Impacts of intimate partner violence and sexual abuse on antiretroviral adherence among adolescents living with HIV in South Africa.

OBJECTIVE: We are failing to reach 95-95-95 for adolescents living with HIV (ALHIV). Sexual abuse and intimate partner violence (IPV) may impact antiretroviral therapy (ART) adherence, with high rates of 17.4 and 29.7%, respectively, across the southern sub-Saharan African region. However, evidence on their associations with adolescent ART adherence remains limited, with only three cross-sectional studies globally. DESIGN: A prospective cohort of ALHIV (sample N = 980, 55% female individuals, baseline mean age 13.6 years) were recruited from 53 health facilities in South Africa's Eastern Cape Province and responded to a structured questionnaire at 18-month and 36-month follow-up (2015-2016, 2017-2018). METHODS: A repeated-measures random effects model assessed multivariable associations of self-reported sexual abuse and IPV with past-week ART adherence, controlling for individual, socioeconomic, and HIV-related factors. Past-week adherence was defined based on currently taking ART and not having missed any doses in the past 7 days (including weekends). We further fitted a moderation model by sex. RESULTS: Fifty-one percent of adolescents reported consistent ART adherence at both time points. Exposure to IPV was associated with lower odds of self-reported ART adherence (aOR 0.39, 95% CI 0.21-0.72, P = 0.003), as was sexual abuse (aOR 0.54, 95% CI 0.29-0.99, P = 0.048). The marginal predicted probability of ART adherence for adolescents with no exposure to either IPV or sexual abuse was 72% (95% CI 70-74%) compared with 38% (95% CI 20-56%) for adolescents with exposure to both IPV and sexual abuse. Moderation results showed similar associations between sexual violence and ART adherence by sex. CONCLUSION: Sexual violence prevention and postviolence care may be essential components of supporting adolescent ART adherence. Integration of HIV and violence prevention services will require accessible services and simple referral systems

Who goes back to school after birth? Factors associated with postpartum school return among adolescent mothers in the Eastern Cape, South Africa

Early motherhood can negatively impact health, educational, and socio-economic outcomes for adolescent mothers and their children. Supporting adolescent mothers’ educational attainment, and timely return to school, may be key to interrupting intergenerational cycles of adversity. Yet, there remains a paucity of evidence on the factors that are associated with mothers’ postpartum return to school and the mediators of this process, particularly across sub-Saharan Africa where adolescent pregnancy rates remain high . This paper is based on interviews with 1,046 adolescent mothers from South Africa. Mothers who had returned to school after birth showed lower poverty, fewer repeated grades preceding the pregnancy, continued schooling during pregnancy, higher daycare/crèche use, more family childcare support, and lower engagement in exclusive breastfeeding within six months postpartum. Mediation analyses showed that lower poverty was directly associated with school return and via two indirect pathways: continued schooling during pregnancy and using daycare/crèche services. This study demonstrates that lacking childcare constitutes a major hurdle to mothers’ school return which needs to be addressed in addition to socioeconomic and individual-level barriers. Policy makers and practitioners should consider supporting young mothers with combination interventions which include services supporting school retention during pregnancy and access to, and financial supplements for, daycare

Exploring self-reported adherence measures to screen for elevated HIV viral load in adolescents: a South African cohort study

The timely identification of ART non-adherence among adolescents living with HIV presents a significant challenge, particularly in resource-limited settings where virologic monitoring is suboptimal. Using South African adolescent cohort data (N = 933, mean age 13.6 ± 2.89 years, 55.1% female, follow-up = 2014–2018), we examined the association between elevated viral load (VL ≥ 1000 copies/mL) and seven self-reported adherence measures on missed doses, and clinic appointments –with varying recall timeframes. The best performing measures, which were significantly associated with elevated viral load in covariate-adjusted models are: any missed dose –past 3 days (sensitivity = 91.6% [95%CI: 90.3–92.8], positive predictive value (PPV) = 78.8% [95%CI: 77.2–80.4]), –past week (sensitivity = 87% [95%CI: 85.4–88.6], PPV = 78.2% [95%CI: 76.5–79.9]), –past month (sensitivity = 79.5% [95%CI: 77.5–81.4], PPV = 78.2% [95%CI: 76.4–79.9]), any past-month days missed (sensitivity = 86.7% [95%CI: 85.1–88.3], PPV = 77.9% [95%CI:76.2–79.6]), and any missed clinic appointment (sensitivity = 88.3% [95%CI: 86.8–89.8], PPV = 78.4% [95%CI: 76.8–79.9]). Combining the three best performing measures missed dose –past 3 days, –past week, and any past-year missed clinic appointment increased sensitivity to 96.4% while maintaining a PPV of about 78%. The discriminatory power of simple and easy-to-administer self-reported adherence measures in detecting elevated viral load warrants consideration in resource-limited settings and may contribute to the aims of the new Global Alliance to End AIDS in children and adolescents by 2030

