STACKing the odds for adolescent survival: health service factors associated with full retention in care and adherence amongst adolescents living with HIV in South Africa

Abstract

IntroductionThere are two million HIV‐positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self‐reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)‐initiated adolescents in South Africa.MethodsWe collected clinical records and detailed standardized interviews (n = 1059) with all 10‐ to 19 year‐olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost‐to‐follow‐up (90.1% of eligible adolescents interviewed). Associations between full self‐reported retention in care (no past‐year missed appointments and 85% past‐week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility.ResultsAbout 56% of adolescents had self‐reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention.ConclusionsThis study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV‐positive adolescents.

Multiple forms of discrimination and internalized stigma compromise retention in HIV care among adolescents: findings from a South African cohort

“…All adolescents who had ever initiated HIV treatment in 53 government‐run health facilities were identified through clinic patient records and traced back to 180 communities, to ensure inclusion of those not engaged in care [3]. Adolescents were interviewed in their first language (97% Xhosa) and could choose their place of interview (either at the clinics or in their homes, schools or other locations they identified as safe).…”

“…At a time when efficacious antiretroviral treatment (ART) enables people living with HIV to live long and healthy lives, young people between the ages of 13 and 24 are the only age group for whom AIDS‐related mortality is on the rise [2]. The exceptionally low rates of ART adherence and retention in HIV care in this age group [3,4] have contributed to AIDS being the leading cause of death among adolescents in Africa [1]. But there is limited evidence of successful interventions to support adolescent retention in HIV care and their long‐term survival.…”

“…But there is limited evidence of successful interventions to support adolescent retention in HIV care and their long‐term survival. Existing intervention research is focused on clinic‐based interventions [5], which are essential but insufficient to meet the complex needs of adolescents living with HIV [3,4], including adolescents who are not engaging with the health system.…”

“…Adolescents living with HIV are subjected to discrimination within their communities and families both because of their own HIV status and, sometimes, because of their caregivers’ HIV status [8‐10]. Adolescents living with HIV also report frequent instances of healthcare providers getting angry and shouting at them, which they experience as discrimination [3]. Being a target of discrimination can lead to internalized stigma [11], which occurs when adolescents internalize stigmatizing characterizations of people living HIV and accept them as applicable to themselves [12].…”

Coming of age with HIV: a temporal understanding of young women’s experiences in Zambia

“…As optimum interventions are being developed to support this "biogeneration" of young people living with HIV (for example, Cluver et al, 2018;Graves et al, 2018;Li et al, 2017;Mavhu et al, 2017), our data aid understanding of their experiences, providing valuable evidence as to how to provide comprehensive support. Increasingly support groups are being established to support young people living with HIV (Bateganya, Amanyeiwe, Roxo, & Dong, 2015;Cowan et al, 2019;Mavhu et al, 2017).…”