Human immunodeficiency virus infection/Acquired immunodeficiency syndrome (HIV/AIDS) accounted for approximately 38 million people living with HIV, 1.7 million new infections, 690,000 AIDS-related deaths and children aged 0–14 years representing 9% of new infections (1, 2). In Jamaica AIDS is a leading cause of death in 15 to 49 age group and the second leading cause of death in children aged 1 to 4 years (3). The vulnerable populations (men who have sex with men, commercial sex workers and heterosexuals engaging in high-risk sexual behaviors), and those presenting late with opportunistic infections are particularly at risk. Cumulatively, over 34,125 HIV cases and 9,517 deaths attributed to AIDS were reported in Jamaica between 1982 and 2015, 1250 deaths in children 0–19 years (4), with continued rise in new infections to date (5).
Increased access to and utilization of highly active antiretroviral therapy in HIV-infected children has been facilitated through international funding, and established unified parallel treatment programmes for paediatric HIV in the Kingston Metropolitan area and centers island-wide through collaborative efforts between the Kingston Paediatric and Perinatal HIV/AIDS Programme and National HIV/AIDS Programme, Ministry of Health, Jamaica since 2003 (6, 7). The consequent outcomes of improved survival and reduction in HIV-attributable morbidity among children and adolescents necessitates further strengthening of adherence particularly among adolescents living with HIV (ALHIV) who are less likely compared to other age groups to achieve viral load suppression (8, 9, 10), internationally benchmarked at 62% adherence (11).
Among 1.8 million children (0–14 years) and 5 million young adults (15–25 years) living with HIV (12), increased access to antiretroviral therapy (ART) has resulted in growing numbers of perinatally-infected and behaviourally-infected adolescents surviving to late adolescence and adulthood (13, 14, 15, 16, 17). Majority ALHIV (82%) globally reside in Africa, highest prevalence in Sub-Saharan countries (18, 19), and female predominance (20, 21). Higher HIV prevalence among female adolescents, gay, bisexual boys and transgender adolescents call for urgent interventions to mitigate risk in these vulnerable groups. ALHIV have lower rates of retention in care and viral suppression resulting in increased HIV-attributable mortality especially in 15–19 age group (22, 23, 24, 25, 26, 27).
Adherence is the single most important factor determining the success of ART, optimal efficacy requiring at least 95% (8, 9, 10). Sub-optimal adherence results in treatment failure, development of viral resistance, and subsequent negative outcomes for survival and morbidity (28, 29). Monitoring measures include directly observed therapy, pharmacy reporting, patient reports, clinic appointment checks, and biomedical markers such as viral load levels (6). Self-reported surveys recalling missed doses over the last four days have been shown to be valid and reliable (30, 31, 32).
Transition from paediatric HIV services to the adult care is a vulnerable window associated with disengagement from care, and decreased viral suppression rates (33), and poor adherence is considered a risk-taking behavior common during adolescent development (34).
Across developed and developing country settings, barriers to adherence include complicated regimens, pill burden, forgetfulness, falling asleep, suspicions of treatment, access to medication, work and family responsibilities, fear of disclosure, life stages, negative experiences with ART and poor health literacy, being orphaned, poor adult support, lack of economic resources, and health system delays (35, 36, 37). Facilitators include positive effects of ART, acceptance of diagnosis, sense of self-worth, understanding need for adherence, reminder tools, simple regimen, strong family, peer and health support system, permanency planning, having married parents, parent also on ART, ART/HIV literacy, and rewards for adherence. Early paediatric ART regimes had frequent dosing, high pill/volume burden and toxicities (38, 39) but these barriers are currently mitigated by simpler, coformulated regimes, reduced pill burden and dosing frequency, and improved side effect profiles, hence optimising adherence and virological suppression (40, 41).
Globally, the Covid-19 pandemic disrupted health care systems, hospitals were overwhelmed and non-essential services, including outpatient activities scaled back or suspended (42). Internationally the progress toward HIV epidemic control has been derailed, but strategies have been implemented to mitigate effects of the Covid-19 pandemic (43).
ALHIV are vulnerable to the developmental, social, and environmental factors that affect adherence to ART. Access to newer combination therapies with reduced side effect profiles and optimized management approaches, and the Covid-19 pandemic have prevailed since adherence was last evaluated in ALHIV in Jamaica (6). Against this background and limited data on ART adherence from resource-limited settings, we aimed to characterize current adherence patterns among ALHIV attending outpatient clinics in Kingston, Jamaica, and assess perception of the impact of the prevailing COVID-19 pandemic on adherence.