Social, economic, and health effects of the COVID-19 pandemic on adolescents retained in or recently disengaged from HIV care in Kenya

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

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

Methods

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

Results

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

Conclusion

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

Impact of enacted stigma on mental health, substance use, and HIV-related behaviors among sexual minority men in Zambia

Sexual minority men (SMM) in Zambia face significant challenges including stigma, discrimination, and mental health issues, which further impact their HIV-related risk behaviors. This study aimed to investigate the associations between enacted stigma, substance abuse, HIV-related behaviors, and mental health (i.e., depression, anxiety, and post-traumatic stress disorder [PTSD] symptoms) among SMM in Zambia. SMM aged 18-35 years who reported having multiple and/or concurrent sexual partners or low and/or inconsistent condom use in the past three months were recruited from four districts in Zambia between February and November 2021. Participants completed an anonymous interviewer-administered survey. Key variables of interest were compared between participants with higher vs. lower levels of enacted stigma. Independent samples t-tests were used for continuous variables, and chi-squared tests were used for categorical variables. A total of 197 eligible SMM participated in the study (mean age = 24.41 years). Participants with a higher level of enacted stigma showed a higher level of anxiety symptoms (χ2 = 12.91, p ≤ .001), PTSD symptoms (χ2 = 7.13, p < .01), tobacco use (χ2 = 10.47, p < .01), cannabis use (χ2 = 5.90, p < .05), and a higher number of sexual partners (t = 1.99, p < .05) in the past three months. Stigma reduction interventions may help mitigate substance abuse, HIV-related behaviors, and adverse mental health outcomes among SMM in Zambia. Health care providers, especially psychiatric-mental health nurses, can incorporate strategies for recognizing and addressing stigma into their practice through training and integrate multiple resources to create an inclusive and non-judgmental environment for SMM to improve their well-being.

COVID-19 pandemic stressors, familial discord, and anxiety among adolescents living with HIV in South Africa: pathways to non-adherence

Adolescents living with HIV (ALHIV) have poorer adherence to antiretroviral treatment (ART). This study investigates the interconnectivity of stressors induced by the COVID-19 pandemic, anxiety and family dynamics on adolescents' adherence to ART. A telephone survey was conducted among 196 South African ALHIV previously enrolled in support groups. Generalized structural equations modeling was used to understand how pandemic-related stressors affected ART adherence. Respondents reported experiencing life stressors since the implementation of COVID-19 restrictions, including doing worse at school (32%), loss of household income (44%) and less food available (38%). Forty-two percent reported greater verbal aggression from adults at home and 60% experienced anxiety. The structural equations model demonstrated a direct path from experiencing life stressors to increased verbal aggression from caregivers, which led to anxiety and ultimately, poorer ART adherence. Each stressor experienced increased the odds of experiencing verbal aggression by 51% (OR=1.51, 95%CI=1.14-2.00) which, in turn, increased the odds of having anxiety four-fold (OR=4.1, 95%C =2.16-7.76). Anxiety was associated with a 74% reduction in the odds of being fully ART adherent (OR=0.26, 95%CI=0.08-0.81). COVID-19-induced stressors exacerbated the mental and physical vulnerability of ALHIV. Findings elucidate how both discord at home and anxiety can result in poorer ART adherence.

Assessing the health, social, educational and economic impact of the COVID-19 pandemic on adolescents in low- and middle-income countries: a rapid review of the literature

COVID-19 has caused profound health, social, educational and economic devastation around the world, especially among the lives of adolescents in low- and middle-income countries. This paper looks at a wide array of outcomes impacting adolescents' daily lives including health (mental, physical, sexual and reproductive health, vaccine perceptions and overlap between these topics), social relationships (family and peer), education and socio-economic disparities. Both scientific and grey literature between December 2019 and February 2022 were sought from PubMed, Google Scholar and organisations conducting research among adolescents, and coded. A total of 89 articles were included, 73% of which were peer-reviewed; 37% of the articles were from WHO's Western Pacific region; 62% of the articles were cross-sectional; 75% were quantitative. Three major topics emerged in more than half the articles: mental health (72%), education (61%) and socio-economic ramifications (55%). However, there were regional differences in topics and many of them overlapped. The results indicate that, where there has been research, almost all findings have been linked to worse mental health during the pandemic. Overall, remote education was seen as a negative experience. The ramification of school closures on future aspirations, in particular early school leaving, highlights the importance of prioritising education during future pandemics based on the situation within the country. Gender and other disparities have made marginalised adolescents vulnerable to the economic ramifications of containment measures. Given the risks identified, there is a pressing need to put adolescents at the centre of establishing priorities for their health agenda for post-pandemic recovery.

The impact of COVID-19 on HIV treatment of adolescents in sub-Saharan Africa: A scoping review

Background

Adolescents living with HIV are a key population who are susceptible to poor health. The global coronavirus disease 2019 pandemic and widespread national COVID-19 restrictions has disrupted health service delivery and HIV support services, affecting treatment adherence among adolescents with HIV.

Aim

This study aimed to review the available literature on the impact of the COVID-19 pandemic on the HIV treatment of adolescents in sub-Saharan Africa.

Method

Seven online databases were searched for articles published between 2020 and 2022 that focused on the impact of COVID-19 on adolescents living with HIV on antiretroviral therapy. A data charting extraction form and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA) flowchart were used for screening and reporting the articles in this review. A narrative synthesis was conducted.

Results

Five overarching themes emerged from the articles in this review, which highlighted the mental, social, and economic impacts of the COVID-19 pandemic, as well as the impact of the reallocation of healthcare services and challenges to accessing HIV care services on the antiretroviral therapy (ART) adherence of adolescents living with HIV.

Conclusion

The global COVID-19 pandemic affected adolescents living with HIV in sub-Saharan Africa in many ways, but very little research has been done to describe the various ways in which the physical and mental well-being of adolescents were impacted.

Contribution

The findings of this review can be used to further inform policies and interventions aimed at the care and well-being of adolescents on antiretroviral therapy within sub-Saharan Africa.

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

INTRODUCTION

The COVID-19 pandemic has disrupted access to critical health services, resulting in diminished gains in HIV epidemic control. This review assesses the magnitude of the impact that the COVID-19 pandemic has had on HIV services for adolescents.

METHODS

PEPFAR Monitoring, Evaluation, and Reporting programmatic data were analyzed from across 16 USAID-supported adolescent care and treatment programs for fiscal year 2020 (FY20; October 2019-September 2020). Descriptive statistics were used to calculate absolute number and percent change between the pre-COVID-19 (Quarters 1-2; October 2019-March 2020) and COVID-19 periods (Quarters 3-4; April 2020-September 2020) for clinical cascade indicators. All analyses were conducted in Microsoft Excel.

RESULTS

The number of HIV tests conducted during COVID-19 decreased by 21.4% compared with pre-COVID-19, with a subsequent 28% decrease in adolescents identified living with HIV. The rate of proxy linkage to antiretroviral therapy increased between periods, from 86.9% to 90.4%. There was a 25.9% decrease in treatment initiations among adolescents during COVID-19. During FY20, viral load coverage rates for adolescents dropped from 81.6% in FY20Q1 to 76.5% in FY20Q4, whereas the rates of viral load suppression for adolescents increased from 76.1% in FY20Q1 to 80.5% in FY20Q4.

CONCLUSION

There was a substantial decrease in case-finding, treatment initiations, and viral load coverage rates for adolescents supported in USAID/PEPFAR programs during the COVID-19 pandemic. Additional health systems adaptations and strategies are required to ensure adolescents have continued access to HIV services during pandemic disruptions.

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.

Effects of the COVID-19 pandemic on late postpartum women living with HIV in Kenya

Although an estimated 1.4 million women living with HIV (WHIV) are pregnant each year globally, data describing the effects of the COVID-19 pandemic on postpartum women in low- and middle-income countries (LMICs) are limited. To address this gap, we conducted phone surveys among 170 WHIV ≥18 years and 18-24 months postpartum enrolled in HIV care at the Academic Model Providing Access to Healthcare in western Kenya, and assessed the effects of the pandemic across health, social and economic domains. We found that 47% of WHIV experienced income loss and 71% experienced food insecurity during the pandemic. The majority (96%) of women reported having adequate access to antiretroviral treatment and only 3% reported difficulties refilling medications, suggesting that the program's strategies to maintain HIV service delivery during the early phase of the pandemic were effective. However, 21% of WHIV screened positive for depression and 8% for anxiety disorder, indicating the need for interventions to address the mental health needs of this population. Given the scale and duration of the pandemic, HIV programs in LMICs should work with governments and non-governmental organizations to provide targeted support to WHIV at highest risk of food and income insecurity and their associated adverse health outcomes.

The impact of the COVID-19 pandemic on mental health, associated factors and coping strategies in people living with HIV: a scoping review

INTRODUCTION

The COVID-19 pandemic and associated measures implemented by authorities have created additional stressors and increased the risk of psychological illnesses among people living with HIV (PLWH). Yet, there is no collective evidence on the mental health status of this population during the global pandemic and associated factors. This scoping review aimed to synthesize the evidence in the current literature related to the mental health outcomes and challenges faced by PLWH during the COVID-19 pandemic, identify the associated factors with psychological distress and summarize various coping strategies to ease these psychological distresses used by this population.

METHODS

We conducted a scoping review following the PRISMA-ScR guideline and a literature search in four electronic databases in August 2022. Three reviewers independently screened all the search records and extracted the data from studies that met the inclusion criteria. Factors associated with worsened mental health outcomes were synthesized according to the socio-ecological framework.

RESULTS

Among 1100 research records, 45 articles met the eligibility criteria and were included in the final review and data extraction, most of which were quantitative analyses. PLWH reported high rates of mental health problems during the pandemic. Multi-level factors were associated with increased psychological distress, including substance use, antiretroviral adherence, social support, financial hardship and economic vulnerability during the pandemic. PLWH used social media as a coping strategy to foster social support to deal with growing mental distress. Increased mental health illnesses were associated with increased substance use, it was also found associated with suboptimal medication adherence and antiretroviral therapy (ART) care engagement.

DISCUSSION

PLWH experienced high rates of mental health illnesses, such as depression during the global COVID-19 pandemic. There is an urgent need to provide comprehensive HIV treatment and mental health services as the pandemic continues to evolve.

CONCLUSIONS

The review summarized how the mental health of PLWH was affected during the COVID-19 pandemic. Future work in the implementation of effective interventions to promote mental health in this population is needed, not only to ensure their quality of life but also to help them maintain ART adherence and healthcare during more unprecedented times.

Enhancing retention in care in HIV-infected adolescents during COVID-19 in Mozambique: results from the DREAM program

INTRODUCTION

Around 1,7 million adolescents aged 10-19 years worldwide are infected with HIV, 84% of them living in Sub-Saharan Africa. Mozambique is one of the countries with the highest prevalence of HIV in the world. According to UNAIDS, HIV services for adolescents should be tailored and specifically designed for them.

METHODS

We aimed to evaluate a package of activities to enhance the retention of HIV-infected adolescent in Mozambique. We retrospectively reviewed routine data from 7 health centers involved in 26 months, from March 2020 to May 2022. A package of tailored interventions was implemented in all the sites. We reviewed activity data from the included centers.

RESULTS

The median number of patients per center was 343 (IQR: 289-466) at the beginning of the period and 395 (IQR: 322-453) at the end. The median overall retention in care and rate of lost to follow-up at the beginning and the end of the period were respectively: 94.2% (IQR 91.9-97.3%) to 99.0% (IQR 96.8-99.5%), 1.5% (IQR 1-3.2%) to 0% (IQR 0.0-0.3%). The total number of deaths increased reaching a plateau after September 2021. All the indicators improved after the beginning of the intervention, also during COVID-19 pandemic.

CONCLUSIONS

Our data support the idea that enhancing retention in care for HIV positive adolescents need tailored interventions, based on deep rooting in the specific social context. Tailored intervention can resist external shock such as COVID-19.

Barriers and facilitators to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review and meta-analysis

BACKGROUND

Human Immunodeficiency Virus (HIV) significantly affects adolescents globally, with the sub-Saharan Africa (SSA) reporting a high burden of the disease. HIV testing, treatment, and retention to care are low among adolescents. We conducted a mixed-method systematic review to assess anti-retroviral therapy (ART) adherence; barriers and facilitators to ART adherence and ART outcomes among adolescents living with HIV and on ART in sub-Saharan Africa.

