Implementation of a Psychosocial Support Intervention for Adolescents on Antiretroviral Treatment: Challenges and Experiences from Ehlanzeni District, South Africa

Adolescents living with HIV (ALHIV) need support from family, peers and health workers to remain on antiretroviral therapy and achieve and sustain viral suppression. This paper qualitatively explores the implementation of a psychosocial support intervention (PSS) in five primary health care facilities in the Ehlanzeni district, South Africa. Data were collected through key informant interviews and focus group discussions with ALHIV on ART. Data analysis employed inductive thematic analysis. Informed consent was obtained prior to all data collection. The PSS intervention facilitated full disclosure of HIV status to adolescents, supported treatment adherence through health education, peer support, health care provider- and client relations, and quick access to health service delivery. However, COVID-19 restrictions and regulations challenged the implementation of the intervention. The PSS intervention showed promise to support adolescent’s adherence and retention in care. We recommend innovative approaches to account for systemic disruptions, as evidenced by the COVID-19 pandemic

Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10–24 years): a scoping review

Mental health disorders such as high levels of anxiety, isolation, depression and suicide ideation reported among young people living with HIV (10–24 years;YPLHIV) contribute significantly to poor medication adherence and retention in care. While there is evidence supporting the role of psychosocial support interventions in promoting adherence and retention in antiretroviral treatment (ART) among adults living with HIV, there is little evidence on the role of psychosocial support on medication adherence among YPLHIV. This scoping review was designed to identify and classify the types and effects of psychosocial support interventions designed to improve adherence and retention in ART among YPLHIV globally

Desperate times call for desperate measures: Adapting antiretroviral service delivery in the context of the COVID-19 pandemic

On 23 March 2020, President Cyril Ramaphosa announced a nation-wide lockdown to help curb the spread of the COVID-19 epidemic in South Africa (SA). While these containment measures are considered to have limited the spread of COVID-19 in SA, the economic and social consequences, including the impact on healthcare service delivery, are prominent. Regarding healthcare service delivery, there are concerns about people who could be at risk of experiencing severe COVID-19 infection, and about meeting the needs of people with chronic diseases such as people living with HIV (PLHIV). In the context of the COVID-19 pandemic, PLHIV with an unsuppressed viral load may be at increased risk of developing severe COVID-19-related conditions and potentially dying, especially those who are co-infected with tuberculosis (TB)

Two-year retention in care for adolescents on antiretroviral therapy in Ehlanzeni district, South Africa: a baseline cohort analysis

Adolescents living with HIV (ALHIV) struggle to remain engaged in HIV-related care and adhere to antiretroviral treatment (ART) due to a myriad of physical, psychological and cognitivedevelopmental challenges. We report on the profile of ALHIV aged 10–19 years on ART and the clinical factors associated with their retention in care. A retrospective cohort analysis was conducted with 16,108 ALHIV, aged 10–19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Anonymised data were obtained from electronic medical records (Tier.net). Trends in retention in care among adolescents on ART was described using Kaplan-Meier survival estimates. Cox proportional analysis was performed to identify factors associated with retention in care over 2 years. More than half (53%) were females, and median duration on ART was 8 months. Retention in care among adolescents at months 6, 12, 18 and 24 was 90.5%, 85.4%, 80.8% and 76.2%, respectively. After controlling for confounders, risk of dying or lost to follow up increased for female adolescents (aHR = 1.28, 95% CI 1.10–1.49); being initiated on ART while pregnant (aHR = 2.72, 95% CI 1.99–3.69); history of TB infection (aHR = 1.71, 95% CI 1.10–2.65); and started ART at age 10–14 years (aHR = 2.45, 95% CI 1.96–3.05), and 15–19 years (aHR = 9.67, 95% CI 7.25–12.89). Retention in care among adolescents on ART over two-year period was considerably lower than the UNAIDS 2030 target of 95%. Of particular concern for intervention is the lower rates of retention in care among females and pregnant adolescents and starting ART between the ages of 10 and 19 years. Family or caregivers and peer support groups centred interventions designed to promote early initiation and retention in care through early case identification are needed

