Correlates of Adherence to Antiretroviral Therapy in HIV-Infected Children in Lomé, Togo, West Africa

We assessed pediatric adherence to antiretroviral therapy (ART) and examined associated factors among children in Togo, West Africa. Structured interviews of caregivers of consecutively enrolled HIV-infected children receiving ART in three HIV/AIDS care centers in Lome, Togo were conducted. Child perfect adherence reflected caregivers’ report of no antiretroviral drug doses missed neither in the past 4 days nor in the month before the interview. A total of 74 ART-treated children were included (median age 6 years). Of these, 42% of caregivers declared perfect adherence. In univariate analyses, the major factors relating to child non-adherence were: being female, living in an individual setting (vs. compound with enlarged family), receiving other ART than an NNRT-based regimen, drug regimens with six pills/spoons or more per day, caregiver other than biological parent, caregiver not declaring HIV-status, not participating to support groups and having perceived difficulty of antiretroviral (ARV) administration. In multivariate analysis, female gender, living in an individual setting, receiving other than NNRTI-based regimen and caregivers’ perceived difficulty of ARV administration remained independently associated with the reported child’s non-adherence. These data show low rates of perfect adherence to ART in children in West Africa, influenced by child and caregiver characteristics and suggest a need for counseling and education interventions as well as continuous psychological and social support.     

Barriers and facilitators to antiretroviral medication adherence among HIV-infected paediatric patients in Ethiopia: A qualitative study

Medication adherence is a complex behaviour with multiple determinants. Understanding the barriers and facilitators of adherence is invaluable for programme improvement, which assists the foundation of adherence intervention strategies. A qualitative study was conducted in six selected hospitals of Addis Ababa in 2008, to explore barriers and facilitators to antiretroviral medication adherence among HIV-infected paediatric patients. Twelve caregivers of adherent and non-adherent children and 14 key informants in five hospitals were included in the study. The findings revealed that over-dosage (heavy pill burden), fear of stigma and discrimination, cost and access to transportation, lack of understanding of the benefit of taking the medication, economic problems in the household, and lack of nutritional support were the barriers to adherence to HAART. The presence of mobile/wall alarm, the presence of follow-up counselling, improved health of the child, ART clinic setups, and disclosure of HIV serostatus were among the facilitators. This study indicated that paediatric adherence to antiretroviral therapy faces a huge challenge. It suggests the provision of income-generating schemes to caregivers for assisting HIV-infected children. Health care providers should address proper usage of medication reminders.     

HIV disclosure and its effect on treatment outcomes in perinatal HIV-infected Thai children

The World Health Organization guideline recommends informing children of their HIV status between the ages of 6–12 years. Primary caregivers of perinatal HIV-infected Thai children ≥6 years were interviewed in order to assess the HIV status disclosure rate. In addition, pill counts of antiretroviral therapy (ART) were performed every three months. CD4 and HIV-RNA were performed every six months. Of the 260 children/adolescents included, the median age of disclosure was 14.8 years. The disclosure rate among those from 6 to 12 years was 21% and for those greater than 12 years of age was 84%. When comparing children aged 6–12 years whose HIV status had been disclosed to them, to children whose HIV had yet to be disclosed, no difference was noted in median ART adherence by pill count, CD4 count, or proportion of HIV-RNA <50 copies/ml (p > 0.05). Factors associated with HIV disclosure were an age of ≥12 years (OR 17.8, 95% CI 8.86–35.79) and a current CD4 ≤ 30% (OR 2.09, 95% CI 1.20–3.62). In conclusion, although the majority of adolescents ≥12 years were aware of their HIV status only one-fifth of children aged 6–12 years were aware. Moreover, the child's/adolescent's disclosure status had no bearing on ART adherence by pill count or immunological and virological outcomes.     

