating HAART had good adherence when estimated by caregiver self-report and pharmacy refill data but lower adherence when measured by home-visit pill counts. Adherence to tablet formulation of HAART was significantly better than syrup formulation. Medication formulation did not significantly affect viral suppression.

Suitability of measures of self-reported medication adherence for routine clinical use: a systematic review

BACKGROUND

There is a recognised need to build primary care medication adherence services which are tailored to patients' needs. Continuous quality improvement of such services requires a regular working method of measuring adherence in order to monitor effectiveness. Self report has been considered the method of choice for clinical use; it is cheap, relatively unobtrusive and able to distinguish between intentional and unintentional non-adherence, which have different underlying causes and therefore require different interventions. A self report adherence measure used in routine clinical practice would ideally be brief, acceptable to patients, valid, reliable, have the ability to distinguish between different types of non-adherence and be able to be completed by or in conjunction with carers where necessary.

METHODS

We systematically reviewed the literature in order to identify self report adherence measures currently available which are suitable for primary care and evaluate the extent to which they met the criteria described above. We searched the databases Medline, Embase, International Pharmaceutical Abstracts, Pharmline, CINAHL, PsycINFO and HaPI to identify studies reporting the development, validation or reliability of generic adherence measures. One reviewer screened all abstracts and assessed all relevant full text articles obtained and a second reviewer screened/assessed 10% to check reliability.

RESULTS

Fifty eight measures were identified. While validation data were presented in support of the vast majority of self reported measures (54/58), data for a relatively small number of measures was presented for reliability (16/58) and time to complete (3/58). Few were designed to have the ability to be completed by or in conjunction with carers and few were able to distinguish between different types of non-adherence, which limited their ability be used effectively in the continuous improvement of targeted adherence enhancing interventions. The data available suggested that patients find it easier to estimate general adherence than to report a specific number of doses missed. Visual analogue scales can be easier for patients than other types of scale but are not suitable for telephone administration.

CONCLUSIONS

There is a need for a measure which can be used in the routine continual quality monitoring of adherence services.

Barriers to and facilitators of adherence to pediatric antiretroviral therapy in a sub-Saharan setting: insights from a qualitative study

Despite the need for HIV-positive children to adhere effectively to antiretroviral treatment (ART), a guiding theory for pediatric ART in resource-limited settings is still missing. Understanding factors that influence pediatric ART adherence is critical to developing adequate strategies. In-depth qualitative interviews were undertaken in Kinshasa, Democratic Republic of the Congo, with 20 sets of HIV disclosed and nondisclosed children along with respective caregivers to better characterize barriers, facilitators, and adherence experiences in children taking ART. Commonly cited barriers included lack of food or nutritional support, lack of assistance or supervision for children, lack of assistance for caregivers, and being unable to remember to take medicines on a consistent basis. Facilitators included having a strong caregiver-child relationship and support system along with strategies for maintaining adherence. Similar themes arose within the child-caregiver sets, but were often characterized differently between the two. Children who were aware of their HIV status displayed fewer instances of frustration and conflict concerning taking medicines and within the child-caregiver relationship. Continued study on pediatric ART adherence should account for differing perspectives of children and caregivers, as well as between status disclosed and nondisclosed children. Areas of future intervention should focus on child-caregiver relationships, disclosure of HIV status, and available nutritional and psychosocial support for children and their caregivers.

Predictors of adherence to antiretroviral treatment and therapeutic success among children in South Africa

The recent years have shown an up-scaling of treatment programs for HIV-infected children in resource-limited settings, with an increased focus on adherence. Little is known, however, about the influence of socioeconomic as well as caregivers' health beliefs on both adherence and virologic outcome of pediatric antiretroviral treatment in these settings. We conducted a cross-sectional study with 57 caregiver-child dyads at a public hospital in Cape Town, South Africa. Adherence was electronically monitored over three months, viral loads were available pre- and post-study. Caregivers answered questionnaires on their socioeconomic situation, attitudes toward and knowledge about treatment, and quality of life. Young children with a mean age of 51 months (SD 25.6) were investigated, and all were cared for by female caregivers. Mean adherence was 81%, and 67% of children achieved virologic suppression (VS). Household income, educational status, and child characteristics were not significantly correlated with adherence. Disclosure of both the child's and the caregiver's HIV status was linked to achieving VS and was a significant predictor for VS. A model including child's health status, caregiver's language skills, caregiver's disclosure, and perceived stigmatization could explain 95% of the variance in VS. Adherence and VS were not associated with socioeconomic factors in this population. Social factors such as stigmatization, fear of disclosure, and caregivers' attitudes toward the health-care system influenced VS but not adherence.

