Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Abstract

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

Seeking wider access to HIV testing for adolescents in sub-Saharan Africa

“…Pregnant adolescent females (46,47), adolescents with early sexual debut, married, or partnered but living separately, engaging in transactional sex, especially in rural areas (62,63), having multiple or older sexual partners (59,60,64), and those experiencing high mobility and labor migration (65,66), have also been identified to be at increased risk of HIV infection and unfavorable outcomes. Lastly, the significant proportions of perinatally-infected individuals surviving into young adolescence and young adulthood should not be overlooked (51,61,67). While advocating for and strengthening HTC uptake and coverage, linkage to quality care should be available to make HTC ultimately beneficial.…”

“…This is especially important for girls. (54,67). This limits the ability of funders and policy-makers to make evidence-based recommendations positively impacting on all adolescents and has further implication for mixed epidemic countries where detailed subnational data is necessary to know where testing should be concentrated.…”

Adolescent antiretroviral management: Understanding the complexity of non-adherence

“…[12] Other studies cite the following psychosocial risk factors for poor ART adherence: being orphaned, mental health problems, changes of guardianship, and absence of parental and social support. [5] As seen with the case presented, major hindrances to adolescent adherence are the lack of autonomy and reliance on adult caregivers to access care, complying with clinic visits, collecting medication and adhering to the dosage schedule. [11] These are further confounded by issues surrounding status disclosure, autonomy and maturity.…”

“…However, evidence suggests that non-disclosure is associated with various negative outcomes. [5] Often, status disclosure is deferred until children approach cognitive maturity and puberty, but the decision to disclose is dependent on the family and caregivers, especially as adolescent status disclosure simultaneously discloses the status of the biological mother. [5,11] Non-adherence to ART is further complicated by behavioural experimentation typical of this phase of development.…”

“…[4] Despite guidance in the management of adolescent ART issued by the WHO in 2013 there have, however, been serious impediments to reducing delays in the initiation of appropriate ART, in supporting adherence to treatment and in retention of adolescents in care. [1] Currently, approximately 90% of the estimated 3 million children living with HIV globally [1] reside in sub-Saharan Africa [5] only 27% of those who require ART receive it. [1] Furthermore, in SA only 45% of the 369 000 HIV-infected children aged 10 -14 years, and 14.3% of the 720 000 aged 15 -24 years, currently receive ART.…”