October 30, 2019
Recent trends in the Government of South Africa’s HIV treatment programs indicate that despite the rise in adolescents seeking treatment, many barriers still hinder care for adolescents living with HIV (ALWH). In a commentary written for The Lancet HIV, Professor of Epidemiology Audrey Pettifor, PhD, of the UNC Gillings School of Global Public Health, noted that these barriers can prevent ALWH from receiving and continuing treatment — or even being tested at all.
South Africa, currently the country with the largest number of people living with HIV, has made great strides in increasing the availability of HIV treatment. However, among adolescents, the global trend indicates that ALWH are less likely to get tested for HIV and be on HIV treatment if they test positive.
In South Africa, fewer than half of ALWH who sought care started antiretroviral therapy (ART). These statistics fall short of the 90-90-90 target set by the Joint United Nations Programme on HIV and AIDS (UNAIDS), which states that by 2020, 90% of HIV-infected individuals will know their status, 90% of those infected with HIV will start ART and 90% of those on ART will have a suppressed viral load.
Common barriers to testing can include fear of the stigma of being tested, of learning the results or of having the confidentiality of said results breached. Other barriers include a lack of knowledge about the risks of infection and the availability of testing.
The subject of Pettifor’s commentary — a study led by Mhairi Maskew, PhD, from the University of the Witwatersrand, South Africa – indicated that the gap in HIV care comes not only from lack of testing, but also from the insufficient rates with which HIV-diagnosed adolescents gain access to care and treatment. This is commonly referred to as “poor linkage in care.” Barriers that contribute to this poor linkage are similar to barriers in testing, but also can include poor treatment by health care providers, lack of adolescent-friendly care and denial about an HIV diagnosis.
The Maskew et al. study reports that only 45% of girls aged 15-19 and 42% of boys aged 15-19 who presented at a clinic with HIV ultimately started treatment. Pettifor and co-authors theorize that the number of HIV-positive adolescents not receiving HIV treatment in South Africa may actually be higher, however, because the study covers an adolescent population that has already gained access to potential treatment in the HIV care system.
“Given gaps in testing and linkage to care, the number of HIV-positive adolescents not in care reported […] is likely an underestimate,” Pettifor states. Even so, she believes that the Maskew et al. study has highlighted a significant need for strengthening the gaps in both testing and linkage to care for adolescents.
“To date, there are limited evidence-based interventions to improve linkage to and retention in care for adolescents. There are even fewer that have been taken to scale — this must change now if we want to see reductions in new infections and alter the course of the HIV epidemic,” Pettifor states. “A first step to addressing the adolescent epidemic is understanding the problem. Maskew and colleagues take an important step in highlighting that the battle against HIV is far from over and that government, donors, programs and researchers must act with urgency to develop, test and implement evidence-based interventions to prevent new infections and improve linkage to and retention in care for adolescents.”
Contact the Gillings School of Global Public Health communications team at firstname.lastname@example.org.