Supporting Adherence and Viral Suppression Goals for Adolescents and Young Adults Living with HIV in Kenya

Abstract

Background: Achieving viral suppression goals for adolescents living with HIV (ALHIV) requires individual adherence to ART and efficient and effective health systems to monitor viral load (VL) and coach adolescents when adherence falters. The purpose of this three-study dissertation is to understand individual and health systems drivers of adherence and VL monitoring among ALHIV in Kenya. Aim 1 sought to assess if VL results are available in EMR and ALHIV knowledge of their VL results. Aim 2 sought to identify factors impacting the return of VL information to clinics and clients and how healthcare providers make decisions on when to repeat confirmatory VL testing. Aim 3 measured adherence self-efficacy to ART at an individual level and evaluated the relationship between ART adherence self-efficacy, viral suppression, and its predictors. Methods: 1. We compared VL results of ALHIV aged 15-19 available in the National Database and compared them to clinic-based electronic medical records (EMR) for accuracy and completeness at six facilities in Kiambu and Nakuru counties. Additionally, ALHIV attending care at these facilities participated in exit surveys, and the modified Poisson regression model assessed the relationship between ALHIV characteristics and knowledge of VL results. 2. We conducted focus group discussions and in-depth interviews with purposively selected healthcare providers from various phases of VL information flow. 3. We further analyzed baseline data from a longitudinal cohort of Kenyan ALHIV enrolled in the Data-informed Stepped Care study to assess correlates of ART adherence self-efficacy and HIV viral suppression. Mixed effects regression models, clustering for facility, assessed associations between HIV adherence self-efficacy scores, viral suppression, and predictors of interest. Results: 1. Of 207 charts that were randomly selected, 86% (n=179) of the VL matched National Database source records; however, ≥ 10% of VL results were missing in the EMR or incongruent with the National Database source. Out of 132 ALHIV who participated in the survey, only half (52%) reported receiving their last VL result, and older ALHIV (18-19 years) were more likely to receive their test results than younger ALHIV (15-17 years). 2. Identified themes from facility staff were: (1) individual and family level challenges and (2) facility-level challenges to obtaining VL samples, (3) facility-developed strategies to improve sample collection, (4) supply chain constraints affecting laboratory-related delays, (5) lack of VL information affecting treatment decisions, (6) client-specific factors impacting return of VL results, and (7) first healthcare providers to address non-suppressed VL were adherence counselors (8) reluctance to repeat VL until adherence challenges are resolved and (9) measuring adherence through subjective means. 3. Among 1,033 ALHIV, those with no or mild depressive symptoms had higher HIV-adherence self-efficacy (HIV-ASES) scores than those with moderate-to-severe depressive symptoms. ALHIV with high perceived social support scores had higher odds of suppressed viral loads than those with low social support. Although not statistically significant, ALHIV with high adherence self-efficacy scores more frequently had suppressed viral loads compared to those with low levels of adherence self-efficacy scores. Conclusion: To meet viral suppression goals, interventions that support ALHIV VL knowledge and mental health, combined with efficient health systems processes such as mobile tools, are necessary.