METHODS

We conducted searches in four scientific databases for studies conducted between 2010 and March 2022 to identify relevant primary studies. Studies were screened against inclusion criteria and assessed for quality, and data was extracted. Meta-analysis of rates and odd ratios was used to plot the quantitative studies and meta-synthesis summarized the evidence from qualitative studies.

RESULTS

A total of 10 431 studies were identified and screened against the inclusion/ exclusion criteria. Sixty-six studies met the inclusion criteria (41 quantitative, 16 qualitative, and 9 mixed-methods study designs). Fifty-three thousand two hundred and seventeen (53 217) adolescents (52 319 in quantitative studies and 899 in qualitative studies) were included in the review. Thirteen support focused interventions for improved ART adherence were identified from quantitative studies. The plotted results from the meta-analysis found an ART adherence rate of 65% (95%CI 56-74), viral load suppression was 55% (95%CI 46-64), un-suppressed viral load rate of 41% (95%CI 32-50), and loss to follow up of 17% (95%CI 10-24) among adolescents. Meta-synthesis found six themes of barriers to ART (social, patient-based, economic, health system-based, therapy-based, and cultural barriers) in both the qualitative and quantitative studies, and three themes of facilitators to ART were also identified (social support, counselling, and ART education and secrecy or confidentiality) from qualitative studies.

CONCLUSION

ART adherence remains low among adolescents in SSA despite multiple interventions implemented to improve ART adherence. The low adherence rate may hinder the attainment of the UNAIDS 2030 targets. Additionally, various barriers to ART adherence due to lack of support have been reported among this age group. However, interventions aimed at improving social support, educating, and counselling adolescents may improve and sustain ART adherence.

TRIAL REGISTRATION

Systematic review registration: PROSPERO CRD42021284891.

Experiences of Caring for Adolescents Living with HIV (ALHIV): A Qualitative Interview with Caregivers

Purpose

This study aims at exploring experiences of people caring for adolescents living with HIV, also known as caregivers. By 2021, 150,000 adolescents were living with HIV and 32,000 adolescents were dying of AIDS related causes. HIV/AIDS remains one of the most serious public health problems, especially among the adolescents. This has placed a heavy burden on many caregivers, yet they are essential in caring for ALHIV. However, focus of all interventions has excluded caregivers of ALHIV. Thus, this is the reason why this study is being conducted to find out caregivers' experience in caring for ALHIV.

Participants and Methods

A phenomenological study was carried out. Purposive sampling was used to select a total of 15 caregivers to participate in the study. These participants were subjected to in-depth semi-structured interviews. Their responses were recorded, transcribed and translated for thematic analysis.

Results

While analyzing the results, six themes emerged. They include: diagnosis and reaction to diagnosis, experiences on adolescent's HIV serostatus disclosure, stigma and discrimination, care disengagement, and lastly, challenges during care and coping strategies. Caregivers experienced feelings of fear, Guilt, suicidal thoughts after diagnosis. Stigma and discrimination of adolescents living with HIV which was common at school and from the neighbors and the adolescent stage were some of the challenges experienced by the caregivers and it makes it hard to retain ALHIV in care.

Conclusion

Families are the main source of caregiving to the adolescents living with HIV (ALHIV). The study's findings indicate that caregivers in the families experience challenges related to family needs, and psychological challenges resulting from the adolescence stage. So, families should not be left to shoulder the burden of caring for ALHIV. As a way forward, social network and financial support should also be strengthened for most caregivers as a coping strategy.

Impacts of the COVID-19 pandemic on access to HIV and reproductive health care among women living with HIV (WLHIV) in Western Kenya: A mixed methods analysis

Introduction

The COVID-19 pandemic has impacted access to health services. Our objective was to understand the pandemic's impact on access to HIV, pregnancy, and family planning (FP) care among women living with HIV (WLHIV).

Methods

Data were collected after June 2020, when questions about the pandemic were added to two ongoing mixed methods studies using telephone surveys and in-depth interviews among WLHIV in western Kenya. The Chaguo Langu (CL) study includes primarily non-pregnant WLHIV receiving HIV care at 55 facilities supported by AMPATH and the Opt4Mamas study includes pregnant WLHIV receiving antenatal care at five facilities supported by FACES. Our outcomes were self-reported increased difficulty refilling medication, accessing care, and managing FP during the pandemic. We summarized descriptive data and utilized multivariable logistic regression to evaluate predictors of difficulty refilling medication and accessing care. We qualitatively analyzed the interviews using inductive coding with thematic analysis.

