Qualitative Comparison of Barriers to Antiretroviral Medication Adherence Among Perinatally and Behaviorally HIV-Infected Youth

A qualitative exploration of how to support PrEP adherence among young men who have sex with men

New HIV infections disproportionately affect young men who have sex with men (YMSM). PrEP is effective in preventing HIV acquisition; however, adherence is critical and is often suboptimal among YMSM. Interventions addressing the unique PrEP adherence challenges faced by YMSM are needed. We conducted qualitative interviews with 20 HIV-negative, YMSM (ages 15-24) with a PrEP indication and 11 healthcare professionals to inform adaption of a PrEP adherence intervention (Life-Steps for PrEP) for YMSM. We explored environmental, healthcare, and individual factors influencing uptake, adherence, attitudes, and perspectives (including desired modifications) on the Life-Steps intervention. Interviews were analyzed using content analysis. Of YMSM study participants (mean age 21.6) 55% were White, 15% Hispanic, and 5% Black. Most YMSM were PrEP-experienced (70%). Healthcare professionals (6 prescribers, 1 nurse, 2 health educators, 2 other/unspecified) averaged 6.9 years of experience caring for YMSM. All described stigma as a barrier to PrEP; YMSM expressed concern around being perceived as "risky" and concern about inadvertent PrEP disclosure if family/friends found their medication, or if parental insurance was used. Difficulty with planning for potential adherence challenges were identified by both groups. YMSM highlighted benefits of a nurse-led intervention (i.e., adding "legitimacy"), but stressed need for nonjudgmental, "savvy" interventionists. YMSM expressed a desire for comprehensive YMSM-specific sexual health information. These findings informed modification and expansion of Life-Steps content. Results highlight key potential barriers, many of which center around privacy. Content that addresses PrEP stigma, disclosing PrEP use, navigating insurance, and planning ahead in a nonjudgmental environment by trusted providers emerged as important components of a YMSM-focused delivery of Life-Steps for PrEP.

Social and mental health characteristics of adolescents living with HIV in Mexico: Implications for adherence to antiretroviral treatment

Mexico is the third Latin American country with the most children and adolescents living with human immunodeficiency virus (ALHIV). There is a lack of information on the characteristics of this population. We aimed to describe the social and mental health characteristics of Mexican ALHIV. A census was conducted of all adolescent patients with HIV at a pediatric hospital (n = 47; mean age 14.39, S.D. = 3.65) and their caregivers. We collected data on socio-demographic characteristics, family, intelligence, mental health, adverse life events, substance use, treatment, knowledge of Antiretroviral Treatment (ART) and HIV, and biomarkers. Most cases were transmitted vertically and self-reported ART adherence was above 90%. Some obstacles to adherence were medicine discomfort, believing that they did not need it, and forgetfulness. The vulnerabilities were intellectual disability, adverse life events, possible mental health problems, and little knowledge of their illness and treatment. These findings suggest the importance of interventions to improve the perception and knowledge of HIV and ART to increase ART adherence.

Qualitative Interviews to Add Patient Perspectives in Colorectal Cancer Screening: Improvements in a Learning Health System

Health systems are interested in increasing colorectal cancer (CRC) screening rates as CRC is a leading cause of preventable cancer death. Learning health systems are ones that use data to continually improve care. Data can and should include qualitative local perspectives to improve patient and provider education and care. This study sought to understand local perspectives on CRC screening to inform future strategies to increase screening rates across our integrated health system. Health insurance plan members who were eligible for CRC screening were invited to participate in semi-structured phone interviews. Qualitative content analysis was conducted using an inductive approach. Forty member interviews were completed and analyzed. Identified barriers included ambivalence about screening options (e.g., "If it had the same performance, I'd rather do home fecal sample test. But I'm just too skeptical [so I do the colonoscopy]."), negative prior CRC screening experiences, and competing priorities. Identified facilitators included a positive general attitude towards health (e.g., "I'm a rule follower. There are certain things I'll bend rules. But certain medical things, you just got to do."), social support, a perceived risk of developing CRC, and positive prior CRC screening experiences. Study findings were used by the health system leaders to inform the selection of CRC screening outreach and education strategies to be tested in a future simulation model. For example, the identified barrier related to ambivalence about screening options led to a proposed revision of outreach materials that describe screening types more clearly.

Retention and Viral Suppression Among Adolescents Newly Initiating Antiretroviral Therapy in Adult HIV Care in Lima, Peru: A Retrospective Cohort Study

PURPOSE

Published data on outcomes among adolescents newly initiating antiretroviral treatment in the Latin American context are sparse. We estimated the frequency of sustained retention with viral load suppression (i.e., successful transition) and identified predictors of successful transition into adult care among youth (aged 14-21 years) with recently acquired HIV in Lima, Peru.

METHODS

A retrospective cohort study was conducted among 184 adolescents and young adults who initiated antiretroviral therapy in an adult public sector HIV clinic between June 2014 and June 2019. Sustained retention (no loss-to-follow-up or death) with viral suppression was calculated for the first 12 and 24 months following treatment initiation. We conducted regression analyses to assess factors associated with successful transition to adult HIV care, including gender, age, occupation, nationality, pregnancy, same-sex sexual behavior, presence of treatment supporter, number of living parents, and social risk factors that may adversely influence health (e.g., lack of social support, economic deprivation).

RESULTS

Patients were predominantly male (n = 167, 90.8%). Median age was 19 years (interquartile range: 18-21). Frequency of sustained retention with viral load suppression was 42.4% (78/184) and 35.3% (30/85) at 12 and 24 months following treatment initiation. In multivariable analyses, working and/or studying was inversely associated with successful transition into adult care at 12 months; number of known living parents (relative risk: 2.20; 95% confidence interval: 1.12, 4.34) and absence of social risk factors (relative risk: 1.68; 95% confidence interval: 0.91, 3.11) were positively associated with successful transition at 24 months.

