Impact of COVID-19 on HIV Adolescent Programming in 16 Countries With USAID-Supported PEPFAR Programs

"I-We-I": Visualizing Adolescents' Perceptions and Apprehension to Transition to Adult HIV Care at a Supportive Transition Facility in the Cape Town Metropole, South Africa

Adolescents living with HIV (ALHIV) (10-19 years) make up approximately 4.2% (320,000) of people living with HIV in South Africa. Adolescence is a developmental period characterized by pervasive biological, social and psychological changes, which challenges adherence and retention in care for ALHIV on antiretroviral therapy (ART). Further, as ALHIV grow "older", they are expected to transition to the adult HIV treatment programme, where they should assume greater responsibility for managing their chronic condition and healthcare pathway. Whereas it is imperative that ALHIV are transitioned when they are ready, little is known about the challenges and experiences of ALHIV before and during transition. The aim of this paper was to report on the experiences and challenges of transition for ALHIV who received ART at an adolescent-friendly service that is adjunct to a public primary healthcare facility in the Western Cape province of South Africa.

METHODS

Photovoice methods were employed to explore the transition experiences of ALHIV on ART at a "supportive transition" public health facility in the Cape Town Metro in South Africa. Participants took pictures that depict their experience pre- and during transition to adult care and discussed these in groups with peers. Audio data were digitally recorded and transcribed verbatim and subjected to thematic analysis using Atlas.Ti version 24.

RESULTS

The emergent themes described their apprehension to transitioning to adult care; self-management; challenges to adherence; the need for psychosocial support; and how adolescent-friendly services were filling the gap.

CONCLUSIONS

We illuminate the "I-We-I" configuration, to reflect (the first "I") individual ALHIV experiences as isolated before being transferred to the supportive facility; how they experience a sense of belonging and family ("we") in the supportive facility; but face apprehension about transitioning to adult care in the local clinic, where they have to self-manage (final "I").

Determinants of viral load suppression among adolescents on antiretroviral therapy in Eswatini: a cross-sectional study

BACKGROUND

The goal of antiretroviral therapy (ART) is to achieve a sustained HIV suppressed viral load. However, adolescents often present poor adherence to ART which is associated with lower rates of viral load suppression (VLS). The objective of this study was to determine the viral load suppression levels and the associated factors among adolescents living with HIV (ALHIV) and on ART in Eswatini.

METHODS

We conducted cross-sectional analysis of data from 911 adolescents aged 10 to 19 living with HIV and on ART between the period January 2017 and September 2022. We collected data of demographic and clinical variables, using a standardized data abstraction tool. We defined viral load suppression as the latest viral load result of ≤ 1000 copies/ml. Univariable and bivariable logistic regression analysis was done to identify factors associated with VLS and factors with p < 0.1 were included in the multivariable regression analysis to adjust for the confounding effect of other variables such as age, sex, and duration of ART. Factors with p < 0.05 were considered statistically significant.

RESULTS

Among the 911 participants, 60% (457) were female. The mean age of the participants was 16.3 years, with mean duration on ART of 1.8 years. Viral suppression was attained by 88.5% (806/911) of the participants. Residence in the Shiselweni region was an independent factor associated with viral load suppression (aOR 0.37; 95% CI 0.15-0.19; p˂0.027).

CONCLUSION

Low VLS is a risk factor for increased viral resistance and perpetuates HIV transmission within the population. Achieving viral suppression among ALHIV in Eswatini is challenging as data shows that VLS is way below the UNAIDS 95% cut off level among individuals on ART. This is particularly more problematic in the Shiselweni region, where viral suppression is lower than the other regions. Therefore, reinforcement of public health interventions is needed to improve treatment support for achieving sustained viral suppression among ALHIV in Eswatini.

Challenges Faced by Perinatally-Infected Kenyan Adolescents and Youth Living with HIV During the COVID-19 Pandemic

