CAN THE SDGs HELP SOLVE THE ADHERENCE PUZZLE? Professor Lucie Cluver Dr Elona Toska & Roxanna Haghighat Oxford University/University of Cape Town

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1 CAN THE SDGs HELP SOLVE THE ADHERENCE PUZZLE? Professor Lucie Cluver Dr Elona Toska & Roxanna Haghighat Oxford University/University of Cape Town

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3 Mzantsi Wakho 3-year child and adolescent cohort 1000 HIV-positive 500 HIV-negative Eastern Cape health district, SA Every adolescent ever initiated ART 72 health facilities, 180 communities Clinical data, questionnaires 94% 3-year retention HEY BABY Sister study (ongoing) 700 adolescent mothers (half HIV+) and their children Spectrum sampling Cluver, L, Toska, E, Orkin, M et al (2016). AIDS Care

4 Adolescent ART-adherence (n=1000, South Africa) past-week adherence T1 64% past-week adherence T2 42% 2-year past-week adherence 29% Self-reported past-week non-adherence validity check Viral failure (56% VL in past 2 years) Symptomatic pulmonary TB OR 2.3 CI , p<.001 OR 1.5, CI , p<.02 Independent of age, gender, perinatal/horizontal infection, rural/urban location, ethnicity, formal/informal home, maternal/paternal orphan, general health status, time on treatment, travel time to clinic Cluver, L. Toska, E, Orkin, M Sherr, L. (2017). AIDS Care.

5 Number of participants : The Reality of Viral Suppression among ART-initiated Adolescents in South Africa R. Haghighat 1 2, E. Toska 2 3, N. Bungane 2, L. D. Cluver 1 4 roxanna.haghighat@spi.ox.ac.uk. Thursday 1-2pm THPDE01. #NextGeneration: Programming for adolescents. Hall 11B HIV Treatment Cascade 678 ** % 92.5% 76.3% % 407 Horizontally infected Vertically infected HIV+ adolescents in Mzantsi Wakho cohort Found patient files Available VL data VL 1000 copies/ml Undetectable VL ( 50 copies/ml) Participants (n=943) were female (54.0%), median age 13 years (IQR 11-16), urban-living (76.8%) 30.0% of participants attended 2 healthcare facilities, and 51.1% received decentralised care Of total HIV+ cohort, 62.9% (n=665) had VL 1000 copies/ml; 48.5% had undetectable VL (n=513) Only 63.1% of viral loads were measured within the past 2 years

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7 Why is taking meds so hard? POVERTY Odds ratio P-value Food insecurity OR No transport money OR Lack of basic necessities OR VIOLENCE Odds ratio P-value Community violence - - Emotional/physical abuse OR Domestic violence OR Teacher violence OR Clinic verbal violence OR

8 ART blockers (n=1060) HOME Poverty Abuse Domestic violence Lack of storage Parenting CLINIC Transport problems Unsafe area Unaccompanied Told no alcohol with ART Unhelpful staff Stockouts TEEN Mental health Cognitive delay Fear of ART SOCIAL LIFE Worried friends will find out Having a boyf/girlf Drinking Circumcision camp Sports club Gang membership

9 Violence and viral load (n=1060) % adolescents non-adherent to ART Violence type, %, impact on non-adherence Physical abuse 20% OR 1.4 Teacher violence 41% OR 1.7 IPV 12% OR 1.7 Clinic shouting 19% OR Violence exposure (number of types) Cluver, L. Meinck, F. Toska, E Sherr, L. (2018). AIDS. Marginal effects controlling for age, gender, location, informal housing, maternal death, paternal death, vertical or horizontal HIV infection, general health, date of ART initiation, type of healthcare facility, pediatric, general care

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11 Cash + care + clinic: lower non-adherence (n=1060) Cluver, Toska, Orkin, Meinck, Hodes, Yakubovich, Sherr, AIDS Care 2016

12 Cash + care + clinic: retention in HIV care (n=1060) 70% Stocked with medication OR 3.0*** CI Time for teens by staff OR 2.7*** CI Accompanied by family to clinic OR 2.4*** CI Cash for transport to clinic OR 1.4* CI Kind Staff at Clinic OR 2.5*** CI % 5% 8% 8% 8% 9% NONE CASH ACCOMPANY KIND TIME STOCKED ALL Cluver, Pantelic, Toska, Orkin, Casale, Bungane, Sherr, JIAS in press

13 Cash + care + clinic: positive prevention (n=500) 60% Unprotected sex among HIV+ girls % probabilities controlling for covariates 50% 49% 40% 38% 33% 30% 23% 20% 10% 9% 0% none parental supervision school access sensitive clinic care all three Toska, Cluver, Boyes, Isaacsohn, Hodes, Sherr (2017) AIDS & Behaviour

14 More SDGs: more survival 60,0% 50,0% 40,0% Viral failure/symptomatic untreated TB SDG 1+2 Basic necessities & social protection.625* SDG 3 Healthy caregiver.574*** SDG 8 Household Access to work.672** SDG 16 Protection from child abuse.652** 30,0% 20,0% 10,0% 0,0% 51% 43% 31% 23% 13% 0 SDGs Any 1 SDG Any 2 SDGs Any 3 SDGs All 4 SDGs Cluver, L, Pantelic, M, Orkin, M, Toska, E, Medley, S, Sherr, L (2018) JIAS

15 CBO access: improved outcomes for HIV-affected children OR:.11*** Abuse OR:.22** Domestic violence CBO contact OR:.41* B: -.40* Suicidal ideation Depression B: -.40*** Stigma B: -1.08*** Peer problems B: -.77*** Conduct problems Sherr L et al (2016). PlosOne. B: 1.40*** Prosocial behaviour

16 Psychological support for bereaved adolescents reduces mental health distress Thurman T. R et al (2017). The Lancet Global Health, 5(6), e RCT of a bereavement support group for adolescent females in South Africa demonstrated significant improvements in psychological health of participants: Reduced maladaptive grief Reduced depression Lower caregiver-reported adolescent behavioural problems. Method: 382 adolescents aged years randomly assigned to receive the intervention or waitlisted for enrolment the following year. Survey data were collected from adolescents and their caregivers prior to the intervention and again at 3 months post-intervention.