Adherence to Both Cotrimoxazole and Placebo is Associated with Improved Survival Among HIV-Infected Zambian Children

In the CHAP randomized placebo-controlled trial of cotrimoxazole prophylaxis in HIV-infected Zambian children conducted between 2001 and 2003, cotrimoxazole was associated with significant mortality reductions. In a secondary analysis we used Cox regression models to estimate the association between adherence measured by bottle weights and caregiver report and subsequent mortality in children surviving >28 days (n = 496, 153 deaths). Adherence was high and similar in both cotrimoxazole and placebo groups; adherence from bottle weights was 100% at 71% of visits, while caregivers reported 100% adherence at 79% of visits. Every 10% lower adherence to cotrimoxazole or placebo measured by bottle weights was associated with a 10–11% increase in mortality risk. Effects remained after adjustment for baseline predictors of survival and for current and recent change in primary caregiver. Caregiver-reported adherence was not associated with survival. The association between bottle-weight adherence to placebo and survival is likely capturing unmeasured caregiver effects, whose identification will be essential for quantifying the impact of antiretroviral therapy (ART) adherence on clinical outcomes in children. All authors are on behalf of the Children with HIV Antibiotic Prophylaxis Trial (CHAP Trial).     

Barriers to and facilitators of adherence to pediatric antiretroviral therapy in a sub-Saharan setting: insights from a qualitative study

Despite the need for HIV-positive children to adhere effectively to antiretroviral treatment (ART), a guiding theory for pediatric ART in resource-limited settings is still missing. Understanding factors that influence pediatric ART adherence is critical to developing adequate strategies. In-depth qualitative interviews were undertaken in Kinshasa, Democratic Republic of the Congo, with 20 sets of HIV disclosed and nondisclosed children along with respective caregivers to better characterize barriers, facilitators, and adherence experiences in children taking ART. Commonly cited barriers included lack of food or nutritional support, lack of assistance or supervision for children, lack of assistance for caregivers, and being unable to remember to take medicines on a consistent basis. Facilitators included having a strong caregiver-child relationship and support system along with strategies for maintaining adherence. Similar themes arose within the child-caregiver sets, but were often characterized differently between the two. Children who were aware of their HIV status displayed fewer instances of frustration and conflict concerning taking medicines and within the child-caregiver relationship. Continued study on pediatric ART adherence should account for differing perspectives of children and caregivers, as well as between status disclosed and nondisclosed children. Areas of future intervention should focus on child-caregiver relationships, disclosure of HIV status, and available nutritional and psychosocial support for children and their caregivers.     

High prevalence of non-adherence to antiretroviral therapy among undisclosed HIV-infected children in Ghana

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7–18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0%–100.0%). However, only 47.5% of children had ≥95% adherence (“good adherence”) using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29–6.56), p?=?0.010) or elementary education only (aOR, 2.20, CI, 1.24–3.88, p?=?0.007) were more likely to have “good adherence” (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).     

Barriers and facilitators to paediatric adherence to antiretroviral therapy in rural South Africa: a multi-stakeholder perspective

Poor adherence to antiretroviral therapy (ART) contributes to the development of drug resistance. HIV-infected children, especially those 5 years and under, are dependent on a caregiver to adhere to ART. However, characteristics of the caregiver, child, regimen, clinic and social context affect clinic attendance and medication-taking, both of which constitute adherent behaviour. We conducted nine interviews and three focus groups to determine how doctors, nurses, counsellors, traditional healers and caregivers understood the barriers and facilitators to ART adherence among children residing in rural South Africa. The data were transcribed, translated into English from isiZulu where necessary, and coded using Atlas.ti version 7. Results were interpreted through the lens of Bronfenbrenner's Ecological Systems Theory. We found that at the micro-level, palatability of medication and large volumes of medication were problematic for young children. Characteristics of the caregiver including absent mothers, grandmothers as caregivers and denial of HIV amongst fathers were themes related to the micro-system. Language barriers and inconsistent attendance of caregivers to monthly clinic visits were factors affecting adherence in the meso-system. Adherence counselling and training were the most problematic features in the exo-system. In the macro-system, the effects of food insecurity and the controversy surrounding the use of traditional medicines were most salient. Increased supervision and regular training amongst lay adherence counsellors are needed, as well as regular monitoring of the persons attending the clinic on the child's behalf.     

