title: Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa?
abstract: Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews find no effective adolescent adherence-promoting interventions. Social protection has demonstrated benefits for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10-19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa's Eastern Cape were traced and interviewed in 2014-2015 (n = 1175 eligible). About 90% of the eligible sample was included (n = 1059). Social protection provisions were "cash/cash in kind": government cash transfers, food security, school fees/materials, school feeding, clothing; and "care": HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p = .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1-3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42-.76, p < .001); HIV support group attendance (aOR .60, CI .40-.91, p < .02), and high parental/caregiver supervision (aOR .56, CI .43-.73, p < .001). Combination social protection showed additive benefits. With no social protection, non-adherence was 54%, with any one protection 39-41%, with any two social protections, 27-28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of "cash plus care", may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents.
authors.affiliation: a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.|b Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa.
authors.forename: L D
authors.initials: LD
authors.lastname: Cluver
authors.affiliation: a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.|c AIDS and Society Research Unit, Centre for Social Science Research , University of Cape Town , Cape Town , South Africa.
authors.forename: E
authors.initials: E
authors.lastname: Toska
authors.affiliation: d DPHRU, School of Clinical Medicine, and DST-NRF Centre of Excellence in Human Development , University of the Witwatersrand , Johannesburg , South Africa.
authors.forename: F M
authors.initials: FM
authors.lastname: Orkin
authors.affiliation: a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.
authors.forename: F
authors.initials: F
authors.lastname: Meinck
authors.affiliation: a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.|c AIDS and Society Research Unit, Centre for Social Science Research , University of Cape Town , Cape Town , South Africa.
authors.forename: R
authors.initials: R
authors.lastname: Hodes
authors.affiliation: a Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.
authors.forename: A R
authors.initials: AR
authors.lastname: Yakubovich
authors.affiliation: e Health Psychology Unit, Research Department of Infection & Population Health, University College London , London , UK.
authors.forename: L
authors.initials: L
authors.lastname: Sherr
mesh_terms: D000293:Adolescent; D000351:Africa, Eastern; D002648:Child; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control / Q000523:psychology* / Q000821:virology; D006801:Humans; D008297:Male; D055118:Medication Adherence; D010290:Parents; D011640:Public Policy; D040242:Risk Reduction Behavior; D012657:Self-Help Groups; D012944:Social Support; D013019:South Africa; D016896:Treatment Outcome; D019562:Viral Load; D055815:Young Adult
keywords: Adolescents; adherence; antiretroviral therapy (ART); social protection