Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa

"Swallowing these drugs every day, you get tired": a mixed-methods study to identify barriers and facilitators to retention and HIV viral load suppression among the adolescents living with HIV in TASO Mbale and TASO Soroti centers of excellence

BACKGROUND

Adolescents aged 10-19 years, living with HIV (ALHIV) lag in attaining optimal viral load suppression (VLS) rates and retention in care. This study aimed to identify barriers and facilitators to both treatment outcomes in TASO Mbale and TASO Soroti centers of excellence.

METHODS

We used a mixed methods approach, extracting secondary data on ALHIV who were active in care during April-June 2022 quarter to determine one year retention and VLS (HIV RNA copies < 1000/ml). Analysis was done in STATA Corp, 15.0. We used logistic regression to determine predictors and adjusted odds ratio (aOR) to report levels of predictability, using 95% confidence interval (CI) and P < 0.05 for statistical significance. For qualitative component, purposive sampling of 59 respondents was done. Focused group discussions, key informant interviews, and in-depth interviews were used to collect data. Thematic content analysis was done using Atlas ti.

RESULTS

There were 533 ALHIV, median age of 15 years, interquartile range of 11-18 and 54.2% females. 12-month retention rate was 95.9% and VLS of 84.0%. Poor and fair adherence [aOR = 0.044, 95% CI 0.010-0.196, P < 0.001)], [aOR = 0.010, 95% CI (0.002-0.039) P < 0.001] respectively had decreased odds for VLS while multi-month dispensing of drugs (aOR = 3.403, 95% CI 1.449-7.991, P = 0.005) had increased odds of VLS. For retention, being with a non-biological caregiver (aOR = 0.325, 95% CI 0.111-0.9482 P = 0.04) decreased the odds. Meanwhile key barriers included: individual ones such as internal stigma and treatment/drug fatigue; facility-level such as prolonged waiting time and lack of social activities; community level include stigma and discrimination, inadequate social support and food shortage. In terms of facilitators, individual level ones included good adherence and knowledge of one's HIV status; facility-level such as provision of adolescent friendly services and community-level like social support and decent nutrition.

CONCLUSIONS

VLS rate was sub-optimal mainly due to poor adherence. HIV programs could utilize the barriers and facilitators identified to improve VLS. Conversely, retention rate at one year was good, likely due to provision of adolescent friendly health services. ALHIV and their caregivers need to be empowered to sustain retention and improve VLS.

Characterizing adolescent and youth-friendly HIV services: a cross-sectional assessment across 16 global sites

INTRODUCTION

Adolescent and youth-friendly health services (AYFHS) have been promoted as a best practice for adolescents and young people living with HIV (AYLH). However, thorough descriptions of AYFHS for AYLH remain scarce. We sought to characterize adolescent-friendly HIV services in a global paediatric research consortium.

METHODS

Cross-sectional data were collected from 16 global sites in the Adolescent and Young Adult Network of IeDEA (AYANI) of the International epidemiology Databases to Evaluate AIDS consortium between August 2020 and October 2022 using a standardized site assessment tool that collected data on clinic, patient and provider characteristics, differentiated care, and transition to adult services processes. Descriptive analyses characterized the health services available across the participating sites, using frequencies and proportions for categorical variables and medians and interquartile range for continuous variables. Data were analysed using RStudio.

RESULTS

Overall, 13 of 16 sites (81%) reported having dedicated adolescent services, which most often consisted of dedicated clinic days (62%, n = 8/13), primarily offered on weekdays. Across all sites, nurses and counsellors delivered services to adolescents. Over half of all clinics (69%, n = 11/16) reported offering health education to adolescents to facilitate adolescent health literacy. Peer educators and navigators were involved in delivering services at 62% of sites, primarily in those with dedicated adolescent services (69%, n = 9/13). There was limited integration of sexual and reproductive health services into HIV clinics for adolescents. With 63% of clinics conducting pregnancy screening, 50% providing family planning methods and 38% providing cervical cancer screening. Under half of all HIV clinics screened for physical abuse or violence (44%, n = 7/16) and sexual abuse or rape (38%, n = 6/16). A low proportion of clinics screened for risk factors related to young key populations, including drug use (56%, n = 9/16), homelessness (38%, n = 6/16) young men having sex with men (31%, n = 5/16) and transactional sex (31%, n = 5/16). Mental health screening for concerns was variable.

CONCLUSIONS

Findings suggest gaps in AYFHS for AYLH across the HIV clinics included in this analysis. There is a vital need to design health services for AYLH that are accessible, equitable, and effective and meet the global standards for delivering high-quality healthcare to adolescents.

Examining teen club attendance and viral load suppression among adolescents under differentiated HIV care in Malawi: a sub-optimal scenario

BACKGROUND

In Malawi, compared to adults, adolescents have higher rates of high HIV viremia and poorer antiretroviral therapy (ART) outcomes. The Ministry of Health, supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), implemented the provision of differentiated care clubs for adolescents living with HIV (ALHIV), called "teen clubs," to provide psychosocial support and an HIV care package to improve clinical outcomes. We evaluated teen club attendance and factors associated with unsuppressed viral load (VL) in ALHIV enrolled in these teen clubs.

METHODS

This cross-sectional study used program data from 35 health facilities in four districts that offered teen club services. We enrolled all ALHIV receiving ART ages 10-19 years who attended teen clubs between July 2018- September 2019 and had documented viral load results. Unsuppressed VL was defined as HIV RNA = > 1000 copies/mL, and optimal ART adherence was defined as having an expected pill count suggesting that between 95 and 105% of pills prescribed were consumed. We used multivariable logistic regression to identify factors associated with unsuppressed VL, adjusting for sex, age, education, district, adherence assessment, disclosure of one's HIV status, and teen club attendance.

RESULTS

Our analysis included 1,162 ALHIV with a median age of 15 years (IQR 13-17). The majority were female (n = 614, 53%) and attended one or two teen club visits (n = 665, 57%). Unsuppressed VL was identified in 28% of ALHIV. ALHIV with sub-optimal ART adherence were twice as likely to have unsuppressed VL (adjusted odds ratio [aOR] 2.0, 95% confidence interval (CI): 1.42-2.62) compared to those with optimal ART adherence. ALHIV on second-line treatments, were nearly four times more likely to have unsuppressed VL (aOR 3.7, 95% CI: 1.64-9.09) compared with those on first-line ART. ALHIV who had attained secondary school education were less likely to have unsuppressed VL (aOR 0.42, 95% CI 0.21-0.81) than those who only attained primary school education.

CONCLUSION

Even amongst adolescents enrolled in teen clubs, teen club attendance is low and high HIV viremia prevails. A continual focus on adolescents is needed to promote consistent teen club attendance and consistent ART adherence among the adolescents enrolled in differentiated service delivery.

Expanding single-venue services to better engage young people who inject drugs: insights from India

BACKGROUND

Over the last decade, India has had an alarming rise in injection of opioids across several cities. Although scale-up of public sector services for people who inject drugs (PWID) in India has occurred over decades, accessibility has been diminished by fragmented services across physical locations. To circumvent this barrier, and in alignment with the World Health Organization's guidelines to provide comprehensive care to key populations, Integrated Care Centers (ICCs) were established across 8 Indian cities as a public-private service delivery model for providing free single-venue services to PWID. ICCs have been very successful in expanding service availability and convenience for PWID generally. However, few studies from low- and middle-income countries (LMIC) have evaluated how well young PWID (defined as those ≤ 29 years of age) engage with single-venue service models like ICCs or specific services provided in such models. Young PWID are an important subpopulation in India, as they bear a disproportionate burden of new HIV infections because of greater risk and evidence of lower receipt of HIV testing and harm reduction services compared to older PWID. In this comment, we offer insights specific to young PWID drawn from multiple quantitative and qualitative studies examining the reach and effectiveness of ICCs, which may provide generalizable insights into limitations of services for young PWID more broadly in India and globally.

FINDINGS

Our studies suggest that while ICCs have expanded service availability, particularly in cities with emerging injection drug use epidemics, population-level reach to foster initial engagement among young PWID can be optimized. Additionally, young PWID who do engage with ICCs experience gaps in substance use treatment receipt and retention, and experience barriers to receipt of ICC services that are distinct from those experienced by older PWID. Notably, HIV incidence among ICC clients is concentrated in young PWID. Finally, ICCs were not intended to reach adolescent PWID, and new services are needed for this subpopulation.

CONCLUSIONS

In addition to co-locating services, iterative optimization of models such as ICCs should incorporate youth-specific differentiated interventions and be accompanied by policy changes that are critical to improving the reach and effectiveness of harm reduction and HIV services among young PWID in India.

