Health System Responses to Address Treatment Gaps of Unsuppressed Adolescents on HIV Treatment in Public Primary Health Care Facilities in Windhoek, Namibia.

Background: Adolescents living with HIV (ALHIV) face unique challenges that result in persistent gaps in achieving and maintaining suppressed viral load. Although effective evidence-based interventions to address treatment gaps in adolescents are readily available, health systems in resource-constrained, high HIV prevalence settings are challenged to implement them to achieve epidemic control. Here, we describe the health system responses to address the treatment gap of unsuppressed ALHIV on antiretroviral therapy in Windhoek, Namibia. Methods: We conducted a qualitative descriptive and exploratory study in Windhoek between June and October 2023. Nineteen purposively selected key informants, ranging from pediatric HIV program managers to healthcare providers, were interviewed. In-depth interviews were audio-recorded and transcribed verbatim. The transcripts were uploaded to ATLAS.ti and subjected to thematic analysis. Results: The four main themes elucidated challenges related to adherence and retention as well as health system responses in the form of interventions and support programs. The predominant adherence and retention challenges faced by ALHIV were mental health issues, behavioral and medication-related challenges, and inadequate care and social support. The health system responses to the identified challenges included providing psychosocial support, peer support, optimization of treatment and care, and the utilization of effective service delivery models. Key health system support elements identified included adequately capacitated human resources, efficient medication supply chain systems, creating and maintaining an enabling environment for optimum care, and robust monitoring systems as essential to program success. Conclusion: The health system responses to address the remaining treatment gaps of unsuppressed ALHIV in Windhoek are quite varied and, although evidence-based, appear to be siloed. We recommend harmonized, multifaceted guidance, integrating psychosocial, treatment, care, and peer-led support, and strengthening client-centred differentiated service delivery models for unsuppressed adolescents.

Experiences of support by unsuppressed adolescents living with HIV and their caregivers in Windhoek, Namibia: a qualitative study.

Background: Adolescents living with HIV (ALHIV) lag behind younger children and adults in the achievement of HIV care and treatment targets for HIV epidemic control. Treatment outcomes for adolescents may be influenced by their experiences with the support provided in HIV programs. We report on the experiences of virally unsuppressed adolescents and their caregivers with the current support in primary healthcare settings in Namibia. Methods: A qualitative descriptive and exploratory study was conducted in 13 public primary healthcare facilities in Windhoek, Namibia. A total of 25 in-depth interviews were conducted with unsuppressed adolescents (n = 14) and their caregivers (n = 11) between August and September 2023. The audio-recorded interviews were transcribed verbatim, and uploaded into ATLAS.ti software, and subjected to thematic content analysis. Findings: Three main support domains for the unsuppressed adolescents emerged from our analysis, namely: psychosocial, clinical and care, and socioeconomic support. The psychosocial support was delivered through peer support (teen clubs and treatment supporters) and enhanced adherence counselling mostly. The clinical and care support included implementing adolescent-friendly HIV services, differentiated service delivery approaches, and caregivers and healthcare worker care support for improved ART adherence, clinic attendance and continuous engagement in care. Socioeconomic support was provided for nutritional support, transport to access clinics, and school supplies, as well as income-generating projects. Conclusion: Psychosocial, clinical and care, and socioeconomic support are key elements in addressing the needs of adolescents challenged with achieving viral suppression. Health systems may benefit from whole-of-society and whole-of-government approaches to meet the needs of ALHIV that are beyond the scope of health service delivery such as nutritional, education and socioeconomic influences on both the health and well-being of ALHIV.

Policy and Programming Towards Addressing Treatment Gaps in Adolescents Living with HIV: A Content Analysis of Policy and Programme Documents in Namibia.

