Excellent Adherence to Antiretrovirals in HIV+ Zambian Children Is Compromised by Disrupted Routine, HIV Nondisclosure, and Paradoxical Income Effects

Veronica Mulenga,Chifumbe Chintu,Adrian Cook,A Sarah Walker,Margaret Thomason,Desiree Kabamba,Marjorie Ngambi,Johan K Sandberg,Diana M Gibb,Cissy Kityo,Alex Ferrier,Jessica E Haberer,David R Bangsberg

doi:10.1371/journal.pone.0018505

Abstract

IntroductionA better understanding of pediatric antiretroviral therapy (ART) adherence in sub-Saharan Africa is necessary to develop interventions to sustain high levels of adherence.Methodology/Principal FindingsAdherence among 96 HIV-infected Zambian children (median age 6, interquartile range [IQR] 2,9) initiating fixed-dose combination ART was measured prospectively (median 23 months; IQR 20,26) with caregiver report, clinic and unannounced home-based pill counts, and medication event monitoring systems (MEMS). HIV-1 RNA was determined at 48 weeks. Child and caregiver characteristics, socio-demographic status, and treatment-related factors were assessed as predictors of adherence. Median adherence was 97.4% (IQR 96.1,98.4%) by visual analog scale, 94.8% (IQR 86,100%) by caregiver-reported last missed dose, 96.9% (IQR 94.5,98.2%) by clinic pill count, 93.4% (IQR 90.2,96.7%) by unannounced home-based pill count, and 94.8% (IQR 87.8,97.7%) by MEMS. At 48 weeks, 72.6% of children had HIV-1 RNA <50 copies/ml. Agreement among adherence measures was poor; only MEMS was significantly associated with viral suppression (p = 0.013). Predictors of poor adherence included changing residence, school attendance, lack of HIV disclosure to children aged nine to 15 years, and increasing household income.Conclusions/SignificanceAdherence among children taking fixed-dose combination ART in sub-Saharan Africa is high and sustained over two years. However, certain groups are at risk for treatment failure, including children with disrupted routines, no knowledge of their HIV diagnosis among older children, and relatively high household income, possibly reflecting greater social support in the setting of greater poverty.

Highlights

A better understanding of pediatric antiretroviral therapy (ART) adherence in sub-Saharan Africa is necessary to develop interventions to sustain high levels of adherence
Over two million children under 15 years of age live with HIV/ AIDS, 90% of whom reside in sub-Saharan Africa.[1]
The two goals of the study were to 1) conduct a comparative evaluation of several widely used adherence measures; and 2) identify factors associated with adherence to fixed-dose combination (FDC) tablets in a resource-limited setting

Summary

Introduction

A better understanding of pediatric antiretroviral therapy (ART) adherence in sub-Saharan Africa is necessary to develop interventions to sustain high levels of adherence. Over two million children under 15 years of age live with HIV/ AIDS, 90% of whom reside in sub-Saharan Africa.[1] Efforts to provide children with antiretroviral therapy (ART) are increasing. ART use in HIV-infected children leads to reduced plasma HIV RNA levels, increased CD4 cell counts, decreased incidence of opportunistic infections, improved growth and development, and decreased morbidity and mortality.[3,4] High levels of sustained adherence, are needed to achieve these benefits.[5,6]. A better understanding of the determinants of adherence is necessary to improve adherence and treatment outcomes This need is important in resource-constrained settings with limited treatment options

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Conclusion