Correlates of HIV treatment adherence self-efficacy among adolescents and young adults living with HIV in southwestern Uganda

Adherence to antiretroviral therapy (ART) among adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa is sub-optimal compared to younger children and older adults. Adherence self-efficacy is one of the intrapersonal factors most strongly correlated with ART adherence. The role of adherence self-efficacy in ART adherence among AYLHIV is not well studied in Uganda. We enrolled 300 AYLHIV between October and December 2021 from an HIV clinic in southwestern Uganda. We collected information on adherence self-efficacy, HIV stigma, depression, self-management, and social skills. We used linear regression to estimate the association between adherence self-efficacy and the covariates of interest. At multivariable adjustment self-management (b = 0.29, 95% CI 0.23-0.35, p<0.001) and social skills (b = 0.16, 95% CI 0.08-0.24; p<0.001) were statistically significantly associated with adherence self-efficacy. The findings imply that interventions directed at enhancing self-management and social skills in AYLHIV may increase adherence self-efficacy and, potentially, HIV outcomes among AYLHIV.

Can Support Groups Improve Treatment Adherence and Reduce Sexual Risk Behavior among Young People Living with HIV? Results from a Cohort Study in South Africa

Adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa experience poorer HIV outcomes than adults, including lower ART adherence and virologic suppression. They also have high rates of unprotected sex, increasing the risk of adverse sexual health outcomes and onward transmission. This one-arm, pre-post study investigates a structured 14-session support group aiming to boost treatment adherence and sexual protective behavior for AYLHIV in South Africa. Logistic and Poisson regression analyses were performed on self-reported pre- and post-intervention survey data collected approximately 7.5 months apart from a cohort of 548 AYLHIV. Participants were significantly more likely to report at least 95% adherence at follow-up and rate their health as "good;" they also demonstrated greater treatment knowledge and had fewer absences from school overall and due to illness. Among sexually active AYLHIV, contraception use at last sex increased significantly, while condom use did not. Effects were small, and greater programmatic emphasis on adherence and multifaceted service packages is likely necessary to promote viral suppression. Nonetheless, the intervention addresses an important gap in service provision for AYLHIV in South Africa. Findings denote the potential for incorporating care and treatment components into sexual and reproductive health interventions tailored for AYLHIV.

Acceptability, feasibility and preliminary effectiveness of the mHealth intervention, InTSHA, on retention in care and viral suppression among adolescents with HIV in South Africa: a pilot randomized clinical trial

We describe the results of a pilot randomized clinical trial of a mobile phone-based intervention, InTSHA: Interactive Transition Support for Adolescents with HIV, compared to standard care. Encrypted, closed group chats delivered via WhatsApp provided peer support and improved communication between adolescents with HIV, their caregivers, and healthcare providers. We randomized 80 South African adolescents ages 15 to 19 years with perinatally-acquired HIV to receive either the intervention (n=40) or standard of care (n=40). We measured acceptability (Acceptability of Intervention Measure [AIM]) and feasibility (Feasibility of Intervention Measure [FIM]) as primary outcomes. We evaluated impact on retention in care and viral suppression six months after randomization as secondary endpoints. We performed bivariable and multivariable analyses using logistic regression models to assess the effect of the InTSHA intervention compared to standard of care. Among the adolescents randomized to the InTSHA intervention, the median AIM was 4.1/5.0 (82%) and median FIM was 3.9/5.0 (78%). We found no difference in retention in care or in viral suppression comparing intervention and control groups. Among adolescents who attended three or more sessions, retention in care was 100% at 6 months. InTSHA is an acceptable and feasible mHealth intervention warranting further study in a larger population.

Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review

INTRODUCTION

Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries.

METHODS

We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs.

RESULTS

We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs.

DISCUSSION

Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression.

CONCLUSIONS

Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.

HIV epidemiology, prevention, treatment, and implementation strategies for public health

The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.

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.

"Swallowing these drugs every day, you get tired": a mixed-methods study to identify Barriers and facilitators to retention and HIV Viral Load suppression among the Adolescents living with HIV in TASO Mbale and TASO Soroti centers of excellence

Background

Adolescents aged 10-19, living with HIV (ALHIV) lag behind in attaining optimal viral load suppression (VLS) rates and retention in care, an important impediment to reaching epidemic control. This study aimed to identify barriers and facilitators to both VLS and retention among in the sub-population who seek care from TASO Mbale and TASO Soroti centers of excellence, to facilitate adaptation of the operation triple zero in the setting.

Methods

We used a mixed methods approach, extracting secondary data on ALHIV who were active in care during April-June 2022 quarter to determine one year retention in care. Analysis was done in STATA Corp, 15.0. We used logistic regression to determine associated factors and adjusted odds ratio (aOR) to report level of predictability, using 95% confidence interval (CI) and P<0.05 for statistical significance. For qualitative component, purposive sampling of 59 respondents was done. Focused group discussions, key informant interviews, and in-depth interviews were used to collect data. Thematic content analysis was done using Atlas ti.

Results

There were 533 ALHIV, with 12-month retention rate of 95.9% and VLS rate of 74.9%. Predictors for good VLS included good adherence [aOR:95%CI 0.066(0.0115, 0.38) P=0.02], being on first line treatment [aOR:95%CI 0.242 (0.0873,0.6724) P=0.006]. For retention, they include being a school going [aOR:95%CI 0.148(0.024,0.9218) P=0.041], multi month dispensing aOR:95%CI 32.6287(5.1446,206.9404) P<0.001, OVC enrolment aOR:95%CI 0.2625(0.083, 0.83) P=0.023]. Meanwhile key barriers included: individual ones such as internal stigma, lack of transport and treatment/drug fatigue; facility-level such as prolonged waiting time and lack of social activities; community level include stigma and discrimination, inadequate social support and food shortage. In terms of facilitators, individual level ones include good adherence and knowledge of one's HIV status; facility-level such as provision of adolescent friendly services and community-level such as social support and decent nutrition.

Conclusions

VLS rate was sub-optimal mainly due to poor adherence. HIV programs could utilize the barriers and facilitators identified to improve VLS. Conversely, retention rate at one year was good, likely due to provision of adolescent friendly health services. ALHIV and their caregivers need to be empowered to sustain retention and improve VLS.

Contributions to science

By accentuating the barriers and facilitators to retention and VLS among the ALHIV, we ensure HIV programs continue to prioritize effective interventions and discard others as the epidemic evolves. To this, our findings strategically validate the effectiveness of provision of adolescent friendly services and client-centered care in attaining good retention rate.Secondly, being a mixed-methods study, complementarily adds value to the existing body of knowledge on barriers and facilitators while reminding programmers that VLS remains sub-optimal and more efforts are necessary.Finally, different stakeholders could use our findings to advocate for more resources to address some of the barriers such as food shortage, empowerment of ALHIV and caregivers and strengthening skilling programs for ALHIV, especially the out-of-school.

Youth-friendly services was the magic: Experiences of adolescent girls and young women in the community PrEP study, South Africa

Adherence to daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been challenging for adolescent girls and young women (AGYW). As part of The Community PrEP Study (CPS), AGYW were randomised to HIV-prevention empowerment counselling (intervention) or basic medication pick-up (control). In this qualitative sub-study, we interviewed AGYW participants (n = 39) to explore PrEP use and study experiences by study arm, and study staff (n = 7) to explore study implementation, site environment, and participant engagement. Data were thematically analysed using a constant comparison approach. Comparative matrices assessed similarities and differences in study experiences and PrEP support preferences. Friendly, non-judgmental, non-stigmatizing study staff were described as central to participant's positive experiences. Participants highly valued CPS staff's holistic health support (e.g. physical and psycho-social). Intervention participants described empowerment counselling as helpful in supporting PrEP disclosure. However, control participants also described disclosing PrEP use to trusted individuals. Participants and staff recommended public-sector PrEP services provide holistic, confidential, and integrated sexual and reproductive health services, and community sensitisation. An adolescent and youth-friendly environment was the primary factor motivating AGYW's study engagement. While HIV-prevention empowerment counselling was well received, welcoming, respectful and non-judgmental staff may be the 'secret sauce' for implementing effective PrEP services to AGYW.

Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial

A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.

Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya

BACKGROUND

Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya.

METHODS

This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention.

RESULTS

Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant.

CONCLUSIONS

This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.

A youth-centred approach to improving engagement in HIV services: human-centred design methods and outcomes in a research trial in Kisumu County, Kenya

IntroductionInnovative interventions are needed to improve HIV outcomes among adolescents and young adults (AYAs) living with HIV. Engaging AYAs in intervention development could increase effectiveness and youth acceptance, yet research is limited. We applied human-centred design (HCD) to refine adherence-support interventions pretrial and assessed HCD workshop acceptability.

METHODS

We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants.

RESULTS

Twenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants.

CONCLUSIONS

Research employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

Viral suppression rate at operation triple zero (Otz) and regular art follow-Up programs and associated factors among adolescent clients of Addis Ababa Ethiopia: a comparative cross-sectional study

BACKGROUND

- Viral suppression is the main goal of currently available treatment and it is used as a primary indicator of successful treatment for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). This ensures a reduction in AIDS-associated morbidity and mortality and decreases the risk of both vertical and horizontal viral transmission. This study aimed to investigate the magnitude of viral suppression and its associated factors among adolescents, comparing the operation triple zero (OTZ) program to regular antiretroviral therapy (ART) follow-up programs.