DISCUSSION

Sustained retention in HIV care was uncommon. Parental support and interventions targeting social risk factors may contribute to successful transition into adult HIV care in this group.

Beliefs about antiretroviral therapy and their association with adherence in young people living with perinatal HIV in England: a cross-sectional analysis

This cross-sectional analysis aimed to describe beliefs about antiretroviral therapy (ART) in young people living with perinatal HIV (PHIV) in England, and the association between these beliefs and adherence to ART. The Beliefs About Medicine Questionnaire (Highly Active Antiretroviral Therapy version), was used to measure participants' beliefs in the necessity of ("Necessity score") and concerns regarding ("Concerns score") ART. Participants were classified as having high/low total scores using midpoints of the score scales. Associations between beliefs and being Last Month Adherent (LMA; self-reported not missing more than 2 consecutive ART doses in the month prior to the interview) were analysed using logistic regression, adjusting for sociodemographic, clinical, and psychosocial variables. Of 247 PHIV (median age = 18.6 years), 158 (64%) were LMA. 224 (91%) had a high Necessity score and 54 (22%) a high Concerns score. There was no association between high Necessity score and LMA in multivariable analysis (adjusted odds ratio (aOR) = 1.34, 95% confidence interval (CI) = 0.34-5.28, p = 0.679); however, high Concerns score was independently associated with a reduced odds of being LMA (aOR = 0.19, CI = 0.07-0.47, p < 0.001). Interventions to address the concerns young people living with PHIV have about ART should be explored as a strategy to improve their adherence.

Exploring Self-reported Adherence Measures to Screen for Elevated HIV Viral Load in Adolescents: A South African Cohort Study

The timely identification of ART non-adherence among adolescents living with HIV presents a significant challenge, particularly in resource-limited settings where virologic monitoring is suboptimal. Using South African adolescent cohort data (N = 933, mean age 13.6 ± 2.89 years, 55.1% female, follow-up = 2014-2018), we examined the association between elevated viral load (VL ≥ 1000 copies/mL) and seven self-reported adherence measures on missed doses, and clinic appointments -with varying recall timeframes. The best performing measures, which were significantly associated with elevated viral load in covariate-adjusted models are: any missed dose -past 3 days (sensitivity = 91.6% [95%CI: 90.3-92.8], positive predictive value (PPV) = 78.8% [95%CI: 77.2-80.4]), -past week (sensitivity = 87% [95%CI: 85.4-88.6], PPV = 78.2% [95%CI: 76.5-79.9]), -past month (sensitivity = 79.5% [95%CI: 77.5-81.4], PPV = 78.2% [95%CI: 76.4-79.9]), any past-month days missed (sensitivity = 86.7% [95%CI: 85.1-88.3], PPV = 77.9% [95%CI:76.2-79.6]), and any missed clinic appointment (sensitivity = 88.3% [95%CI: 86.8-89.8], PPV = 78.4% [95%CI: 76.8-79.9]). Combining the three best performing measures missed dose -past 3 days, -past week, and any past-year missed clinic appointment increased sensitivity to 96.4% while maintaining a PPV of about 78%. The discriminatory power of simple and easy-to-administer self-reported adherence measures in detecting elevated viral load warrants consideration in resource-limited settings and may contribute to the aims of the new Global Alliance to End AIDS in children and adolescents by 2030.

Lost to follow up: the (non)psychosocial barriers to HIV/AIDS care in southeast Nigeria

Medication withdrawal remains a problem in Nigeria's HIV care. The Enugu state of southeast Nigeria has 3,736 people living with HIV/AIDS (PLHIV), with a 1.9% HIV-positive prevalence rate among the age band of 15-49 years, higher than 1.3%, the national average for the same cohort. Despite the disease burden, many cases are "lost to follow-up" in this region. Through four focus groups of patients (20 participants in total) and in-depth interviews with four clinicians from four public hospitals, this study aimed to understand the barriers to attending healthcare appointments faced by young adults. The participants were recruited through flyers, posters, and snowballs at clinics; both data sets were first analysed separately yet used to triangulate each other. We found that clinical interruptions are mainly attributable to factors such as stigma, suicidal ideation, loss of means of livelihood due to PLHIV's "new identities", and thus poverty and malnutrition. These barriers, complicated by the COVID-19 pandemic and armed conflicts in the region, have made medication adherence further challenging. Therefore, we recommend the Nigerian government integrate non-biomedical support for PLHIV into people-centred HIV care.

Mode of HIV acquisition among adolescents living with HIV in resource-limited settings: A data-driven approach from South Africa

