Organization: N/a problem and Purpose

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Boston University School of Public Health

Department of Global Health – Culminating Experience

Option One – Policy Brief

Title: Examining the differences in ART adherence among adolescents in South Africa: A gender stratified analysis

Organization: N/A
Problem and Purpose
At the end of 2012, the United Nations Children’s Fund (UNICEF) estimated that 2.1 million adolescents, youth aged ten to nineteen, were living with HIV/AIDS worldwide. Approximately 85% of these infections among adolescents were in sub-Saharan Africa (1). These statistics include adolescents who acquired HIV/AIDS behaviorally, and also those who became ill through mother-to-child transmission, either perinatally or postnatal transmission through breastfeeding. While there is a vast amount of information on HIV/AIDS in children and youth ages 15 to 24, respectively, adolescents are often excluded from research for a variety of reasons, including their changing physical and emotional states, the potential for reproductive decision-making, and the trying transition from pediatric to adult care. These difficulties are seldom documented in the United States (2), let alone in less developed countries such as South Africa.

This policy brief will examine the differences in adherence to antiretroviral therapy (ART) among adolescents in South Africa, specifically, if there is a difference in adherence among males and females. A systematic review of studies from 53 countries reported that adolescence can be characterized by high-risk sexual behavior, a lack of interaction with health services, and a desire to fit in with their peers in social situations (3); these circumstances, among others, will likely lead to a decrease in adherence to ART during adolescence. Based on the current research, this policy brief will make recommendations at a systems level on ways to improve adherence to ART among male and female adolescents in South Africa.


1. Idele P, Gillespie A, Porth T, Suzuki C, Mahy M, Kasedde S, et al. Epidemiology of HIV and AIDS among adolescents: current status, inequities, and data gaps. J Acquir Immune Defic Syndr [Internet]. 2014 Jul 1;66 Suppl 2:S144–53. Available from:

2. Village EG. Transitioning HIV-infected youth into adult health care. Pediatrics [Internet]. 2013 Jul [cited 2014 Sep 12];132(1):192–7. Available from:

3. Kim S-H, Gerver SM, Fidler S, Ward H. Adherence to antiretroviral therapy in adolescents living with HIV: systematic review and meta-analysis. AIDS [Internet]. 2014 May 16 [cited 2014 Sep 10];(April). Available from:

Working Outline

  1. Introduction

    1. Define the problem – present basic facts about HIV/AIDS among adolescents worldwide, discuss the issues of adolescence and matters of adherence to ART

    2. Describe the problem in the context of South Africa – In July 2014, South Africa raised the CD4 count to 500, greatly increasing the number of people who are eligible for ART, many of these will likely be adolescents

    3. Answer the “so what?” question – why is this research importantAdolescence is already a rocky time period, further compounded by HIV/AIDS, need to ensure that support services are in place to smooth this transition and maintain proper adherence

  2. Current Situation

    1. Number of adolescents living with HIV/AIDS in South Africa

    2. Current sex-aggregated data on adherence to ART if available – total number on treatment

    3. Programs in place to improve adherence among adolescents – success/failures?

    4. Transition from pediatric to adult HIV care

  3. Potential Solutions

    1. Identify approaches to address the problem – mHealth applications to encourage adherence, support groups, etc.

    2. Describe the target population – different recommendations based on sex? See what the evidence recommends

  4. Discussion and Recommendations

    1. Examine cost and benefits – have actual costs for the program

    2. Whether or not intervention has been successful in South Africa or in a similar country

    3. Look at feasibility – what would the South African Ministry of Health actually implement

      1. Identify the administrative department that would be responsible for implementation

    4. Monitoring and evaluation – when and how will the program be evaluated

  5. Conclusion

    1. Stress the importance of implementing these programs – further note the stress associated with a typical adolescent period, which is made harder by having a chronic disease

    2. Remind the audience of the urgency – adherence is a major issue and needs to be treated as one

Work Plan for Submitting Drafts
In order to complete the GH Culminating Experience by the fall semester deadline, the following drafts will be submitted on or before the corresponding dates:
PPS and CE Contract: September 12, 2014

Draft 1: October 10, 2014

Draft 2: November 7, 2014

Draft 3: December 5, 2014

Final Draft: December 19, 2014
Working Bibliography

Adherence to Antiretroviral Therapy among Older Children and Adolescents with HIV: A Qualitative Study  of Psychosocial Contexts. (n.d.). Retrieved September 10, 2014, from

Crankshaw, T., Corless, I. B., Giddy, J., Nicholas, P. K., Eichbaum, Q., & Butler, L. M. (2010). Exploring the patterns of use and the feasibility of using cellular phones for clinic appointment reminders and adherence messages in an antiretroviral treatment clinic, Durban, South Africa. AIDS Patient Care and STDs, 24(11), 729–34. doi:10.1089/apc.2010.0146

Dowshen, N., & D’Angelo, L. (2011). Health care transition for youth living with HIV/AIDS. Pediatrics, 128(4), 762–71. doi:10.1542/peds.2011-0068