METHODS

- The research consisted of a comparative cross-sectional study, which included a total sample size of 446 adolescents on Active Antiretroviral Therapy (ART) - 223 enrolled in OTZ, and 223 in regular ART from public hospitals. Sociodemographic data were obtained using a self-administered semi-structured questionnaire, and clinical data were extracted from medical records. To examine the prevalence of viral suppression (VS) the latest status was used and multivariate logistic regression analysis was performed to identify factors associated with VS.

RESULTS

- Overall, the adolescent viral suppression was 88.3%, with 92.4% in the OTZ group and 84.3% in the regular ART group. Among OTZ participants, the factors that significantly reduced the odds of viral suppression were having a history of admission in the last year, alcohol use, biological mother not alive, cigarette smoking, social discrimination, and current medication regimen TDF/3TC/EFZ. Among those in regular ART, factors associated with a lesser chance of viral suppression were alcohol use, social discrimination, unscheduled appointments, and current medication regimen TDF/3TC/EFZ when compared to their counterparts. When we compared the two programs, OTZ had a 26.1 times greater chance of suppressing HIV viral load (AOR = 26.1, 95% CI: 3.499-133.9; P = 0.041).

CONCLUSION

- The overall VS was 88.3%, while viral suppression is better achieved through the OTZ program than through regular ART services. Alcohol use, biological mother not alive, cigarette smoking, social discrimination, and current medication regimen TDF/3TC/EFZ were identified to be factors associated with viral nonsuppression. Therefore, it is advisable to implement the OTZ program in all HIV care centers and focus on factors reducing viral suppression.

Impact of a teen club model on HIV outcomes among adolescents in rural Neno district, Malawi: a retrospective cohort study

OBJECTIVE

To compare the impact of a teen club model to the standard care model on HIV treatment outcomes among adolescents (10-19 years of age).

DESIGN

Retrospective cohort study.

SETTING

HIV clinics in Neno district, Malawi.

PARTICIPANTS

Adolescents living with HIV enrolled in teen clubs (n=235) and matched participants in standard HIV care (n=297).

OUTCOME MEASURES

Attrition from HIV care, defined as a combination of treatment outcomes 'died', 'defaulted' and 'transferred out'.

RESULTS

Over a 4-year follow-up period, adolescents who participated in the teen club had a significantly higher likelihood of remaining in care than those who did not (HR=2.80; 95% CI: 1.46 to 5.34). Teen clubs also increased the probability of having a recent measured viral load (VL) and BMI, but did not change the probability of VL suppression. The age at antiretroviral treatment initiation below 15 years (aHR=0.37; 95% CI: 0.17 to 0.82) reduced the risk of attrition from HIV care, while underweight status (aHR=3.18; 95% CI: 1.71 to 5.92) increased the risk of attrition, after controlling for sex, WHO HIV staging and teen club participation.

CONCLUSIONS

The teen club model has the potential to improve treatment outcomes among adolescents in rural Neno district. However, in addition to retaining adolescents in HIV care, greater attention is needed to treatment adherence and viral suppression in this special population. Further understanding of the contextual factors and barriers that adolescents in rural areas face could further improve the teen club model to ensure high-quality HIV care and quality of life.

Development and validation of a prediction tool to support engagement in HIV care among young people ages 10-24 years in Kenya

INTRODUCTION

Loss to follow-up (LTFU) among adolescents and young adults living with HIV (AYALWH) is a barrier to optimal health and HIV services. We developed and validated a clinical prediction tool to identify AYALWH at risk of LTFU.

METHODS

We used electronic medical records (EMR) of AYALWH ages 10 to 24 in HIV care at 6 facilities in Kenya and surveys from a subset of participants. Early LTFU was defined as >30 days late for a scheduled visit in the last 6 months, which accounts for clients with multi-month refills. We developed a tool combining surveys with EMR ('survey-plus-EMR tool'), and an 'EMR-alone' tool to predict high, medium, and low risk of LTFU. The survey-plus-EMR tool included candidate sociodemographics, partnership status, mental health, peer support, any unmet clinic needs, WHO stage, and time in care variables for tool development, while the EMR-alone included clinical and time in care variables only. Tools were developed in a 50% random sample of the data and internally validated using 10-fold cross-validation of the full sample. Tool performance was evaluated using Hazard Ratios (HR), 95% Confidence Intervals (CI), and area under the curve (AUC) ≥ 0.7 for good performance and ≥0.60 for modest performance.

RESULTS

Data from 865 AYALWH were included in the survey-plus-EMR tool and early LTFU was (19.2%, 166/865). The survey-plus-EMR tool ranged from 0 to 4, including PHQ-9 ≥5, lack of peer support group attendance, and any unmet clinical need. High (3 or 4) and medium (2) prediction scores were associated with greater risk of LTFU (high, 29.0%, HR 2.16, 95%CI: 1.25-3.73; medium, 21.4%, HR 1.52, 95%CI: 0.93-2.49, global p-value = 0.02) in the validation dataset. The 10-fold cross validation AUC was 0.66 (95%CI: 0.63-0.72). Data from 2,696 AYALWH were included in the EMR-alone tool and early LTFU was 28.6% (770/2,696). In the validation dataset, high (score = 2, LTFU = 38.5%, HR 2.40, 95%CI: 1.17-4.96) and medium scores (1, 29.6%, HR 1.65, 95%CI: 1.00-2.72) predicted significantly higher LTFU than low-risk scores (0, 22.0%, global p-value = 0.03). Ten-fold cross-validation AUC was 0.61 (95%CI: 0.59-0.64).

CONCLUSIONS

Clinical prediction of LTFU was modest using the surveys-plus-EMR tool and the EMR-alone tool, suggesting limited use in routine care. However, findings may inform future prediction tools and intervention targets to reduce LTFU among AYALWH.

Development of "Yima Nkqo," a community-based, peer group intervention to support treatment initiation for young adults with HIV in South Africa

AIMS

Half of young adults diagnosed with HIV in South Africa start antiretroviral therapy (ART). We developed and field tested a facilitator-guided peer support group called Yima Nkqo ("Standing Tall" in isiXhosa) to promote treatment initiation for young adults newly diagnosed with HIV in communities around Cape Town.

METHODS

Following an adapted version of the UK Medical Research Council's framework for developing complex interventions, we 1) identified evidence on previous interventions to improve ART uptake in sub-Saharan Africa; 2) collected and analyzed qualitative data on the acceptability of our proposed intervention; 3) proposed a theoretical understanding of the process of behavior change; and 4) developed an intervention manual and feedback tools. During field-testing, participant feedback on intervention acceptability, and team feedback on consistency of content delivery and facilitation quality, were analyzed using an iterative, rapid-feedback evaluation approach. In-depth written and verbal summaries were shared in weekly team meetings. Team members interpreted feedback, identified areas for improvement, and proposed suggestions for intervention modifications.

RESULTS

Based on our formative research, we developed three, 90-minute sessions with content including HIV and ART education, reflection on personal resources and strengths, practice disclosing one's status, strategies to overcome stressors, and goal setting to start treatment. A lay facilitator was trained to deliver intervention content. Two field testing groups (five and four participants, respectively) completed the intervention. Participants highlighted that strengths of Yima Nkqo included peer support, motivation, and education about HIV and ART. Team feedback to the facilitator ensured optimal consistency of intervention content delivery.

CONCLUSIONS

Iteratively developed in collaboration with youth and healthcare providers, Yima Nkqo is a promising new intervention to improve treatment uptake among young adults with HIV in South Africa. The next phase will be a pilot randomized controlled trial of Yima Nkqo (ClinicalTrials.gov Identifier: NCT04568460).

Improving retention and HIV viral load suppression among adolescents living with HIV in TASO Soroti and TASO Mbale centers of excellence using Operation Triple Zero model: a before and after study protocol

BACKGROUND

Retention in care and HIV viral load suppression remains sub-optimal among HIV positive adolescents in many settings including TASO Uganda, despite the implementation of interventions such as regimen optimization and community-based approaches like multi-month drug dispensing. To this end, the implementation of additional intervention is urgently required to address gaps in current programming which include inadequate centralization of the HIV positive adolescents and their caregivers in the designs. This study, thus, proposes to adapt and implement the Operation Triple Zero (OTZ) model in TASO Soroti and Mbale centers to improve both retention and viral load suppression among the adolescents living with HIV.

METHODOLOGY

A before and after study design is preferred, employing both qualitative and quantitative approaches. To identify barriers and facilitators to retention and HIV viral load suppression among the HIV positive adolescents, secondary data, focused group discussions, and key informant interviews will be used to understand perspectives of the adolescents, their caregivers, and the health-workers. The Consolidated Framework for Implementation Research (CFIR) will help in designing the intervention, while Knowledge to Action (K2A) will support the adaptation process. To test the intervention, Reach, Effectiveness, Adaption, Implementation and Maintenance (RE-AIM) framework will be used. A paired t-test will be used to compare means of retention and viral load suppression in the before and after study periods.

DISCUSSION

This study aims at adapting and implementing the OTZ model in TASO Soroti and Mbale Centers of Excellence (COEs) to attain optimal retention and HIV viral load suppression rates among the HIV positive adolescents in care. Uganda is yet to adapt the touted OTZ model and findings from this study will be important in providing the necessary lessons to inform a policy shift for potential scale up of the model. Furthermore, results of this study could provide additional evidence for the effectiveness of OTZ in attaining optimal HIV treatment outcomes among the adolescents living with HIV.

The Status of Adolescent Testing and Treatment in PEPFAR-Supported Programs, October 2017 to September 2020

BACKGROUND

Adolescents have poorer outcomes across the HIV cascade compared with adults. We aimed to assess progress in HIV case finding, antiretroviral treatment (ART), viral load coverage (VLC), and viral load suppression (VLS) among adolescents enrolled in the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported programs over a 3-year period that included the beginning of the COVID-19 pandemic.

METHODS

We analyzed PEPFAR program data in 28 countries/regions for adolescents aged 10-19 years between year 1 (October 2017to September 2018), year 2 (October 2018 to September 2019), and year 3 (October 2019 to September 2020). We calculated the number and percent change for HIV tests, HIV-positive tests, and total number on ART. Calculated indicators included positivity, percent of positives newly initiated on ART (ART linkage), VLC (percent of ART patients on ART for ≥6 months with a documented viral load result within the past 12 months), and VLS (percent of viral load tests with <1000 copies/mL).

RESULTS

Between years 1 and 3, the number of HIV tests conducted decreased by 44.2%, with a 29.1% decrease in the number of positive tests. Positivity increased from 1.3%-1.6%. The number of adolescents receiving ART increased by 10.4%. In addition, ART linkage increased (77.8%-86.7%) as did VLC (69.4%-79.4%) and VLS (72.8%-81.5%).

CONCLUSIONS

Our findings demonstrate PEPFAR's success in increasing the adolescent treatment cohort. We identified ongoing gaps in adolescent case finding, linkage, VLC, and VLS that could be addressed with a strategic mix of testing strategies, optimal ART regimens, and adolescent-focused service delivery models.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Challenges and Fears of Adolescents and Young Adults Living with HIV Facing Transition to Adult HIV Care

Adolescents and young adults living with perinatally-acquired HIV (AYLPHIV) have poor outcomes along each step of the HIV care continuum due to challenges in seeking care and advocating for themselves. The transition from paediatric to adult HIV care is a particularly high-risk period for AYLPHIV in rural Uganda. We conducted in-depth interviews with AYLPHIV (n = 30), caregivers (n = 10), and healthcare providers (n = 10) to understand challenges facing AYLPHIV during the transition from paediatric to adult HIV care. Themes were identified by thematic content analysis. Transition-related challenges and fears included difficulty navigating the adult HIV clinic; loss of informational support; long wait times at the adult HIV clinic; lack of privacy, and fear of HIV status disclosure and stigma; and loss of support from caregivers, and health care providers. Before transitioning to adult HIV care, AYLPHIV should be adequately prepared and given appropriate information to help them navigate adult HIV care.

Determinants of viral load suppression among orphaned and vulnerable children living with HIV on ART in Tanzania

Introduction

In Tanzania, only 66% children 0–14 years living with HIV know their HIV status, 66% are on treatment while 47% of children on ART are virally suppressed. Although retention on ART and poor adherence remain a challenge for children living with HIV, orphans and vulnerable children (OVC) face a greater limitation of access to and utilization of comprehensive HIV care and treatment. In response to this, the current study assessed the determinants of viral load suppression (VLS) among OVC aged 0–14 years living with HIV enrolled in HIV interventions.

Methods

This was a cross-sectional study that used secondary data collected by the USAID Kizazi Kipya project in 81 district councils of Tanzania. Included in this study are 1,980 orphans and vulnerable children living with HIV (OVCLHIV) (0–14 years) enrolled and served by the project for 24 months. Data analysis involved multivariable logistic regression, with viral load suppression as the outcome of interest and HIV interventions as the main independent variables.

Results

The overall VLS rate among the OVCLHIV was 85.3%. This rate increased from 85.3, 89.9, 97.6 to 98.8% after 6, 12, 18, and 24 months of retention on ART, respectively. Similar rates were observed as the duration of adherence to ART increased. In the multivariable analysis, OVCLHIV attending people living with HIV (PLHIV) support groups were 411 times more likely to be virally suppressed than those not attending (aOR = 411.25, 95% CI 168.2–1,005.4). OVCLHIV with health insurance were 6 times more likely to achieve viral suppression than those without (aOR = 6.05, 95% CI 3.28–11.15). OVCLHIV with &gt;95% adherence to ART were 149 times more likely to be virally suppressed than those not adherent to ART (aOR = 148.96, 95% CI 42.6–520.6, p &lt; 0.001). Other significant factors included food security and family size. OVCLHIV reached by the different HIV community-based interventions were more likely to be virally suppressed than those who were not.

Discussion

To advance viral suppression, efforts should be made to ensure that all OVCLHIV are reached by community-based interventions as well as integrating food support in HIV treatment interventions.

Viral load suppression in HIV-infected adolescents in cameroon: towards achieving the UNAIDS 95% viral suppression target

BACKGROUND

Achieving the UNAIDS 95% sustained viral suppression (VS) rate requires considerable global efforts, particularly among adolescents living with HIV (ALHIV) who are often associated with high rates of virological failure (VF). In this study, we prospectively assessed the rate of VS, and the factors associated with VF in a cohort of adolescents followed up according to the WHO guidelines in Cameroon.

METHODS

A cross-sectional study was carried out in 2021 among adolescents (aged 10-19 years) receiving ART in the national program in Cameroon. Socio-demographic and clinical data were collected using patients' medical files and a brief interview with the participant and/or his guardian. Thereafter, a first viral load test (VL1) was performed using the ABBOTT Platform. For adolescents with VL1 > 1000 copies/ml, adherence-enhancing interventions were routinely performed each month for 3 consecutive months, after which a second viral load (VL2) was measured. Adolescents with VL2 > 1000 copies/ml were considered in VF.

RESULTS

Overall, 280 adolescents were enrolled, of whom 89.3% (250/280) acquired HIV infection via mother-to-child transmission. The median age was 16.0 (IQR: 13.0-18.0) years and the median duration on ART was 9.8 (IQR: 5.1-12.8) years. Females and males were almost equally represented, as 52.1% (146/280) were female, while 47.9% (134/280) were males (p = 0.47). The VS rate was 88.2% (CI: 83.8-91.7%) overall; 89.0% (CI: 82.0-93.1%) and 88.7% (CI: 81.2-93.0%) in females and males, respectively. Being on second or third-line ART, self-declared suboptimal adherence, and a history of past VF were independently associated with VF.

CONCLUSION

The high rate of VS we report in this study is welcome in the era of the 95/95/95 UNAIDS goals, and indicates that improving treatment outcomes in this specific and fragile population that represent adolescents in Sub-Saharan Africa is achievable.

TRIAL REGISTRATION

20/10/2020 NCT04593979 ( https://clinicaltrials.gov/ct2/show/NCT04593979 ).

Determinants and rates of retention in HIV care among adolescents receiving antiretroviral therapy in Windhoek, Namibia: a baseline cohort analysis

BACKGROUND

Long-term engagement in HIV care is essential to achieving and maintaining viral suppression. Adolescents living with HIV (ALHIV) experience many barriers to remaining engaged in care and treatment programs. Higher attrition among adolescents compared to adults remains a huge concern due to unique psychosocial and health systems challenges adolescents face, and recently the COVID-19 pandemic effects. We report on determinants and rates of retention in care in adolescents aged 10-19 years enrolled on antiretroviral therapy (ART) in Windhoek, Namibia.

METHODS

A retrospective cohort analysis of routine clinical data of 695 adolescents aged 10-19 years enrolled for ART at 13 Windhoek district public healthcare facilities, between January 2019 and December 2021 was conducted. Anonymized patient data were extracted from an electronic database and registers. Bivariate and Cox proportional hazards analysis were performed to determine factors associated with retention in care among ALHIV at 6, 12, 18, 24 and 36 months. Retention in care trends were also described using the Kaplan-Meier survival analysis.

RESULTS

The retention in care rates at 6, 12, 18, 24 and 36 months were 97.7%, 94.1%, 92.4%, 90.2%, and 84.6%, respectively. Our study population had predominantly treatment-experienced adolescents, who initiated ART between birth and 9 years (73.5%), were on treatment for > 24 months (85.0%), and on first-line ART (93.1%). After controlling for confounders, the risk of dropping out of care was increased for older adolescents aged 15-19 years (aHR = 1.964, 95% CI 1.033-3.735); adolescents on switched ART regimens (Second line + Third line regimen) (aHR = 4.024, 95% CI 2.021-8.012); adolescents who initiated ART at 15-19 years (aHR = 2.179, 95%CI 1.100-4.316); and male adolescents receiving ART at a PHC clinic (aHR = 4.322, 1.332-14.024). Conversely, the risk of ALHIV dropping out of care decreased for adolescents whose TB screen results were negative (aHR = 0.215, 95% CI 0.095-0.489).

CONCLUSION

Retention in care rates among ALHIV in Windhoek do not meet the UNAIDS revised target of 95%. Gender-specific interventions are needed to keep male and older adolescents motivated and engaged in long-term care, and to promote adherence amongst those adolescents who were initiated on ART in late adolescence (15-19 years).

"Whenever you need support, you first turn to the group": motivations and functions of WhatsApp groups for youth living with HIV

Social support is a critical component of achieving positive health outcomes for youth living with HIV (YLWH). Mobile health (mHealth) has significant potential for providing social support to YLWH. However, little is known about the domains of social support most needed by YLWH which mHealth interventions might address. Drawing on the spontaneous creation of WhatsApp support groups by YLWH in Nairobi, Kenya, we characterized Kenyan YLWH's social support needs and potential roles of social media groups in meeting them. We conducted interviews and focus-groups with 68 YLWH, 24 caregivers and 20 healthcare workers, and observed two YLWH-led WhatsApp groups for 6 weeks. Youth reported that existing support systems, including family and healthcare workers, already provided informational and instrumental support. However, they emphasized unmet companionship and emotional support needs, leading to isolation, hopelessness, and medication adherence challenges. Participants identified connection with other YLWH as a unique source of emotional and companionship support that allowed them to feel more secure and less isolated. Interviews and observed WhatsApp chats demonstrated that WhatsApp groups were a desirable medium for companionship support that overcame barriers to in-person connection.

Caring for Adolescents and Young Adults With Tuberculosis or at Risk of Tuberculosis: Consensus Statement From an International Expert Panel

Background:

Despite being a preventable and treatable disease, tuberculosis (TB) is a leading cause of death among young people globally. Each year, an estimated 1.8 million adolescents and young adults (AYAs; 10–24 years old) develop TB. In 2019, an estimated 161,000 AYAs died of the disease. AYAs have unique developmental, psychosocial, and healthcare needs, but these needs have been neglected in both TB care and research agendas. In order to improve outcomes in this age group, the specific needs of AYAs must be considered and addressed.

Methods:

Through a consensus process, an international panel of 34 clinicians, researchers, TB survivors, and advocates with expertise in child/adolescent TB and/or adolescent health proposed interventions for optimizing AYA engagement in TB care. The process consisted of reviewing the literature on TB in AYAs; identifying and discussing priority areas; and drafting and revising proposed interventions until consensus, defined a priori , was reached.

Results:

The panel acknowledged the dearth of evidence on best practices for identifying and managing AYAs with TB. The final consensus statement, based on expert opinion, proposes nine interventions to reform current practices that may harm AYA health and well-being, and nine interventions to establish high-quality AYA-centered TB services.

Conclusion:

AYA-specific interventions for TB care and research are critical for improving outcomes in this age group. In the absence of evidence on best practices, this consensus statement from an international group of experts can help address the needs of AYA with TB or at risk for TB.

Asking the Experts: Using Cognitive Interview Techniques to Explore the Face Validity of the Mental Wellness Measure for Adolescents Living with HIV

There has been an increased focus on the mental health of adolescents living with HIV (ALHIV), because evidence shows that poor mental health outcomes are associated with lower rates of adherence and retention in HIV care. However, the research to date has predominantly focused on addressing mental health problems and reducing symptoms of mental illness rather than strengthening mental wellness [positive mental health]. Consequently, little is known about the critical mental wellness indicators that should be targeted in services for ALHIV. There is a need for valid and appropriate measures of mental wellness to drive research and provide evidence on the mental wellness needs of ALHIV that would inform service delivery as well as the monitoring and evaluation of treatment outcomes. To this end, we developed the Mental Wellness Measure for Adolescents Living with HIV (MWM-ALHIV) for ALHIV in the South African context. In this paper, we report on the findings from a cognitive interview study with nine ALHIV aged 15-19 years receiving treatment at a public healthcare facility in the Cape Metropole, South Africa. Through interviews, participants identified key issues related to the wording, relevance and understanding of the items and provided suggestions to improve the instrument's overall face validity.

Individual-, Interpersonal- and Institutional-Level Factors Associated with HIV Stigma Among Youth in Kenya

HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15-24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions.

Advanced HIV Disease at Antiretroviral Therapy Initiation and Treatment Outcomes Among Children and Adolescents Compared to Adults Living With HIV in Kinshasa, Democratic Republic of the Congo

Background: Little is known about advanced HIV disease (AHD) at antiretroviral therapy (ART) initiation among children and adolescents living with HIV (CALHIV) and related age disparities in the Democratic Republic of the Congo (DRC). Methods: We conducted a retrospective cohort analysis of routine program data collected among adults, adolescents, and children living with HIV in 6 health zones in Kinshasa, DRC from 2005 to 2020. Results: Thirty-two percent of those who initiated ART had AHD. Compared to adults, adolescents had a 15% higher risk of AHD (RR: 1.15; 95% CI: 1.08-1.21; P < .001). Despite their higher risk of AHD, adolescents had a lower risk of mortality (aSHR: 0.72; 95% CI: 0.52-0.99; P = .047) and lower cumulative death events versus adults (aSHR: 0.44; 95% CI: 0.34-0.59; P < .001). Conclusions: ADH at ART initiation is highly prevalent in Kinshasa, DRC, and adolescents are disproportionally impacted. There is a need to scale up high-impact HIV interventions targeting CALHIV.

Contextual Factors Influencing Self-Management of Adolescents and Youth Living with HIV: A Cross-Sectional Survey in Lesotho

Background: HIV treatment outcomes of adolescents and youth living with HIV (AYLWH) are lagging. One way to improve outcomes is through supporting AYLWH to acquire self-management skills. Although self-management is associated with improved health outcomes, condition-specific, individual/family, and social/environmental contextual factors influence self-management. We aimed to describe factors influencing the self-management of AYLWH in Lesotho. Methods: A cross-sectional survey design was used. AYLWH (n = 183) aged 15−24 were conveniently sampled from two HIV treatment sites in Lesotho. Participants completed self-report questionnaires in English or Sesotho. Results: Participants (89.1% female) had high HIV self-management scores (mean 92.7%, SD 5.3%) that corresponded with treatment outcomes (98.9% adherent and 100% viral load < 1000 copies/mL). This might be attributed to condition-specific factors, including once-daily doses (100%) and longer duration of treatment (81.4% on ART for more than 10 years). Participants were older (median age 22), and the majority (61.7%) had stable living conditions. Individual strengths were associated with higher self-management scores (p < 0.01) and mental health problems with lower self-management scores (p < 0.05). Most (97.9%) were satisfied with their health care services. Conclusions: Uncomplicated treatment regimens, longer duration of treatment, stable living conditions, individual strengths, good mental health, and satisfaction with healthcare services have a positive influence on self-management.

Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania

HIV treatment outcomes may be improved by ameliorating psychosocial challenges adolescents living with HIV (ALHIV) face. This analysis describes participation in existing facility-based adolescent clubs and the associations between club attendance, adolescent well-being and HIV treatment outcomes. Data were collected through interviews with a sub-sample of adolescents age 10-19 years and medical record abstraction of all adolescents attending HIV services at seven clinics in Tanzania. Independent variables included adolescent club attendance, self-esteem, self-efficacy, mental distress, social capital and other health utilization or HIV experience characteristics. Study outcomes included visit adherence, viral suppression (<1000 cp/ml), and retention. Of 645 adolescents attending HIV services, 75% attended clubs at least once with a median of eight club sessions attended over a two-year period. Mental distress was prevalent, with 67% of the adolescents scoring above a recognized cut-off of ≥5. Adolescents who attended 10 or more clubs, compared to those not attending any clubs over a two-year period were at an almost three-fold increased odds of having good visit adherence (odds ratio [OR] 2.72, 95% confidence interval [CI]: 1.25, 5.94). Club attendance was also associated with sustained retention in the following year: adolescents who attended some clubs (1-9) had three-times the odds of being retained (OR 3.01; 95%CI: 1.86, 4.87) while those who attended 10+ had over seven-times the odds (OR 7.29; 95%CI: 4.34, 12.22). Among the 154 adolescents who were interviewed, being in the top self-efficacy tertile was positively associated with viral suppression (OR 3.04, 95%CI: 1.08, 8.60) and retention (OR 4.44, 95%CI: 1.19, 17.40). Attending the HIV clinic with a guardian/treatment supporter (OR 3.29, 95%CI: 1.17, 9.22) was also associated with viral suppression. Self-efficacy, social capital and treatment support are associated with better health outcomes among adolescents. However, many ALHIV either never attended or did not regularly attend clubs.

Viral suppression among adolescents on HIV treatment in the Sedibeng District, Gauteng province

BACKGROUND

 Progress has been made to increase access to antiretroviral therapy (ART) for adolescents living with HIV (ALHIV) to improve their survival, but ALHIV still have worse treatment adherence and viral suppression compared to adults and children.

OBJECTIVE

 To determine the prevalence of viral suppression and the associated factors among adolescents aged 10-19 years on ART at an urban public primary healthcare facility in the Sedibeng district, Gauteng.

