Longitudinal evaluation of adherence, retention, and transition patterns of adolescents living with HIV in Nigeria

Abstract

Introduction Adherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic. Setting The Jos University Teaching Hospital, United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria. Methods We conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ≥95% MPR and the proportion with virologic suppression (viral load ≤400 copies/mL) within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed. Results A total of 476 patients received at least one dose of ART as an adolescent (ages 10–19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ≥95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%–64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression. Conclusions Our evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ≥95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals.

Factors Associated with Poor Viral Suppression Among Children and Adolescents Accessing Antiretroviral Therapy in Selected Health Facilities in Lagos, Nigeria

“…Several studies have demonstrated suboptimal viral suppression in children and adolescents in high and lowresource settings. A study conducted in Nigeria, observed that the viral load suppression rates through adolescence and post-transition were only 55.6-64.0% [10]. Another study in Cambodia showed a relatively low viral suppression rate amongst adolescents compared to the adult population groups, with the viral suppression rate at 76.8% and 90% respectively [11].…”

Adolescents and Young Adults Knowledge, Adherence and Experiences While on Antiretroviral Therapy in a Tertiary Hospital in Lagos, Nigeria: A Mixed-Method Study

“…2 Globally, HIV is the second leading cause of death among adolescents. 3 It is also estimated that over 80% of adolescents living with HIV in the world reside in sub-Saharan Africa. 34 In Africa, this group constitutes a third of the population with Zimbabwe, Nigeria, and South Africa bearing the burden.…”

“…13,14 However, attaining and sustaining the HIV treatment endpoints, requires not less than 95% continuous adherence to ART. 3,15,16 Failure of which results in the selection of resistant strains of the virus, which leads to disease progression, reduction of future therapeutic options, and increased risk of HIV transmission due to high viral load (VL). Adolescents have been generally identified as having poor adherence to ART and hence poorer outcomes compared to their adult counterparts.…”

“…A 2014 systematic review has identified adherence levels of between 16% to 99% in adolescents. 3 In Thailand, suboptimal adherence was recorded in 48.4% of the perinatally infected adolescents. 10 Optimal level of adherence was obtained in 84% AYAs (12-24 years) in Africa and Asia from the systematic review and meta-analysis done by Kim and colleagues.…”

Transitioning Adolescents with Perinatally Acquired HIV from Paediatric to Adult Centered Care: Caregivers’ Perspective

“…Several studies in low and middle income countries (LMIC) have investigated the transition to adult care of adolescents with chronic medical conditions such as sickle cell disease and asthma [23][24][25]. A few studies involving ALHIV have focused on transition readiness assessment [26], patient and healthcare providers' perspectives on transition and some have investigated transition programs [12,27]. Very little is known about caregiver perspective on transitioning ALHIV from paediatric HIV care to adult services especially in Nigeria.…”