Improved virological suppression in children on antiretroviral treatment receiving community-based adherence support: A multicentre cohort study from South Africa

Abstract

Adherence to antiretroviral treatment (ART) is a challenge in childhood, and children on ART have reduced virological suppression compared to adults. This study evaluated the effect of community-based adherence support (CBAS) on virological outcomes amongst children receiving ART in four South African provinces. Patient Advocates are lay CBAS workers who provide adherence and psychosocial support for patients, undertaking home visits to address household challenges affecting adherence. Patient Advocates provide counselling for children's carers regarding adherence and psychosocial problems. A multicentre cohort study using routinely collected data was conducted at 57 public ART sites including ART-naive children (<16 years) starting ART. Virological suppression until four years of ART was compared between children who received and did not receive CBAS. Analyses were by intention-to-treat, controlling for confounding using multivariable generalised estimating equations. A total of 4853 children were included, of whom 982 (20.2%) received CBAS. The median baseline age was 6.3 years and the baseline CD4 cell percentage was 12.0%; both were equivalent between the two groups. CBAS children had more advanced baseline clinical disease (62.1% vs. 52.6% World Health Organisation stages III or IV; P < 0.0001). A total of 5908 viral load results were analysed. Virological suppression was 65.6% (95% confidence interval [CI]: 62.7-68.4%) vs. 55.5% (95% CI: 54.1-57.0%) in CBAS and non-CBAS children, respectively, at any time-point on treatment (P < 0.0001). In analyses controlling for baseline clinical, demographic, site-related variables and time on ART, children receiving CBAS were more likely to achieve virological suppression, adjusted odds ratio (aOR) 1.60 (95% CI: 1.35-1.89; P < 0.0001). The effect of CBAS increased in magnitude with increasing durations of ART, and CBAS particularly improved virological suppression in a higher-risk subgroup (children younger than two years, aOR 2.47 [95% CI: 1.59-3.84]). CBAS was associated with improved virological suppression in children receiving ART. Expanded implementation of this low-cost intervention should be considered in resource-poor settings.

An update on the HIV treatment cascade in children and adolescents

“…In another study from the USA, only 50.5% of youth, aged 12-24 years, had virological suppression, despite reporting good adherence [73]. A study from South Africa reported on virological suppression rates of between 55 and 65%, depending on whether or not the children received community-based adherence support [74]. Of note, they found that virological suppression was lower in children <2 years of age.…”

A 10-year cohort analysis of routine paediatric ART data in a rural South African setting

“…This reinforces calls for early diagnosis and early ART initiation to reduce paediatric morbidity and mortality [39]. Furthermore, systems to flag high VL results are needed and adherence, crucial to achieving and maintaining viral suppression, must be reinforced – ongoing counselling must be provided from the time of ART initiation to address children's changing adherence barriers, and community-based adherence support should be considered with community workers providing education and psychosocial support to address household challenges impacting on adherence [40, 41]. …”

Community-Based ART Programs: Sustaining Adherence and Follow-up

“…About 20 % of the children received community-based adherence support, which included home visits by patient advocates to provide psychosocial support and address contextual household challenges affecting adherence. A significant difference in rates of virologic suppression was found: 65.6 % among those who received the intervention compared to just 55 % among those who did not [30]. …”