Results

We analyzed 1,402 surveys and 15 in-depth interviews. Many (32%) CL participants reported greater difficulty refilling medications and a minority (14%) reported greater difficulty accessing HIV care during the pandemic. Most (99%) Opt4Mamas participants reported no difficulty refilling medications or accessing HIV/pregnancy care. Among the CL participants, older women were less likely (aOR = 0.95, 95% CI: 0.92-0.98) and women with more children were more likely (aOR = 1.13, 95% CI: 1.00-1.28) to report difficulty refilling medications. Only 2% of CL participants reported greater difficulty managing FP and most (95%) reported no change in likelihood of using FP or desire to get pregnant. Qualitative analysis revealed three major themes: (1) adverse organizational/economic implications of the pandemic, (2) increased importance of pregnancy prevention during the pandemic, and (3) fear of contracting COVID-19.

Discussion

The two unique participant groups included in our study encountered overlapping problems during the COVID-19 epidemic. Access to HIV services and antiretrovirals was interrupted for a large proportion of non-pregnant WLHIV in western Kenya, but access to pregnancy/family planning care was less affected in our cohort. Innovative solutions are needed to ensure HIV and reproductive health outcomes do not worsen during the ongoing pandemic.

The impact of COVID-19 non-pharmaceutical interventions on HIV care continuum in China: An interrupted time series analysis

BACKGROUND

China implemented strict non-pharmaceutical interventions to contain COVID-19 at the early stage. We aimed to evaluate the impact of COVID-19 on HIV care continuum in China.

METHODS

Aggregated data on HIV care continuum between 1 January 2017 and 31 December 2020 were collected from centers for disease control and prevention at different levels and major infectious disease hospitals in various regions in China. We used interrupted time series analysis to characterize temporal trend in weekly numbers of HIV post-exposure prophylaxis (PEP) prescriptions, HIV tests, HIV diagnoses, median time intervals between HIV diagnosis and antiretroviral therapy (ART) initiation (time intervals, days), ART initiations, mean CD4+ T cell counts at ART initiation (CD4 counts, cells/μL), ART collections, and missed visits for ART collection, before and after the implementation of massive NPIs (23 January to 7 April 2020). We used Poisson segmented regression models to estimate the immediate and long-term impact of NPIs on these outcomes.

FINDINGS

A total of 16,780 PEP prescriptions, 1,101,686 HIV tests, 69,659 HIV diagnoses, 63,409 time intervals and ART initiations, 61,518 CD4 counts, 1,528,802 ART collections, and 6656 missed visits were recorded during the study period. The majority of outcomes occurred in males (55·3-87·4%), 21-50 year olds (51·7-90·5%), Southwestern China (38·2-82·0%) and heterosexual transmission (47·9-66·1%). NPIs was associated with 71·5% decrease in PEP prescriptions (IRR 0·285; 95% CI 0·192-0·423), 36·1% decrease in HIV tests (0·639, 0·497-0·822), 32·0% decrease in HIV diagnoses (0·680, 0·511-0·904), 59·3% increase in time intervals (1·593, 1·270-1·997) and 17·4% decrease in CD4 counts (0·826, 0·746-0·915) in the first week during NPIs. There was no marked change in the number of ART initiations, ART collections and missed visits during the NPIs. By the end of 2020, the number of HIV tests, HIV diagnoses, time intervals, ART initiations, and CD4 counts reached expected levels, but the number of PEP prescriptions (0·523, 0·394-0·696), ART collections (0·720, 0·595-0·872), and missed visits (0·137, 0·086-0·220) were still below expected levels. With the ease of restrictions, PEP prescriptions (slope change 1·024/week, 1·012-1·037), HIV tests (1·016/week, 1·008-1·026), and CD4 counts (1·005/week, 1·001-1·009) showed a significant increasing trend.

INTERPRETATION

HIV care continuum in China was affected by the COVID-19 NPIs at various levels. Preparedness and efforts to maintain the HIV care continuum during public health emergencies should leverage collaborations between stakeholders.