Adolescents living with HIV (ALHIV) face unique treatment and care challenges which may differ by how they acquired HIV, whether vertically (in-utero, perinatal or postnatal exposure during breastfeeding) or sexually (sexual exposure). Distinguishing and documenting the mode of HIV acquisition (MOHA) is crucial to further research on the different needs and outcomes for ALHIV and to tailor HIV services to their needs. Age-based cut-offs have been used to attribute MOHA but have not been validated. We analysed data from a three-wave cohort of n = 1107 ALHIV part of a longitudinal study in South Africa. Age-based MOHA was allocated using age at ART initiation, validated against a logic-tree model based on literature-hypothesised factors: self-reported HIV, sexual, and family history. After testing six ART initiation age cut-offs (10 to 15 years old), we determined the optimal MOHA cut-off age by calculating the sensitivity and specificity for each cut-off, measured against the final logic-tree allocation. Following validation using this longitudinal study, the methodology is extended to 214 additional third-wave participants-adolescent girls and young women living with HIV who became mothers before the age of 20. Finally, descriptive statistics of the final allocations are presented. Among the 1,063 (96.0%) cohort study participants classified, 68.7% acquired HIV vertically, following validation. ART initiation before cut-off age 10 had the highest sensitivity (58.9%) but cut-off age 12 had the largest area under the curve (AUC) (0.712). Among the additional young mothers living with HIV, 95.3% were estimated to have acquired it sexually, following the same algorithm. For this group, while cut-off ages 10 to 12 had the highest sensitivity (92.2%), age 14 had the highest AUC (0.703). ART initiation before 10 years old is strongly associated with vertical HIV acquisition. Therefore, a cut-off age of 10 would remain the recommendation in LMIC regions with similar epidemiology as South Africa for determining MOHA in research and clinic settings.

Patient preferences and health state utilities associated with the treatment process of antiretroviral therapy for people living with HIV

PURPOSE

People living with HIV (PLHIV) have reported challenges associated with daily oral antiretroviral therapy (ART), including missed doses, negative psychological impact, and difficulty remaining discreet while at home or traveling. Recently approved long-acting injectable (LAI) ART may help eliminate these concerns. The purpose of this study was to examine patient preferences and estimate health state utilities associated with oral and LAI treatment for ART.

METHODS

Four health state vignettes were developed based on published literature, clinician interviews, and a pilot study. All vignettes included the same description of HIV, but differed in treatment regimens: (A) single daily oral tablet, (B) two daily oral tablets, (C) injections once monthly, and (D) injections every two months. PLHIV in the UK reported their preferences and valued the health states in time trade-off utility interviews.

RESULTS

The sample included 201 PLHIV (83.1% male; mean age = 44.9y). The health states frequently selected as most preferable were D (n = 119; 59.2%) and A (n = 75; 37.3%). Utility differences among health states were relatively small, which is typical for treatment process utilities (mean utilities: A, 0.908; B, 0.905; C, 0.900; D, 0.910). Statistically significant differences in utility were found for one vs. two tablets and injections every month vs. every two months (p < 0.001). Participants' quotations highlight the wide range of reasons for treatment process preferences.

CONCLUSIONS

Current results indicate that many PLHIV would prefer LAI ART. The reported utilities may be useful in economic modeling comparing oral vs. LAI ART.

Patient and provider perceptions of a community-based accompaniment intervention for adolescents transitioning to adult HIV care in urban Peru: a qualitative analysis

INTRODUCTION

Adolescents living with HIV (ALWH) experience higher mortality rates compared to other age groups, exacerbated by the suboptimal transition from paediatric to adult HIV care, during which decreased adherence to antiretroviral therapy (ART) and unsuppressed viremia are frequent. Care transition-a process lasting months or years-ideally prepares ALWH for adult care and can be improved by interventions that are youth-friendly and address psychosocial issues affecting ART adherence; however, such interventions are infrequently operationalized. Community-based accompaniment (CBA), in which laypeople provide individualized support and health system navigation, can improve health outcomes among adults with HIV. Here, we describe patient and provider perceptions of a novel HIV CBA intervention called "PASEO" for ALWH in Lima, Peru.

METHODS

PASEO consisted of six core elements designed to support ALWH during and after the transition to adult HIV care. During 2019-2021, community-based health workers provided tailored accompaniment for ALWH aged 15-21 years over 9 months, after which adolescent participants were invited to provide feedback in a focus group or in-depth interview. HIV care personnel were also interviewed to understand their perspectives on PASEO. A semi-structured interview guide probing known acceptability constructs was used. Qualitative data were analysed using a framework analysis approach and emergent themes were summarized with illustrative quotes.

RESULTS

We conducted five focus groups and 11 in-depth interviews among N = 26 ALWH and nine key-informant interviews with HIV care personnel. ALWH participants included males, females and one transgender female, and those with both early childhood and recent HIV infection. ALWH praised PASEO, attributing increased ART adherence to the project. Improved mental health, independence, self-acceptance and knowledge on how to manage their HIV were frequently cited. HIV professionals similarly voiced strong support for PASEO. Both ALWH and HIV professionals expressed hope that PASEO would be scaled. HIV professionals voiced concerns regarding financing PASEO in the future.

CONCLUSIONS

A multicomponent CBA intervention to increase ART adherence among ALWH in Peru was highly acceptable by ALWH and HIV programme personnel. Future research should determine the efficacy and economic impact of the intervention.

Storyboarding HIV Infected Young People's Adherence to Antiretroviral Therapy in Lower- to Upper Middle-Income Countries: A New-Materialist Qualitative Evidence Synthesis

Young people living with perinatal infections of Human Immunodeficiency Virus (YLPHIV) face a chronic disease, with treatment including adherence to lifelong antiretroviral treatment (ART). The aim of this QES was to explore adherence to ART for YLPHIV as an assemblage within the framework of the biopsychosocial model with a new materialist perspective. We searched up to November 2021 and followed the ENTREQ and Cochrane guidelines for QES. All screening, data extraction, and critical appraisal were done in duplicate. We analysed and interpreted the findings innovatively by creating images of meaning, a storyboard, and storylines. We then reported the findings in a first-person narrative story. We included 47 studies and identified 9 storylines. We found that treatment adherence has less to do with humans' preferences, motivations, needs, and dispositions and more to do with how bodies, viruses, things, ideas, institutions, environments, social processes, and social structures assemble. This QES highlights that adherence to ART for YLPHIV is a multisensorial experience in a multi-agentic world. Future research into rethinking the linear and casual inferences we are accustomed to in evidence-based health care is needed if we are to adopt multidisciplinary approaches to address pressing issues such as adherence to ART.

