Successful approaches to managing HIV in adolescents and young adults were reported by researchers from two sub-Saharan African countries at the 11th International AIDS Society Conference on HIV Science this week.
Dr Toivo Shikesho from the Namibian Ministry of Health and Social Services reported a 30-percentage-point increase in viral suppression among those aged 15 to 24, while Dr Franklin Emerenini, from Columbia University, presented results from Nigeria, where there was a 50-percentage-point increase in viral load testing and a 20-percentage-point increase in suppression among those aged 10 to 24. Both countries implemented targeted community-based interventions aimed at the specific needs of adolescents and young adults.
Adolescents and young people (aged 15 to 24) made up approximately a third of all new HIV infections in sub-Saharan Africa. Among adolescents aged 10 to 19 in the region, only around 43% are engaged in care, 31% remain in care and 30% are virally suppressed. AIDS-related illnesses are the leading cause of death for adolescents living in sub-Saharan Africa.
In 2018, viral load suppression among people living with HIV in four high-burden HIV regions of northern Namibia (including Kavongo, Omusati and Oshikoto) was at 92% overall. However, only 44% of adolescents and young adults (aged 15 to 24) were virally suppressed in these regions.
Shikesho shared the results from a quality improvement collaborative intervention including 25 treatment facilities (providing care to 66,400 people living with HIV) in the three aforementioned regions to improve viral suppression among adolescents and young adults between August 2018 and December 2020.
The intervention consisted of a dedicated team of three professionals (an antiretroviral therapy (ART) nurse, data clerk and medical officer) in each facility, who introduced new approaches and monitored viral suppression rates by submitting data to a central source. This team attended four learning sessions and received support from regional and national quality improvement coaches.
Strategies included the use of high viral load registers (to monitor those who had not achieved viral suppression, implemented at all sites), enhanced adherence counselling (80% of sites), directly observed therapy (52%), pill boxes (32%), initiating or strengthening existing teen adherence clubs (64%), and ensuring timely switching to a different ART regimen if required (all sites). Facility-based teams reported on specific strategies that were successfully implemented to encourage higher rates of viral suppression (less than 1000 copies/ml).
While only 407 adolescents and young adults had achieved viral suppression at baseline (44%), this increased to 719 (74%) by the end of 2020.
“A quality improvement collaborative approach applied with a dedicated team of healthcare workers and coaches led to improvements in viral load suppression in the 15 to 24 age group,” Shikesho concluded. “Facility-level teamwork and quality improvement learning sessions were critical to the success of the initiative.”
Adolescents and young adults account for about 7% of people living with HIV in Nigeria, and often have poor treatment outcomes.
Emerenini presented results from Operation Triple Zero, carried out in four Nigerian states (Adamawa, Akwa Ibom, Cross River and Niger) aimed at adolescents and young adults living with HIV, aged 10 to 24 from April to September 2020. The ‘triple zero’ refers to the three key targets of the intervention: zero missed appointments, zero missed doses and zero viral load.
Strategies used to achieve these goals included adolescent-focused case management, peer support, specific behavioural interventions aimed at targeting adherence issues and the inclusion of rewards that appeal to these age groups, such as free Wi-Fi and games.
A total of 33 health facilities across the four states participated in the intervention. At these sites, 4617 adolescents and young adults were enrolled in the programme (80% of all those eligible), with 66 of these trained as ‘youth champions’ – trained to support health workers in providing adherence support, to assist new patients in navigating the clinic and to provide peer mentoring.
Outcomes at the end of the intervention period were compared to indicators from the period prior, October 2019 to March 2020. Emerenini reported impressive results on all measures when compared to the pre-intervention period. For all age groups, approximately 99% of participants were on an optimal ART regimen by the end of the intervention. This represented a 62-percentage-point increase for those aged 10 to 14, a 61-percentage-point increase those aged 15 to 19 and a 53-percentage-point increase for those aged 20 to 24.
"Adolescents and young people can easily get ‘missed in the crowd’ and require tailored, specific interventions to facilitate adherence.”
The number of those who received viral load testing increased by 50 percentage points, reaching 78% of adolescents and young adults.
Viral suppression significantly increased by the end of the intervention period for all age groups. By September 2020, it was at 82% among those aged 10 to 14 (a 15-percentage-point increase from baseline), 83% among those aged 15 to 19 (a 31-percentage-point increase) and 85% among those aged 20 to 24 (a 17-percentage-point increase).
In addition to involving adolescents and youth more directly, Emerenini attributed the success of the intervention to strategies similar to those used in Namibia, such as keeping a list of those who had not achieved viral suppression, enhanced adherence counselling (both for caregivers and youth, in-person and virtually) and ensuring that optimal ART regimens were used. Additionally, he mentioned specific health system modifications, such as the establishment of dedicated clinic hours (such as over the weekend) and making clinics more adolescent-friendly by providing free Wi-Fi and games. Additionally, health workers were trained on how best to be responsive to the needs of adolescents in a non-judgemental manner.
“Adolescents and young people can easily get ‘missed in the crowd’ and require tailored, specific interventions to facilitate adherence,” Emerenini concluded. “These findings validate the use of integrated, asset-based strategies to improve HIV treatment outcomes among adolescents and young people living with HIV.”
Shikesho T et al. Quality improvement collaborative approach to improve viral load suppression in the 15-24-year age group in Namibia, 2018-2020. 11th IAS Conference on HIV Science, abstract OAD0501, 2021.
Emerenini F et al. Optimizing antiretroviral treatment and viral suppression for adolescents and young people living with HIV by implementing Operation Triple Zero in four states in Nigeria: Lessons Learned. 11th IAS Conference on HIV Science, abstract OAD0505, 2021.