Adolescents living with HIV (ALHIV) face unique challenges resulting in persistent treatment gaps, particularly viral non-suppression. Country programs adopt policies, guidelines, and innovations, based on WHO recommendations and best practices from elsewhere. However, it is unclear to what extent these tools address the management of adolescents with viral non-suppression. We report on a review of guidelines for the provision of HIV services to ALHIV in Namibia. We conducted a systematic document review using Content Analysis and Thematic Analysis methodology, and the READ approach. We identified seven relevant policy documents, four of which somewhat addressed viral non-suppression (treatment gap) in ALHIV and outlined interventions to improve treatment outcomes in adolescents considering their lived experience and unique challenges. The persistent treatment gap may reflect policy implementation gaps in specifically addressing viral non-suppression. It may be worthwhile to leverage existing documents to develop specific operational guidance for ALHIV with unsuppressed viral loads.

Study analysing the potential gaps in the contents of policies and programme documents meant to address management of adolescents living with HIV with high viral load Viral load suppression is a huge challenge in adolescents living with HIV (ALHIV). Globally, adolescents lag when compared to children and adults in achieving viral suppression levels set for achieving HIV epidemic control. The WHO and global HIV program initiatives recommend evidence-based interventions to be included in policies and guidelines to address unique barriers adolescents face that prevent them from staying in HIV care and adhering to their medication. The extent to which country policies guide service providers in managing high viral load cases among adolescents is important in identifying and addressing the persistent gaps. We reviewed the contents of policies, guidelines and other programmatic documents that address HIV management in adolescents in Namibia to assess the extent to which the documents guide management of ALHIV who have high viral load. Seven documents addressing management of ALHIV in Namibia were identified. Four documents address viral suppression among adolescents and recommend some interventions to improve treatment outcomes in adolescents in general. The documents acknowledge the uniqueness of the adolescence, with unique experiences and challenges. However, the documents fall short in providing comprehensive and specific guidance in managing adolescents with high viral loads, for program implementers and direct service providers for ALHIV. The fragmented guidance on managing adolescents with unsuppressed viral loads may be leading to implementation gaps or uncertainties among service providers on how to manage unique cases. It would be essential to focus future efforts on consolidation or development of comprehensive guidance on management of adolescents with high viral load, and capacitating the healthcare providers and stakeholders engaged in addressing social determinants of health affecting these adolescents. A multisectoral approach may provide a pathway to improved viral suppression among ALHIV.

Assisted Partner Notification Services in Namibia: Comparison of Case-Finding in Persons With New and Previously Diagnosed Human Immunodeficiency Virus, and Success as a Platform for PrEP Referral.

BACKGROUND: Assisted partner notification services (APS) are widely implemented throughout sub-Saharan Africa. The effectiveness of APS among persons with previously diagnosed human immunodeficiency virus (HIV) infection is uncertain, and there are few published data on the success of integrating referrals for HIV preexposure prophylaxis (PrEP) into APS. METHODS: Staff in 22 Namibian Ministry of Health and Social Service clinics offered APS to patients newly and previously diagnosed with HIV (index cases [ICs]) between October 2019 and June 2021. Counselors used a structured interview guide to elicit ICs' sex partners and biological children and assisted ICs to arrange testing of contacts. Contacts testing HIV-positive were linked to HIV services and those 14 years or older testing negative were offered PrEP. The primary outcome was the case-finding index (contacts testing HIV-positive ÷ ICs receiving APS). RESULTS: Staff provided APS to 1222 (78%) of 1557 newly diagnosed ICs eliciting 1155 sex partners and 649 biological children. Among 280 previously diagnosed ICs, 279 sex partners and 158 biological children were elicited. The case-finding index was higher among ICs with newly diagnosed HIV compared with previously diagnosed HIV (0.14 vs 0.09, P = 0.46), though this difference was not statistically significant. Most sex partners testing HIV-negative were initiated on PrEP (67% in sex partners from newly diagnosed ICs; 74% in sex partners from previously diagnosed ICs). CONCLUSIONS: Assisted partner notification services successfully identified sex partners and biological children with undiagnosed HIV infection when provided to both newly and previously diagnosed ICs. Integration of referral to PrEP resulted in many HIV-negative partners initiating PrEP.