southern Africa in an observational cohort study originating from Aid for AIDS

southern Africa in an observational cohort study originating from Aid for AIDS, a private sector disease management program in southern Africa. Adolescents (age 11-19 years; n = 154) and adults (n = 7622) initiating antiretroviral treatment between 1999 and 2006 and having a viral load measurement within 1 year after antiretroviral treatment initiation were included. The primary outcomes were virologic suppression (HIV viral load antiretroviral treatment initiation. Secondary outcome was adherence assessed by pharmacy refills at 6, 12, and 24 months. The authors used a multivariate loglinear regression and Cox proportional hazards. A significantly smaller proportion of adolescents achieved 100% adherence at each time point (adolescents: 20.7% at 6 months, 14.3% at 12 months, and 6.6% at 24 months; adults: 40.5%, 27.9%, and 20.6% at each time point, respectively; P <0.01).>Patients achieving 100% 12-month adherence were significantly more likely to exhibit virologic suppression at 12 months, regardless of age. However, adolescents achieving virologic suppression had significantly shorter time to viral rebound (adjusted hazard ratio 2.03; 95% confidence interval: 1.31 to 3.13;P <0.003).>Adolescents were less likely to experience long-term immunologic recovery despite initial CD4 T-cell counts comparable to adults. Compared with adults, adolescents in southern Africa are less adherent to antiretroviral treatment and have lower rates of virologic suppression and immunologic recovery and a higher rate of virologic rebound after initial suppression. Studies must determine specific barriers to adherence in this population and develop appropriate interventions.

Editors’ note: Both because the number of adolescents on antiretroviral treatment continues to expand and because this population is most likely to benefit from optimal adherence with longest life expectancy on optimal treatment, determining the underlying reasons for the poor adherence that increases risk of morbidity and drug resistance is urgent. This study assessed adherence and outcomes among adolescents started on antiretroviral treatment when their CD4+ counts fell to 350 cells whose parents were employed by companies participating in a private sector employer-subsidized medical insurance programme in 9 countries in southern Africa. The adolescents were less likely than were adults to be on the non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens which can achieve viral suppression with moderate levels (70-90%) of adherence. However, this cannot fully explain why adolescents were 50% less likely to maintain perfect adherence at all time points and were 70-75% less likely to be virologically suppressed at 1 and 2 years after treatment initiation. Equivalent studies in the public sector are needed to confirm these findings and qualitative studies are needed to determine the causes and provide avenues for solutions to what must be underscored as a priority treatment programme challenge.

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