Pediatric HIV remains a significant global health dilemma, especially in resource-constrained nations. As access to ART increases around the world, areas of concern in pediatric HIV treatment include age-appropriate disclosure of HIV status to children and development of adherence habits over time. This review was conducted to synthesize quantitative associations reported between disclosure and adherence among children living with HIV in resource-limited settings. An electronic database search of PubMed, MEDLINE and Cochrane returned 1348 results after removal of duplicates, 14 of which were found to meet inclusion criteria. Review of these reports showed conflicting results regarding the impact of disclosure on adherence, with 5 showing no association, 4 showing a negative impact of disclosure on adherence, and 5 showing positive benefits of disclosure for adherence habits. Thus, there was no clear consensus on the effect, if any, that disclosure has on medication adherence. Longitudinal, prospective research needs to be conducted to evaluate further impacts that disclosure may have on adherence habits over time, and interventions must be structured to link the two processes together in order to maximize health benefit to the child or adolescent.

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7 to 18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0% – 100.0%). However, only 47.5% of children had ≥95% adherence (“good adherence”) using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29 to 6.56), p = 0.010) or elementary education only (aOR, 2.20, CI, 1.24 to 3.88, p = 0.007) were more likely to have “good adherence” (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).

Uptake of HIV pre-exposure prophylaxis (PrEP) is low among women at risk for HIV acquisition. Of 468,000 women, whom the United States Centers for Disease Control and Prevention estimates to be eligible for PrEP, only 10,000 unique women have begun therapy through the third quarter of 2015. These data suggest insufficient HIV prevention efforts. This study, conducted at the site of an urban academic medical center with an emergency department HIV prevalence rate of 4%, assesses the knowledge, attitudes, and beliefs of women toward PrEP. A self-administered survey was conducted among women at a family planning obstetrics/gynecology clinic at Temple University Hospital (Philadelphia, PA). Participants assessed their HIV acquisition risk and answered eight questions regarding knowledge, attitudes, and beliefs toward PrEP. Three hundred eighty-nine surveys met inclusion criteria. Sixty-five percent of women were black, and 73% were between 18 and 33 years of age. The median self-perceived risk score was 0 (interquartile range = 2) using a Likert scale. Thirty-three percent of women believed that PrEP could work, and 27% knew that such a regimen existed. Concerns existed toward cost (44%) and side effects (39%). Fifty-seven percent of women surveyed stated that they would take a medication to prevent HIV, and 64% felt comfortable discussing the subject with her doctor. Our data demonstrate a lack of PrEP knowledge, although willingness for uptake among women at risk for HIV acquisition, and a need for directed education and outreach.

Supplementary Figure 2. Figure 1. Kaplan-Meier plot of probability of disclosure stratified by age. (A) children <11 at 1-year follow-up; (B) children ≥11 at 1-year follow-up; (C) children <11 at 3-year follow-up; and (D) children ≥11 at 3-year. KATH, Komfo Anokye Teaching Hospital; KBTH, Korle-Bu Teaching Hospital; CI, Confidence Interval. Inserted numbers represent 'Patient at Risk', who have not been disclosed to. Data are Hazard Ratios (HR) with 95% Confidence Interval (CI) unless otherwise noted. SupplementaryTable 1: Demographics characteristics of caregivers at intervention site (KATH) by disclosure status Disclosure status Disclosed (N = 171) not Disclosed (N = 69) Total (N = 240) P Value Site KATH 171 (100.00%) 069 (100.00%) 240 (100.00%) Missing 000 (0.00%) 000 (0.00%) 000 (0.00%) Age caregiver β Mean (SD) 43.51 (10.24) 41.06 (12.48) 42.81 (10.96) 0.15 Median (IQR) 42 (37 -48) 40 (33 -46) 42 (36 -48) N (N Missing) 171 (0) 69 (0) 240 (0) Child Age < 11 089 (52.05%) 048 (69.57%) (57.08%) ≥ 11 075 (43.86%) 017 (24.64%) (38.33%) Missing 007 (4.09%) 004 (5.80%) 011 (4.58%) 0.006 ** Gender Female 145 (84.80%) 058 (84.06%) (84.58%) Male 026 (15.20%) 011 (15.94%) (15.42%) Missing 000 (0.00%) 000 (0.00%) 000 (0.00%) 0.89 Caregiver HIV status No or Unsure 059 (34.50%) 035 (50.72%) (39.17%) Yes 109 (63.74%) 032 (46.38%) (58.75%) Missing 003 (1.75%) 002 (2.90%) 005 (2.08%) 0.016 * * Education No School 025 (14.62%) 014 (20.29%) (16.25%) Elementary Education 121 (70.76%) 041 (59.42%) (67.50%) Secondary & Postsecondary Education 022 (12.87%) 014 (20.29%) (15.00%)

Prior studies show an association between caregiver depression and child health outcomes. There has been little examination of depression among caregivers of HIV-infected children in sub-Saharan countries where pediatric HIV is concentrated. Using baseline data collected in the pediatric HIV disclosure intervention trial, Sankofa, we examined the prevalence and factors associated with depression among caregivers (N=446) of children infected with HIV in Ghana. Data were analyzed with descriptive and regression analyses. The mean age of the caregivers was