Rashida A Ferrand Reader in International Health London School of Hygiene and Tropical Medicine Rashida Ferrand has no financial relationships with commercial entities to disclose The HIV care cascade ID: 734653
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Slide1
Adolescent Adherence and Retention: The Weakest Link
Rashida A FerrandReader in International HealthLondon School of Hygiene and Tropical Medicine
Rashida Ferrand has no financial relationships with commercial entities to disclose. Slide2
The HIV care cascade
HIV -
ve
HIV +
ve
HIV testing & counselling
Linkage to HIV care
Retention in care
Treatment adherence
HIV prevention
Improved Health
outcomes
Virological
suppression
Reduced HIV
transmission
Retention in care and adherence to therapy are life-long
50% INCREASE in mortality in adolescents despite ART scale-up
90%
virologically
suppressed
90% on sustained ART
90% tested Slide3
Retention in HIV care among adolescents
Bygrave
PLoS One 2012; Evans AIDS Res Hum Retro 2013
Slide4
Lost to follow-up after movement to next age-band: ZIMBABWE (n=3545: 2004-2010)
Age at ART start
Rate of lost to follow-up per 100 person years (95%
CI)
Adjusted
RR* (95% CI),
p-value
Before transition to next age-band
After transition to next age-band
5 – 9y
4.9 (3.95, 5.98)
2.3 (1.47, 3.45)
0.7 (0.38, 1.11),
p = 0.113
10 – 14y
3.2 (2.44, 4.15)
4.9 (3.41, 7.07)
1.6 (0.96, 2.60),
p = 0.074
15 –19y
9.1 (7.12, 11.5)
16.7 (10.9, 25.6)
2.0 (1.19, 3.39),
p = 0.009
*
Adjusted for gender, time on ART and calendar year
Kranzer
K et al, 2016- manuscript in preparation Slide5
Table: Immunological and
virological
responses at 6 and 12 months after antiretroviral therapy initiation, stratified by age category
Maintaining HIV treatment
As in other chronic diseases, adherence lower in adolescence
Key life events: medicines are not a priority
Period of experimentation & high-risk behaviours
Nachega
JAIDS 2009; Charles Bull WHO 2008;
Bakanda
PLoS
One 2011; Evans AIDS Res Hum Retro 2013
TUAB01 ABSTRACTS
M.Maskew
A. JuddSlide6
Shubber
et al: Poster THPEB074Slide7
Kim AIDS 2014; Dow AIDS Care 2016;
Haberer
PLoS
One 2011;
Biadgilign
SAHARA J 2009;
Nabukeera-Barungi
Ann Trop
Paediatr
2007
Correlates of poor adherenceSlide8
ONCE DAILY REGIMENS
ART REGIMENS WITH REDUCED TOXICITY
AIDS 2015;29:2447-57
FIXED-DOSE COMBINATIONS
INNOVATIVE FORMULATIONS
Drug related
Margolis et al CROI 2016. Abs 31LB
Musiime
V et al
2014; 66:148–154Slide9
TREATMENT INTERRUPTIONS
BREATHER: Lancet HIV 2016
N=199:
virologically
suppressed participants
INCENTIVES
Foster 2014 AIDS Patient
Care STDS
N=11: Incentives and motivational interviewing
DIRECTLY OBSERVED THERAPY
Gilkman
Paediatrics 2007
N=9: Hospital admission
Parsons 2006 AIDS Patient Care STDS
N=14: 40 days admission
HOLDING REGIMENS
Linder V et al PIDJ 2016
N= 71: 3TC monotherapy
KNOWLEDGE & EMPOWERMENT
Berrien 2004 AIDS Patient Care STDS (N=37)Letourneau 2013 AIDS Care (N=34)Chokephaibulkit 2015 J Assoc Nur AIDS Care (N=139)Kaihin 2015 Behav Med (N=46)Bhana 2014 AIDS Care (N=65)Home visits by nurses
Multisystemic therapy sessions Individual and group sessionsIndividualSlide10
“ADOLESCENT FRIENDLY” SERVICES
Lee AIDS 2016 Patient Care STDSDavila 2013 AIDS CareTeasdale 2016 JAIDS Youth-friendly waiting area
Trained health providersText-messaging to providers
Evening clinics
Dedicated clinic dayIntegrated SRHPeer groups
Structural
Social
PEER SUPPPORT
Funck
-Brentano AIDS 2005
N=30: Peer support group sessions
Decentralisation
Task Shifting
Home initiation
Home delivery
Same day ART initiation Slide11
The GAPSFew studies: 11 studies in 14 years; majority in high-income settings
Limits of the evidence base: small sample sizes, no comparison groups, choice and definition of outcomes, selection biasResource-intensive interventions applied at individual level: limited duration of effect
Single-effect interventions for multi-dimensional determinantsNeeds of adolescents as individuals vs delivering long-term treatment at scale in low-resource settings with constrained health systems
Macpherson P et al 2015 Trop Med
Int Health Judd A et al 2016 Curr Opin HIV AIDS Slide12
Conclusions
Adherence and retention are not one-off events-require maintenance life-long and critical to successful outcomesAdherence and retention determined by multiple factors: individual, social and structuralNeed a menu of interventions tailored to context and resources
Interventions need to combine a public health approach AS WELL AS being responsive to individual needsSlide13
Moving forwardAdolescents and communities empowered and active agents for change
Interventions that address mental health-key determinant to adherenceCaregiver support strategies as mediators for adolescents to achieving good outcomesSchool-based interventions plus focus on teachers Slide14
Acknowledgements
LSHTM
Richard Hayes
Helen Weiss
Katharina
Kranzer
Liz Corbett
Joanna
Busza
Vicky Simms
BRTI
Ethel
Dauya
Tsitsi Bandason
Grace McHugh
Suba
DakshinaZENITH Study Team
University of Zimbabwe
Hilda
Mujuru
Kusum NathooHarare City Health ServicesMinistry of Health & Child Care Zimbabwe
Population Services InternationalChild Protection SocietyWHODavid RossJane FergusonBruce DickRachel Baggaley