Figure 1 shows the PRISMA diagram illustrating the selection process of the included studies. The literature search resulted in 5,244 citations [Figure 1], which were imported into a reference manager. Electronic (31) and manual (28) deduplication identified 59 duplicates. After screening for potentially relevant titles and abstracts 5,162 articles were excluded. After screening full-texts, 17 papers were further excluded because they did not report on the effects of a psychosocial support intervention on adherence and retention in ART for YPLWH. Subsequently, six papers were included in the review of having good quantitative standards. Five studies were considered to be of good methodological quality [27–31] and one of a fair quality [32].
Characteristics of included Studies
The characteristics of the studies included in the review are summarised in Table 2.
Table 2:Characteristics of Included Studies (N=6)
Characteristics
|
Count
|
References
|
Year of Publication
2011 – 2015
2016 – 2020
|
3
3
|
[27] [28] [30]
[29][31][32]
|
Country
United States of America
Kenya
Uganda
South Africa
Zimbabwe
|
2
1
1
1
1
|
[28][30]
[29]
[32]
[27]
[31]
|
Study design (sample size)
Pre and post intervention studies (61; 952)
Randomized controlled trial (4,504; 66; 94)
Retrospective cohort (174)
|
2
3
1
|
[29][30]
[27][31][32]
[28]
|
The six papers were disseminated between 2011 and 2019. Two of the studies were conducted in United States of America [28, 30] and four in Southern and Eastern Africa (Uganda, Kenya, South Africa and Zimbabwe) [27, 29, 31, 32]. Two of the papers were pre- and post-intervention studies (n=1,113) [29, 30], three randomized control trials (RCT) [27, 31, 32] (n=4,664), and one retrospective cohort study (n=174) [28].
Intervention duration
The duration of study was between 3 months and 10 years [Table 3].
Table 3: Intervention/study location and duration of intervention
Article
|
Country (location)
|
Duration of intervention
|
Wohl et al. [30]
|
USA (Los Angeles)
|
2 years
|
Davila et al. [28]
|
USA (Texas)
|
Decentralised era: 2 years
Centralised area: 3 years
Enhanced youth services: 10 years
|
Ruria et al. [29]
|
Kenya (Homa Bay)
|
6 months
|
Graves et al. [32]
|
Uganda
|
6 months
|
Bhana et al. [27]
|
South Africa (KwaZulu-Natal)
|
3 months
|
Willis et al. [31]
|
Zimbabwe (Gokwe south district)
|
12 months
|
Six studies evaluated psychosocial support interventions, namely: psychosocial education, group adherence counselling, individual counselling and peer-support groups and peer counselling. Two studies evaluated the impact of a family-centred appointment scheduling and health education on patient retention and adherence to monthly appointment scheduling [27, 32]. Three studies evaluated a youth centred management model that combined psychosocial case management, treatment education/adherence support and HIV risk reduction counselling to provide a client-centred intervention through which care was coordinated [28, 30, 31]. Three studies [29, 30, 32] evaluated interventions that included fast-track service deliveries to streamline medication pick-up. Table 4 illustrates the nature and characteristics of the interventions identified.
Health and psychosocial education delivered in the form of educational activities and workshops to provide information on HIV and other relevant topics formed an integral part of all six interventions [27–32]. Health education was delivered using posters and cartoons in a structured manner that provided participants with real life situations on navigating through being orphaned by AIDS; moving in with relatives; learning about own HIV diagnosis and treatment needs, while coping with family loss, stigma, peer relationships, identity, and family functioning [27–32]. Furthermore, trained staff who were equipped with the tools to care for and skilled in treating adolescents were employed in six of the interventions e.g. adolescent care providers, youth-focused social workers and psychologist [27–32].