Pathways to survival: Identifying psychosocial, family and service mechanisms to improve anti-retroviral adherence amongst adolescents living with HIV in Southern Africa

This report summarises the study findings and impact of a research project implemented jointly by the Universities of Oxford and Cape Town: Pathways to survival: identifying psychosocial, family and service mechanisms to improve anti-retroviral adherence amongst HIV-positive adolescents in Southern Africa (hereafter: Mzantsi Wakho and#8211; Your South Africa and#8211; its locally used name). The core source of funding for this high-impact and successful study came from the Nuffield Foundation. This study was also supported by supplementary co-funding. This study was the first to systematically examine potential causes of ART non-adherence and non-retention in HIV care amongst adolescents (10-19 years old) in Sub-Saharan Africa. Through additional funding awarded to the research team, additional research aims were also examined. The research project was implemented by a team of more than 50 researchers, including capacity-building for early-career academics and students in South Africa and the UK. In July 2015 and#8211; March 2018, this multi-disciplinary, mixed-methods team engaged with over 1,600 adolescents, 100 caregivers, and 120 healthcare providers through participatory workshops, in-depth interviews, ethnographic research, and three waves of quantitative surveys. In parallel, a clinic team engaged with over 79 public health facilities collecting data from clinic managers, healthcare providers, and patient files (with appropriate consent). With the essential support of the Nuffield Foundation, this study became the worldand#8217;s largest longitudinal cohort of adolescents living with HIV. Mzantsi Wakhoand#8217;s research team successfully followed up and maintained high retention rates across three time points, as research participants transitioned from early adolescence into youth. The study has already had major impact on policy, UN guidelines and programming for adolescents living with HIV.</p

Pathways to survival: Identifying psychosocial, family and service mechanisms to improve anti-retroviral adherence amongst adolescents living with HIV in Southern Africa

This report summarises the study findings and impact of a research project implemented jointly by the Universities of Oxford and Cape Town: Pathways to survival: identifying psychosocial, family and service mechanisms to improve anti-retroviral adherence amongst HIV-positive adolescents in Southern Africa (hereafter: Mzantsi Wakho – Your South Africa – its locally used name). The core source of funding for this high-impact and successful study came from the Nuffield Foundation. This study was also supported by supplementary co-funding. This study was the first to systematically examine potential causes of ART non-adherence and non-retention in HIV care amongst adolescents (10-19 years old) in Sub-Saharan Africa. Through additional funding awarded to the research team, additional research aims were also examined. The research project was implemented by a team of more than 50 researchers, including capacity-building for early-career academics and students in South Africa and the UK. In July 2015 – March 2018, this multi-disciplinary, mixed-methods team engaged with over 1,600 adolescents, 100 caregivers, and 120 healthcare providers through participatory workshops, in-depth interviews, ethnographic research, and three waves of quantitative surveys. In parallel, a clinic team engaged with over 79 public health facilities collecting data from clinic managers, healthcare providers, and patient files (with appropriate consent). With the essential support of the Nuffield Foundation, this study became the world’s largest longitudinal cohort of adolescents living with HIV. Mzantsi Wakho’s research team successfully followed up and maintained high retention rates across three time points, as research participants transitioned from early adolescence into youth. The study has already had major impact on policy, UN guidelines and programming for adolescents living with HIV.</p