The HIV care cascade for adolescents initiated on antiretroviral therapy in a health district of South Africa: a retrospective cohort study

Abstract

Background Little evidence exists to comprehensively estimate adolescent viral suppression after initiation on antiretroviral therapy in sub-Saharan Africa. This study examines adolescent progression along the HIV care cascade to viral suppression for adolescents initiated on antiretroviral therapy in South Africa. Methods All adolescents ever initiated on antiretroviral therapy (n=1080) by 2015 in a health district of the Eastern Cape, South Africa, were interviewed in 2014–2015. Clinical records were extracted from 52 healthcare facilities through January 2018 (including records in multiple facilities). Mortality and loss to follow-up rates were corrected for transfers. Predictors of progression through the HIV care cascade were tested using sequential multivariable logistic regressions. Predicted probabilities for the effects of significant predictors were estimated by sex and mode of infection. Results Corrected mortality and loss to follow-up rates were 3.3 and 16.9%, respectively. Among adolescents with clinical records, 92.3% had ≥1 viral load, but only 51.1% of viral loads were from the past 12 months. Adolescents on ART for ≥2 years (AOR 3.42 [95%CI 2.14–5.47], p< 0.001) and who experienced decentralised care (AOR 1.39 [95%CI 1.06–1.83], p=0.018) were more likely to have a recent viral load. The average effect of decentralised care on recent viral load was greater for female (AOR 2.39 [95%CI 1.29–4.43], p=0.006) and sexually infected adolescents (AOR 3.48 [95%CI 1.04–11.65], p=0.043). Of the total cohort, 47.5% were recorded as fully virally suppressed at most recent test. Only 23.2% were recorded as fully virally suppressed within the past 12 months. Younger adolescents (AOR 1.39 [95%CI 1.06–1.82], p=0.017) and those on ART for ≥2 years (AOR 1.70 [95%CI 1.12–2.58], p=0.013) were more likely to be fully viral suppressed. Conclusions Viral load recording and viral suppression rates remain low for ART-initiated adolescents in South Africa. Improved outcomes for this population require stronger engagement in care and viral load monitoring.

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

“…Therefore, young people living with HIV constitute a growing and key sub-population of people living with HIV globally. The increase in HIV prevalence amongst adolescents (10 to 19 years) is the result of the generation of children infected with HIV perinatally who are surviving into adolescence because of improved access to antiretroviral treatment (ART), and increased HIV incidence as a result of risky (sexual) behaviour in this age group [3,4]. Despite tremendous gains in the reduction of over-all AIDS-related deaths to the tune of 43%, AIDS-related deaths amongst adolescents in Eastern and Southern Africa have increased in the last decade [5].…”

Viral Load Monitoring for People Living with HIV in the Era of Test and Treat: Progress Made and Challenges Ahead – A Systematic Review

“…Screening titles and abstracts identi ed 66 studies for full-text examination, of which 32 studies met the inclusion criteria and were included. Bibliography review identi ed two additional studies, making a total of 34 studies included in the review (Figure 1) Twenty-nine of the 34 included studies were conducted in and/or had data collected from sub-Saharan Africa (SSA) countries, including South Africa [21][22][23][24][25][26][27][28][29][30][31],…”

“…Of 11 studies from South Africa, four were conducted in Cape Town, reporting relatively high VL coverage of 72-89% [22,[24][25][26]. Other studies were conducted in KwaZulu-Natal [21,30,31], Eastern Cape [23,27] and Gauteng [29], and another study [28] included data from ART patients in nine different provinces across the country. Studies with interventions to improve quality of ART program had a VL coverage of >90% whilst other studies reported a VL range of 25%-81%.…”

Predictors and consequences of HIV status disclosure to adolescents living with HIV in Eastern Cape, South Africa

“…Quantitative interviews were self-administered using standardised questionnaires on tablet devices. Available viral load data were extracted from participants' clinical records and linked to their questionnaire data [33,34]. This analysis was restricted to adolescents who acquired HIV perinatally (APHIV) (Figure 1) determined by ART initiation age 10-years or younger and validated using other supporting evidence such as history of parental death, maternal HIV-status and self-reported sexual history [33,35].…”

“…Available viral load data were extracted from participants' clinical records and linked to their questionnaire data [33,34]. This analysis was restricted to adolescents who acquired HIV perinatally (APHIV) (Figure 1) determined by ART initiation age 10-years or younger and validated using other supporting evidence such as history of parental death, maternal HIV-status and self-reported sexual history [33,35]. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review)…”