17 Peer supporters: increased viral suppression PATA (2018) Impact of adolescent/youth peer supporters living with HIV 71 health facilities 13 Sub-Saharan African countries Adolescents Multivariate logistic regression

18 Within and beyond the clinic: new evidence Malawi: MacKenzie et al JIAS 2017 Nested case-control study, 1 hospital Adolescent Teen Club model Lower treatment dropout (OR.27) South Africa: Zanoni et al PLOSOne 2017 Retrospective cohort, 1 hospital Adolescent-friendly clinic Higher viral suppression (OR 3.7) Higher retention in care (OR 8.5)

19 Loss to follow up 40% reduction: ahr: 0.60 (95% CI: ); P<0.0001) Mortality ahr: 0.52 (95% CI: ); P<0.0001) After 5 years the risk of an elevated viral load was lower amongst those with community support: adjusted OR= 0.24 (95% CI: 0.06 to 1.03) Cost of community support: $ 49.5 per client/year supported. Cost-effectiveness: $600 per loss (through death or loss to followup) averted after one year. Cumulative incidences of a) loss to follow-up and b) mortality after starting ART Conclusions: CBS for adolescents and youth receiving ART was associated with substantially reduced patient attrition, and is a low-cost intervention with reasonable cost-effectiveness that can aid progress toward several health, economic and equality-related SDG targets.

20 Economic empowerment: better adolescent HIV outcomes SUUBI+ Cluster RCT: 702 adolescents LHIV, 39 clinics, Uganda PI: F Ssewemala, Mellins, C *Child Development Accounts (matched 1:1) *Mentorship, *Financial literacy, *Family microenterprise training *Adolescent HIV care & treatment *Adherence counselling Bermudez, L, Ssewamala, F, Neilands, B, Lu, L, Jennings, L, Nakigozi, G, Mellins, C, McKay, M. (2018) AIDS & Behavior

21 Adolescent HIV+ mothers: early findings 17% lifetime pregnancy 10% 1-year incident pregnancy 7% multiple pregnancies. 17% do not know their child s HIV-status 4.4% 1+ HIV-positive child (known). 44% stopped ART when pregnant 23% mixed-feeding their child 68% ART non-adherent in past 3 days Toska & Cluver 2018 (can t wait for data to be finished before taking a look)

22 Adolescent mothers and sexual risks % adolescent girls reporting transactional sex in past year Driven by adolescent motherhood not HIV % adolescent girls with sexual partners 5+ years older in past year Interaction effect of HIV x adolescent motherhood: OR 5 p<03 26,8 13,1 14,2 8,6 4,6 5,3 4 3,6 CONTROL HIV+ CONTROL MOMS HIV+ MOMS CONTROL HIV+ CONTROL MOMS HIV+ MOMS

23 RCTs: Compelling evidence on ECD and HIV care Malawi: (Lewycka et al 2013) Cluster RCT women s support groups lower perinatal mortality (OR.67) Lower neonatal mortality (OR.59) Lower infant mortality (OR.72) Lower maternal mortality (OR.26) South Africa: (Grimwood et al 2012) Multicentre cohort psychosocial support Lower pediatric mortality (HR.39) Higher viral suppression (OR 1.6) Increased ART retention (HR.57) South Africa: (Richter et al 2014, Tomlinson et al 2014) 2 RCTs, maternal peer mentoring within PMTCT Increased height-for-weight z-scores for HIV+ & HEU infants Adherence to infant ART (OR 1.7) and maternal ART Increased exclusive breastfeeding (RR 1.92) South Africa: (Myer, Phillips, Zerbe, Brittain, Lesosky, Hsaio, Remien, Mellins, McIntyre, Abrams 2018) RCT Integrated Maternal and Child Healthcare & ART Care Increased maternal retention & suppressed VL (ARD 21%) Longer breastfeeding (exclusive and any)

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25 Accelerator effects % improvement on incidence rates of targets in SDG3 (Health) SDG 4 (Education) SDG 5 (Gender equality) and SDG 16 (Peace) 20% 15% 14% 30% 14% 12% 24% 15% 20% 14% 18% 14% 16% 21% 14% 14% 28% 16% N=1000 adolescents living with HIV, South Africa. Marginal effects of logistic regressions for incidence rates of SDG outcomes, controlling for baseline outcome, other predictors, age, gender, urban/rural residence.

26 Super-accelerator effects 16.2 no violence perpetration + 26% 16.2 no abuse + 21% 3.8 HIV care retention + 14% 16.6 no community violence + 31% 5.6 no high-risk sex + 30% 5.2 no sexual abuse + 14% 4.4 school progression + 19% 3.3 ART adherence + 31% 3.5 good mental health + 31% 3.5 no substance use + 31% 4.5 school enrolment + 15% N=1000 adolescents living with HIV, South Africa. Marginal effects of logistic regressions for incidence rates of SDG outcomes, controlling for baseline outcome, other predictors, age, gender, urban/rural residence.

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