A Social Media-Based Support Group for Youth Living With HIV in Nigeria (SMART Connections): Randomized Controlled Trial.

BACKGROUND: Youth living with HIV (YLHIV) enrolled in HIV treatment experience higher loss to follow-up, suboptimal treatment adherence, and greater HIV-related mortality compared with younger children or adults. Despite poorer health outcomes, few interventions target youth specifically. Expanding access to mobile phone technology, in low- and middle-income countries (LMICs) in particular, has increased interest in using this technology to improve health outcomes. mHealth interventions may present innovative opportunities to improve adherence and retention among YLHIV in LMICs. OBJECTIVE: This study aimed to test the effectiveness of a structured support group intervention, Social Media to promote Adherence and Retention in Treatment (SMART) Connections, delivered through a social media platform, on HIV treatment retention among YLHIV aged 15 to 24 years and on secondary outcomes of antiretroviral therapy (ART) adherence, HIV knowledge, and social support. METHODS: We conducted a parallel, unblinded randomized controlled trial. YLHIV enrolled in HIV treatment for less than 12 months were randomized in a 1:1 ratio to receive SMART Connections (intervention) or standard of care alone (control). We collected data at baseline and endline through structured interviews and medical record extraction. We also conducted in-depth interviews with subsets of intervention group participants. The primary outcome was retention in HIV treatment. We conducted a time-to-event analysis examining time retained in treatment from study enrollment to the date the participant was no longer classified as active-on-treatment. RESULTS: A total of 349 YLHIV enrolled in the study and were randomly allocated to the intervention group (n=177) or control group (n=172). Our primary analysis included data from 324 participants at endline. The probability of being retained in treatment did not differ significantly between the 2 study arms during the study. Retention was high at endline, with 75.7% (112/163) of intervention group participants and 83.4% (126/161) of control group participants active on treatment. HIV-related knowledge was significantly better in the intervention group at endline, but no statistically significant differences were found for ART adherence or social support. Intervention group participants overwhelmingly reported that the intervention was useful, that they enjoyed taking part, and that they would recommend it to other YLHIV. CONCLUSIONS: Our findings of improved HIV knowledge and high acceptability are encouraging, despite a lack of measurable effect on retention. Retention was greater than anticipated in both groups, likely a result of external efforts that began partway through the study. Qualitative data indicate that the SMART Connections intervention may have contributed to retention, adherence, and social support in ways that were not captured quantitatively. Web-based delivery of support group interventions can permit people to access information and other group members privately, when convenient, and without travel. Such digital health interventions may help fill critical gaps in services available for YLHIV. TRIAL REGISTRATION: ClinicalTrials.gov NCT03516318; https://clinicaltrials.gov/ct2/show/NCT03516318.

Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature.

INTRODUCTION: Globally, an estimated 30% of new HIV infections occur among adolescents (15-24 years), most of whom reside in sub-Saharan Africa. Moreover, HIV-related mortality increased by 50% between 2005 and 2012 for adolescents 10-19 years while it decreased by 30% for all other age groups. Efforts to achieve and maintain optimal adherence to antiretroviral therapy are essential to ensuring viral suppression, good long-term health outcomes, and survival for young people. Evidence-based strategies to improve adherence among adolescents living with HIV are therefore a critical part of the response to the epidemic. METHODS: We conducted a systematic review of the peer-reviewed and grey literature published between 2010 and 2015 to identify interventions designed to improve antiretroviral adherence among adults and adolescents in low- and middle-income countries. We systematically searched PubMed, Web of Science, Popline, the AIDSFree Resource Library, and the USAID Development Experience Clearinghouse to identify relevant publications and used the NIH NHLBI Quality Assessment Tools to assess the quality and risk of bias of each study. RESULTS AND DISCUSSION: We identified 52 peer-reviewed journal articles describing 51 distinct interventions out of a total of 13,429 potentially relevant publications. Forty-three interventions were conducted among adults, six included adults and adolescents, and two were conducted among adolescents only. All studies were conducted in low- and middle-income countries, most of these (n = 32) in sub-Saharan Africa. Individual or group adherence counseling (n = 12), mobile health (mHealth) interventions (n = 13), and community- and home-based care (n = 12) were the most common types of interventions reported. Methodological challenges plagued many studies, limiting the strength of the available evidence. However, task shifting, community-based adherence support, mHealth platforms, and group adherence counseling emerged as strategies used in adult populations that show promise for adaptation and testing among adolescents. CONCLUSIONS: Despite the sizeable body of evidence for adults, few studies were high quality and no single intervention strategy stood out as definitively warranting adaptation for adolescents. Among adolescents, current evidence is both sparse and lacking in its quality. These findings highlight a pressing need to develop and test targeted intervention strategies to improve adherence among this high-priority population.

