Paediatric antiretroviral HIV treatment : measurement and correlates of adherence in a resource-poor setting

Doctoral Thesis


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University of Cape Town

[Objectives] There is a paucity of data regarding paediatric adherence in resource-limited settings (RLS) especially among the very young age groups (<7yrs). The study investigated the rates of adherence, the identification of the adherence measurement, amongst four, which best correlates with viral load suppression; as well as correlates of adherence amongst a cohort of children younger than 7 years on antiretroviral HIV treatment. Design: A Prospective cohort study with 6 months follow-up [ Methods ] Measures of adherence used: caregiver self-report (CSR), medicine measure/pill count, pharmacy refill and clinic attendance. Child, caregiver, socio-economic and health service characteristics were assessed for impact on adherence. Bivariate and multivariate analyses were used to determine agreement between measures and viral load outcome and to determine correlates of adherence. [ Results ] Mean age of children enrolled into the study was 27.08 months with a cohort mean adherence rate of 85% and mean viral load suppression of 74% at 6 months. Biological mothers were the majority primary caregivers (85%) and the majority (76%) of caregivers were unemployed with 60% receiving some form of social welfare grant. Results showed that caregiver selfreported adherence (CSR) was significantly correlated with viral load at 6 months (p=0.004). Correlations were found between clinic visits and pharmacy refill (highest values 0.35; p=0.000) and between medicine measure and clinic visits (highest value -0.21; p=0.04) but none of these measures were significantly correlated with viral load. Sensitivity and specificity analysis for CGSR showed that >95% adherence ensured a good viral load outcome. Four factors were significantly associated with adherence in bivariate analyses. These were: access to social welfare grants (OR=2.7; p=0.05); being counselled for initiation of ARV treatment by a counsellor vs. a doctor or nurse (OR 3.2, p=0.03); having another person in the household other than the index child infected with HIV (OR = 0.34, p=0.05) and caregiver depression (OR=0.07, p=0.01). However, in multivariate analyses certain other child, caregiver, socio-economic and health system characteristics as well as the abovementioned variables emerged as significant. [ Conclusion ] Key findings indicate that adherence rates are relatively high in this cohort and CGSR is valid in a resource-poor setting but medicine measure was problematic as a paediatric HAART adherence measure. Certain child, caregiver, socio-economic and health system characteristics have a significant impact on adherence.

Includes bibliographical references (p. 212-244).