Wellness challenges experienced by adolescents and youth living with HIV (AYLWH) during COVID-19 are unknown and could guide HIV care in resource-limited settings. Between February/2021 and July/2022, perinatally-infected AYLWH at the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya completed surveys assessing psychological, physical, socioeconomic, and antiretroviral nonadherence challenges and underwent viral load (VL) testing evaluating for virologic (VL > 40 copies/mL) or treatment (VL > 1,000 copies/mL) failure. Patterns in challenges, nonadherence, and VL measures by enrolment were evaluated using general additive models. Associations between challenges and nonadherence scores were quantified using linear regression; associations between non-adherence and failure were quantified using logistic regression. Both were adjusted for age, gender, and clinic. Among 442 participants enrolled in this cross-sectional study (median age 17 years, 49% female), 89% reported challenges (48% psychological, 66% physical, 62% socioeconomic) and 74% reported nonadherence. Significant between-individual variations by enrolment date were noted in physical challenges (e.g., illnesses and hospitalizations). Reporting more psychological, physical, or socioeconomic challenges were each associated with higher nonadherence. Higher nonadherence was associated with virologic and treatment failure (OR = 1.22 per 1-unit higher nonadherence, 95% CI = 1.01-1.47, p < 0.036; and OR = 1.29, 95% CI = 1.01-1.64, p < 0.035, respectively). Kenyan AYLWH faced psychological, physical, and socioeconomic challenges during the COVID-19 pandemic. Although longitudinal studies are needed to determine whether these challenges exceed pre-pandemic levels or contribute to the observed increased antiretroviral nonadherence and treatment failure, our findings provide support for the important relationships among these measures and may help clinicians and caregivers identify opportunities for interventions to support this vulnerable population.

Trends in continuity of treatment among children and adolescents living with HIV in 14 districts in South Africa from 2018-2023: A retrospective program analysis

Objectives

UNAIDS estimates 152,984 children under 15 years living with HIV (C/ALHIV) by 2022 in South Africa. Monitoring the continuity of antiretroviral treatment remains challenging without electronic health records. We explored treatment cohort growth and interruption trends in 14-USAID-PEPFAR-supported districts.

Methods

We reviewed data from 2018 to 2023. We triangulated this data with NAOMI HIV estimates. We used Tableau version 2023.2 for analysis to understand heterogeneity in outcomes.

Results

HIV incidence halved from 4.3 per 1000 in 2017 to 2.5 per 1000 in 2022. HIV testing doubled: 188,371 in FY19Q1 to 399,708 in FY23Q4 while testing positivity declined from 3.3% to 0.7%. Linkage to treatment increased from 67% to 102%, viral suppression increased from 79% to 84%. C/ALHIV treatment cohort started at 82,897 in FY19Q1 and increased to 105,107 in FY20Q2. Subsequently, the cohort decreased to 79,288 in FY23Q4 despite 42,498 initiations and 62,256 returns.

Conclusions

The C/ALHIV treatment and viral suppression increased substantially commensurate with expected trends. Subsequent cohort decline was aligned to vertical transmission reduction, HIV incidence decline, and expected aging. We highlight the inadequacy of the information systems to quantify losses. We underscore a need for resources to enhance program monitoring and interventions to address this gap.

Illustrations of Coping and Mental Well-Being of Adolescents Living with HIV in Cape Town, South Africa During COVID: A Photovoice Study

Adolescents living with HIV (ALHIV) are the fastest-growing population living with HIV globally. The COVID-19 pandemic disrupted health systems, thereby negatively affecting the quality and availability of HIV care and support services. This study describes the challenges and treatment experiences of ALHIV on ART at a public primary healthcare facility in a low-socioeconomic community in Cape Town, South Africa during the COVID-19 pandemic. A qualitative photovoice study was conducted with 21 adolescents (aged 14-19 years; 13 females and 8 males). Participants shared pictures illustrating their experiences during the COVID-19 pandemic in groups. Group discussions were audio-recorded and transcribed in full and subjected to content analysis. Seven themes emerged describing ALHIV's personal, social, and economic challenges, their means of coping, and feelings of vulnerability. Challenges included the loss of significant others, lack of social support and opportunities, experiences of HIV-related stigma and discrimination in the household, loneliness, and isolation. In spite of difficulties, some ALHIV displayed resilience by continuing their medication routines during lockdown periods. After the COVID-19 pandemic, there is a need for the restoration of the health system and services, including psychosocial support to re-engage ALHIV in care and treatment.

Assessing the impact of COVID-19 on HIV care cascade for people living with HIV in Ethiopia: a retrospective longitudinal study

OBJECTIVE

The study aimed to investigate the impact of COVID-19 on the cascade of HIV care for people living with HIV (PLHIV) in Ethiopia.

DESIGN

A retrospective longitudinal study.

SETTING

The study was conducted in North Showa Zone, Ethiopia, from pre-COVID-19 (January 2018-December 2019) and during COVID-19 (January 2020-December 2021).

PARTICIPANTS

We identified 61901 records from 3925 PLHIV, of which 23 848 were recorded during the pandemic.

MAIN OUTCOME MEASURE

We investigated indicators from four stages of the HIV care cascade, including HIV screening and diagnosis, HIV care, HIV treatment and HIV disease progression, according to a WHO framework. The indicator changes were assessed with incidence rate ratios (IRRs).

