ART adherence, sexual practices and reproductive health among ALHIV in ESA
A growing evidence base shows that biomedical interventions combined with social programmes are the best means of reducing new HIV infections and, ultimately, turning the tide of the AIDS epidemic (Padian et al., 2010), especially among young people (Cluver et al., 2016a). However, while reducing incidence through keeping adolescents HIV-free is critical, it is also important to support those already living with HIV to lead safe and healthy lives, including through viral suppression, engaging in safer sex and having planned, safe pregnancies and parenthoods. This section briefly reviews factors related to non-adherence and sexual risk-taking among adolescents living with HIV. It describes how different forms of social protection may help to support ART-adherence and reduce sexual risk-taking among adolescents in hyper-enclemic contexts.
ART offers an opportunity for the survival and long-term well-being of people living with HIV Yet many of the estimated 1.2 million children and adolescents living with HIV in ESA struggle to initiate and remain on ART. Once initiated on ART, 80%-95% adherence is required to avoid medication resistance, meaning that even occasional lapses in adherence to the ART regimen could reduce its efficacy (Paterson et al., 2000). Promisingly, increased linkages to ensure that adolescents access both sexual and reproductive health (SRH) and HIV services have been shown to increase
HIV-positive adolescents’ access to and use of treatment services (UNICEF, 2015) and healthcare (Hodes et al., 2018a, 2018b).
Understanding the sexual practices and reproductive health needs of adolescents living with IIIV remains critical for positive prevention. A recent systematic review focusing on sexual risk-taking among adolescents found mostly cross-sectional evidence on eight sexual risk-taking outcomes in 13 ESA countries (Toska et al., 2017b). Studies reported widely varying rates of sexual risk-taking, with nearly half of adolescents being sexually active, 33%-50% reporting unprotected sex, and 10%-66% reporting other sexual risk practices such as transactional sex, multiple sexual partners in the last year or sex with older men (Toska et al., 2017b). Adolescent girls living with HIV reported higher prevalence of transactional sex, unprotected sex and sex with older partners, though adolescent boys were more likely to report early sexual debut and multiple sexual partners.
Social, economic and structural drivers of sexual risk behaviours and non-adherence to ART
The limited research on adolescent ART adherence shows that many adolescents struggle to comply with ART regimens (Auld et al., 2014) and reveals exceptionally low rates of children and adolescents maintaining ART adherence (Oliver et al., 2016b; Hudelson 8c Oliver, 2015; Nachega et al., 2009). Evidence suggests that a combination of factors, including lack of social support, disclosure challenges, food insecurity and the costs of clinic attendance make it difficult for adolescents to initiate and remain on treatment (Cluver et al., 2016b; Hudelson 8c Oliver, 2015; Nachega et al., 2009). A burgeoning literature documents the additional, various experiential, clinical and operational challenges that adolescents living with HIV face in engaging with health programmes (Bernays et al., 2016; Delanv- Moretlwe et al., 2015; Toska et al., 2015; Vale, Hodes 8c Oliver, 2017; Visser, Zungu & Ndala-Magoro, 2015).
Drivers of ART non-adherence and sexual risk-taking among adolescents living with HIV include (1) social, economic and structural issues; (2) nondisclosure, stigma and discrimination; (3) caregiver well-being, disrupted family structures and caregiver-child relationships; and (4) healthcare services and health systems factors (Campbell et al., 2012; Gittings et al., 2016; Hudelson 8c Oliver, 2015). A growing literature also demonstrates the interconnections between structural deprivations, non-adherence to ART and sexual risk-taking (Kidman et al., 2018; Toska 8c Oliver, 2018). This evidence is presented below, providing an overview on how structural drivers, stigma and discrimination, caregiver relationships and family structure, and health sendees are linked to both poor .ART adherence and sexual risk outcomes.
Social, economic, and structural drivers - Poverty and related food insecurity are known barriers to ART adherence. Many adolescents living with HIV in ESA face food insecurity, and believe that these medicines must be taken with food (Gittings et al., 2016; WHO, 2015). Food insecurity and poverty are also known drivers of HIV risk behaviours for adolescent girls because they promote high-risk relationships with older partners, in which transactional sex provides the means of subsistence or survival for girls and young women. These vulnerabilities are mutually reinforcing, fostering a concatenation of risky behaviours, including unprotected sex and ART non-adherence. Understanding the gendered dimension of ART nonadherence for adolescents is also important because certain social protection interventions may affect boys and girls differently (Oliver et al., 2016b; Handa et al., 2014), and a higher proportion of new adolescent infections occur in girls (UNAIDS, 2017). Given that age-disparate sex is a driver of these infections, work with their older male partners on safer sexual practices and improved ART adherence is also warranted.