METHOD

 A cross-sectional survey was conducted among 192 adolescents who were on ART for at least six months between 2015 and 2018. A self-developed data extraction tool was used to collect data from the Tier.Net electronic database and clinical folders. Data were captured on Microsoft Excel, and descriptive and inferential analyses were performed using SPSS 27 statistical software.

RESULTS

 The median age at ART initiation of adolescents was 9.0 years (interquartile range [IQR]: 5.0-12.0), and the median duration on ART was 70.5 (IQR: 30.25-105.5) months. The prevalence of viral suppression ( 1000 copies/mL) among adolescents on ART was 74%, with 41% achieving full suppression ( 50 copies/mL). Those adolescents who reported optimal ART adherence were more likely to be virally suppressed compared to those who reported poor adherence (98.1% vs 25.0%; p ≤ 0.001).

CONCLUSION

 Adolescent viral suppression of 74% is higher than in comparable sites, but still way too short of the UNAIDS target of 90%. We recommend adherence support for adolescents to achieve viral suppression.Contribution: The study highlights the urgent need for targeted adherence support interventions for adolescents living with HIV on antiretroviral therapy to improve rates of viral suppression to meet UNAIDS target of 95%.

Factors associated with HIV viral suppression among adolescents in Kabale district, South Western Uganda

Background

The goal of antiretroviral therapy is to achieve sustained human immune deficiency virus (HIV) viral suppression. However, research on factors associated with viral load suppression among adolescents in low and middle-income countries is limited. The objectives of this study were to determine HIV viral suppression levels among adolescents in Kabale district and the associated clinical, adherence and psychosocial factors.

Methods

Cross-sectional and retrospective cohort study designs were used. Two hundred and forty-nine adolescents living with HIV that attended clinics between September and October 2019 at nine health facilities were interviewed and their medical records reviewed. A data abstraction tool was used to collect clinical data from adolescent’s clinical charts, face to face interviews were conducted using semi-structured questionnaire adopted from the HEADS tool and in-depth interviews conducted with ten key informants. Qualitative data was analyzed using thematic content analysis. Logistic regression was used to determine the magnitude by which clinical and psychosocial factors influence viral load suppression. Odds Ratios (ORs) were used for statistical associations at 95% confidence interval considering statistical significance for p-values less than 0.05. Qualitative data collected from Key informants to support our quantitative findings was analyzed using thematic content analysis.

Results

HIV viral suppression among (n = 249) adolescents was at 81%. Having no severe opportunistic infections was associated with viral load suppression among adolescent living with HIV (OR = 1.09; 95%CI [1.753–4.589]; p<0.001) as well as having no treatment interruptions (OR = 0.86; 95% CI [2.414–6.790]; p = 0.004). Belonging to a support group (OR = 1.01; 95% CI [1.53–4.88]; P = 0.020), having parents alive (OR = 2.04; 95% CI[1.02–4.12]; P = 0.047) and having meals in a day (OR = 5.68; C.I = 2.38–6.12, P = 0.010), were significantly associated to viral load suppression. The findings also indicated that long distances from health facilities, transport challenges and unprofessional conduct of health workers that make adolescent unwelcome at health facilities negatively affected viral suppression among adolescents.

Conclusion

The findings indicate that HIV viral suppression among adolescents on ART was at 81%. Kabale district was likely not to achieve the third 90 of the UNAIDS 90-90-90 global target for this population category. The findings further indicate that having no severe opportunistic infection and no treatment interruptions, good nutrition status, peer support and support from significant others, were highly associated with viral load suppression.

Predictors of loss to follow up from antiretroviral therapy among adolescents with HIV/AIDS in Tanzania

Access to Antiretroviral Therapy (ART) is threatened by the increased rate of loss to follow-up (LTFU) among adolescents on ART care. We investigated the rate of LTFU from HIV care and associated predictors among adolescents living with HIV/AIDS in Tanzania. A retrospective cohort analysis of adolescents on ART from January 2014 to December 2016 was performed. Kaplan-Meier method was used to determine failure probabilities and the Cox proportion hazard regression model was used to determine predictors of loss to follow up. A total of 25,484 adolescents were on ART between 2014 and 2016, of whom 78.4% were female and 42% of adolescents were lost to follow-up. Predictors associated with LTFU included; adolescents aged 15–19 years (adjusted hazard ratio (aHR): 1.57; 95% Confidence Interval (CI); 1.47–1.69), having HIV/TB co-infection (aHR: 1.58; 95% CI, 1.32–1.89), attending care at dispensaries (aHR: 1.12; 95% CI, 1.07–1.18) or health center (aHR: 1.10; 95% CI, 1.04–1.15), and being malnourished (aHR: 2.27; 95% CI,1.56–3.23). Moreover, residing in the Lake Zone and having advanced HIV disease were associated with LTFU. These findings highlight the high rate of LTFU and the need for intervention targeting older adolescents with advanced diseases and strengthening primary public facilities to achieve the 2030 goal of ending HIV as a public health threat.

"I have never talked to anyone to free my mind" - challenges surrounding status disclosure to adolescents contribute to their disengagement from HIV care: a qualitative study in western Kenya

Introduction

Adolescents living with HIV (ALHIV, ages 10–19) experience complex barriers to care engagement. Challenges surrounding HIV status disclosure or non-disclosure to adolescents may contribute to adolescent disengagement from HIV care or non-adherence to ART. We performed a qualitative study to investigate the contribution of disclosure challenges to adolescent disengagement from HIV care.

Methods

This was a qualitative study performed with disengaged ALHIV and their caregivers, and with healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Inclusion criteria for ALHIV were ≥1 visit within the 18 months prior to data collection at one of two clinical sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Analysis was conducted by multiple independent coders, and narratives of disclosure and care disengagement were closely interrogated. Overarching themes were elucidated and summarized.

Results

Interviews were conducted with 42 disengaged ALHIV, 32 caregivers, and 28 HCW. ALHIV were average age 17.0 (range 12.9–20.9), and 95% indicated awareness of their HIV diagnosis. Issues surrounding disclosure to ALHIV presented important barriers to HIV care engagement. Themes centered on delays in HIV status disclosure; hesitancy and reluctance among caregivers to disclose; struggles for adolescents to cope with feelings of having been deceived prior to full disclosure; pervasive HIV stigma internalized in school and community settings prior to disclosure; and inadequate and unstructured support after disclosure, including for adolescent mental health burdens and for adolescent-caregiver relationships and communication. Both HCW and caregivers described feeling inadequately prepared to optimally handle disclosure and to manage challenges that may arise after disclosure.

Conclusions

Complex challenges surrounding HIV status disclosure to adolescents contribute to care disengagement. There is need to enhance training and resources for HCW, and to empower caregivers to support children and adolescents before, during, and after HIV status disclosure. This should include counseling caregivers on how to provide children with developmentally-appropriate and accurate information about their health from an early age, and to support adolescent-caregiver communication and relationships. Optimally integrating peer support can further promote ALHIV wellbeing and retention in care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13519-9.

Systematic review: Development of a person-centered care framework within the context of HIV treatment settings in sub-Saharan Africa

OBJECTIVES

Person-centred care (PCC) meets the needs of individuals by increasing convenience, providing supportive and culturally appropriate services to diverse populations, and engaging families, communities, and stakeholders in planning and provision of care. While the evidence demonstrates that PCC approaches can lead to clinical improvements across the HIV care continuum, it is not yet well defined in the context of HIV service delivery.

METHODS

A systematic review was conducted to define PCC practices for HIV treatment services in health facilities in sub-Saharan Africa. Data synthesis led to the development of a PCC framework including domain and sub-domain development. The study team used the Effective Public Health Project Practice tool for quantitative studies to assess the quality of the included studies.

RESULTS

Thirty-one studies from 12 countries met the inclusion criteria, including 56,586 study participants (females 42%-100% and males 0%-58%), resulting in three major domains and 11 sub-domains. These include staffing (sub-domains of composition, availability, and competency); service delivery standards (sub-domains of client feedback mechanisms; service efficiency and integration; convenience and access; and digital health worker support tools); and direct client support services (sub-domains of psychosocial services, logistics support, client-agency, and digital client support tools). Twenty-five of the person-centred interventions within these domains resulted in improvements in linkage to care, treatment retention, and/or viral suppression.

CONCLUSIONS

The PCC framework can help to provide a more consistent classification of HIV treatment interventions and will support improved assessment of these interventions to ensure that people receive personalised care.

Interventions addressing the adolescent HIV continuum of care in South Africa: a systematic review and modified Delphi analysis

INTRODUCTION

Compared with adults, adolescents in South Africa have larger gaps at each step of the HIV continuum of care resulting in low levels of viral suppression.

METHODS

We conducted a systematic review and modified Delphi analysis of interventions addressing the HIV continuum of care for adolescents in South Africa. We searched PubMed, Science Direct, and Google Scholar and online conference proceedings from the International AIDS Society, the International AIDS Conference, and the Conference on Retrovirology and Opportunistic Infections from 1 January 2010 to 30 September 2020. We then conducted a modified Delphi analysis with 29 researchers involved in the National Institutes of Health's Fogarty International-supported Adolescent HIV Implementation Science Alliance-South Africa to evaluate interventions for efficacy, feasibility and potential for scale-up.