To tell or not to tell: Dimensions of disclosure to children with HIV in the Zambezi region of Northern Namibia

ABSTRACT

The survival rates of prenatally HIV-infected children in Africa have significantly improved with the advent of antiretroviral therapy (ART). Few studies examined the HIV status disclosure of children and the sociodemographics of their caregivers in Northern Namibia. This was a cross-sectional exploratory study with a sample of 83 caregiver-child dyads of HIV-affected children ages 6–18 in Namibia. The mean age of caregivers was 37.1 [range 15–93, SD?=?11.9], and the majority were female (87.5%). More than half of the HIV-infected children (55.7%) were between 6–10 years of age at the time of the study. More than two thirds of children (67.1%) had their HIV diagnosis disclosed to them. Some caregivers believed it was very important (42.2%) or good (39.8%) to disclose the HIV status to children, and just a few (3.6%) mentioned it was not important at all. More research is warranted to describe HIV-infected children accessing ART and their caregivers to better inform HIV/AIDS interventions and policies.     

The importance of caregivers in the outcome of pediatric HIV management,Mombasa, Kenya

We assessed programmatic gaps that prevent the optimal treatment of pediatric HIV infection despite free antiretroviral care in Kenya. Of 626 HIV-infected Kenyan children, the median age was five years, 54% were male and the mortality rate was 3.2 per 100 person-years. A total of 380 (61%) children initiated antiretroviral therapy (ART) during the study period. Among the 246 children who never started ART, 129 (52%) met the criteria for ART initiation. Immunologic failure occurred in 20% of children who received ART for >24 weeks. In multivariate analysis, immunological failure was associated with having nonimmediate relative or unrelated caregivers accompanying the child to clinic (AOR = 69.16, p = 0.008). Having ≥3 types of accompanying caregivers was also associated with virologic failure in multivariate analysis (AOR = 3.84, p = 0.03). The lost to follow-up rate was 8.7/100 persons-years for the entire cohort, and significantly higher (17.7/100 persons-years) among children not on ART (p < 0.001). Among children who do initiate ART, those with the best treatment outcomes were those who had a limited number of close relatives as caregivers and good adherence to ART. Focus on early ART initiation and education of the right caregiver will likely improve retention and quality of pediatric HIV care in Kenya.     

HIV status disclosure rate and reasons for non-disclosure among infected children and adolescents in Enugu,southeast Nigeria

Aims: To determine the rate of HIV status disclosure, caregivers’ reasons for non-disclosure, and factors influencing disclosure among a sample of HIV-infected children in Enugu, southeast Nigeria. Methods: Data were collected prospectively via a questionnaire on HIV-infected children and their caregivers who visited the pediatric HIV clinic of the University of Nigeria Teaching Hospital between July 1, 2012, and June 30, 2013. The data analysis was performed using Statistical Package for the Social Sciences version 19 software. Results: Caregivers of 107 children (age 5–16 years; mean 10.1?±?3.2 years) were enrolled in the study. There were 53 (49.5%) boys and 54 (50.5%) girls. HIV status had been disclosed to 31 (29%) of them. The major reason for non-disclosure was the child being considered too young. Age (p?p?p?=?.008) were seen as significant predictors of HIV disclosure. Conclusions: There is a low rate of HIV disclosure to infected children, and it was found to be lower for younger children. We recommend improving efforts for disclosure counseling to caregivers in pediatric HIV clinics.     

