Abstract
BackgroundAdherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood.Methodology/Principal FindingsTo understand the level, distribution, and correlates of ART adherence behavior, we prospectively determined monthly ART adherence through multiple measures and six-monthly HIV RNA levels among 121 Ugandan children aged 2–10 years for one year. Median adherence levels were 100% by three-day recall, 97.4% by 30-day visual analog scale, 97.3% by unannounced pill count/liquid formulation weights, and 96.3% by medication event monitors (MEMS). Interruptions in MEMS adherence of ≥48 hours were seen in 57.0% of children; 36.3% had detectable HIV RNA at one year. Only MEMS correlated significantly with HIV RNA levels (r = −0.25, p = 0.04). Multivariable regression found the following to be associated with <90% MEMS adherence: hospitalization of child (adjusted odds ratio [AOR] 3.0, 95% confidence interval [CI] 1.6–5.5; p = 0.001), liquid formulation use (AOR 1.4, 95%CI 1.0–2.0; p = 0.04), and caregiver’s alcohol use (AOR 3.1, 95%CI 1.8–5.2; p<0.0001). Child’s use of co-trimoxazole (AOR 0.5, 95%CI 0.4–0.9; p = 0.009), caregiver’s use of ART (AOR 0.6, 95%CI 0.4–0.9; p = 0.03), possible caregiver depression (AOR 0.6, 95%CI 0.4–0.8; p = 0.001), and caregiver feeling ashamed of child’s HIV status (AOR 0.5, 95%CI 0.3–0.6; p<0.0001) were protective against <90% MEMS adherence. Change in drug manufacturer (AOR 4.1, 95%CI 1.5–11.5; p = 0.009) and caregiver’s alcohol use (AOR 5.5, 95%CI 2.8–10.7; p<0.0001) were associated with ≥48-hour interruptions by MEMS, while second-line ART (AOR 0.3, 95%CI 0.1–0.99; p = 0.049) and increasing assets (AOR 0.7, 95%CI 0.6–0.9; p = 0.0007) were protective against these interruptions.Conclusions/SignificanceAdherence success depends on a well-established medication taking routine, including caregiver support and adequate education on medication changes. Caregiver-reported depression and shame may reflect fear of poor outcomes, functioning as motivation for the child to adhere. Further research is needed to better understand and build on these key influential factors for adherence intervention development.
Highlights
As of the end of 2009, an estimated 2.5 million children were living with HIV/AIDS globally, and 354,000 were receiving antiretroviral therapy (ART) [1]
Factors related to family structure [3,4], socioeconomic status [3,5], disclosure [5,6,7,8], hospitalization [8] and medication routine and/or regimen [4,5,9] have all been significantly associated with ART adherence
36.3% have detectable HIV RNA, and 30% have,90% adherence by medication event monitors (MEMS) indicates that a better understanding of adherence and adherence interventions are needed
Summary
As of the end of 2009, an estimated 2.5 million children were living with HIV/AIDS globally, and 354,000 were receiving antiretroviral therapy (ART) [1]. Studies to date on adherence to ART among pediatric populations in developing settings have shown mixed results with adherence ranging from 49% to 100% [2]. Few have compared multiple adherence measures to HIV RNA [5,17]. Variations in measures and in adherence estimates call for a more comprehensive and accurate assessment of adherence to ART in this population in order to develop evidence-based interventions for promoting sustained adherence. Adherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood
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