Traversing the cascade: urgent research priorities for implementing the ‘treat all’ strategy for children and adolescents living with HIV in sub-Saharan Africa

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Abstract

Children and adolescents living with HIV (CALHIV) in sub-Saharan Africa experience significant morbidity and alarmingly high mortality rates due to critical gaps in the HIV care cascade, including late diagnosis and initiation of treatment, as well as poor retention in care and adherence to treatment. Interventions to strengthen the adult HIV care cascade may not be as effective in improving the cascade for CALHIV, for whom specific strategies are needed. Particular attention needs to be paid to the contexts of sub-Saharan Africa, where more than 85% of the world's CALHIV live. Implementing the ‘treat all’ strategy in sub-Saharan Africa requires dedicated efforts to address the unique diagnosis and care needs of CALHIV, in order to improve paediatric and adolescent outcomes, prevent viral resistance and reduce the number of new HIV infections. We consider the UNAIDS 90-90-90 targets from the perspective of infants, children and adolescents, and discuss the key challenges, knowledge gaps and urgent research priorities for CALHIV in implementation of the ‘treat all’ strategy in sub-Saharan Africa.

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Antiretroviral therapy adherence, virologic and immunologic outcomes in adolescents compared with adults in southern Africa.

Jean Nachega, Michael Hislop, Hoang Nguyen … (2009)

To determine adherence to and effectiveness of antiretroviral therapy (ART) in adolescents vs. adults in southern Africa. Observational cohort study. Aid for AIDS, a private sector disease management program in southern Africa. Adolescents (age 11-19 years; n = 154) and adults (n = 7622) initiating ART between 1999 and 2006 and having a viral load measurement within 1 year after ART initiation. Primary: virologic suppression (HIV viral load < or = 400 copies/mL), viral rebound, and CD4 T-cell count at 6, 12, 18, and 24 months after ART initiation. Secondary: adherence assessed by pharmacy refills at 6, 12, and 24 months. Multivariate analyses: loglinear regression and Cox proportional hazards. A significantly smaller proportion of adolescents achieved 100% adherence at each time point (adolescents: 20.7% at 6 months, 14.3% at 12 months, and 6.6% at 24 months; adults: 40.5%, 27.9%, and 20.6% at each time point, respectively; P < 0.01). Patients achieving 100% 12-month adherence were significantly more likely to exhibit virologic suppression at 12 months, regardless of age. However, adolescents achieving virologic suppression had significantly shorter time to viral rebound (adjusted hazard ratio 2.03; 95% confidence interval: 1.31 to 3.13; P < 0.003). Adolescents were less likely to experience long-term immunologic recovery despite initial CD4 T-cell counts comparable to adults. Compared with adults, adolescents in southern Africa are less adherent to ART and have lower rates of virologic suppression and immunologic recovery and a higher rate of virologic rebound after initial suppression. Studies must determine specific barriers to adherence in this population and develop appropriate interventions.

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High attrition before and after ART initiation among youth (15-24 years of age) enrolled in HIV care.

Teresa Alwar, Batya Elul, Matthew Lamb … (2014)

