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      Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave

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          Abstract

          Context

          South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression.

          Objective

          To determine the adolescent HIV continuum of care in South Africa.

          Data sources

          We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015.

          Data extraction

          We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15–24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression.

          Results

          Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed.

          Limitations

          This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents.

          Conclusions

          Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.

          Related collections

          Most cited references30

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          Acute care utilization and rehospitalizations for sickle cell disease.

          M L Mosso, Julie A Panepinto, David C Brousseau … (2010)
          Published rates of health care utilization and rehospitalization by people with sickle cell disease have had limited generalizability and are not population based. To provide benchmark data for rates of acute care utilization and rehospitalizations for patients with sickle cell disease. Retrospective cohort of sickle cell disease-related emergency department (ED) visits and hospitalizations from select states in the 2005 and 2006 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and State Emergency Department Databases. Eight geographically dispersed states (Arizona, California, Florida, Massachusetts, Missouri, New York, South Carolina, and Tennessee) that provide encrypted identifiers and have sufficient numbers of patients with sickle cell disease; together these states have 33% of the US population with sickle cell disease. A total of 21,112 patients with sickle cell-related treat-and-release ED visits or inpatient hospitalizations. Rates of acute care utilization and rehospitalizations. Population-based utilization rates were also calculated. The 21,112 people with sickle cell disease had 109,344 encounters, a mean of 2.59 (95% confidence interval [CI], 2.53-2.65) encounters per patient per year, 1.52 (95% CI, 1.48-1.55) encounters for hospitalizations and 1.08 (95% CI, 1.04-1.11) for treat-and-release ED visits. Utilization was highest for 18- to 30-year-olds, 3.61 (95% CI, 3.47-3.75) encounters per patient per year, and those with public insurance, 3.22 (95% CI, 3.13-3.31) encounters per patient per year. Publicly insured 18- to 30-year-olds had 4.80 (95% CI, 4.58-5.02) encounters per patient per year. Approximately 29% of the population had no encounters while 16.9% had 3 or more encounters per year. The 30-day and 14-day rehospitalization rates were 33.4% (95% CI, 33.0%-33.8%) and 22.1% (95% CI, 21.8%-22.4%), respectively. The rehospitalization rate was highest for 18- to 30-year-olds, with 41.1% (95% CI, 40.5%-41.7%) rehospitalized within 30 days and 28.4% (95% CI, 27.8%-29.0%) within 14 days. Rehospitalizations were also highest for publicly insured patients. Among patients with sickle cell disease, acute care encounters and rehospitalizations were frequent, particularly for 18- to 30-year-olds.
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            Predictors of adherence to antiretroviral medications in children and adolescents with HIV infection.

            Kathleen M Malee, John Farley, S. Williams … (2006)
            Most evaluations of adherence to antiretroviral therapy in children with HIV infection have focused on validation of adherence measures via their association with virological outcomes. However, few studies have fully explored associations with other factors to guide development of adherence interventions. In this study, we examined the relationship of self-reported medication adherence to health, demographic, and psychosocial characteristics of children and their caregivers, using data from an ongoing multicenter prospective observational study of long-term outcomes of HIV infection conducted by the Pediatric AIDS Clinical Trials Group. Child and caregiver characteristics were evaluated for association with adherence via univariate and multiple logistic regression models. Of the 2088 children and adolescents, 84% reported complete adherence to antiretroviral therapy medications over the past 3 days. The median viral load was approximately 10 times higher among nonadherent than adherent children, and the strength of this association increased with age. Factors associated with at least marginally significant increases in nonadherence in a multiple logistic regression model included increasing age in years, female gender, detectable HIV viral load, occurrence of recent stressful life events, repeating a grade in school, self-assessment of adherence by the subject, and diagnosis of depression or anxiety. Having an adult other than the biological parent as the primary caregiver, using a buddy system to remember to take antiretroviral therapy medications, higher caregiver education level, previous adherence assessments, and taking antipsychotic medications were each associated with improved adherence. After controlling for these characteristics, there was no significant association of adherence with race, knowledge of HIV status, medication burden, CD4 percentage, or current antiretroviral therapy. Rates of self-reported adherence were relatively high and were influenced by multiple child and family characteristics. These findings identify targets for adherence interventions and highlight the importance of evaluating and supporting the family environment to optimize adherence.
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              Changes in programmatic outcomes during 7 years of scale-up at a community-based antiretroviral treatment service in South Africa.

              Mweete Nglazi, Stephen D Lawn, Richard Kaplan … (2011)
              To assess sustainability of programmatic outcomes in a community-based antiretroviral therapy (ART) service in South Africa during 7 years of scale-up. Prospective cohort of treatment-naive patients aged ≥ 15 years enrolled between 2002 and 2008. Data were analyzed by calendar period of ART initiation using time-to-event analysis and logistic regression. ART was initiated by 3162 patients (67% women; median age, 34 years) who were followed-up for a median of 2.4 years (interquartile range, 1.2-3.8). After 6 years, the cumulative probability of death and loss to follow-up (LTFU) was 37.4%. The probabilities of transfer-out to another ART service and of virological failure were 21.6% and 23.1%, respectively. Low mortality risk and excellent virological and immunological responses during the first year of ART were not associated with calendar period of ART initiation. In contrast, risk of LTFU and virological failure both increased between successive calendar periods in unadjusted and adjusted analyses. The number of patients per member of clinic staff increased markedly over time. Successful early outcomes (low mortality and good immunological and virological responses) were sustained between sequential calendar periods during 7 years of scale-up. In contrast, the increasing cumulative probabilities of LTFU or virological failure may reflect decreasing capacity to adequately support patients during long-term therapy as clinic caseload escalated.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Glob Health
                Journal ID (iso-abbrev): BMJ Glob Health
                Journal ID (hwp): bmjgh
                Journal ID (publisher-id): bmjgh
                Title: BMJ Global Health
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2059-7908
                Publication date Collection: November 2016
                Publication date (Electronic): 24 October 2016
                Volume: 1
                Issue: 3
                Electronic Location Identifier: e000004
                Affiliations
                [1 ]Massachusetts General Hospital , Boston, Massachusetts, USA
                [2 ]Harvard Medical School , Boston, Massachusetts, USA
                [3 ]University of KwaZulu-Natal Nelson Mandela School of Medicine , Durban, South Africa
                [4 ]Department of Pediatrics, King Edward Hospital , Durban, South Africa
                [5 ]Dalla Lana School of Public Health, University of Toronto , Toronto, Ontario, Canada
                [6 ]Brigham and Women's Hospital , Boston, Massachusetts, USA
                Author notes
                [Correspondence to ] Dr Brian C Zanoni; bzanoni@ 123456mgh.harvard.edu
                Author information
                http://orcid.org/0000-0001-5845-3190
                Article
                Publisher ID: bmjgh-2015-000004
                DOI: 10.1136/bmjgh-2015-000004
                PMC ID: 5321340
                PubMed ID: 28588949
                SO-VID: 958b9a39-1da4-4386-b140-ffde254f1314
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 29 October 2015
                Date revision received : 23 June 2016
                Date accepted : 8 August 2016
                Categories
                Subject: Research
                Subject: 1506

                Data availability:

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