Receipt of a combined economic and peer support intervention and clinical outcomes among HIV-positive youth in rural Rwanda: A retrospective cohort

INTRODUCTION

To combat poor clinical outcomes among HIV-positive youth, Partners In Health/Inshuti Mu Buzima (PIH/IMB) implemented Adolescent Support Groups (ASGs), which combined peer support and group-based economic incentives to promote treatment adherence, economic empowerment, and viral suppression. This study assesses the association between ASG membership and clinical outcomes among HIV-positive youth living in rural Rwanda.

METHODS

We constructed a retrospective cohort using PIH/IMB's electronic medical record (EMR) system. ASG members were matched to control youth within strata defined by health facility, year of birth, and whether the patient had enrolled in HIV services as a pediatric patient, as a PMTCT mother, or through another route. Our 12-month outcomes of interest were a) death-free retention in care, b) death-free retention with active follow-up, c) ≥80% adherence to appointment keeping, and d) viral load suppression (<20 copies/ml). We used generalized linear mixed models to estimate odds ratios for the association between ASG participation and each outcome. To mitigate possible unmeasured confounding, we additionally included participant data from the previous year and conducted a difference-in-difference analysis for each outcome to assess whether ASG members experienced greater changes compared to control youth over a similar period.

RESULTS

Two-hundred sixty ASG members were identified in the EMR and matched to 209 control youth for analysis. After 12 months of follow-up, ASG members had similar outcomes to the control youth in terms of death-free retention (93% vs. 94%), death-free retention with active follow-up (79% vs. 78%), ≥80% adherence to appointment keeping (42% vs. 43%), and viral suppression (48% vs. 51%). We did not observe any significant associations between ASG participation and clinical outcomes in crude or adjusted models, nor did ASG members experience greater improvements than control youth in our difference-in-difference analysis.

CONCLUSIONS

The ASG program did not improve retention, appointment adherence, or viral suppression among HIV positive youth in rural Rwanda. Challenges implementing the intervention as designed underscore the importance of incorporating implementation strategies and youth perspectives in program design. This population remains vulnerable to poor clinical outcomes, and additional research is needed to better serve youth living with HIV.

Impaired fasting glucose levels among perinatally HIV-infected adolescents and youths in Dar es Salaam, Tanzania

OBJECTIVE

This study assessed impaired fasting glucose and associated factors among perinatally HIV-infected adolescents and youths in Dar es salaam Tanzania.

BACKGROUND

Impaired fasting glucose is a marker of heightened risk for developing type 2 diabetes among perinatally HIV-infected individuals. Therefore, identifying individuals at this stage is crucial to enable early intervention. Therefore, we assessed impaired fasting glucose (IFG) and associated factors among perinatally HIV-infected population in Dar es salaam Tanzania.

METHODS

A cross-sectional study was conducted among 152 adolescents and youth attending HIV clinic at Muhimbili National Hospital and Infectious Disease Centre from July to August 2020. Fasting blood glucose (>8 hours) was measured using one-touch selects LifeScan, CA, USA. We also examined C-Reactive Protein and interleukin-6 inflammatory biomarkers in relation to impaired fasting glucose (IFG). Associations between categorical variables were explored using Chi-square, and poison regression with robust variance was used to calculate the prevalence ratios.

RESULTS

Of the 152 participants, the majority were male (n=83[54.6%]), and the median age was 15(14-18) years. Overweight or obesity was prevalent in 16.4%, while more than one in ten (13.2%) had high blood pressure (≥149/90mmHg). All participants were on antiretroviral therapy (ART); 46% had used medication for over ten years, and about one in three had poor medication adherence. Among the recruited participants, 29% had impaired fasting glucose. The odds of IFG were two times higher in males compared to females (PR, 2.07, 95% CI 1.19 -3.59 p=0.001). Moreover, we found with every increase of Interleukin 6 biomarker there was a 1.01 probability increase of impaired fasting glucose (PR, 1.01, 95% CI 1.00 - 1.02 p=0.003).

CONCLUSION

About one in three perinatally HIV-infected youths had impaired fasting glucose in Dar es Salaam, Tanzania, with males bearing the biggest brunt. Moreover, with every increase of 1.101 of the probability of having IFG increased. This calls for urgent measures to interrupt the progression to diabetes disease and prevent the dual burden of disease for this uniquely challenged population.

Site-Randomized Controlled Trial of a Combined Cognitive Behavioral Therapy and a Medication Management Algorithm for Treatment of Depression Among Youth Living With HIV in the United States

BACKGROUND

Depression is frequent among youth living with HIV (YLWH). Studies suggest that manualized treatment guided by symptom measurement is more efficacious than usual care.

SETTING

This study evaluated manualized, measurement-guided depression treatment among YLWH, aged 12-24 years at 13 US sites of the International Maternal Pediatric Adolescent AIDS Clinical Trials Network.

METHODS

Using restricted randomization, sites were assigned to either a 24-week, combination cognitive behavioral therapy and medication management algorithm (COMB-R) tailored for YLWH or to enhanced standard of care, which provided standard psychotherapy and medication management. Eligibility included diagnosis of nonpsychotic depression and current depressive symptoms. Arm comparisons used t tests on site-level means.