RESULTS

For HIV screening and diagnosis, the monthly number of HIV tests experienced a 46% decline from 2520 to 1361 since the pandemic (IRR 0.553; 95% CI 0.546 to 0.561). For HIV care, the monthly number of consultations was reduced by 49.6% (from 1582 to 798) since the pandemic (IRR 0.591; 95% CI 0.581 to 0.601). Similarly, the monthly number of viral load tests was reduced by 42.8% (IRR 0.614; 95% CI 0.581 to 0.650). For HIV treatment, the number of antiretroviral therapy (ART) initiations was reduced by 27.8% and the number of ART adherence by 52.5% since the pandemic. For HIV disease progression, the monthly number of PLHIV achieving viral suppression was reduced by 61.6%, while HIV-related deaths doubled during the pandemic.

CONCLUSION

The study highlights pandemic-induced disruptions in the cascade of care for PLHIV. Targeted interventions are necessary to protect PLHIV in public health emergencies.

Impacts of the COVID-19 pandemic on HIV care and treatment services among adolescents attending a tertiary hospital in Dar es Salaam, Tanzania: a qualitative study

Background

The COVID-19 pandemic has caused substantial disruption on HIV care and treatment programmes, especially for adolescents living with HIV (ALHIV) who are known to have poorer health outcomes compared with adults. Efforts made to overcome the pre-existing challenges were hampered by the emergence of the pandemic which interrupted adolescent-friendly healthcare services. Therefore, the aim of this study was to assess the impacts of the pandemic on HIV care and treatment services from healthcare providers and adolescents' experiences at a tertiary hospital in Dar es Salaam, Tanzania.

Methods

A descriptive qualitative study using in-depth interviews was conducted with 17 study participants. Purposive and convenient sampling techniques were used to recruit healthcare providers and adolescents, respectively. Swahili semistructured interview guide was used to conduct interviews. Thematic analysis was conducted to generate themes and subthemes describing the experiences on effects brought by COVID-19 on HIV care and treatment among adolescents.

Results

The study revealed that alteration of approach in delivery of healthcare and limited human and non-human resources in healthcare facilities during the COVID-19 pandemic decreased effectiveness and quality of care which resulted in adolescent's poor adherence to medication and loss to follow-up. Loss of family income, food insecurity and limited socialisation posed threat to adolescent's mental health and overall quality of life.

Conclusion

Our findings underscore the impacts of COVID-19 and its immediate responses that significantly affected adolescent HIV care and treatment services. Reinforcement of sustainable ALHIV programmes and funding supports to these programmes are essential to promote retention and engagement to care during pandemics.

Assessing the resilience of HIV healthcare services provided to adolescents and young adults after the COVID-19 pandemic in the city of Beira (Mozambique): an interrupted time series analysis

BACKGROUND

The COVID-19 pandemic has put the provision of health services globally at risk. In Sub-Saharan Africa, it had a major impact on HIV services. However, there is a lack of data on the post-pandemic period. This study aims to evaluate the resumption of HIV services and retention in care for adolescents and young people in the period following the COVID-19 pandemic.

METHODS

A retrospective cohort study was conducted using interrupted time series analysis. Three periods were considered: pre-pandemic (form June 2019 to March 2020), pandemic (form April 2020 to March 2022) post-pandemic (from April 2022 to March 2023). Six outcome measures were considered: number of outpatient visits, HIV tests, HIV positivity ratio, the antiretroviral treatment (ART) non-adherence ratio, recall ratio, and the return ratio for adolescent and young adults on ART.

RESULTS

During the study period, 447,515 outpatient visits and 126,096 HIV tests were recorded. After a reduction at the beginning of the pandemic period, both visits and tests increased during the pandemic (p < 0.05) and decreased in the post-pandemic (p < 0.05), recovering the pre-pandemic trends. The HIV positivity ratio slightly decreased from 3.3% to 1.7% during the study period (p < 0.05). The ART non-adherence ratio decreased from 23.4% to 2.4% throughout the study period (p < 0.05), with a drop at the beginning of the post-pandemic period (p < 0.05). The recall ratio increased during the study period (p < 0.05) with a drop at the beginning of the pandemic and post-pandemic periods (p < 0.05). The return ratio decreased at the beginning of the pandemic (p < 0.05) but returned to the pre-pandemic ratio in the post-pandemic period.

CONCLUSIONS

The post-pandemic values of the investigated outcomes were comparable to pre-pandemic period, or even improved. Differently from other services, such as the community activities, that have been severely affected by COVID-19 pandemic, the HIV service system has shown resilience following emergency situation.