A recent study found that exposure to violence - at home and school and in clinics - was strongly linked with increased ART non-adherence, as shown in Figure 11.1 (Cluver et al., 2018), with exposure to multiple types of violence associated with higher levels of ART non-adherence. The study focuses on the detrimental effects of clinic victimisation in particular, identifying the negative impact that punitive, debasing and violent healthcare services have on both healthcare attendance and compliance with medical regimens among adolescents. Regarding other forms of violent victimisation beyond healthcare facilities, several studies in Uganda and Kenya reported that gender-based violence was linked with unintended pregnancies (Nhamo, 2013; Obare, Birungi & Kavuma, 2011) and transactional sex (Nhamo, 2013). The association between violence and ART non-adherence requires further investigation.
Disclosure, stigma and discrimination - Social barriers to treatment must be challenged, particularly HIV-related stigma and discrimination and legislation addressing the criminalisation of HIV non-disclosure, onward transmission, and age of consent to access testing sendees and criminalising same-sex practices through legislation. Evidence from community- based HIV testing programmes suggests that removing such barriers would encourage more people to get tested and seek out treatment (Iwuji et al., 2018; Orne-Gliemann et al., 2015). For fear of unwanted disclosure, some adolescents and young adults may not adhere to medicines when they are in situations where they might be seen taking medicines (leading to unintended HI-positive serostatus disclosure) - such as in public, or even in social situations and with friends, family members or intimate partners (Hodes et al., 2018a). This issue may be compounded by fear of loss of material support in situations in which adolescents are also receiving material support from their partners (Toska et al., 2015) and family or community members.
Negative effects on adherence have also been seen in children and adolescents who have not been disclosed to at an appropriate age, defined by WHO as starting at the age of 10 and completed by the age of 12 (Cluver et al., 2015; Hudelson & Cluver, 2015). This may be due to poor understanding of
Figure 11.1 Marginal effects model testing for additive effect of violence on adolescent ART adherence (Cluver et al., 2018 - figure INCLUDED with AUTHOR permission).
Source: Oliver cl al. (2018).
the reasons for which they are taking medication or issues with acceptance of their HIV-positive status. By contrast, adolescents who were disclosed to early, and in a sensitive and supportive way, achieve better adherence and sexual health outcomes (Cluver et al., 2015; Toska et ah, 2015).
Caregiver relationships and family structures - Living alone or with a partner (compared to living with a caregiver) were strongly associated with sexual risk-taking among adolescents living with HIV in two studies in Uganda (Baryamutuma et ah, 2010; Mbalinda et ah, 2015). Moreover, caregiver monitoring is closely linked to safe sexual practices among adolescents living with HIV (Toska et ah, 2017a). For this reason, it has been suggested that caregiver psychosocial and physical well-being is fundamental to supporting ART adherence and safe sexual practices (Cluver et ah, 2018; Hudelson & Cluver, 2015; Toska et ah, 2017a; WHO, 2015).
Healthcare services and system factors - There are also many documented healthcare-related barriers to ART adherence, including treatment costs, travel costs and distances to clinics and transition between paediatric and adult care (Cluver et ah, 2018; Hudelson & Cluver, 2015; PATA & WHO,
2015) . Additionally, accessing HIV and reproductive health services separately can be stigmatising, which is a core reason for integration of HIV and sexual healthcare to support all SRH services to be HIV-inclusive rather than HIV-specific1 (Hodes, 2013; Gittings et ah, 2016). HIV-related stigma and discrimination can exacerbate social exclusion and create barriers to the uptake of health services, particularly among adolescents. Transformative social protection aims to create enabling legal and normative environments for the deliver)' of provisions that address stigma and reduce barriers to uptake of health services (Gittings et ah, 2016).
Syndemic risk factors for ART adherence and sexucd risk-taking - The research among ALHIV in ESA outlined in the section below' suggests a strong overlap between factors shaping ART adherence, sexual risk-taking and retention in HIV/SRH care in this vulnerable group of young people. Many of these factors are shared for both of these health outcomes and are closely linked to structural vulnerabilities. Given that non-adherence combined with risky sexual practices fosters high-risk situations for HIV onward transmission, efforts to improve adherence must go hand in hand with those aimed at promoting safer sex.