RESULTS

Thirteen sites enrolled 156 YLWH, with a median of 13 participants per site (range 2-16). At baseline, there were no significant differences between arms on demographic factors, severity of depression, or HIV status. The average site-level participant characteristics were as follows: mean age of 21 years, 45% male, 61% Black, and 53% acquired HIV through perinatal transmission. At week 24, youth at COMB-R sites, compared with enhanced standard of care sites, reported significantly fewer depressive symptoms on the Quick Inventory for Depression Symptomatology Self-Report (QIDS-SR score 6.7 vs. 10.6, P = 0.01) and a greater proportion in remission (QIDS-SR score ≤ 5; 47.9% vs. 17.0%, P = 0.01). The site mean HIV viral load and CD4 T-cell level were not significantly different between arms at week 24.

CONCLUSIONS

A manualized, measurement-guided psychotherapy and medication management algorithm tailored for YLWH significantly reduced depressive symptoms compared with standard care at HIV clinics.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Associations Between Key Psychosocial Stressors and Viral Suppression and Retention in Care Among Youth with HIV in Rural South Africa

Despite improvements in access to antiretroviral treatment over the past decade, sub-optimal HIV care outcomes persist among youth with HIV (YWH) in rural South Africa. Psychosocial stressors could impede improved HIV treatment outcomes within this population. We linked self-reported psychosocial health and demographic data from a cross-sectional survey conducted among YWH aged 12-24 in rural South Africa to individual medical record data, including facility visit history and viral load measurements. Poisson regression with robust standard errors was used to estimate the associations between five psychosocial stressors- heightened depressive symptoms (Center for Epidemiological Studies-Depression scale scores ≥ 16), lower social support (Medical Outcomes Social Support Scale scores ≤ 38), lower resilience (Conner-Davidson Resilience Scale scores ≤ 73), lower self-esteem (Rosenberg Self-Esteem Scale scores ≤ 21), and higher perceived stress (Sheldon Cohen Perceived Stress Scale scores ≥ 10)- and viral non-suppression (viral load ≥ 400 copies/mL) and loss to care (no documented clinic visits within the 90 days prior to survey), separately. A total of 359 YWH were included in this analysis. The median age of study participants was 21 (interquartile range: 16-23), and most were female (70.2%), single (82.4%), and attending school (54.7%). Over a quarter of participants (28.1%) had heightened depressive symptoms. Just 16.2% of all participants (n = 58) were lost to care at the time of survey, while 32.4% (n = 73) of the 225 participants with viral load data were non-suppressed. The prevalence of non-suppression in individuals with lower self-esteem was 1.71 (95% confidence interval: 1.12, 2.61) times the prevalence of non-suppression in those with higher self-esteem after adjustment. No meaningful association was observed between heightened depressive symptoms, lower social support, lower resilience, and higher perceived stress and viral non-suppression or loss to care in adjusted analyses. Retention in care and viral suppression among YWH in rural South Africa are below global targets. Interventions aimed at improving viral suppression among YWH should incorporate modules to improve participant's self-esteem as low self-esteem is associated with viral non-suppression in this setting. Future studies should longitudinally explore the joint effects of co-occurring psychosocial stressors on HIV care outcomes in YWH and assess meaningful differences in these effects by age, gender, and route of transmission.

HIV-Related Stigma Among Youth Living With HIV in Western Uganda

We present an explanatory theory for HIV-related stigma from the perspectives of youth living with HIV/AIDS (YLWHA) in Western Uganda, on which the fight against this relentless stigma in this age group and locality can be founded. A constant comparative method was used to analyze textual data from in-depth interviews with 35 YLWHA, selected from three health facilities. A stigma process model for YLWHA was developed with the stigmatizing feelings and behaviors as the core category. Concepts delineating causes, consequences, and moderators of HIV-related stigma emerged from the data to complete the stigma process. The specific focus on YLWHA and contextual characteristics adds new dimensions to the understanding of HIV-related stigma that are scant in existing HIV-related stigma models. In light of our findings, research is necessary to identify context-specific strategies to overcome the deep-rooted causes of stigmatizing views and behaviors in all social spheres of YLWHA within Western Uganda.

Psychological Reactance is a Novel Risk Factor for Adolescent Antiretroviral Treatment Failure

Psychological reactance is an aversive response to perceived threats against personal agency. For adolescents receiving HIV treatment in Botswana, we utilized a two-question, medication-specific reactance tool to assess whether: (1) verbal reminders to take medicines made adolescents want to avoid taking them, and, (2) whether adolescents felt anger when reminded to take medicines. Reactant adolescents had 2.05-fold (95% CI 1.23, 3.41) greater odds of treatment failure than non-reactant adolescents (p = 0.03). Adjusted risk of treatment failure was 14% (95% CI 3%, 28%) greater for each point elevation in reactance score (p = 0.016). Autonomy over medication-taking did not modify the association between reactance and treatment failure. Psychological reactance may be a useful interventional target for improving adolescent adherence.

Optimizing Disclosure of HIV Status to a Diverse Population of HIV-Positive Youth at an Urban Pediatric HIV Clinic

PURPOSE

The purpose of the study was to increase the proportion of youth living with HIV (YLWH) aged ≥11 years who undergo developmentally appropriate disclosure about their HIV status.

METHODS

A quality improvement project was initiated at an urban pediatric HIV clinic between July 2018 and March 2020. The primary outcome measure was the proportion of YLWH aged ≥11 years who were disclosed to about their HIV status. The proportion of undisclosed YLWH who had documented nondisclosure status was also assessed as a process measure. Plan-Do-Study-Act (PDSA) cycles for change included monthly clinic staff check-ins to discuss new disclosures, quarterly team meetings to discuss strategies to improve disclosure, and modifying a clinic note template to prompt providers to document disclosure status. Annotated run charts were used to analyze the data.