Generalized and COVID related anxiety as risk factors for health outcomes among adolescents with HIV during COVID-19 in Tanzania

The COVID-19 pandemic and associated prevention strategies caused widespread interruptions to care and treatment for people living with HIV. Adolescents living with HIV (AWHIV) were particularly vulnerable to poor mental and physical health during COVID-19. We assessed the burden of generalized and COVID-19-related anxiety and associations with adherence to HIV care and treatment and viral load suppression (VLS) among AWHIV during the peak of the COVID-19 pandemic in Tanzania.

Methods

This cross-sectional study was conducted among AWHIV aged 15-19 years attending 10 clinics in Dar es Salaam from April 2022-February 2023. Study participants completed a self-administered questionnaire including Generalized Anxiety Disorder (GAD), COVID-19-related anxiety, and other psychosocial and physical health and support measures. HIV visit adherence, viral load and sociodemographic data were abstracted from patient health records.Analysis:: Multivariable (MV) quasibinomial and logistic regression models examined associations of Generalized and COVID-19-related anxiety with visit adherence and HIV virologic suppression (HIV VL < 50 copies/mL). Data were analyzed using R software.

Results

658 AWHIV (52% male) were included in this analysis. Most (86%) had been on antiretroviral treatment (ART) for at least four years, 55% attended at least 75% of their scheduled clinic visits, and 78% were HIV virologically suppressed. The median GAD and COVID-19-related anxiety scores were 2 (IQR: 0-5, and 26 (IQR: 13-43; respectively. Only 2% scored moderate-severe generalized anxiety (score 10-21). We found no significant associations between COVID-19-related anxiety or GAD and visit adherence. Higher GAD was inversely associated with VLS (adjusted odds ratio (AOR): 0.89 (95% CI 0.81, 0.98)). Female gender and higher quality of physical life were significantly associated with VLS.

Conclusion

Low levels of generalized and COVID-19 related anxiety were reported among Tanzanian AWHIV. Integrating screening and management of generalized anxiety screening into HIV care for AWHIV could improve VLS among this population.

SARS-CoV-2 seroprevalence and associated factors, based on HIV serostatus, in young people in Sofala province, Mozambique

INTRODUCTION

In Sofala province (Mozambique), young people living with HIV (YPLHIV) are estimated at 7% among people aged 15-24 years. Even though the COVID-19 pandemic threatened HIV health services, data on the impact of COVID-19 on YPLHIV people are lacking. This study aimed at exploring the seroprevalence of SARS-CoV-2 and associated factors among young people based on their HIV status.

METHODS

A cross-sectional study was conducted, including people aged 18-24 attending a visit at one of the adolescent-friendly health services in Sofala province between October and November 2022. People vaccinated against SARS-COV-2 or YPLHIV with WHO stage III-IV were excluded. A SARS-CoV-2 antibodies qualitative test and a questionnaire investigating socio-demographic and clinical characteristics were proposed. SARS-CoV-2 seroprevalence was calculated with Clopper-Pearson method. The odds ratio (OR) of a positive SARS-CoV-2 antibodies test was estimated through multivariable binomial logistic regression.

RESULTS

In total, 540 young people including 65.8% women and 16.7% YPLHIV participated in the survey.. The mean age was 20.2 years (SD 2.0). Almost all the sample (96.1%) reported adopting at least one preventive measure for COVID-19. The weighted seroprevalence of SARS-CoV-2 in the whole sample was 46.8% (95%CI 42.6-51.2) and 35.9% (95%CI 25.3-47.5) in YPLHIV. The adjusted OR of testing positive at the SARS-CoV-2 antibodies test was higher in students compared to workers (aOR:2.02[0.95CI 1.01-4.21]) and in those with symptoms (aOR:1.52[0.95CI 1.01-2.30]). There were no differences based on HIV status(aOR:0.663[95%CI 0.406-1.069]). Overall, COVID-19 symptoms were reported by 68 (28.2%) people with a positive serological SARS-CoV-2 test and by 7 (21.7%) YPLHIV (p = 0.527). No one required hospitalization.

CONCLUSIONS

SARS-CoV-2 seroprevalence was 46.8% without differences in risk of infection or clinical presentation based on HIV status. This result may be influenced by the exclusion of YPLHIV with advanced disease. The higher risk among students suggests the schools' role in spreading the virus. It's important to continue monitoring the impact of COVID-19 on YPLHIV to better understand its effect on screening and adherence to treatment.