title: Excellent adherence to antiretrovirals in HIV+ Zambian children is compromised by disrupted routine, HIV nondisclosure, and paradoxical income effects.
abstract: BACKGROUND
  A better understanding of pediatric antiretroviral therapy (ART) adherence in sub-Saharan Africa is necessary to develop interventions to sustain high levels of adherence.
  
  
  RESULTS
  Adherence among 96 HIV-infected Zambian children (median age 6, interquartile range [IQR] 2,9) initiating fixed-dose combination ART was measured prospectively (median 23 months; IQR 20,26) with caregiver report, clinic and unannounced home-based pill counts, and medication event monitoring systems (MEMS). HIV-1 RNA was determined at 48 weeks. Child and caregiver characteristics, socio-demographic status, and treatment-related factors were assessed as predictors of adherence. Median adherence was 97.4% (IQR 96.1,98.4%) by visual analog scale, 94.8% (IQR 86,100%) by caregiver-reported last missed dose, 96.9% (IQR 94.5,98.2%) by clinic pill count, 93.4% (IQR 90.2,96.7%) by unannounced home-based pill count, and 94.8% (IQR 87.8,97.7%) by MEMS. At 48 weeks, 72.6% of children had HIV-1 RNA <50 copies/ml. Agreement among adherence measures was poor; only MEMS was significantly associated with viral suppression (p = 0.013). Predictors of poor adherence included changing residence, school attendance, lack of HIV disclosure to children aged nine to 15 years, and increasing household income.
  
  
  CONCLUSIONS
  Adherence among children taking fixed-dose combination ART in sub-Saharan Africa is high and sustained over two years. However, certain groups are at risk for treatment failure, including children with disrupted routines, no knowledge of their HIV diagnosis among older children, and relatively high household income, possibly reflecting greater social support in the setting of greater poverty.
authors.affiliation: Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, United States of America. jhaberer@partners.org
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Haberer
authors.forename: Adrian
authors.initials: A
authors.lastname: Cook
authors.forename: A Sarah
authors.initials: AS
authors.lastname: Walker
authors.forename: Marjorie
authors.initials: M
authors.lastname: Ngambi
authors.forename: Alex
authors.initials: A
authors.lastname: Ferrier
authors.forename: Veronica
authors.initials: V
authors.lastname: Mulenga
authors.forename: Cissy
authors.initials: C
authors.lastname: Kityo
authors.forename: Margaret
authors.initials: M
authors.lastname: Thomason
authors.forename: Desiree
authors.initials: D
authors.lastname: Kabamba
authors.forename: Chifumbe
authors.initials: C
authors.lastname: Chintu
authors.forename: Diana M
authors.initials: DM
authors.lastname: Gibb
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002648:Child; D030881:Disclosure; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D010349:Patient Compliance; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents