Adolescents living with HIV in South Africa are less likely to be adherent to their HIV treatment after experiencing or witnessing violence in the home, in school or in a healthcare environment.
In a study by researchers at the University of Oxford, University of Cape Town, North-West University, University of the Witwatersrand and University College London, just over 1,000 10 to 19 year olds were recruited in Eastern Cape, South Africa, to determine the relationship between violence and antiretroviral treatment (ART) adherence. This group generally has high rates of non-adherence for a number of known factors, such as pill burden, depression and other behavioural issues – which can lead to poorer HIV health outcomes.
Aids is also the leading cause of death of all adolescents in Africa. Despite this, and high rates of violence against children across the African continent, no known studies have been conducted to understand the impact of different types of violence exposure on adherence patterns.
Through a survey and clinical follow-up of treatment failure – defined as having a viral load more than 1,000 copies/ml or symptomatic tuberculosis (TB) – they found that 36% of adolescents reported being non-adherent to treatment in the past week.
Ten different types of violence exposure were assessed, from witnessing or experiencing violence in the home, in school, among their peers, in the community, or in a healthcare setting.
They found that four types of violence were independently associated with adherence – physical abuse by caregivers; witnessing domestic violence; teacher violence; or verbal victimisation by healthcare staff.
Rates of non-adherence rose from 25% in the group who experienced no violence, to 74% in these four groups of violence exposure.
In their discussion, the researchers comment that violence and victimisation from these sources “evoke a sense of betrayal among adolescents for whom they are hoped-for sources of care and support. Just as positive relationships with adult role-models may be protective for adolescent health behaviour, abusive relationships may be exceptionally detrimental.”
They continue, that while it is a challenge in resource-restrained environments, preventing violence is an “essential and insufficiently addressed component of adolescent HIV care,” and vital for ending Aids by 2030 on the continent.
Objective(s): HIV-positive adolescents have low ART-adherence, with consequent increased risks of mortality, morbidity and viral resistance. Despite high rates of violence against children in the Africa region, no known studies have tested impacts on HIV-positive adolescents. We examine associations of ART-adherence with adolescent violence victimisation by caregivers, teachers, peers, community members, and healthcare providers.
Design and methods: HIV-positive adolescents were interviewed (n = 1060), and clinic biomarker data collected. We sampled all 10–19 year olds ever ART-initiated within 53 clinics in 180 South African communities (90.1% reached). Analyses examined associations between non-adherence and 9 violence types using sequential multivariate logistic regressions. Interactive and additive effects were tested with regression and marginal effects.
Results: Past-week self-reported ART non-adherence was 36%. Non-adherence correlated strongly with virologic failure (OR 2.3, CI 1.4–3.8) and symptomatic pulmonary tuberculosis (OR 1.49, CI 1.18·2.05). Four violence types were independently associated with non-adherence: physical abuse by caregivers (OR 1.5, CI 1.1–2.1); witnessing domestic violence (OR 1.8, CI 1.22–2.66); teacher violence (OR 1.51, CI 1.16–1.96,) and verbal victimisation by healthcare staff (OR 2.15, CI 1.59–2.93). Past-week non-adherence rose from 25% with no violence, to 73.5% with four types of violence exposure.
Conclusions: Violence exposures at home, school and clinic are major and cumulating risks for adolescent antiretroviral non-adherence. Prevention, mitigation, and protection services may be essential for the health and survival of HIV-positive adolescents.
Cluver, Lucie; Meinck, Franziska; Toska, Elona; Orkin, F, Mark; Hodes, Rebecca, J; Sherr, Lorraine