RESULTS

We identified nine initial published articles containing interventions addressing the adolescent HIV continuum of care in South Africa, including five interventions focused on HIV diagnosis, two on antiretroviral therapy adherence and two on retention in care. No studies addressed linkage to care or transition from paediatric to adult care. Two studies discussed intervention costs. In-home and HIV self-testing, community-based adherence support, and provision of adolescent-friendly services were the most impactful and scalable interventions addressing the adolescent HIV continuum of care.

CONCLUSION

Future interventions should work comprehensively across the adolescent HIV continuum of care and be tailored to the specific needs of adolescents.

Determinants of health-related quality of life in young adults living with perinatally acquired HIV infection in Botswana

Background

Due to the successful antiretroviral therapy (ART) programme in Botswana, large numbers of perinatally HIV-infected adolescents are emerging into young adulthood. Young adulthood is a critical period of human development. However, there is lack of information on the factors affecting the health-related quality of life (HRQOL) of young adults living with perinatally acquired HIV (YALPH) in Botswana.

Objectives

The objective of this study was to assess the HRQOL and its determinants among YALPH who were enrolled on ART at Botswana-Baylor Children’s Clinical Centre of Excellence in Gaborone, Botswana.

Method

A cross-sectional study assessed the HRQOL of 509 YALPH aged 18–30 years using the WHOQOL-HIV BREF. Data about other variables of interest were abstracted from medical records. Bivariate analyses were performed using t and Chi-square tests to determine the associations between demographic and clinical variables and general HRQOL. The variables that were associated with the general HRQOL at P-value < 0.1 were included in the multivariable analysis using the logistic regression approach.

Results

The majority of participants had good general HRQOL (78.4%). The highest mean HRQOL score was in the Physical domain (5.4 [± 2.9]) and the lowest in the Environment domain (13.8 [± 2.7]). The factors that were significantly associated with the general HRQOL included: level of education attained (P = 0.012), employment status (P = 0.069), viral load suppression (P = 0.073) and self-reported illness (P = 0.001).

Conclusion

Interventions that effectively increase educational attainment, employment opportunities, ART adherence, and prevention or management of illness are needed to promote good HRQOL among YALPH in Botswana.

Antiretroviral therapy uptake and predictors of virological failure in patients with HIV receiving first-line and second-line regimens in Johannesburg, South Africa: a retrospective cohort data analysis

OBJECTIVE

This study described the demographics, treatment information and identified characteristics associated with virological failure and being lost to follow-up (LTFU) for patients with HIV on first-line and second-line antiretroviral therapy (ART) regimens in a large South African cohort.

DESIGN

A quantitative retrospective cohort study using secondary data analysis.

SETTING

Seven Johannesburg inner city facilities.

PARTICIPANTS

Unique records of 123 002 people with HIV receiving ART at any point in the period 1 April 2004 to 29 February 2020 were included.

MEASURES

Demographic characteristics, ART status, CD4 count information and retention status were collected and analysed as covariates of outcomes (viral load (VL) and LTFU).

RESULTS

Of the total study patients, 95% (n=1 17 260) were on a first-line regimen and 5% (n=5742) were on a second-line regimen. Almost two-thirds were female (64%, n=79 226). Most patients (60%, n=72 430) were initiated on an efavirenz-based, tenofovir disoproxil fumarate-based and emtricitabine-based regimen (fixed-dose combination). 91% (n=76 737) achieved viral suppression at least once since initiating on ART and 60% (n=57 981) remained in care as at the end of February 2020. Patients from the community health centre and primary healthcare clinics were not only more likely to be virally suppressed but also more likely to be LTFU. Patients on second-line regimens were less likely to reach viral suppression (adjusted OR (aOR)=0.26, CI=0.23 to 0.28) and more likely to be LTFU (aOR=1.21, CI=1.09 to 1.35). Being older (≥25 years) and having a recent CD4 cell count≥100 cells/µL were predictors of viral suppression and retention in patients on ART.

CONCLUSION

Patients on first-line regimens had higher VL suppression rates and were more likely to remain in care than those on a second-line regimen. Being younger and having low CD4 cell counts were associated with poor outcomes, suggesting priority groups for ART adherence support.

'We are not going anywhere': a qualitative study of Kenyan healthcare worker perspectives on adolescent HIV care engagement during the COVID-19 pandemic

INTRODUCTION

Adolescents living with HIV (ALHIV) may be vulnerable to widescale impacts of the COVID-19 pandemic and to health system responses which impact HIV care. We assessed healthcare worker (HCW) perspectives on impacts of the COVID-19 pandemic on adolescent HIV care delivery and engagement in western Kenya.

METHODS

We performed in-depth qualitative interviews with HCW at 10 clinical sites in the Academic Model Providing Access to Healthcare in Kenya, from January to March, 2021. Semistructured interviews ascertained pandemic-related impacts on adolescent HIV care delivery and retention.

RESULTS

Interviews were conducted with 22 HCWs from 10 clinics. HCWs observed adolescent financial hardships, unmet basic needs and school dropouts during the pandemic, with some adolescents relocating to rural homes, to partners or to the street. Marked increases in adolescent pregnancies and pregnancy complications were described, as well as barriers to family planning and antenatal care. Transportation challenges and restrictions limited access to care and prompted provision of multi-month refills, refills at local dispensaries or transfer to local facilities. Adolescent-friendly services were compromised, resulting in care challenges and disengagement from care. Clinic capacities to respond to adolescent needs were limited by funding cuts to multidisciplinary staff and resources. HCW and youth peer mentors (YPMs) demonstrated resilience, by adapting services, taking on expanded roles and leveraging available resources to support adolescent retention and access to care.

CONCLUSIONS

ALHIV are uniquely vulnerable, and adolescent-friendly services are essential to their treatment. The combined effects of the pandemic, health system changes and funding cuts compromised adolescent-friendly care and limited capacity to respond to adolescent needs. There is a need to reinforce adolescent-friendly services within programmes and funding structures. Support for expanded YPM roles may facilitate dedicated, scalable and effective adolescent-friendly services, which are resilient and sustainable in times of crisis.

Prevalence and Correlates of Viral Load Suppression and Human Immunodeficiency Virus (HIV) Drug Resistance Among Children and Adolescents in South Rift Valley and Kisumu, Kenya

BACKGROUND

Children and adolescents living with HIV (CALHIV) face unique challenges, including poorer treatment outcomes, risk for drug-resistance mutations (HIVDRMs), and limited drug formulations. We estimated viral suppression (VS) prevalence and evaluated predictors of VS and HIVDRMs in Kenya.

METHODS

From 2018-2020, CALHIV 1-19 years on antiretroviral therapy (ART) >6 months were enrolled in this cross-sectional study. Participants underwent viral load (VL) testing; those with VL ≥1000 copies/mL had HIVDRM testing. Sociodemographic questionnaires and medical record abstraction were completed. VS prevalence (VL <1000 copies/mL) was estimated; robust Poisson regression models were used to estimate prevalence ratios (PRs) and 95% CIs for associations between potential predictors of VS.

RESULTS

Nine hundred and sixty-nine participants were enrolled. VS prevalence was .80 (95% CI: .78-.83). Being on ART >24 months (adjusted PR [aPR]: 1.22; 95% CI: 1.06-1.41), an integrase strand transfer inhibitor-containing regimen (1.13; 1.02-1.26), and attending a level 3 health facility (1.23; 1.11-1.36) were associated with VS. Missing ≥3 doses of ART in the past month (aPR: .73; 95% CI: .58-.92), having a viremic mother with HIV (.72; .53-.98), and having 3-7 (.90; .83-.97), 8-13 (.89; .82-.97), or ≥14 (.84; .77-.92) compared with <2 adherence counseling referrals were inversely associated with VS. A high proportion (n = 119, 81.5%) of unsuppressed participants had evidence of any major HIVDRM.

CONCLUSIONS

HIV treatment programs should target interventions for pediatric patients at risk for treatment failure-namely, those with a caregiver with failed VS and those struggling with adherence.

Stewart GC, Wamalwa DC, Kohler PK. “I Have Actually not Lost any Adolescent Since I Started Engaging Them one on one:” Training Satisfaction and Subsequent Practice among Health Providers Participating in a Standardized Patient Actor Training to Improve Adolescent Engagement in HIV Care

Background: Poor health care worker (HCW) interactions with adolescents negatively influence engagement in HIV care. We assessed the impact of standardized patient actor training on HCW competence in providing adolescent HIV care in Kenya. Methods: We conducted pre-post cross-sectional surveys and qualitative exit interviews during a stepped wedge randomized trial. Cross-sectional surveys assessed self-rated competence in providing adolescent services before and after the intervention, and training satisfaction. In-depth interviews with a subset of HCW participants one year after training. Results: Over 90% of HCWs reported satisfaction with the training and there was significant improvement in self-rated competence scores (mean = 4.63 [highest possible score of 5] post-training vs 3.86 pre-training, p < 0.001). One-year following training, HCWs reported using skills in patient-centered communication and structuring an adolescent clinical encounter. Conclusions: This SP training intervention improved self-rated competence and showed sustained perceived impact on HCW skills in adolescent HIV service provision one year later.

