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

Abstract

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.

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

“…Economic barriers are often interrelated with other biopsychosocial barriers and pose a barrier to optimal adherence among adolescents with HIV (Hlophe et al 2023 ; Kansiime et al 2021 ). A systematic review of studies in South Africa found that food insecurity is common in most low-socioeconomic settings in South Africa and poses a barrier to adolescents taking their ART medication as prescribed (Muchena & Kalenga 2021 ).…”

Structural, Familial, and Psychosocial Factors Affecting Long-Term Antiretroviral Treatment Adherence amongst Adolescents Living with Perinatally Acquired HIV in Limpopo, South Africa

“…However, the same level of improvement in mortality and morbidity has not been observed amongst adolescents living with perinatal HIV infection (APHIV) [2]. There is evidence that, compared to adults and children, adolescents fail to cope with living with HIV, which is evidenced by a variety of factors such as a high rate of virological failure and loss at follow-up, as well as high defaulter rates [2][3][4][5]. United Nations Children's Fund's (UNICEF) data indicated an increase of about 50% in AIDS-related deaths among APHIV, while they observed mortality decrease among all other age groups [6].…”

“…In South Africa, the majority of APHIV are currently on a one-pill, once-daily, fixed-dose combination antiretroviral regimen (Tenofovir, Emitricibine, and Efavirenz). In South Africa, this regimen was first approved in 2013 [4,7,10]. Adherence to ART remains low among APHIV in SSA despite multiple interventions implemented to improve ART adherence [4].…”

“…In South Africa, this regimen was first approved in 2013 [4,7,10]. Adherence to ART remains low among APHIV in SSA despite multiple interventions implemented to improve ART adherence [4]. However, adolescents struggle with sustaining adherence over time, which is a necessity for the effectiveness of ART [11][12][13].…”

“…However, adolescents struggle with sustaining adherence over time, which is a necessity for the effectiveness of ART [11][12][13]. A systematic review reported an ART adherence rate of 65% among APHIV in the SSA region [4]. Qualitative data from studies conducted in SSA found that only 37% of APHIV were reported to be adherent [14,15].…”