RESULTS

Before the first PDSA cycle, 26/46 (57%) of the target population of YLWH aged ≥11 years had their HIV status disclosed to them, and none of the undisclosed youth had disclosure status documented in their medical record. After 20 months and six PDSA cycles, the proportion of YLWH aged ≥11 years disclosed to about their HIV status increased to 80% and the proportion of undisclosed YLWH with documentation of their disclosure status increased to 100%.

CONCLUSIONS

Several interventions integrated throughout the pediatric HIV care process were associated with an increase in the proportion of YLWH with developmentally appropriate HIV disclosure and documentation of disclosure status, an important psychosocial aspect of care in these individuals.

Importance of support groups to the health and well-being of vulnerable children and young people living with HIV: a case study of the Kids Clubs program in Haiti

BACKGROUND

Although access to antiretroviral therapy (ART) among children and young people living with HIV has increased in recent years, adherence to medication and viral suppression remain challenges. Evidence of benefits of support groups is growing and reflects a range of models and approaches. Since 2014, hospital-linked psychosocial support groups for children and young people living with HIV, known as Kids Clubs, have been established throughout Haiti. The program provides safe spaces for them to meet with peers, supports medication adherence, delivers health and life skills education, and facilitates linkages with clinic visits and social services. This study describes program enrollment and participant engagement, ART adherence and viral suppression among participants, and other outcomes attributed to the program by participants, caregivers, and program implementers.

METHODS

Our mixed methods study included quantitative analysis of program monitoring data on rollout and attendance, and medication adherence and viral load results extracted from medical records. We collected qualitative data from club members, caregivers, and implementers about their experiences with the clubs and the impact of participation.

RESULTS

From January 2014-December 2018, 1330 individuals aged 8-29 were enrolled in the program; over three-quarters participated for at least 12 months. In 2018, 1038 members attended at least one club meeting; more than half missed three or fewer monthly meetings. Three-quarters of ever-enrolled members reported consistent medication use at their most recent clinic visit; 64.2% (600/935) of those with a recent viral load test were virally suppressed. Level of club attendance was positively associated with ART adherence (p < 0.01) and viral suppression (p < 0.05). Club members, caregivers, and implementers noted the value of the clubs to participants' retention in care and medication adherence, health knowledge, and capacity to deal with peer pressure, stigma, shyness, and depression.

CONCLUSIONS

The Kids Club program has been successful in scaling HIV support services to highly vulnerable children and young people through peer-based groups, and program participation has led to a range of benefits. Efforts to innovate, evaluate, and scale support strategies for vulnerable young populations must be accelerated in order to ensure that they survive, thrive, and reach their full potential.

Examining adherence barriers among women with HIV to tailor outreach for long-acting injectable antiretroviral therapy

Background

Long-acting (LA) injectable antiretroviral therapy (ART) has been found non-inferior to daily oral ART in Phase 3 trials. LA ART may address key barriers to oral ART adherence and be preferable to daily pills for some people living with HIV. To date, women have been less represented than men in LA ART research. Using longitudinal data from the Women’s Interagency HIV Study (WIHS) cohort of women living with HIV in the United States, we examined barriers and facilitators of daily oral ART adherence that may be related to or addressed by LA ART.

Methods

We conducted a secondary analysis of WIHS cohort data from 1998 to 2017 among participants seen for at least 4 visits since 1998 who reported using ART at least once (n = 2601). Two dichotomous outcomes, patient-reported daily oral ART adherence and viral suppression were fit using generalized linear models, examining the role of socio-demographic and structural factors.

Results

At study enrollment, the median age was 40.5 years, 63% of participants were African American and 22% were Latina. The majority (82%) reported taking ART more than 75% of the time and 53% were virally suppressed. In multivariate analysis, several sub-groups of women had lower odds of reported adherence and viral suppression: 1) younger women (adherence aOR: 0.71; viral suppression aOR: 0.63); 2) women who inject drugs (adherence aOR: 0.38; viral suppression aOR: 0.50) and those with moderate (adherence aOR: 0.59; viral suppression aOR: 0.74) and heavy alcohol consumption (adherence aOR: 0.51; viral suppression aOR: 0.69); 3) those with depressive symptoms (adherence aOR: 0.61; viral suppression aOR: 0.76); and 4) those with a history of going on and off ART (adherence aOR: 0.62, viral suppression aOR: 0.38) or changing regimens (adherence aOR: 0.83, viral suppression aOR: 0.56).

Conclusions

Current injectable contraceptive users (vs. non-users) had greater odds of oral ART adherence (aOR: 1.87) and viral suppression (aOR: 1.28). Findings identify profiles of women who may benefit from and be interested in LA ART. Further research is warranted focused on the uptake and utility of LA ART for such key subpopulations of women at high need for innovative approaches to achieve sustained viral suppression.

Using Social Media and Technology to Communicate in Pediatric HIV Research: Qualitative Study With Young Adults Living With or Exposed to Perinatal HIV

BACKGROUND

As young adults living with perinatal HIV (PHIV) or perinatal HIV exposure but uninfected (PHEU) grow older and manage the challenges and competing demands of young adulthood, new approaches are needed to facilitate their retention in longitudinal research and clinical care beyond in-person clinic visits. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel virus that causes coronavirus disease (COVID-19), emerged in the United States in January 2020 and has underscored this need; studies are adapting to remote communication with and data collection from participants. However, there are limited data on communication preferences among young adults who are living with PHIV or PHEU.

