title: 'HIV is like a tsotsi. ARVs are your guns': associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa.
abstract: OBJECTIVE
  WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa.
  
  
  METHODS
  A cross-sectional study of the largest known community-traced sample of HIV-positive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10-19 years (52% female, 79% perinatally infected) were interviewed.
  
  
  METHODS
  In a low-resource health district, all adolescents who had ever initiated ART in a stratified sample of 39 health facilities were identified and traced to 150 communities [n = 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative interviews used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers.
  
  
  RESULTS
  About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40-0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47-3.24). Among perinatally infected adolescents who knew their status (n = 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34-5.22). Qualitative findings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status.
  
  
  CONCLUSIONS
  Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.
authors.affiliation: aCentre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford Barnett House, Oxford, UK bDepartment of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa cAIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, Cape Town, South Africa dArnhold Global Health Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA eDST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa fHealth Psychology Unit, Department of Infection & Population Health, University College London, London, UK.
authors.forename: Lucie D
authors.initials: LD
authors.lastname: Cluver
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Hodes
authors.forename: Elona
authors.initials: E
authors.lastname: Toska
authors.forename: Khameer K
authors.initials: KK
authors.lastname: Kidia
authors.forename: F Mark
authors.initials: FM
authors.lastname: Orkin
authors.forename: Lorraine
authors.initials: L
authors.lastname: Sherr
authors.forename: Franziska
authors.initials: F
authors.lastname: Meinck
mesh_terms: D000293:Adolescent; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D002648:Child; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000523:psychology*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D036301:Qualitative Research; D013019:South Africa / Q000453:epidemiology; D011795:Surveys and Questionnaires; D014342:Truth Disclosure; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D044966:Anti-Retroviral Agents