Understanding the role of age in HIV disclosure rates and patterns for HIV-infected children in southwestern Uganda

Highly active antiretroviral therapy has enabled HIV-infected children to survive into adolescence and adulthood, creating need for their own HIV diagnosis disclosure. Disclosure has numerous social and medical benefits for the child and family; however, disclosure rates tend to be low, especially in developing countries, and further understanding of the barriers is needed. This study describes the patterns and correlates of disclosure among HIV-infected children in southwestern Uganda. A cross-sectional study was conducted in a referral hospital pediatric HIV clinic between February and April 2012. Interviews were administered to caregivers of HIV-infected children aged 5–17 years. Data collected included socio-demographic characteristics of the child and caregiver, reported disclosure status, and caregivers' reasons for full disclosure or non-full disclosure of HIV status to their children. Bivariate and multivariate analysis was done to establish the socio-demographic correlates of disclosure. Caregivers provided data for 307 children; the median age was eight years (interquartile range [IQR] 7–11) and 52% were males. Ninety-five (31%) children had received full disclosure (48% of whom were >12 years), 22 children (7%) had received partial disclosure, 39 (13%) misinformation, and 151 (49%) no disclosure. Full disclosure was significantly more prevalent among the 9–11 and 12- to 17-year-olds compared to 5- to 8-year-olds (p-value < 0.001). The most frequently stated reason for disclosure was the hope that disclosure would improve medication adherence; the most frequently stated reason for nondisclosure was the belief that the child was too young to understand his/her illness. There was an inverse relationship between age and full disclosure and partial disclosure was rare across all age groups, suggesting a pattern of rapid, late disclosure. Disclosure programs should emphasize the importance of gradual disclosure, starting at younger ages, to maximize the benefits to the child and caregiver.     

Extent of disclosure: what perinatally HIV-infected children have been told about their own HIV status

How and when to disclose a positive HIV diagnosis to an infected child is a complex challenge for caregivers and healthcare workers. With the introduction of antiretroviral therapy, pediatric HIV infection has transitioned from a fatal disease to a lifelong chronic illness, thus increasing the need to address the disclosure process. As HIV-infected children mature, begin to take part in management of their own health care, and potentially initiate HIV-risk behaviors, understanding the nature of their infection becomes essential. Guidelines recommend developmentally appropriate incremental disclosure, and emphasize full disclosure to school-age children. However, studies from Sub-Saharan Africa report that disclosure to HIV-infected children is often delayed. Between 2013 and 2014, 553 perinatally HIV-infected children aged 4–9 years were enrolled into a cohort study in Johannesburg, South Africa. We assessed the extent of disclosure among these children and evaluated characteristics associated with disclosure. No children aged 4 years had been told their status, while 4% of those aged 5 years, and 8%, 13%, 16%, and 15% of those aged 6, 7, 8, and 9 years, respectively, had been told their status. Age was the strongest predictor of full disclosure (odds ratio 1.6 per year, p?=?.001). An adult living in the household who was unaware of the child’s status was associated with a reduced probability of disclosure, and knowing that someone at the child’s school was aware of child’s status was associated with an increased probability of disclosure. Among caregivers who had not disclosed, 42% reported ever discussing illness in general with the child, and 17% reported ongoing conversations about illness or HIV. In conclusion, a small minority of school-age children had received full disclosure. Caregivers and healthcare workers require additional support to address disclosure. A broader public health strategy integrating the disclosure process into pediatric HIV treatment programs is recommended.     

Disclosure of diagnosis by parents and caregivers to children infected with HIV: prevalence associated factors and perceived barriers in Addis Ababa, Ethiopia

Vertical transmission of HIV from infected mothers to children is a common phenomenon. After the introduction of highly active antiretroviral treatment (HAART), most children live longer than before. Recently, HAART has become widely available to children living in sub-Saharan African countries, and this makes disclosure of HIV status an important issue. We conducted a cross-sectional survey involving 172 parents/caregivers of HIV-infected school-age children who had follow-up at the Pediatric Infectious Disease Clinic of the Yekatit 12 Hospital, Addis Ababa. Only 16.3% of HIV-infected schoolchildren knew their diagnosis. The child's age was the main predictor of disclosure (OR: -0.25; 95% CI: -0.35, -0.09; p<0.05). The main reason for nondisclosure was fear of negative emotional consequences for the child. More than half of the parent/caregivers agreed that they need to tell the children their diagnosis, but 86% reported that they needed health care providers to help them at the event. The low rate of disclosure found in this study shows the need for awareness creation and training of health professionals, and this should be supported by appropriate guidelines to be followed by health professionals working in pediatric ART clinics. Caregivers need to be provided with the necessary knowledge and skills on how to look after children who know their HIV status.     

