Dataset Information

Clinic and care: associations with adolescent antiretroviral therapy adherence in a prospective cohort in South Africa.

ABSTRACT:

Objective

Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments.

Design

A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014-2015, 2015-2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality).

Methods

Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents' language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors.

Results

Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P < 0.001), improvement in perceived healthcare confidentiality (7.1 percentage points, P < 0.04) and shorter travel time to the clinic (13.7 percentage points, P < 0.02). In combination, improvement in violence prevention, travel time and confidentiality were associated with 81% probability of ART adherence, compared with 47% with a worsening in all three.

Conclusion

Adolescents living with HIV need to be safe at home and feel safe from stigma in an accessible clinic. This will require active collaboration between health and child protection systems, and utilization of effective violence prevention interventions.

SUBMITTER: Cluver L

PROVIDER: S-EPMC8183481 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:INTRODUCTION:Differentiated models of care that include referral of antiretroviral treatment (ART) clients to adherence clubs are an important strategy to help clinics manage increased number of clients living with HIV in resource-constrained settings. This study reported on (i) clinical outcomes among ART clients attending community-based adherence clubs and (ii) experiences of adherence clubs and perceptions of factors key to successful adherence club implementation among clients and healthcare workers. METHODS:A retrospective cohort analysis of routine data and a descriptive analysis of data collected through self-administered surveys completed by clients and healthcare workers were completed. Clients starting ART at the study clinic, between January 2014 and December 2015, were included in the cohort analysis and followed up until December 2016. The survey data were collected from August to September 2017. The primary outcome for the cohort analysis was a comparison of loss to follow-up (LTFU) between clients staying in clinic care and those referred to adherence clubs. Survey data reported on client experiences of and healthcare worker perceptions of adherence club care. RESULTS:Cohort analysis reported on 465 participants, median baseline CD4 count 374 (IQR: 234 to 532) cells/μl and median follow-up time 20.7 (IQR 14.1 to 27.7) months. Overall, 202 (43.4%) participants were referred to an adherence club. LTFU was lower in those attending an adherence club (aHR =0.25, 95% CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, 95% CI: 0.12 to 0.65). Factors highlighted as associated with successful adherence club implementation included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members, (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication. CONCLUSIONS:This study showed good clinical outcomes, positive patient experiences and healthcare worker perceptions of the adherence club model. Factors associated with successful adherence club implementation, highlighted in this study, can be used to guide implementers in the scale-up of adherence club services across varied high-burden settings.

Project description:OBJECTIVE:To determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site. DESIGN:Retrospective cohort analysis. SETTING:Government supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa. PARTICIPANTS:Two hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015. INTERVENTION:Attendance in an adolescent-friendly clinic compared to a standard pediatric clinic. OUTCOMES MEASURES:Retention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml. RESULTS:Overall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2-11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3-32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1-5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5-9.7; p = 0.005). CONCLUSION:Adolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.

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Project description:Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services.Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based 'adherence clubs', operated by lay counsellors with medication collection every 2-4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1-2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service.Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL?1000 copies/mL compared to those who remained (p = 0.002).Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.

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