FUNDING

Natural Science Foundation of China.

Substantial Increase in Transactional Sex and HIV Risk Among Adolescents During the COVID-19 Pandemic: Results From a Repeated Cross-Sectional Study in Botswana

The COVID-19 pandemic and resulting public health response has disrupted the lives of adolescents and their families worldwide. We evaluated the impact of the pandemic on attitudes, beliefs, and sexual risk behavior among adolescents in Botswana. Participants were recruited using household-based sampling across residential districts (blocks) in and around Gaborone, Botswana, and completed surveys on laptop computers at a private, central location. We compared baseline survey data from 380 adolescents who completed the survey pre-pandemic (n = 139) to those who completed the survey intra-pandemic (n = 241). Participants had a mean age of 15.2 years; 58.6% were girls and 41.4% were boys. Intra-pandemic, participants reported greater engagement in transactional sex (38.1% compared to 13.6% pre-pandemic, p <. 05), more favorable attitudes toward transactional sex with sugar daddies and sugar mommies (p <. 05), greater intentions to remain sexually active in the future (29.2% vs.13.6%, respectively, p <.05), and lower self-efficacy in handling risky sexual situations (p < .01). Public health interventions that lessen these concerning shifts in attitudes and behaviors will be key to protecting the sexual health of adolescents and to supporting their safe transition to adulthood.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

Longitudinal impacts of the COVID-19 pandemic on adolescents living with HIV in New York City

Adolescents living with HIV (ALWH) are particularly susceptible to disruptions in care, which may lead to poor HIV-related health outcomes. Here, we report the results of a longitudinal phone-based study investigating impacts of the COVID-19 pandemic on ALWH in New York City. Participants (N = 10, mean age 21.2 years, 50% female) demonstrated substantial COVID-19 knowledge and identified Instagram as their primary source of COVID-19 information. Nearly all participants reported loss of income, and 50% reported experiencing food insecurity as a result of the pandemic. These findings highlight existing vulnerabilities among ALWH that may threaten the continuum of care.

Two years after lockdown: reviewing the effects of COVID-19 on health services and support for adolescents living with HIV in South Africa

INTRODUCTION

South Africa's progress towards the 95-95-95 goals has been significantly slower among adolescents living with HIV (ALHIV), among whom antiretroviral therapy (ART) adherence, retention in care and viral suppression remain a concern. After 2 years of living with COVID-19, it is important to examine the direct and indirect effects of the pandemic on healthcare resources, access to HIV services and availability of support structures, to assess their impact on HIV care for ALHIV.

DISCUSSION

The COVID-19 response in South Africa has shifted healthcare resources towards combatting COVID-19, affecting the quality and availability of HIV services-especially for vulnerable populations, such as ALHIV. The healthcare system's response to COVID-19 has threatened to diminish fragile gains in engaging ALHIV with HIV services, especially as this group relies on overburdened public health facilities for their HIV care. Reallocation of limited health resources utilized by ALHIV disrupted healthcare workers' capacity to form and maintain therapeutic relationships with ALHIV and monitor ALHIV for ART-related side effects, treatment difficulties and mental health conditions, affecting their ability to retain ALHIV in HIV care. Prevailing declines in HIV surveillance meant missed opportunities to identify and manage opportunistic infections and HIV disease progression in adolescents. "Lockdown" restrictions have limited access to healthcare facilities and healthcare workers for ALHIV by reducing clinic appointments and limiting individual movement. ALHIV have had restricted access to social, psychological and educational support structures, including national feeding schemes. This limited access, coupled with reduced opportunities for routine maternal and sexual and reproductive health services, may place adolescent girls at greater risk of transactional sex, child marriages, unintended pregnancy and mother-to-child HIV transmission.

CONCLUSIONS

Adolescent HIV care in South Africa is often overlooked; however, ART adherence among ALHIV in South Africa is particularly susceptible to the consequences of a world transformed by COVID-19. The current structures in place to support HIV testing, ART initiation and adherence have been reshaped by disruptions to health structures, new barriers to access health services and the limited available education and psychosocial support systems. Reflecting on these limitations can drive considerations for minimizing these barriers and retaining ALHIV in HIV care.

'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.