Improving retention in HIV care among adolescents and adults in low- and middle-income countries: A systematic review of the literature.

INTRODUCTION: Adolescents living with HIV are an underserved population, with poor retention in HIV health care services and high mortality, who are in need of targeted effective interventions. We conducted a literature review to identify strategies that could be adapted to meet the needs of adolescents living with HIV. METHODS: We searched PubMed, Web of Science, Popline, USAID's AIDSFree Resource Library, and the USAID Development Experience Clearinghouse for relevant studies published within a recent five-year period. Studies were included if they described interventions to improve the retention in care of HIV-positive patients who are initiating or already receiving antiretroviral therapy in low- and middle-income countries. To assess the quality of the studies, we used the NIH NHLBI Study Quality Assessment Tools. RESULTS AND DISCUSSION: Of 13,429 potentially relevant citations, 23 were eligible for inclusion. Most studies took place in sub-Saharan Africa. Only one study evaluated a retention intervention for youth (15-24 years); it found no difference in loss to follow-up between a youth-friendly clinic and a family-oriented clinic. A study of community-based service delivery which was effective for adults found no effect for youths. We found no relevant studies conducted exclusively with adolescent participants (10-19 years). Most studies were conducted with adults only or with populations that included adults and adolescents but did not report separate results for adolescents. Interventions that involved community-based services showed the most robust evidence for improving retention in care. Several studies found statistically significant associations between decentralization, down-referral of stable patients, task-shifting of services, and differentiated care, and retention in care among adults; however, most evidence comes from retrospective, observational studies and none of these approaches were evaluated among adolescents or youth. CONCLUSIONS: Interventions that target retention in care among adolescents living with HIV are rare in the published literature. We found only two studies conducted with youth and no studies with adolescents. Given the urgent need to increase the retention of adolescents in HIV care, interventions that are effective in increasing adult retention in care should be considered for adaptation and evaluation among adolescents and interventions specifically targeting the needs of adolescents must be developed and tested.

Adolescents, young people, and the 90-90-90 goals: a call to improve HIV testing and linkage to treatment.

: The current low rates of HIV diagnosis and treatment initiation among adolescents and young people ages 15-24 continues to present a significant challenge to the epidemic control of HIV. With a 'business as usual' approach to HIV testing and linkage to treatment, new infections among adolescents and youth will likely increase, with the burden compounded by the increasing number of youth in Africa, expected to reach 293 million by 2025. Recent studies reveal significant gaps in the HIV clinical cascade among young people as the global community pursues the Joint United Nations Programme on HIV and AIDS 90-90-90 targets. This AIDS supplement was commissioned with the goal of informing program planners, researchers, policymakers, and funding agencies about the development and design of effective adolescent and youth programs, policies, and strategies for improving the first two 90s among adolescents and youth: HIV testing and diagnosis and linkage to care and treatment. Emerging evidence should inform efforts to better target the youth and adolescents who are most at risk, aiming for early diagnosis and treatment initiation for those who are HIV positive, while also ensuring appropriate primary prevention so that those identified as HIV negative remain so.