OBJECTIVE

The objectives of this qualitative study were to describe participants' perceptions and use of social media and technology in their personal lives and in the context of participating in longitudinal pediatric HIV research and to describe the implications of the use of technology and social media for communication and retention purposes within a longitudinal pediatric study about HIV.

METHODS

We conducted 6 focus group discussions with 31 young adults living with PHIV and 13 in-depth interviews with 6 young adults living with PHIV and 7 living with PHEU. We asked about their preferences for the use of social media and digital technology in the Adolescent Master Protocol, a US-based longitudinal cohort study of youth affected by HIV.

RESULTS

Participants' willingness to use social media platforms, telephone calls, SMS text messages, and video calls within the context of HIV research varied due to fears of HIV stigma and inadvertent disclosure. However, trusting relationships with clinical staff positively impacted their willingness to use these platforms.

CONCLUSIONS

Our findings offer insight into how pediatric studies and clinics can communicate with participants as they age, even as new technologies and social media platforms emerge and replace old ones. For optimal retention, pediatric clinical staff should consider communication approaches offering flexible and tailored options for young adults participating in HIV research.

Adherence in Youth With Multiple Sclerosis: A Qualitative Assessment of Habit Formation, Barriers, and Facilitators

Rates of medication nonadherence in youth with multiple sclerosis (MS) range from 10% to 60%. Qualitative studies of adherence can provide insight into children's own perspectives about barriers and facilitators to their adherence and inform future interventions. This qualitative longitudinal descriptive study included children with MS ( n = 28) participating in a randomized controlled trial focused on medication adherence ( clinicaltrials.gov : NCT02234713). Following established methods, three independent reviewers coded transcripts of motivational interviewing (MI) sessions (three interviews per subject, performed monthly over a 3-month period) for relevant themes. They were subsequently categorized using inductive content analysis. Youth described medication adherence as being dependent on the ability to build and maintain healthy habits related to medication use, including embodiment of these habits. Barriers and facilitators included remembering/forgetting, experiences with fatigue, and experiences with medication. These themes were maintained through the second and third interviews. Future research focus on barriers and facilitators to habit maintenance in this population.

Lower Optimal Treatment Adherence Among Youth Living With HIV in a Universal Health Care Setting Where ART Is Available at No Cost

PURPOSE

We assessed differences in optimal adherence between youth (aged 15-29 years) and adults (aged ≥30 years) enrolled in the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program from 2010 to 2016.

METHODS

Population-level clinical data were used to compare optimal antiretroviral therapy adherence (≥95%), based on pharmacy refill data, among youth and adults. Unadjusted and adjusted generalized estimating estimates were performed to examine the independent relationship between time-dependent age categories and optimal adherence, adjusting for confounders. Factors associated with optimal adherence among youth were examined.

RESULTS

Data for 7,485 individuals living with HIV were included. Median follow-up was 7 years (Q1-Q3: 4-7). Over the study period, the number of individuals categorized as "youth" ranged from 820 in 2010 to 291 in 2016. Multivariable models found youth living with HIV were significantly less likely to be optimally adherent than adults (adjusted odds ratio [aOR] = .55; 95% confidence interval [CI]: .49-.62), after controlling for potential confounders, although youth adherence improved significantly during the study period. Among youth, increasing time-dependent age (aOR = 1.18/year older; 95%CI: 1.11-1.25) and number of years on antiretroviral therapy (aOR = 1.15, 95%CI: 1.10-1.19) were independently associated with optimal adherence, while Hepatitis C-positive serostatus (aOR = .55; 95%CI: .33-.92) and multiple treatment regimen change (aOR = .89/regimen change; 95%CI: .81-.97) were negatively associated with optimal adherence.

CONCLUSIONS

Youth were less likely to be optimally adherent throughout the study period. Findings suggest implications for increased youth-centered adherence support, particularly for youth living with HIV concurrently living with Hepatitis C, newly initiating treatment, and going through medication change.

Reflections on the Use of Audio Diaries to Access Young People's Lived Experiences of HIV in Zimbabwe

This methodological article reflects on the contribution audio diaries can make to accessing important, and commonly silenced, dimensions of the lived experience of growing up with HIV and their acceptability to children. Audio diaries were used by 12 young people, aged 11 to 13 years, as part of a longitudinal qualitative study embedded within the Anti-Retroviral Research for Watoto (ARROW) clinical trial. The method provided an alternative means for young people to express detailed reflections on their day-to-day encounters, as well as ordinarily silenced topics, including hidden and suppressed emotions regarding the circumstance surrounding their perinatal infection. Although the audio diary has great potential as method, its efficacy rests on young people's understanding of how to use it. There are ethical challenges around maintaining confidentiality while participants are in possession of the diaries and provision of appropriate support. The technology used in the study was in many ways cumbersome compared with opportunities increasingly available.

Adherence Connection for Counseling, Education, and Support: Research Protocol for a Proof-of-Concept Study

Background

The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts.

Objective

The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care).

Methods

An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care.

Results

As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior.

Conclusions

Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12543

The Stepped Care Intervention to Suppress Viral Load in Youth Living With HIV: Protocol for a Randomized Controlled Trial

Background

Among youth living with HIV (YLH) aged 12-24 years who have health care in the United States, only 30% to 40% are virally suppressed. YLH must achieve viral suppression in order to reduce the probability of infecting others as well as increasing the length and quality of their own life.

Objective

This randomized controlled trial aimed to evaluate the efficacy of an Enhanced Standard Care condition (n=110) compared to an Enhanced Stepped Care intervention condition (n=110) to increase viral suppression among YLH aged 12-24 years with established infection (not acutely infected).