Table 4: The nature and characteristics of the interventions
Type of intervention
|
N
|
References
|
Psychosocial education
Teaching/education
|
6
|
[27][28][29][30][31][32]
|
Educational workshops
|
3
|
[28][29][32]
|
Adherence counselling
|
|
|
Group counselling/ support groups
|
5
|
[27][28][29][31][32]
|
Individual counselling
|
5
|
[27][29[30]][31][32]
|
Family centered
|
|
|
Family based psychosocial intervention
|
2
|
[27][32]
|
Fast track/fast lane services
|
|
|
Priority clinic scheduling
|
3
|
[29][30][32]
|
Use of reminder cards/sms
|
|
|
Reminder cards/sms
|
1
|
[32]
|
Intervention agent
|
Social worker
|
2
|
[30][28]
|
Adolescent care provider
|
3
|
[29][31][32]
|
Clinical psychologist/Bachelor-level counsellor
|
2
|
[27][30]
|
General practitioner/Nurse
|
3
|
[27][29][32]
|
Peer counsellor
|
4
|
[28][29][31][32]
|
Lay counsellor/CHW
|
2
|
[27][32]
|
Point of intervention delivery
|
Facility-based
|
6
|
[27][28][29][30][31][32]
|
Community-based
|
2
|
[28][31]
|
School-based
|
1
|
[29]
|
Components of intervention
|
Knowledge/education on HIV/AIDS
|
6
|
[27][28][29][30][31][32]
|
Adherence to treatment and retention in care
|
6
|
[27][28][29][30][31][32]
|
Family-focused programme
|
2
|
[27][32]
|
Scheduled visits
|
3
|
[29][30] [32]
|
Emotional/Affective support
|
4
|
[27][30][31][32]
|
Structural support (youth clinic)
|
4
|
[28][29][31][32]
|
Sexual and reproductive health
|
5
|
[27][28][29][30][31]
|
Disclosure, stigma and discrimination
|
5
|
[27][28][29][31][32]
|
Health promotion
|
1
|
[32]
|
AIDS related loss and bereavement care
|
1
|
[27]
|
Six studies evaluated interventions that involved individual and peer counselling as part of the interventions [27–32]. The counselling sessions were facilitated by trained community adolescent treatment supporters (CATS), social workers, lay health workers, trained health professionals, or research teams, and aimed to increase HIV knowledge and address adherence and retention barriers [27-32]. These individual counselling methods used a client-centred approach [27, 30–32], or motivational interviewing [28] or peer counselling [29]. Group counselling or support groups were found in five articles as a means of psychosocial support [27-29, 31, 32]. Youth specific support groups addressed issues such as emotional needs; developing self-management skills; capacity building; sexual health; and the stigma related to HIV [28, 31, 32].
One study implemented a school-based programme to create a supportive environment for adherence for YPLWH [29]. The programme offered counselling at schools on sexual and reproductive health and encouraged adolescents to establish health clubs among themselves [29]. In addition, the intervention provided HIV medication on the school premises to enhance adherence and linkage to care, as well supporting participating learners in disclosure [29].
Two of the interventions had family-centred services [27, 32]; with one intervention implementing a family clinic day (FCD) [32]. FCD applied to paediatric and adolescents living with HIV and their immediate family who received priority HIV-care and counselling on a day allocated specifically to them [32]. Another component of FCD was the use of reminder cards and calendars for scheduling appointments. Health education workshops were held, which were led by peers equipped in leading discussions around HIV, sexual and reproductive health, adherence, disclosure, puberty and life skills [27-29, 32]. In addition, the Vuka family programme [27] another family-centred intervention conducted 10 health education workshop sessions that covered subject areas addressing mental and depressive disorders experienced by adolescents living with HIV. These sessions included AIDS-related loss and bereavement, HIV transmission and treatment knowledge; disclosure of HIV status to others; youth identity, acceptance, and coping with HIV; adherence to medical treatment; stigma and discrimination; caregiver child communication, particularly on sensitive topics such as puberty and HIV. The Vuka family programme also identified and developed strategies to keep children safe in high-risk situations where sexual behaviour and drug use are common [27]. Furthermore, integrated group sessions were held that were comprised of HIV-infected youth and their caregiver/s, as well as separate group activities for caregivers and preadolescents.
In the case of the Red-Carpet Intervention, adolescents were given VIP express cards- a card offering adolescents fast-track counselling and HIV treatment [29]. One of the interventions also offered adolescents the opportunity to schedule their appointments [32]. Moreover, adolescent waiting areas were implemented to create an adolescent-friendly environment aimed at improving retention to ART services at facilities [28, 32]. Although referral systems were used in two of the programmes, the programmes lacked the services needed by participants, like individual counselling [27]; and support groups for substance abusers; and housing or nutrition services.
