Barriers To Engagement In HIV
Care Among Adolescents Females
Participating In An HIV Prevention
Intervention
Tiarney D. Ritchwood,1-2 Rushina Cholera,2 & Audrey Pettifor 2-3
Medical University of South Carolina,1 University of North Carolina at
Chapel Hill,2 University of the Witwatersrand 3
Presenting Author:
Tiarney D. Ritchwood, PhD
Assistant Professor
Medical University of South Carolina
Introduction
• 15% of South African young women (15-24 years of age) and 5% of young
men are currently infected with HIV. 1-2
• South African adolescents often delay HIV care engagement until their
CD4 counts are well below recommended rates for ART initiation. 3
• Timely initiation of ART improves prognoses, decreases early mortality,
and allows for communication of prevention messages that lead to risk
reduction and decreased secondary transmission.4-6
• Loss to care can occur at any stage along this engagement in care
continuum- a person may not initiate care after diagnosis or they may not
maintain care after initiation.
• To improve the link between HIV testing and treatment among young
people, modifiable barriers that might preclude HIV positive adolescents
from accessing clinical services must be understood.
Aims
• Identify barriers to engagement in care among HIV
positive South African female adolescents who had
not sought care since the baseline intervention
assessment
• Identify facilitators of engagement in care among
HIV positive South African female adolescents
reporting that they had sought care since the
baseline assessment
Study Site: Agincourt Health and
Socio-Demographic Surveillance Site
(AHDSS)
• Ehlanzeni
District,
Mpumalanga
Province
• 28 villages,
115,000 people,
420 km2
• HIV Prevalence
46% and 45%
among women
and men 35-39
years.
Kahn K, et al. IJE 2012.; Gomez-Olive X, et al AIDS Care 2013.
Design: Study Design & Population
• A phase III RCT to determine whether the use of cash transfers
conditional on school attendance leads to reduced sexual risk
and subsequent HIV infection.
Eligibility Criteria:
• Female
• Enrolled in grades 8, 9, 10 or 11 in participating high schools
• Age 13-20 years
• Not married or pregnant by self-report
• Parent/guardian living in household
• Able to complete a computer survey on her own
• Residing in study area
* girls testing HIV positive at baseline were not excluded but rather
stayed in the study and were randomized to the intervention
Results: HPTN 068 Baseline
• 2,533 young women
were enrolled March
2011- December
2012.
• 2,448 were HIV
uninfected at
enrollment (81 HIV+,
4 unknown status).
Baseline
Age (Median, IQR)
15 (14-17)
Ever sex
26.6%
HIV
3.2%
HSV-2
4.4%
Ever Pregnant
8.9%
Orphan
28.6%
Food insecurity
34.3%
HH receives CSG
79.0%
Engage Study (N=38)
Parental
consent for
Engagement
in Care
study
Attends 1 year
Swa Koteka
camp
CD4 collection
visit scheduled
At visit,
adolescent
consent or
assent
obtained
Counselors
administer
questionnaire
Adolescents not engaged in
Care (N=14)
Disclosure
Mother
Father
Sister
Brother
Other relative
Friend
Results: Barriers to Care
20% or more responding that the following factors
were either somewhat or very important reasons for
lack of engagement in HIV care (N=14)
Don't know where to go
Wait because not sick
Side effects
%
No money for transport
Not ill
0
20
40
60
80
Adolescents engaged in Care
(N=24)
Disclosure
Mother
Father
Sister
Brother
Other relative
Friend
Grandmother
Top Facilitators for engagement in
Care for HIV+ Young Women
Most important factor in facilitating engagement in HIV
care (N=24)
It is easy and affordable for
you to get transport.
Your family supports your
decision to seek HIV care.
The clinic is near your home.
You had a positive experience
at your local clinic in the past.
Clinic Experiences of Adolescents engaged in
HIV Care
Spent plenty of time with you.
Treated you in a friendly manner.
Made you feel embarrassed about being HIV+.
Listened carefully to what you had to say.
Made you feel better than before.
Criticized you.
Guided you as to what you must do.
Strongly
agree
Agree
Disagre
e
Strongly
disagree
8.7
69.6
17.4
4.3
13.0
69.6
13.0
4.3
--
13.0
60.9
26.1
17.4
78.3
4.3
--
26.1
65.2
4.3
4.3
--
9.1
68.2
22.7
26.1
73.9
--
--
Summary & Conclusions:
Barriers
• Barriers to engagement in care among HIV+ young South African
women in rural villages focused on four main areas:
• Perception of illness (i.e., don’t need treatment, not ill, can wait)
• Clinic accessibility (i.e., money for transportation, distance)
• Stigma (i.e., fear of someone finding out)
• Awareness (i.e., where to go, treatment side effects)
• To combat such challenges, should consider:
• Public Health campaigns promoting the importance of early
engagement in care marketed towards youth
• Mobile health options
• Community outreach aimed at increasing awareness and decreasing
stigma
Summary & Conclusions:
Facilitators
• Facilitators to engagement in care among HIV+ young South
African women in rural villages focused on two main areas
• Clinic accessibility (i.e., affordable transportation, proximity,
positive experiences, & convenient hours)
• Most appreciated the services provided by their specific clinic
providers and felt that they were receiving proper guidance, adequate
information, and that staff were friendly
• Family support was the most frequently cited facilitator to
engagement in care
• Important, developmentally, for adolescents and transitioning adults
• How can we engage families in care?
ACKNOWLEDGEMENTS
Engage Study Principal Investigators
Rushina Cholera (UNC)
Bill Miller (UNC)
HPTN 068 Study Investigators
Audrey Pettifor (UNC)
Kathleen Kahn (MRC/Wits Agincourt)
Catherine MacPhail (WrHI/UNE)
Xavier Gomez-Olive (MRC/Wits Agincourt)
UNC
Amanda Selin
Aimee Julien
Cheryl Marcus
Mary Jane Hill
Lisa Albert
Suchindran Chirayath
Harsha Thirumurthy
Sudhanshu Handa
Joseph Eron
Tamu Daniel
MRC/Wits- Agincourt
Ryan Wagner
Stephen Tollman
Rhian Twine
Wonderful Mabuza
Immitrude Mokoena
Tsundzukani Siwelane
Simon Mjoli
Dumisani Rebombo
Edwin Maroga
Senamile Ndlovu
Audrey Khosa
WrHI
Nomhle Khoza
Sinead Delaney
Helen Rees
HPTN Laboratory Center
Susan Eshleman
Estelle Piwowar-Manning
Oliver Laeyendecker
Yaw Agyei
LeTanya Johnson-Lewis
HPTN LOC at FHI360
Phil Andrew
Erica Hamilton
Rhonda White
NIMH
Susannah Allison
Dianne Rausch
NIAID
Sheryl Zwerski
Ellen Townley
Paul Sato
Jenese Tucker
HPTN SDMC
Jim Hughes
Jing Wang
Diana Lynn
Laura McKinstry
Lynda Emel
LSHTM
James Hargreaves
ACKNOWLEDGEMENTS
The HIV Prevention Trials Network is sponsored by the
National Institute of Allergy and Infectious Diseases,
the National Institute of Mental Health, and the National
Institute on Drug Abuse, all components of the
U.S. National Institutes of Health.
This project was funded by the National Institute of Mental Health
(F30MH096664, PI: Cholera)