Methods

YLH (N=220) who are not virally suppressed will be identified at homeless shelters, health clinics, and gay-identified community-based organizations in Los Angeles, CA, and New Orleans, LA. Informed consent will be obtained from all participants. YLH will be randomly assigned to one of two study conditions: Enhanced Standard Care, which includes standard clinical care plus an automated messaging and monitoring intervention (AMMI), or an Enhanced Stepped Care, which includes three levels of intervention (AMMI, Peer Support via social media plus AMMI, or Coaching plus Peer Support and AMMI). The primary outcome is viral suppression of HIV, and YLH will be assessed at 4-month intervals for 24 months. For the Enhanced Stepped Care intervention group, those who do not achieve viral suppression (via blood draw, viral load<200 copies/mL) at any 4-month assessment will “step up” to the next level of intervention. Secondary outcomes will be retention in care, antiretroviral therapy adherence, alcohol use, substance use, sexual behavior, and mental health symptoms.

Results

Recruitment for this study began in June 2017 and is ongoing. We estimate data collection to be completed by the end of 2020.

Conclusions

This is the first known application of an Enhanced Stepped Care intervention model for YLH. By providing the lowest level of intervention needed to achieve viral suppression, this model has the potential to be a cost-effective method of helping YLH achieve viral suppression and improve their quality of life.

Trial Registration

ClinicalTrials.gov NCT03109431; https://clinicaltrials.gov/ct2/show/NCT03109431

International Registered Report Identifier (IRRID)

DERR1-10.2196/10791

Five Approaches to Qualitative Comparison Groups in Health Research: A Scoping Review

Qualitative researchers have much to gain by using comparison groups. Although their use within qualitative health research is increasing, the guidelines surrounding them are lacking. The purpose of this article is to explore the extent to which qualitative comparison groups are being used within health research and to outline the lessons learned in using this type of methodology. Through conducting a scoping review, 31 articles were identified that demonstrated five different types of qualitative comparison groups. I highlight the key benefits and challenges in using this approach.

Positive Strategies to Enhance Problem-Solving Skills (STEPS): A Pilot Randomized, Controlled Trial of a Multicomponent, Technology-Enhanced, Customizable Antiretroviral Adherence Intervention for HIV-Infected Adolescents and Young Adults

Adolescents are disproportionately impacted by HIV in the United States. Optimal effects from antiretroviral therapy (ART) can be achieved through stringent adherence to a daily medication regimen; for adolescents, this may be interrupted due to complex barriers unique to this age group. We previously conducted formative qualitative interviews with HIV-infected adolescents to identify key barriers facing adolescents regarding ART adherence and potential strategies to address these barriers. These data were used to inform an ART adherence intervention designed to overcome difficulties unique to HIV-infected adolescents (e.g., internalized stigma and HIV-related shame, disclosure to sexual partners, social life, and extracurricular activities at school, etc.). The resulting intervention-"Positive Strategies To Enhance Problem-solving Skills (Positive STEPS)"-combines five individual counseling sessions with daily text message reminders. We conducted a pilot randomized controlled trial of the intervention against a standard of care control and report on the feasibility of procedures and participant acceptability of the intervention in terms of content, structure, and format. ART adherence was measured in both arms through Medication Event Monitoring System pill caps and self-report. Feasibility and acceptability of the Positive STEPS intervention was evidenced by 90% retention for the intervention sessions; 100% completion of the four-month assessment; and positive responses on postintervention evaluation forms (all intervention participants rated Positive STEPS as "acceptable" or "very acceptable") and brief exit interviews. At the 4-month assessment visit, the change in ART adherence among the intervention group [mean change score = 13%, standard deviation (SD) = 29.5] was significantly higher compared with the standard of care group (mean change score = -26%, SD = 26.0; Cohen's d effect size = 1.43, confidence interval = 0.17-2.49, p = 0.02). Future testing of the intervention in a fully powered randomized controlled trial to determine efficacy is warranted.

Positive STEPS - a randomized controlled efficacy trial of an adaptive intervention for strengthening adherence to antiretroviral HIV treatment among youth: study protocol

Background

HIV infection among youth in the United States is on the rise. A high level of antiretroviral therapy (ART) adherence is crucial to treatment success and can minimize the population burden of the disease. However, the overall rate of ART adherence among youth is generally suboptimal and no published efficacious interventions exist to address the specific needs of this population. This paper describes the design of a stepped-care, “adaptive” ART adherence intervention protocol for HIV-infected adolescents and young adults.

Methods

This is a randomized controlled trial (RCT) to establish the efficacy of “Positive STEPS,” a behavioral and technology-based intervention to optimize ART adherence and viral suppression among HIV-infected youth, ages 16 to 29. Participants are equally randomized to 1) the Positive STEPS intervention, which begins with two-way daily text messaging as a reminder system to take their medications; participants progress to a more intensive in-person counseling intervention if text messaging is not sufficient to overcome barriers; or 2) or standard of care (SOC). At randomization, all participants receive standardized ART adherence education. During the 4 major study assessment visits (baseline, 4-, 8-, and 12-months), participants have their blood drawn to measure HIV viral load and complete a mix of computer-based self-administered and interviewer-administered behavioral and psychosocial measures. The primary outcomes are improvements in viral load and ART adherence measured via a medication-tracking device (i.e., Wisepill) and self-report.

Discussion

Behavioral interventions are greatly needed to improve ART adherence among HIV-infected adolescents and young adults and prevent onward transmission. If effective, the intervention tested here will be one of the first rigorously-designed efficacy trials to promote ART adherence in this population, using an approach that holds promise for being readily integrated into real-world clinical settings.

Trial registration

ClinicalTrials.gov number NCT03092531, registered March 28, 2017.