Determinants of viral suppression among adolescents on antiretroviral treatment in Ehlanzeni district, South Africa: a cross-sectional analysis

Achieving undetectable viral load is crucial for the reduction of HIV transmissions, AIDS-related illnesses and death. Adolescents (10 to19 years) living with HIV (ALHIV) on antiretroviral treatment (ART) have worse treatment adherence and lower viral suppression rates compared to adults. We report on the clinical factors associated with viral suppression among ALHIV in the Ehlanzeni district, Mpumalanga in South Africa.A cross-sectional analysis was conducted with 9386 ALHIV, aged 10 to 19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Clinical and immunological data were obtained from electronic medical records (Tier.net). ALHIV were categorised as having achieved viral suppression if their latest viral load count was<1000 ribonucleic acid (RNA) copies/mL. Using a backward stepwise approach, a multivariate logistic regression analysis was performed to identify factors independently associated with viral suppression

Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach

BACKGROUND: Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing intervention to enhance the retention in care of patients on ART and their adherence to medication. Although empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health system contexts the adherence club intervention works (or not). METHODS: We undertook a realist evaluation study to uncover the programme theory of the adherence club intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes of the adherence club intervention, guided by retroductive inferencing. RESULTS: We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when required works because patients’ self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility and the community. CONCLUSION: Understanding what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, could inform guidelines for effective implementation in different contexts and scaling up of the intervention to improve population-level ART adherence

A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa

BACKGROUND: The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province. METHODS: The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers’ and managers’ assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic – retroduction. RESULTS: We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities. CONCLUSION: The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in “real intervention cases” using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works

Two-year viral load suppression among adolescents receiving antiretroviral therapy in the Cape Metropole, South Africa, 2013 - 2015: A retrospective cohort analysis

Background. In 2018, 4% of all people living with HIV globally were adolescents aged 10 - 19 years. It is reported that adolescents on antiretroviral therapy (ART) are at increased risk of poor viral load suppression (VLS) compared with children and adults.Objectives. To determine the 24-month prevalence of VLS among adolescents initiated on ART in 2013 in public health facilities in the Metro District Health Services of Western Cape Province, South Africa.Methods. A retrospective cohort analysis was done on 220 adolescents initiated on ART in 2013; they were followed up for 24 months. Data were extracted from the provincial Tier.Net electronic database and patients’ clinical records, and captured in Excel. SPSS statistical software was used for descriptive and inferential analysis; bivariate analysis was used to determine significance and strength of associations between VLS and various sociodemographic and clinical characteristics at 4, 12 and 24 months (with significance set at p&lt;0.05).Results. VLS declined over the study period, with rates of 59.5%, 40.0% and 25.0% at 4, 12 and 24 months post initiation on treatment, respectively. In bivariate analysis, VLS was significantly associated with younger age (10 - 14 years) at month 12 (crude risk ratio (RR) 1.83 (95% confidence interval (CI) 1.35 - 2.49)) and month 24 (RR 3.38 (95% CI 2.24 - 5.10)) after initiation on ART. Male adolescents were significantly more likely to achieve VLS than females (month 4: RR 1.49 (95% CI 1.22 - 1.81); month 12: RR 1.50 (95% CI 1.07 - 2.12); and month 24: RR 2.33 (95% CI 1.50 - 3.62)). Pregnant adolescents were significantly less likely to attain VLS (month 4: RR 0.69 (95% CI 0.53 - 0.89); month 12: RR 0.64 (95% CI 0.44 - 0.94); and month 24: RR 0.24 (95% CI 0.11 - 0.50)) compared with those who were not pregnant. However, of those adolescents who were retained in care, VLS was higher at months 4, 12 and 24, with rates of 86.8%, 79.3% and 68.8%, respectively.Conclusions. Targeted interventions are required to improve retention in care and VLS among adolescents on ART, with specific focus on older (15 - 19-year-olds) and pregnant adolescents

Ambulanssjuksköterskors erfarenheter av att delta vid prehospitala förlossningar

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