Dowshen, N., Kuhns, L. M., Johnson, A., Holoyda, B. J., & Garofalo, R. (2012). Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. Journal of Medical Internet Research, 14(2), e51. doi:10.2196/jmir.2015

Evans, D., Menezes, C., Mahomed, K., Macdonald, P., Untiedt, S., Levin, L., … Maskew, M. (2013). Treatment outcomes of HIV-infected adolescents attending public-sector HIV clinics across Gauteng and Mpumalanga, South Africa. AIDS Research and Human Retroviruses, 29(6), 892–900. doi:10.1089/AID.2012.0215

Ferrand, R. a, Bandason, T., Musvaire, P., Larke, N., Nathoo, K., Mujuru, H., … Corbett, E. L. (2010). Causes of acute hospitalization in adolescence: burden and spectrum of HIV-related morbidity in a country with an early-onset and severe HIV epidemic: a prospective survey. PLoS Medicine, 7(2), e1000178. doi:10.1371/journal.pmed.1000178

Hailey, J. H. N., & Arscott, J. (2013). Using technology to effectively engage adolescents and young adults into care: STAR TRACK Adherence Program. The Journal of the Association of Nurses in AIDS Care : JANAC, 24(6), 582–6. doi:10.1016/j.jana.2013.03.001

Idele, P., Gillespie, A., Porth, T., Suzuki, C., Mahy, M., Kasedde, S., & Luo, C. (2014). Epidemiology of HIV and AIDS among adolescents: current status, inequities, and data gaps. Journal of Acquired Immune Deficiency Syndromes (1999), 66 Suppl 2, S144–53. doi:10.1097/QAI.0000000000000176

Jiménez-montero, B., Beceiro, J., José-gómez, M. I. De, González-tomé, M. I., Gurbindo-gutierrez, D., Martínez-pérez, J., … Rojo-conejo, P. (2014). No Title.

Kahana, S. Y., Rohan, J., Allison, S., Frazier, T. W., & Drotar, D. (2013). A meta-analysis of adherence to antiretroviral therapy and virologic responses in HIV-infected children, adolescents, and young adults. AIDS and Behavior, 17(1), 41–60. doi:10.1007/s10461-012-0159-4

Kim, S.-H., Gerver, S. M., Fidler, S., & Ward, H. (2014). Adherence to antiretroviral therapy in adolescents living with HIV: systematic review and meta-analysis. AIDS (London, England), (April). doi:10.1097/QAD.0000000000000316

Manuscript, A. (2011). qualitative investigation, 22(8), 970–978. doi:10.1080/09540121003623693.Psychosocial

Manuscript, A., & Adherence, A. T. (2010). NIH Public Access, 51(1), 65–71. doi:10.1097/QAI.0b013e318199072e.Antiretroviral

Mavhu, W., Berwick, J., Chirawu, P., Makamba, M., Copas, A., Dirawo, J., … Cowan, F. M. (2013). Enhancing psychosocial support for HIV positive adolescents in Harare, Zimbabwe. PloS One, 8(7), e70254. doi:10.1371/journal.pone.0070254

Ndiaye, M., Nyasulu, P., Nguyen, H., Lowenthal, E. D., Gross, R., Mills, E. J., & Nachega, J. B. (2013). Risk factors for suboptimal antiretroviral therapy adherence in HIV-infected adolescents in Gaborone, Botswana: a pilot cross-sectional study. Patient Preference and Adherence, 7, 891–5. doi:10.2147/PPA.S47628

Nglazi, M. D., Kranzer, K., Holele, P., Kaplan, R., Mark, D., Jaspan, H., … Bekker, L.-G. (2012). Treatment outcomes in HIV-infected adolescents attending a community-based antiretroviral therapy clinic in South Africa. BMC Infectious Diseases, 12(1), 21. doi:10.1186/1471-2334-12-21

Rakhmanina, N. Y., Anker, J. N. Van Den, Soldin, S. J., & Van, R. H. (2011). Can TDM Improve Pharmacotherapy of HIV Infection in, 32(3), 273–281. doi:10.1097/FTD.0b013e3181dca14b.Can

Shroufi, A., Gunguwo, H., Dixon, M., Nyathi, M., Ndebele, W., Saint-Sauveur, J.-F., … Ferrand, R. a. (2013). HIV-infected adolescents in southern Africa can achieve good treatment outcomes: results from a retrospective cohort study. AIDS (London, England), 27(12), 1971–8. doi:10.1097/QAD.0b013e32836149ea

Tide, A. T., & Teenagers, A. (2008). South African National HIV Prevalence , Incidence , Behaviour and Communication Survey , 2008 A Turning Tide Among Teenagers ?

Village, E. G. (2013). Transitioning HIV-infected youth into adult health care. Pediatrics, 132(1), 192–7. doi:10.1542/peds.2013-1073

Wegner, L., Flisher, a J., Caldwell, L. L., Vergnani, T., & Smith, E. a. (2008). Healthwise South Africa: cultural adaptation of a school-based risk prevention programme. Health Education Research, 23(6), 1085–96. doi:10.1093/her/cym064
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