Page 425 - HIVMED_v21_i1.indb

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subtracting those who died and transferred out from both the and health outcomes. Clinicians tend to monitor individuals
numerator and denominator. who are at WHO stages III and IV more closely because
of other comorbidities such as tuberculosis and other
Younger adolescents (10–14 years) demonstrated better RiC opportunistic infections requiring clinical assessments.
rates, compared with the older group. This observation could However, Matyanga et al. found that a low CD4 count and
be attributed to the disproportionate attention offered to advanced HIV infection at initiation were associated with
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younger adolescents. In spite of the unique challenges posed LTFU. We also found that adolescents classified as WHO
by adolescents and ART, there is a dearth of comprehensive stage I at ART initiation had significantly lower rates of RiC
health services for adolescents, including interventions to at 4 months post-initiation versus those with a WHO stage
improve RiC in sub-Saharan Africa. Nevertheless, younger III. Contrary to the results in our study, another Ugandan
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adolescents show better RiC rates because they depend, to a study found that the risk of LTFU of adolescents at 12 months
greater extent, on their caregivers to handle their treatment was significantly greater amongst those on WHO clinical
journey. In this way, the RiC of the young adolescent is an stages III and IV, compared with those on WHO stages I and
extension of the dedication and understanding of the II. People living with HIV at WHO stage I hardly display
31
caregiver. Another study designed to investigate the RiC signs and symptoms associated with AIDS. The literature has
rates between younger and older adolescents in Zimbabwe attributed this low RiC behaviour amongst adolescents at
demonstrated no differences in attrition amongst younger stage I to not feeling ‘sick’ or feeling ‘well’ as a proxy of
versus older adolescents. 20 nothing being wrong.

We found that older adolescents (15–19 years) were Although the primary focus of our study was not on pregnant,
significantly less likely to be retained in care over the first HIV-infected adolescents, many in this sub-group were
24 months, compared with younger adolescents. This finding captured in our sample. This could be explained by the fact
is congruent with the trends reported in other studies 21,22 and that pregnant, HIV-infected adolescents are often horizontally
corresponds to the transition of adolescents from paediatric infected and receive their positive HIV test result for the first
to adult HIV programmes – a known high-risk period for time when booking for antenatal care. Although vertical
disengagement with care. 23,24,25 Several authors have argued transmission of HIV is common amongst younger ALWH,
that patient-level challenges, such as developmental delays, horizontal transmission is a frequent mode of transmission in
mental health issues, stigma and social support at home and older adolescents. Adolescent boys tend to not access HIV
school, must be adequately addressed for a successful treatment because they mostly remain asymptomatic at
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transition to take place. A supported transition requires a this stage.
skilful adult treatment team and the provision of facilitated
care aimed at overcoming the disruptions of the patient– Interventions such as task shifting, community-based
paediatric provider relationship. The loss of ancillary support adherence support, mHealth platforms and group adherence
is required to foster independence, the exercise of autonomy counselling emerged as strategies in adult populations that
and the growth of personal responsibility. 27,28 could be adapted for adolescents. 32,33 These interventions
may benefit older adolescents, especially those transitioning
Although male adolescents constituted a smaller proportion to adult programmes that utilise them. However, the
of the study sample, on average, they had greater RiC effectiveness of, for example, ‘teen clubs’, has had mixed
throughout the observation period, compared with females. results. MacKenzie et al. reported that Malawian ALWH
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Just under half of the female adolescents (n = 84/182, 46%) who were not in a teen club were less likely to be retained
were initiated on ART whilst pregnant. They exited care at an than those in teen clubs. On the other hand, Munyayi and
alarming rate, that is, 44%, 64% and 79% at 4, 12 and van Wyk found that group-based adherence interventions
35
24 months, respectively. These findings correspond to those such as teen clubs did not improve retention rates for younger
of Nuwagaba-Biribonwoha et al. who found a greater rate adolescents in specialised paediatric ART clinics in Namibia
of LTFU amongst pregnant and non-pregnant female but did hold potential for improving rates in older
adolescents, compared with male adolescents. The current adolescents. Adolescent-only clinics and monthly meetings
29
study reports lower RiC rates, compared with the 76.4% RiC have been shown to improve the RiC of adolescents. To this
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at 12 months noted in a recent systematic review of pregnant end, we support the calls of other authors for interventions,
and post-partum women in Africa. This report found especially targeting older adolescents whose needs are
30
younger age and same-day ART initiation to be risk factors increased during the transition period. 23
for poor retention, as was initiating during pregnancy,
particularly late pregnancy.
Conclusion
Our findings indicate that adolescents who were classified as Our study highlights low RiC for adolescents over the first
WHO stage IV at ART initiation showed better RiC rates at 2 years after initiation on ART. Critical intervention is needed
months 4, 12 and 24 post-initiation, although no statistical to motivate adolescents to remain in care, adhere to treatment
significance was achieved. Individuals at WHO stages III and and ultimately to achieve and maintain VL suppression (even
IV are likely to remain in care because they are motivated by when they are not feeling sick). Targeted interventions to
their health status and by the association between treatment address transition coordination – pre- and post-transition

http://www.sajhivmed.org.za 417 Open Access