Reminders cards and sms were used in one of the studies [32]. Participants were scheduled to attend their next appointment visit using reminder cards and reminded to take their medications by sending SMS messages at regular intervals.
Outcomes measured
The primary outcomes of interest were adherence to ART and retention in care. The measures of psychosocial support outcomes reported were: (i) self-management (self-efficacy and self-esteem), which is associated with improved self-concept and future orientation [27, 28, 31, 32]; (ii) reduction of stigma and discrimination [27, 31]; (iii) disclosure and communication [27, 31, 32]; and (iv) perceived support in the form of social support, instrumental support, family and/or peer support and informational support [28-32]. Our findings showed that five of the studies [28-32] reported on both the primary and secondary intended outcomes [Table 5].
Table 5: Reporting of primary and secondary intervention outcomes
Reference 28 only reported outcomes of retention in care and adherence to medication and no other psychosocial outcome. Nevertheless, the reference was included because its intervention included educational activities and support groups offered by social services staff trained in the use of motivational interviewing
Retention in care was investigated in five of the six studies [28-32]. Three studies found retention in care at 24 months [28], 12 months [31], and 6 months [30] to be significantly higher following exposure to the psychosocial interventions. Wohl et al. [30], found that participants’ HIV clinic visits significantly increased between baseline and at six months following the youth case management intervention (p < 0.0001). Davila et al. [28] found that the centralisation of youth services, which was composed of multifaceted psychosocial intervention components, improved the retention in care of YPLWH (p < 0.01) at 12 months. However, there were no significant differences observed in baseline viral load by service era (p = 0.91) [28]
Similarly, Ruria et al. [29] conducted a pre- and post-intervention to measure retention of YPLWH in ART care. The findings indicated that after one month, 90% of patients were linked to care in the pre-intervention cohort compared to 85.7% in the post-intervention cohort. The high rate of linkage to care in the pre-intervention phase was attributed to the national policy on Adolescent Reproductive Health and development [29]. However, the results show that following the implementation of the peer counselling and psychosocial support intervention, a significant increase from 66% to 90%; and 54.4% to 98.6% were observed at three months and six months respectively. While there is a high rate of YPLWH linking to care within the first month of ART initiation, these numbers drop with time, and that the intervention is more successful in linking YPLWH to ART over time.
Results from the Family Clinic Day (FCD) intervention showed a significant increase in patient adherence to clinic appointment schedules, that is 65% (p < 0.01) of adolescent participants were adherent to their appointment schedules compared to 53% participants in the control facilities). However, no effect on retention in care between the control group and the intervention group (p = 0.94) was observed [39].
Adherence to medication was reported as a significant outcome in three studies [27, 31, 32]. According to Bhana et al. [27], a self-reported scale on how often medication was missed over the past six months by participants in the VUKA intervention reported significantly greater adherence to treatment than those in the control group (p < 0.05) [27]. Willis et al. [31] found that the intervention group were 3.9 times more likely to adhere to treatment compared to the control group.
Four of the studies reported on secondary outcomes [27, 30-32]. The study conducted by Wohl et al. [30], showed that personalised case management interventions provided instrumental support for participants (tangible help provided by others). For example, support in the form of referrals for housing, mental health services, risk reduction education and transportation assistance within the first six months post the intervention [30]. Similarly, qualitative findings from the FCD intervention conducted by Graves et al., suggests that the family groups component of the intervention provided participants with increased instrumental, family, peer, and informational support [32]. The findings from the VUKA pilot programme reported significant increases in individual self-concept and future orientation, improved parent-child communication, improved social support and informational support [27]. Furthermore, caregivers reported improved family support, and a decrease in the experience of stigma [27]. One study investigated the effects of community adolescent treatment supporters on psychosocial wellbeing [31]. Willis et al. [31] found a statistical significant increase in confidence, self-esteem and self-worth (p < 0.001). In addition, the intervention group reported a statistically significant improvement in the quality of life, while the control group reported a significant decline in the quality of life (p = 0.028) [31].