of HIV infection among adolescents in resource-poor settings
include malnutrition, chronic lung disease and tuberculosis as well as the
long-term side effects of drugs - including
lipodystrophy, peripheral neuropathy and high blood cholesterol
(dislypidemia) – Dr. Phillipa Musoke
told participants at a bridging session at the Nineteenth International
AIDS Conference in Washington, DC last month.
infected at birth in resource-poor settings because of late diagnosis and
treatment are at significant risk for developmental impairment including growth
stunting and wasting, delayed puberty as well as neurocognitive functioning.
surprisingly against this background and at a critical (and vulnerable)
time in their development, evidence has shown that HIV-infected adolescents in
resource-poor settings have poorer adherence rates and poorer virological
outcomes than their adult counterparts.
and discrimination, late or non-disclosure, denial, limited access to
information, being the primary caregiver often in a family where others are
living with HIV all contribute to the likelihood of adolescents not taking
their medications, and dropping out of health care as well as engaging in high
ART programmes expand, survival among children is increasing and so the number
of adolescents needing ART will also increase. Scale-up will then need
programmes that specifically address the particular needs of adolescents.
are usually managed in adult programmes; service providers, especially in rural
settings, are not trained to work with adolescents, yet evidence from a number
of treatment programmes now shows that adolescents have specific challenges in
relation to antiretroviral treatment and living with HIV. These include:
- Late presentation
to care due to lack of HIV diagnosis
of long-term treatment, particularly lipodystrophy
- Onset of
sexual activity and negotiation of HIV status disclosure
the case of lipodystrophy Dr. Musoke, highlighting a
cross-sectional study by Piloya et al of over 300 children in Uganda aged
between two and 18 years of age, more than 40% over ten years of age on ART for
a median of 3.8 years noted over a quarter had fat redistribution
(lipodystrophy) and more than a third had high blood cholesterol.
Fat redistribution was significantly associated with
Tanner stages 2 to 5 OR=2.3 (95%CI: 1.3-3.8), being over five years of age
OR=3.9 (95% CI: 1.5-9.9) and use of d4T OR= 3.4 (95% CI: 2.0-5.8)
scale (also known as the Tanner
stages) is a scale of physical development in children, adolescents and
The authors concluded that prevalence of lipodystrophy
is high among HIV-infected children on ART, with the likelihood of developing
fat redistribution and metabolic abnormalities increasing during puberty.
While lipodystrophy in itself is not life-threatening
the physical changes in appearance are psychologically damaging and
stigmatising, leading to fear of disclosure, social isolation, poor adherence
and stopping of treatment. All of these are heightened during this especially
vulnerable time for adolescents.
success in Zimbabwe
Wufu Ndbele at a later session, showed that contrary to current but limited
evidence, adolescents on ART can equal or do better than adults on ART in resource-poor
a six-year period the number of adolescents and adults starting ART increased
seven-fold and three-fold respectively at an MSF urban clinic in Bulawayo, Zimbabwe.
the risk for death among adolescents was comparable to that of adults (HR=0.92,
p=0.3793) but loss to follow-up (LTFU) was almost twice as high among adults
(HR=1.92, p<0.0005), Dr. Ndbele reported at a later session.
Ndbele and his colleagues, in this retrospective cohort analysis, looked at the
effects of scale-up among a large cohort of adolescents.
adolescent numbers increased so did management challenges. An adolescent model
of care was put in place. The adolescent clinic is a space separate from the
adult and paediatric clinics. All Mpilo Clinic staff are trained in adolescent
tailored activities to ensure comprehensive care both within the clinic setting
as well as outside were initiated. These included
Dedicated, highly trained counsellors
Life skills activities: pottery, income-generating projects,
expressing feeling through art
Social activities; a camp outside the clinic
Youth club and a “Chill Room”
Actively tracking those defaulting – with the help of their
Importantly, adolescents were active participants in their
care, making informed decisions. Elected peer representatives engaged in clinic
adults and 2014 adolescents (aged 10 or over and under 19) started ART at the
Mpilo OI ART clinic from 2004 until 2010. Over the first three years LTFU among
adolescents steadily increased reaching a peak of 7% but fell to under 5% by
the end of the study period.
were significantly more likely than adults to start ART and to hav reached WHO
stage IV HIV disease (91.5% compared to 60.7% and 32.4% compared to 24.9%,
respectively). HIV diagnosis among adolescents was usually after clinical
illness, consistent with current estimates of 75% of adolescents with HIV
majority of patients were female among both adolescents and adults (52% and 70%
of all actively followed patients were adolescents compared to an estimated 5%
Ndbele concluded there is “a need to increase case-finding efforts by
incorporating innovative approaches to identify HIV-positive adolescents then
link them to care tailored to their needs.”
these results show, he added, good outcomes are feasible in resource-poor
settings with dedicated and psychosocial resources.