title: "The sky is the limit": adhering to antiretroviral therapy and HIV self-management from the perspectives of adolescents living with HIV and their adult caregivers.
abstract: BACKGROUND
  Worldwide, HIV-related mortality among adolescents living with HIV (ALHIV) increased by 50% from 2005 to 2012 and is attributed in part to a lack of support for adolescent retention to care and adherence to antiretroviral therapy (ART). This vulnerability reinforces the need to better understand incomplete ART adherence among ALHIV, particularly in sub-Saharan Africa, where the majority of the world's 2.1 million ALHIV reside.
  
  
  METHODS
  From December 2011 to February 2012, we conducted in-depth interviews with 32 ALHIV (aged 15 to 18) and 23 of their adult caregivers in the Copperbelt Province of Zambia. Interviews were transcribed and translated. An iterative qualitative process was used to code and analyze the data and main themes were summarized regarding the barriers to and facilitators of ART adherence.
  
  
  RESULTS
  More than a quarter of ALHIV reported missing a day or more of ART (ranging from one day to six months). Barriers to ART adherence included fear of disclosure and anticipated stigma. Few youth were willing to take their drugs outside of the home, which led to missed doses of ART. Similarly, families tended to manage HIV within the home only. As a result, although caregivers and families were often the greatest source of emotional and instrumental support, they coped with HIV in isolation of other potential support from their communities, schools or churches. Factors that supported ART adherence included attending clinic-sponsored youth groups, wanting to maintain one's health and using phone and clock alarms. Involvement of adult caregivers in HIV management varied greatly and was often based on the age and health status of the youth. Some caregivers struggled with letting the adolescents assume responsibility for their medication, and ALHIV had few self-management skills and tools to help them regularly take ART.
  
  
  CONCLUSIONS
  These data highlight the importance of families and home environments in supporting adherence to ART among ALHIV. Skill-building and family-based interventions to prepare ALHIV and their adult caregivers for HIV self-management and HIV status disclosure by youth are of paramount importance. Future research and programmes also need to address the fears adolescents and families have regarding HIV-related stigma that shape young peoples' adherence behaviours.
authors.affiliation: Social and Behavioral Health Sciences, FHI 360, Durham, NC, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; jdenison@jhu.edu.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Denison
authors.affiliation: FHI 360, Ndola, Zambia.
authors.forename: Harry
authors.initials: H
authors.lastname: Banda
authors.affiliation: Social and Behavioral Health Sciences, FHI 360, Durham, NC, USA.
authors.forename: Alexis C
authors.initials: AC
authors.lastname: Dennis
authors.affiliation: Social and Behavioral Health Sciences, FHI 360, Durham, NC, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Packer
authors.affiliation: FHI 360, Lusaka, Zambia.
authors.forename: Namakau
authors.initials: N
authors.lastname: Nyambe
authors.affiliation: Social and Behavioral Health Sciences, FHI 360, Durham, NC, USA.
authors.forename: Randy M
authors.initials: RM
authors.lastname: Stalter
authors.affiliation: Arthur Davison Children's Hospital, Ndola, Zambia.
authors.forename: Jonathan K
authors.initials: JK
authors.lastname: Mwansa
authors.affiliation: FHI 360, Lusaka, Zambia.
authors.forename: Patrick
authors.initials: P
authors.lastname: Katayamoyo
authors.affiliation: Social and Behavioral Health Sciences, FHI 360, Durham, NC, USA.
authors.forename: Donna R
authors.initials: DR
authors.lastname: McCarraher
mesh_terms: D000293:Adolescent; D000328:Adult; D017028:Caregivers; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D055118:Medication Adherence; D012648:Self Care; D057545:Social Stigma
keywords: HIV; Zambia; adherence; adolescents; antiretroviral therapy; caregivers; qualitative; sub-Saharan Africa; youth