Compliance descriptors: analysis and evaluation in terms of therapeutic effect

The aim of this work was to evaluate the performance of various compliance parameters in order to identify those which best assess the impact of compliance on therapeutic issues. We will discuss the particularities and restrictions of these parameters by considering two criteria, namely sensitivity index and reliability, which respectively describe strength and robustness of the relationship between these parameters and compliance. Using real and virtual data, performance analysis of compliance parameters was carried out for drugs whose pharmacokinetic properties govern the time course of their actions. Within this context, it was found that the percentage of taken doses (PTD), the most widely used parameter, poorly performed in the evaluation of the therapeutic impact of compliance. On the other hand, the adjusted percentage of correct doses (PCD*) which we propose here, showed the best reliability, making it the most appropriate parameter for the comparison of different compliance patterns. The percentage of correct doses (PCD) has, in its turn, the highest sensitivity index and thus should be preferred for the assessment of changes in compliance. Hence, a perfect parameter for the evaluation of compliance impact cannot be universally identified since each parameter can have its own characteristic advantages and limitations. The methodology proposed here is general enough to be adapted for similar drug classes to evaluate their compliance descriptors.

Standard measures are inadequate to monitor pediatric adherence in a resource-limited setting

This study aims to compare the use and cost of objective and subjective measures of adherence to pediatric antiretroviral treatment in a primary care facility in South Africa. In a 1-month longitudinal study of 53 caregiver-child dyads, pharmacy refill (PR), measurement of returned syrups (RS), caregiver self-report (3DR) and Visual Analogue Scale (VAS) were compared to Medication Event Monitoring System (MEMS). Adherence was 100% for both VAS and 3DR; by PR and RS 100% and 103%, respectively. MEMS showed that 92% of prescribed doses were administered, but only 66% of these within the correct 12-hourly interval. None of the four measures correlated significantly with MEMS. MEMS data suggest that timing of doses is often more deviant from prescribed than expected and should be better addressed when monitoring adherence. Of all, MEMS was by far the most expensive measure. Alternative, cheaper electronic devices need to be more accessible in resource-limited settings.

Long-term outcome of children receiving antiretroviral treatment in rural South Africa: substantial virologic failure on first-line treatment

BACKGROUND

Long-term (>12 months follow-up) virologic data of children receiving antiretroviral therapy (ART) in Sub-Saharan Africa are limited. Data from rural areas are especially scarce. The aim of this study was to evaluate the long-term virologic outcome of a pediatric cohort in rural South Africa.

METHODS

We performed a retrospective, observational cohort study, including children who initiated ART at least 1 year before data-analysis. Regular monitoring, including HIV-RNA testing, was performed. Genotypic resistance testing was done for children with virologic failure (HIV-RNA >1000 copies/mL). Logistic regression analysis was used to determine predictors of virologic failure.

RESULTS

A total of 101 children were included. Median duration since beginning ART was 31 months. Overall patient retention-rate was 76% (77/101), with early mortality being the main cause of attrition (13/24, 54%). Initial immunologic and virologic responses were excellent. However, 38% (31/81) of children subsequently experienced virologic failure. Correlation between virologic failure and immunologic decline was nearly absent. At the time of failure, multiple non-nucleoside reverse transcription inhibitor-associated mutations were observed in 52% (12/23) of children. No definite predictors of virologic failure could be determined.

CONCLUSIONS

ART provides significant benefits for children in this rural African setting, but the finding that a large proportion of children had virologic failure and developed major drug-resistance mutations on first-line ART is worrying. Causes of failure need to be analyzed and effective prevention strategies are needed. Because of the lack of a correlation between immunologic and virologic failure, treatment failure generally stays unnoticed in settings where HIV-RNA testing is not available.

Associations between internalizing symptoms and trajectories of medication adherence among pediatric renal and liver transplant recipients

OBJECTIVES

To examine medication adherence trajectories posttransplantation and the association between adherence trajectories and self-reported internalizing symptoms in a pediatric population.

METHODS

Multilevel modeling was used to examine internalizing symptoms and longitudinal medication adherence, as assessed by electronic monitoring, among 55 children and adolescents who received liver or kidney transplantation.

RESULTS

Medication adherence generally declined over the study assessment window, and higher levels of anxiety were associated with higher and more stable patterns of medication adherence.

CONCLUSIONS

Anxiety may be an important factor to consider when assessing and intervening with posttransplantation medication adherence. Future research should consider the potential reactivity effects of adherence monitoring, as well as individual and family behaviors associated with anxiety that may influence adherence.

Factors sustaining pediatric adherence to antiretroviral therapy in western Kenya

Antiretroviral therapy (ART) requires nearly perfect adherence to be effective. Although 90% of HIV-infected children live in Africa, there are limited data on pediatric adherence from this multicultural continent.We conducted a qualitative study to identify key factors contributing to pediatric ART adherence. Ten focus group discussions (N = 85) and 35 individual interviews were conducted with parents and guardians of HIV-infected children receiving ART in western Kenya. Interviews covered multiple aspects of the experience of having children take ART and factors that inhibited or facilitated medication adherence. Constant comparison, progressive coding, and triangulation methods were used to arrive at a culturally contextualized, conceptual model for pediatric ART adherence derived from the descriptions of the lived experience in this resource-limited setting. Child care, including sustained ART adherence, depends on interacting cultural and environmental determinants at the levels of the individual child, parent/caregiver, household, community, health care system, and society.

Medication diaries do not improve outcomes with highly active antiretroviral therapy in Kenyan children: a randomized clinical trial

BACKGROUND

As highly active antiretroviral therapy (HAART) becomes increasingly available to African children, it is important to evaluate simple and feasible methods of improving adherence in order to maximize benefits of therapy.

METHODS

HIV-1-infected children initiating World Health Organization non-nucleoside reverse transcriptase-inhibitor-containing first-line HAART regimens were randomized to use medication diaries plus counselling, or counselling only (the control arm of the study). The diaries were completed daily by caregivers of children randomized to the diary and counselling arm for nine months. HIV-1 RNA, CD4+ T cell count, and z-scores for weight-for-age, height-for-age and weight-for-height were measured at a baseline and every three to six months. Self-reported adherence was assessed by questionnaires for nine months.

RESULTS

Ninety HIV-1-infected children initiated HAART, and were followed for a median of 15 months (interquartile range: 2-21). Mean CD4 percentage was 17.2% in the diary arm versus 16.3% in the control arm at six months (p = 0.92), and 17.6% versus 18.9% at 15 months (p = 0.36). Virologic response with HIV-1 RNA of <100 copies/ml at nine months was similar between the two arms (50% for the diary arm and 36% for the control, p = 0.83). The weight-for-age, height-for-age and weight-for-height at three, nine and 15 months after HAART initiation were similar between arms. A trend towards lower self-reported adherence was observed in the diary versus the control arm (85% versus 92%, p = 0.08).

CONCLUSION

Medication diaries did not improve clinical and virologic response to HAART over a 15-month period. Children had good adherence and clinical response without additional interventions. This suggests that paediatric HAART with conventional counselling can be a successful approach. Further studies on targeted approaches for non-adherent children will be important.

Staged introduction of antiretroviral therapy into a family with multiple HIV-infected members

Children and families bear a significant burden of human immunodeficiency virus disease globally, particularly in sub-Saharan Africa. Care of severely affected families can be adversely impacted by high medication burdens and overwhelmed caregivers, who themselves may be human immunodeficiency virus infected. Family-centered care involving joint clinic days, treatment preparation, adherence counseling, and community-based follow-up may improve the care of family units. We describe the successful treatment of a single family composed of 6 infected members living in a rural African setting.

Clinical and immunological outcomes of a national paediatric cohort receiving combination antiretroviral therapy in Uganda

OBJECTIVE

We aimed to evaluate clinical and immunological outcomes of paediatric patients receiving combination antiretroviral therapy (cART) enrolled in The AIDS Support Organization (TASO) Uganda national HIV/AIDS programme.

DESIGN

Observational study of patients (age <14 years) enrolled in 10 clinics across Uganda for which TASO has data.

METHODS

We extracted patient demographic, immunological and clinical outcomes from the TASO databases regarding age, sex, cART regimen, CD4 cell count and WHO stage at initiation, tuberculosis, mortality and adherence. Outcomes were analysed using Pearson's rank-order correlations, Wilcoxon's rank sum tests, Cox proportional hazard model and survivor functions.

RESULTS

Of the total 770 HIV children on cART, median age was 9 years (interquartile range, 5-13 years), and median follow-up time was 377 days (interquartile range, 173-624 days). Seven hundred and fifty-one children (97.5%) initiated nonnucleoside reverse transcriptase inhibitor-based regimens. Three hundred and sixty-five children (47.5%) initiated cART with severe immune suppression (CD4 cell percentage <15). Of the 18 (2.3%) children that died, mortality was associated with lower CD4 cell percentage at initiation (B coefficient -0.144, standard error 0.06, P = 0.02). Of the total, 229 (30%) were single or double orphans and more likely to initiate cART at an older age (mean age, 9.25 vs. 8.35 years, P = 0.02) and have a lower CD4 cell count (median, 268 vs. 422 cells/microl, P < or = 0.0001) and CD4 cell percentage (median 12.8 vs. 15.5%, P = 0.02) at initiation. Pulmonary tuberculosis was present in 43 (5.6%) patients at initiation and 21 (2.3%) after cART. Almost all patients (94.9%) demonstrated more than 95% adherence.

CONCLUSION

Children on cART in Uganda demonstrate positive clinical outcomes. However, additional support is required to ensure timely cART access among orphans and young children.