Adolescence and the risk of ART non-adherence during a geographically focused public health intervention: an analysis of clinic records from Nigeria

ABSTRACT

The risk of poor antiretroviral therapy (ART) adherence among adolescents is a challenge to controlling HIV. This study aims to provide guidance for geographically focussed public health interventions to improve adherence. Through clinic records, it investigates adolescents’ non-adherence risk and clinic-level differences in regions of Nigeria which were part of PEPFAR’s geographical pivot. Records (n = 26,365) were selected using systematic random sampling from all PEPFAR-supported facilities (n = 175) in targeted Local Government Areas across three regions in Nigeria. Adolescents’ risk of non-adherence was estimated using region-specific random-effects models accounting for clinic-level variation. These were adjusted for sex, whether a patient had to travel to a different region, clinic location (urban/rural), clinic type (primary, secondary, tertiary). Despite regional variations, adolescents were at higher risk of non-adherence compared to adults. A similar, but weaker, association was found for children. Patients attending tertiary facilities for ART in the South-South region exhibited very high risk of non-adherence. Adolescents and children are at an increased risk of poor ART adherence in rural regions of Nigeria. Regional differences and facility type are critical factors. Future public health programmes focused on the risk of poor adherence targeting “high-prevalence areas” should be sensitive to contextual differences and age-appropriate care.

KEYWORDS:

• HIV
• adolescents
• adherence
• ART
• Nigeria
• clinic records

Acknowledgements

This paper has been made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement AID-OAA-A-14-00061. The contents are the responsibility of the authors and the Coordinating Comprehensive Care for Children (4Children) project and do not necessarily reflect the views of USAID or the United States Government.

The authors are grateful for insightful guidance from Tapfuma Murove, Kelly Bunkers, and Adele Clark (CRS) as well as Franziska Meinck (University of Edinburgh).

Disclosure statement

The corresponding author has been a paid consultant for Catholic Relief Services (CRS) and has received honoraria for teaching statistical programming in R as well as being associate editor for the Journal of Child and Adolescent Mental Health.

Funding details

This paper has been made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement [AID-OAA-A-14-00061].

Data availability statement

The annoymised data and replication syntax that support the findings of this study are openly available at https://doi.org//10.17605/OSF.IO/U56R7.

Notes

1 4Children was a five-year, USAID-funded project improving the health and well-being of vulnerable children affected by HIV and AIDS and other adversities. 4Children draws on global evidence that illustrates that HIV and other hardships are best prevented and addressed when people have access to both high-quality health and social welfare services. More information can be found at https://www.crs.org/our-work-overseas/program-areas/health/4children.

2 Records were sampled in (random) intervals of five, and the samplesizes were calculated for a 5% margin of error.

3 Negative values were set to 1 and decimal places for exceedingly large values were adjusted by 10.

4 Source: Shapefiles: OCHA ROWCA. Date of dataset: September 26, 2017. Available at: https://data.humdata.org/dataset/west-and-central-africa-administrative-boundaries-levels. Accessed January 17, 2018.

5 For the models presented Table 3 for detailed probabilities, see appendix.

6 Given the lower degree of urbanization and thus a stronger contrast between urban and rural contexts in access to care, it is to be expected and indeed observed that attending a clinic in an urban setting in South-South reduces the risk of ART non-adherence. By contrast, the more urban South-West shows no such systematic differences between urban and rural contexts or by clinic level.