Challenges faced by elderly guardians in sustaining the adherence to antiretroviral therapy in HIV-infected children in Zimbabwe

Grandparents throughout sub-Saharan Africa have shown immense courage and fortitude in providing care and support for AIDS-affected children. However, growing old comes with a number of challenges which can compromise the quality of care and support they are able to provide, particularly for children infected by HIV and enrolled on antiretroviral therapy (ART) programmes. For ART to be effective, and for infected children not to develop drug-resistance, a complex treatment regimen must be followed. Drawing on the perspectives of 25 nurses and eight grandparents of HIV-infected children in Manicaland, eastern Zimbabwe, we explore some of the challenges faced by grandparents in sustaining children's adherence to ART. These challenges, serving as barriers to paediatric ART, are poverty, immobility, deteriorating memory and poor comprehension of complex treatments. Although older HIV-infected children were found to play an active role in sustaining the adherence to their programme of treatment by contributing to income and food generating activities and reminding their guardians about check-ups and drug administration, such contribution was not available from younger children. There is therefore an urgent need to develop ART services that both take into consideration the needs of elderly guardians and acknowledge and enhance the agency of older children as active and responsible contributors to ART adherence.     

Challenges to pediatric HIV care and treatment in South Africa

It is estimated that almost 300,000 children in South Africa have human immunodeficiency virus (HIV) infection. The disease is responsible for reversing decreases in child mortality. Few data exist evaluating the outcomes of the prevention of mother-to-child transmission of HIV (PMTCT) program, although PMTCT coverage appears to be low. Hospitals are still witnessing large numbers of admissions of HIV-infected children. Postnatal transmission of HIV is high, reflecting poor education of and support for women in their infant feeding choices. Too few infants and children are entering care through early diagnosis, which should be widely available. Cotrimoxazole prophylaxis coverage is inadequate, contributing to high morbidity and mortality in infants. The number of children receiving antiretroviral therapy (ART) is increasing steadily. However, significant inequalities in access to ART exist between and within provinces. Challenges for pediatric ART include a lack of sufficiently trained health care personnel and inadequate facilities, as well as the complexity of drug regimens and formulations. The compartmentalization of the ART rollout program hinders PMTCT and makes it difficult for children to be identified and referred into appropriate services. This article delineates the challenges to pediatric HIV care in South Africa and provides some practical recommendations to improve it.     

Adherence to antiretroviral therapy and its determinants in children with HIV infection – Experience from Paediatric Centre of Excellence in HIV Care in North India

The objective of this study is to assess adherence to antiretroviral therapy (ART) in HIV-infected children using the pill count method, and determine factors leading to adherence failure. Records of 106 children living with HIV (CLHIV) age <15 years and on ART for >6 months were reviewed. Average adherence to ART by pill count method over preceding six months was calculated and re-assessed by 3-day recall method. The caregivers of 105 children and one child himself were interviewed about the problems encountered while giving ART. Median age of enrolled children was 104 (inter-quartile range [IQR] 77.3–133.8) months. Median duration of ART was 25 (IQR 16–35) months. The desired adherence level of >95% during six months of review assessed by pill count was achieved in 95.3% children. The 3-day recall method yielded >95% adherence in 99% children (p ≤ .001). Caregivers of 59 children (56.2%) reported multiple problems while administering drugs. In most instances, problems encountered were related to family/caregivers, the commonest being multiple caregivers, job constraints and death/illness in the family. In conclusion, we found a very high level of adherence to ART in CLHIV. Poor adherence was mainly associated with issues related to the family/caregivers.     

