Mode of HIV acquisition among adolescents living with HIV in resource-limited settings: A data-driven approach from South Africa

Abstract

Adolescents living with HIV (ALHIV) face unique treatment and care challenges which may differ by how they acquired HIV, whether vertically (in-utero, perinatal or postnatal exposure during breastfeeding) or sexually (sexual exposure). Distinguishing and documenting the mode of HIV acquisition (MOHA) is crucial to further research on the different needs and outcomes for ALHIV and to tailor HIV services to their needs. Age-based cut-offs have been used to attribute MOHA but have not been validated. We analysed data from a three-wave cohort of n = 1107 ALHIV part of a longitudinal study in South Africa. Age-based MOHA was allocated using age at ART initiation, validated against a logic-tree model based on literature-hypothesised factors: self-reported HIV, sexual, and family history. After testing six ART initiation age cut-offs (10 to 15 years old), we determined the optimal MOHA cut-off age by calculating the sensitivity and specificity for each cut-off, measured against the final logic-tree allocation. Following validation using this longitudinal study, the methodology is extended to 214 additional third-wave participants—adolescent girls and young women living with HIV who became mothers before the age of 20. Finally, descriptive statistics of the final allocations are presented. Among the 1,063 (96.0%) cohort study participants classified, 68.7% acquired HIV vertically, following validation. ART initiation before cut-off age 10 had the highest sensitivity (58.9%) but cut-off age 12 had the largest area under the curve (AUC) (0.712). Among the additional young mothers living with HIV, 95.3% were estimated to have acquired it sexually, following the same algorithm. For this group, while cut-off ages 10 to 12 had the highest sensitivity (92.2%), age 14 had the highest AUC (0.703). ART initiation before 10 years old is strongly associated with vertical HIV acquisition. Therefore, a cut-off age of 10 would remain the recommendation in LMIC regions with similar epidemiology as South Africa for determining MOHA in research and clinic settings.

HIV prevalence and associated factors among orphaned adolescents and youth aged 12-24 years in South Africa

“…Nevertheless, maternal transmission still accounts for a number of HIV infections among ALHIV including orphans, previous studies suggest that the HIV virus progresses gradually in some infants, and a sizable percentage of HIV-positive children live until adolescence and beyond [25]. In South Africa more research is needed to distinguish between maternally and sexually acquired HIV and some research is being conducted in the country [34]. Nevertheless, national HIV programmes and interventions for sexual riskreduction strategies and behaviour change communication should also be prioritized for sexually active orphaned adolescents and youth.…”

Healthcare provisions associated with multiple HIV‐related outcomes among adolescent girls and young women living with HIV in South Africa: a cross‐sectional study

“…This was coded as recently initiated (0−3 years on treatment) versus all others. Mode of HIV acquisition ( recent/perinatal ) was computed via an algorithm based on the age of ART initiation, validated with self‐reported data such as the age of first sex, orphanhood cause and experiences of sexual assault [23].…”

Longitudinal Trajectories of Antiretroviral Treatment Adherence and Associations With Durable Viral Suppression Among Adolescents Living With HIV in South Africa

“…Mode of HIV acquisition (perinatally versus sexually acquired HIV) was defined following existing sub-Saharan African pediatric cohorts: age of ART initiation cutoff [≤10 years] 37 validated and updated with a detailed algorithm that considered other strong evidence (ie, self-reported sexual history and parental death) in the absence of definitive clinic notes ascribing mode of HIV acquisition. 38…”

“…Mode of HIV acquisition (perinatally versus sexually acquired HIV) was defined following existing sub-Saharan African pediatric cohorts: age of ART initiation cutoff [#10 years] 37 validated and updated with a detailed algorithm that considered other strong evidence (ie, self-reported sexual history and parental death) in the absence of definitive clinic notes ascribing mode of HIV acquisition. 38 Self-reported data on ART adherence were also collected at each visit using various measures on missed doseswith varying recall time frames-and missed clinic appointments. The measures used in this analysis included 4 on missed doses in the past 3 days, past week, and past month and any past-month days missed adapted from the Patient Medication Adherence Questionnaire, 39 and 1 on missed clinic appointments, which was added into the questionnaire based on recommendations from other studies.…”