Mobile Phone-Based Intervention Among Adolescents Living With Perinatally Acquired HIV Transitioning from Pediatric to Adult Care: Protocol for the Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA) Study

BACKGROUND

Adolescents living with perinatally acquired HIV often have poor retention in care and viral suppression during the transition from pediatric to adult-based care.

OBJECTIVE

The aim of this study is to evaluate a mobile phone-based intervention, Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA), among adolescents living with perinatally acquired HIV as they transition from pediatric to adult care in South Africa.

METHODS

InTSHA uses encrypted, closed group chats delivered via WhatsApp (Meta Platforms Inc) to develop peer support and improve communication between adolescents, their caregivers, and health care providers. The intervention is based on formative work with adolescents, caregivers, and health care providers and builds on several existing adolescent support programs as well as the Social-ecological Model of Adolescent and Young Adult Readiness for Transition (SMART). The final InTSHA intervention involves 10 modules conducted weekly through moderated WhatsApp group chats with adolescents and separately with their caregivers. We will randomly assign 80 South African adolescents living with perinatally acquired HIV who are aware of their HIV status and aged between 15 and 19 years to receive either the intervention (n=40) or standard of care (n=40).

RESULTS

We will measure acceptability of the intervention as the primary outcome and evaluate feasibility and preliminary effectiveness for retention in care and viral suppression after completion of the intervention and at least 6 months after randomization. In addition, we will measure secondary outcomes evaluating the impact of the InTSHA intervention on peer support, self-esteem, depression, stigma, sexual education, connection to health care providers, and transition readiness. Enrollment began on April 15, 2021. As of December 31, 2021 a total of 78 out of expected 80 participants have been enrolled.

CONCLUSIONS

If successful, the intervention will be evaluated in a fully powered randomized controlled trial with a larger number of adolescents from urban and rural populations to further evaluate the generalizability of InTSHA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03624413; https://clinicaltrials.gov/ct2/show/NCT03624413.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35455.

Estimating Tuberculosis Transmission Risks in a Primary Care Clinic in South Africa: Modeling of Environmental and Clinical Data

BACKGROUND

Congregate settings, such as healthcare clinics, may play an essential role in Mycobacterium tuberculosis (Mtb) transmission. Using patient and environmental data, we studied transmission at a primary care clinic in South Africa.

METHODS

We collected patient movements, cough frequency, and clinical data, and measured indoor carbon dioxide (CO2) levels, relative humidity, and Mtb genomes in the air. We used negative binomial regression model to investigate associations.

RESULTS

We analyzed 978 unique patients who contributed 14 795 data points. The median patient age was 33 (interquartile range [IQR], 26-41) years, and 757 (77.4%) were female. Overall, median CO2 levels were 564 (IQR 495-646) parts per million and were highest in the morning. Median number of coughs per day was 466 (IQR, 368-503), and overall median Mtb DNA copies/μL/day was 4.2 (IQR, 1.2-9.5). We found an increased presence of Mtb DNA in the air of 32% (95% credible interval, 7%-63%) per 100 additional young adults (aged 15-29 years) and 1% (0-2%) more Mtb DNA per 10% increase of relative humidity. Estimated cumulative transmission risks for patients attending the clinic monthly for at least 1 hour range between 9% and 29%.

CONCLUSIONS

We identified young adults and relative humidity as potentially important factors for transmission risks in healthcare clinics. Our approach should be used to detect transmission and evaluate infection control interventions.

Virologic non-suppression and early loss to follow up among pregnant and non-pregnant adolescents aged 15-19 years initiating antiretroviral therapy in South Africa: a retrospective cohort study

Introduction

Older adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which puts those living with HIV at a dual vulnerability. Our study assessed the factors associated with VNS and LTFU in older adolescents (including pregnant females) who initiated antiretroviral therapy (ART) in South Africa.

Methods

We included adolescents aged 15–19 years initiating ART between 2004 and 2019, with ≥ one viral load (VL) measurement between 4 and 24.5 months, and ≥ 6 months follow‐up, from six South African cohorts of the International epidemiology Databases to Evaluate AIDS‐Southern Africa (IeDEA‐SA). We defined VNS as VL ≥400 copies/ml and LTFU as not being in care for ≥180 days from ART start and not known as transferred out of the clinic or dead in the first 24 months on ART. We examined factors associated with VNS and LTFU using Fine&Gray competing risk models.

Results

We included a total of 2733 adolescents, 415 (15.2%) males, median (IQR) age at ART start of 18.6 (17.3, 19.4) years. Among females, 585/2318 (25.2%) were pregnant. Over the 24‐month follow‐up, 424 (15.5%) of all adolescents experienced VNS: range (11.1% pregnant females and 20.5% males). Over half of all adolescents were LTFU before any other event could occur. The hazard of VNS reduced with increasing age and CD4 count above 200 cells/μl at ART initiation among all adolescents having adjusted for all measured patient characteristics [adjusted sub‐distribution hazard ratio (aSHR) 19 vs. 15 years: 0.50 (95% CI: 0.36, 0.68), aSHR: >500 vs. ≤200 cells/μl: 0.22 (95% CI: 0.16, 0.31)]. The effect of CD4 count persisted in pregnant females. Increasing age and CD4 count >200 cells/μl were risk factors for LTFU among all adolescents.

Conclusions

Older adolescents had a high risk of LTFU shortly after ART start and a low risk of VNS, especially those initiating treatment during pregnancy. Interventions addressing adherence and retention should be incorporated into adolescent‐friendly services to prevent VNS and LTFU and endeavour to trace lost adolescents as soon as they are identified.

Attrition from HIV care among youth initiating ART in youth-only clinics compared with general primary healthcare clinics in Khayelitsha, South Africa: a matched propensity score analysis

INTRODUCTION

Youth living with HIV (YLWH) are less likely to initiate antiretroviral therapy (ART) and remain in care than older adults. It is important to identify effective strategies to address the needs of this growing population and prevent attrition from HIV care. Since 2008, two clinics have offered youth-targeted services exclusively to youth aged 12-25 in Khayelitsha, a high HIV-prevalence, low-income area in South Africa. We compared ART attrition among youth in these two clinics to youth in regular clinics in the same area.

METHODS

We conducted a propensity score matched cohort study of individuals aged 12-25 years initiating ART at eight primary care clinics in Khayelitsha between 1 January 2008 and 1 April 2018. We compared attrition, defined as death or loss to follow-up, between those attending two youth clinics and those attending general primary healthcare clinics, using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer or dataset closure. We conducted sub-analyses of patients attending adherence clubs.

RESULTS

The distribution of age, sex and CD4 count at ART initiation was similar across Youth Clinic A (N = 1383), Youth Clinic B (N = 1299) and general clinics (N = 3056). Youth at youth clinics were more likely than those at general clinics to have initiated ART before August 2011 (Youth Clinic A: 16%, Youth Clinic B: 23% and general clinics: 11%). Youth clinics were protective against attrition: HR 0.81 (95% CI: 0.71-0.92) for Youth Clinic A and 0.85 (0.74-0.98) for Youth Clinic B, compared to general clinics. Youth Clinic A club patients had lower attrition after joining an adherence club than general clinic patients in adherence clubs (crude HR: 0.56, 95% CI: 0.32-0.96; adjusted HR: 0.48, 95% CI: 0.28-0.85), while Youth Clinic B showed no effect (crude HR: 0.83, 95% CI: 0.48-1.45; adjusted HR: 1.07, 95% CI: 0.60-1.90).

CONCLUSIONS

YLWH were more likely to be retained in ART care in two different youth-targeted clinics compared to general clinics in the same area. Our findings suggest that multiple approaches to making clinics more youth-friendly can contribute to improving retention in this important group.

A Facility-based Family Support Intervention to Improve Treatment Outcomes for Adolescents on Antiretroviral Therapy in the Cape Metropole, South Africa

Adolescents living with human immunodeficiency virus (HIV) (ALHIV) globally, report worse treatment outcomes compared to adults and children on antiretroviral therapy (ART). We conducted a photovoice study with eighteen ALHIV to explore experiences and challenges of being on ART, and individual interviews with 5 health workers to describe the challenges in treating ALHIV. The facility implemented the Family club intervention to facilitate caregivers (parent/guardians) supporting ALHIV on treatment. The health workers revealed that "disclosing HIV status" to children was the biggest challenge for caregivers and health workers. Participating ALHIV reported that family support and having a positive mentality were instrumental for continued treatment adherence. However, disclosure of HIV status to friends remained a challenge due to pervasive community stigma. Treatment fatigue and side-effects were also barriers to adherence. Family support was instrumental in facilitating adherence support for ALHIV. However, this (intervention) should include peer support to improve positive mental well-being in ALHIV.