Caregiver-reported antiretroviral therapy non-adherence during the first week and after a month of treatment initiation among children diagnosed with HIV in Ethiopia

To achieve optimal virologic suppression for children undergoing antiretroviral therapy (ART), adherence must be excellent. This is defined as taking more than 95% of their prescribed doses. To our knowledge, no study in Ethiopia has evaluated the level of treatment adherence at the beginning of the child’s treatment. Our aim was therefore to evaluate caregiver-reported ART non-adherence among children and any predictors for this during the early course of treatment. We conducted a prospective cohort study of 306 children with HIV in eight health facilities in Ethiopia who were registered at ART clinics between 20 December 2014 and 20 April 2015. The adherence rate reported by caregivers during the first week and after a month of treatment initiation was 92.8% and 93.8%, respectively. Our findings highlight important predictors of non-adherence. Children whose caregivers were not undergoing HIV treatment and care themselves were less likely to be non-adherent during the first week of treatment (aOR?=?0.17, 95% CI: 0.04, 0.71) and the children whose caregivers did not use a medication reminder after one month of treatment initiation (aOR?=?5.21, 95% CI: 2.23, 12.16) were more likely to miss the prescribed dose. Moreover, after one month of the treatment initiation, those receiving protease inhibitor (LPV/r) or ABC-based treatment regimens were more likely to be non-adherent (aOR?=?12.32, 95% CI: 3.25, 46.67). To promote treatment adherence during ART initiation in children, particular emphasis needs to be placed on a baseline treatment regimen and ways to issue reminders about the child’s medication to both the health care system and caregivers. Further, large scale studies using a combination of adherence measuring methods upon treatment initiation are needed to better define the magnitude and predictors of ART non-adherence in resource-limited settings.     

Disclosure of HIV status to infected children in a Nigerian HIV Care Programme

With increasing survival of HIV-infected children, parents face the challenges of disclosure to the children. The aim of this study was to assess the rate of HIV disclosure to children in Ibadan and the factors influencing it in order to guide design of strategies for successful disclosure. A semi-structured questionnaire was administered to consecutive consenting caregivers of HIV-infected children aged ≥6 years attending the Paediatric Infectious Disease Clinic of the University College Hospital, Ibadan, between November 2008 and October 2009. Caregivers of 96 children (46 boys, 50 girls) infected with HIV were interviewed. The ages of the children ranged from 6 to 14 years with a mean (SD) of 8.8 (2.2) years. Disclosure had been done in only 13 (13.5%) of the children; ages at disclosure ranged from 4.5 to 13 years with a mean of 8.7 (SD = 2.2). Disclosure was associated with age above 10 years. Reasons given by carers for non-disclosure in 83 caregivers included inability of the children to understand in 53 (63.9%), fear of disclosure to other children 34 (41.0%), fear of disclosure to family/friends in 28 (33.7%), fear of psychological disturbance of the children in 26 (31.3%) and fear of blaming the parents in 22 (26.5%). Twenty (20.8%) of the children have asked questions relating to their diagnosis and the responses are often evasive. Caregivers felt disclosure had helped adherence to antiretroviral therapy in 7 (63.6%) of the 11 children on antiretroviral drugs in whom there was disclosure but no effect on the remaining. There is a need to assist parents and health care providers in successfully disclosing HIV status to infected children without adverse consequences.     

Caregivers’ Intentions to Disclose HIV Diagnosis to Children Living with HIV in South Africa: A Theory-Based Approach

When children know their HIV serostatus, they are more likely to cooperate with steps to manage their health and the risk of transmitting HIV to others. Mounting evidence indicates that caregivers often do not disclose to HIV-positive children that the children are living with HIV, but little is known about the modifiable determinants of pediatric HIV disclosure. The present study examined theory-of-planned-behavior predictors of the intention to disclose to children their HIV diagnosis. The participants were 100 caregivers of HIV-positive children in Eastern Cape Province, South Africa. Proportional-odds logistic regression analysis revealed that normative support for disclosure and caregiver-child communication predicted the intention to disclose, whereas behavioral beliefs regarding the consequences of disclosing and self-efficacy to disclose did not. The results suggest that interventions to increase pediatric HIV disclosure in South Africa should help caregivers enlist support for disclosure among important referents and improve communication with their HIV-infected children.