To compare pre and post-ART attrition between youth (15-24 years) and other patients in HIV care, and to investigate factors associated with attrition among youth. Cohort study utilizing routinely collected patient-level data from 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda. Patients at least 10 years of age enrolling in HIV care between 01/05 and 09/10 were included. Attrition (loss to follow-up or death 1 year after enrollment or ART initiation) was compared between youth and other patients using multivariate competing risk (pre-ART) and traditional (post-ART) Cox proportional hazards methods accounting for within-clinic correlation. Among youth, patient-level and clinic-level factors associated with attrition were similarly assessed. A total of 312,335 patients at least 10 years of age enrolled in HIV care; 147,936 (47%) initiated ART, 17% enrolling in care and 10% initiating ART were youth. Attrition before and after ART initiation was substantially higher among youth compared with other age groups. Among youth, nonpregnant women experienced lower pre-ART attrition than men [sub-division hazard ratio = 0.90, 95% confidence interval (CI): 0.86-0.94], while both pregnant [adjusted hazard ratio (AHR) = 0.85, 95% CI: 0.74-0.97] and nonpregnant (AHR = 0.79, 95% CI: 0.73-0.86) female youth experienced lower post-ART attrition than men. Youth attending clinics providing sexual and reproductive health services including condoms (AHR = 0.47, 95% CI: 0.32-0.70) and clinics offering adolescent support groups (AHR = 0.73, 95% CI: 0.52-1.0) experienced significantly lower attrition after ART initiation. Youth experienced substantially higher attrition before and after ART initiation compared with younger adolescents and older adults. Adolescent-friendly services were associated with reduced attrition among youth, particularly after ART initiation.

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A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa

Maurice Musheke, Harriet Ntalasha, Sara Gari … (2013)

Background Despite Sub-Saharan Africa (SSA) being the epicenter of the HIV epidemic, uptake of HIV testing is not optimal. While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing, systematic reviews to provide a more comprehensive understanding are lacking. Methods Using Noblit and Hare’s meta-ethnography method, we synthesised published qualitative research to understand factors enabling and deterring uptake of HIV testing in SSA. We identified 5,686 citations out of which 56 were selected for full text review and synthesised 42 papers from 13 countries using Malpass’ notion of first-, second-, and third-order constructs. Results The predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as ‘opt-out’ provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers’ inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women’s decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing. Conclusions Improving uptake of HIV testing requires addressing perception of low risk of HIV infection and perceived inability to live with HIV. There is also a need to continue addressing HIV-related stigma, which is intricately linked to individual economic support. Building confidence in the health system through improving delivery of health care and scaling up HIV testing strategies that attenuate social and economic costs of seeking HIV testing could also contribute towards increasing uptake of HIV testing in SSA.

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Author and article information

Journal

Journal ID (nlm-ta): J Virus Erad

Journal ID (iso-abbrev): J Virus Erad

Journal ID (publisher-id): JOURNAL OF VIRUS ERADICATION

Title: Journal of Virus Eradication

Publisher: Mediscript Ltd

ISSN (Print): 2055-6640

ISSN (Electronic): 2055-6659

Publication date (Electronic, collection): November 2018

Publication date (Electronic, pub): 15 November 2018

Volume: 4

Issue: Suppl 2

Pages: 40-46

Affiliations

[ ¹ ] Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine , Indianapolis, IN, USA

[ ² ] Center for Infectious Disease Epidemiology and Research, University of Cape Town , South Africa

[ ³ ] Inserm (French Institute of Health and Medical Research), UMR 1027, Université Toulouse 3 , France

[ ⁴ ] Department of Epidemiology, University of North Carolina at Chapel Hill , NC, USA

[ ⁵ ] Moi Teaching and Referral Hospital , Eldoret, Kenya

[ ⁶ ] Department of Epidemiology and Population Health, Albert Einstein College of Medicine , Bronx, NY, USA

Author notes

[* ]Corresponding author: Leslie Enane, 1044 W Walnut Street, Room 402A, Indianapolis, Indiana, 46202, USA Email: lenane@ 123456iu.edu

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DOI: 10.1016/S2055-6640(20)30344-7

PMC ID: 6248846

PubMed ID: 30515313

SO-VID: c3c5e9e8-b352-4974-a144-70bd8c5cce52

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This is an open access article published under the terms of a Creative Commons License.

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Traversing the cascade: urgent research priorities for implementing the ‘treat all’ strategy for children and adolescents living with HIV in sub-Saharan Africa

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Most cited references 56

Antiretroviral therapy adherence, virologic and immunologic outcomes in adolescents compared with adults in southern Africa.

High attrition before and after ART initiation among youth (15-24 years of age) enrolled in HIV care.

A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa

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