Antiretroviral Therapy Adherence and Associated Factors Among Hiv Patients Aged 10--15: A Cross-Sectional Study at Five Hospitals in Vietnam

doi:10.21203/rs.3.rs-5300414/v1

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Research Article

Antiretroviral Therapy Adherence and Associated Factors Among Hiv Patients Aged 10--15: A Cross-Sectional Study at Five Hospitals in Vietnam

https://doi.org/10.21203/rs.3.rs-5300414/v1

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Introduction: Adherence to antiretroviral therapy (ART) plays an important role in treatment efficiency. Human immunodeficiency virus (HIV)-infected adolescents face
many challenges in terms of their adherence to HIV treatment.

Objectives: (1) To evaluate the ART adherence rate among HIV-infected adolescents aged 10--15 years at five hospitals in Vietnam and (2) to investigate the factors associated with ART adherence.

Methods: This was a cross-sectional study involving 618 HIV patients aged 10--15 years receiving ARV treatment at five hospitals from May 2020 to October 2021. Data were collected through quarterly structured interviews and periodic medical record reviews. Adherence to the ART was assessed following the WHO classification. Adherence is defined as good if it is ≥95%, as documented by the ART healthcare provider.

Results: The overall adherence rate was low (62.4%), and the most common reason for nonadherence was a lack of drugs at the check-up. A waiting time for ARV treatment of less than 1 month after diagnosis [OR=1.85; 95% CI (1.15–2.94)]; [OR=2.38; 95% CI (1.31–4.35)], and patients whose caregiver demonstrated occasional fatigue [OR=1.59 (1.04–2.44)] were significantly associated with ART nonadherence.

Conclusion: Increased efforts should be dedicated to psychological preparation, pre-ARV counseling for patients, and support their families and caregivers to improve adherence to treatment.

antiretroviral therapy

adolescents

adherence to ART

Human immunodeficiency virus/acquired immunodeficiency disease syndrome (HIV/AIDS) is a considerable health problem worldwide. According to the United Nation Children’s Fund (UNICEF), 190000 new HIV infections occurred among adolescents aged 10–19, and 2.8 million children and adolescents were living with HIV in 2018.[1] While the coverage of ART has increased worldwide, only 54% of HIV-infected children have received ART.[1] Although the annual number of AIDS-related deaths worldwide fell by 35% from 2005–2013, the number of deaths among adolescents (aged 10–19) living with HIV sharply increased by 50% (from 71000 to 110000 deaths) from 2005 to 2012.[2] Since 2012, the number of HIV-related deaths has decreased with the expansion of ART worldwide. Mortality among children decreased by 58% between 2010 and 2020, however, among adolescents mortality declined with only 36% in the same period[3]. In the era of antiretroviral therapy, AIDS remains the second leading cause of death among adolescents globally.[2]

Antiretroviral treatment is currently lifelong and improves immunocompetence, prevents HIV-related opportunistic infections, and saves resources.[2, 4] ART with good adherence decreases the serum viral load to undetectable levels in people living with HIV[5] and decreases the risk for HIV transmission. Life expectancy is almost as high as that of the non-HIV population; hence, ART may be compared with insulin-dependent diabetes, a chronic disease that demands lifelong treatment. Adherence to ART plays an important role in achieving therapeutic efficacy. At least 95% of ART prescribed is recommended for optimal adherence.[6]^,[7] Nonadherence to ART leads to increased viral replication, virological treatment failure with a detectable viral load, selection of ART-resistant viral strains, immunological treatment failure and finaly clinical treatment failure with opportunistic infections and mortality.[7–9] An Ethiopian study revealed that poor adherence to the ART regimen was significantly associated with virological treatment failure.[10] ART resistance is an indication that ART should be changed to 2nd and 3rd regimens, which are more expensive, increasing the burden of ART.

Adherence to ART among adolescents is challenging, as it is a complex health behavior that is associated with many factors. Poor ART adherence may be related to psychosocial problems, patient-related factors, clinical and medication factors, and health system-based factors, including economic barriers to accesses to HIV care.[11, 12] Adolescents often struggle with healthcare linkages and retention, with particular challenges experienced by adolescents referred from pediatric to adult HIV outpatient care services.[2] They are often responsible for their own ART and may lack adult support from their parents/caregivers, information or are misinformed about HIV and/or ART.[13] Adolescence is a dynamic development period characterized by profound psychological and physiological changes, including rapid brain development. HIV status disclosure is often at this age and they must learn how to handle the disease and risk of sexual transmission at the same time that hormones trigger sexual and romantic emotions, as well as vulnerability through stigma and discrimination.[13] Many studies have revealed that ART adherence among adolescents is lower than that among adults and young children.[11, 12, 14]

During the COVID-19 pandemic lockdown restrictions have decreased HIV transmission but also negatively affected economic and psychosocial situation for adolescents living with HIV as well as access to healthcare services. As a result of lockdowns, limited accessibility to HIV services has challenged ART adherence. The low availability of ARV medicines due to inadequate human resources, raw materials, and other products in manufacturing and the limited and reduced income of people living with HIV due to COVID-19 has led to a loss of follow-up and and effected the ART adherence.[15] A study conducted in Kenya (Enane, 2021) revealed that 17% of adolescents were concerned about running out of ART during the pandemic, and 5.1% reported skipping medication doses due to concerns about running out of ART medications.[16]

According to data from Vietnam’s Ministry of Health, there are 208371 people living with HIV; of these, 2% are aged 0–14 years, and 3% are aged 14–19 years.[17] Nevertheless, little research has been conducted on adolescents, especially since the COVID-19 pandemic. How well did adolescents in Vietnam adhere to ART during the COVID-19 pandemic, and what variables were linked to this adherence? This study was carried out to evaluate the ART adherence rate among HIV-infected adolescents aged 10–15 years at five hospitals in Vietnam and to investigate the factors associated with ART adherence.

Study design and setting

This study was conducted with a cross-sectional design, utilizing information gathered during the HIV-CHI II Project, implemented in five pediatric HIV outpatient clinics (OPC’s) at: Vietnam National Hospital of Pediatrics, Children’s Hospital 1, Children’s Hospital 2, Hai Phong Hospital of Obstetrics and Pediatrics, and Quang Ninh General Hospital. The selection of these hospitals was based on the substantial number of HIV-infected adolescents receiving ART in their OPC’s. The longitudinal study spanned a period of 12 months, encompassing both initial and quarterly investigations. However, due to the COVID-19 pandemic, data collection across the five hospitals could not be conducted concurrently. Consequently, the study timeline was extended by an additional 5 months beyond the originally planned duration. Therefore, the data collection spanned from May 2020 to October 2021.

Participants

Adolescents aged 10–15 years (as determined by their date of birth), diagnosed with HIV and receiving treatment were included in this study. Participants were recruited from five hospitals involved in the HIV-CHI II project. The decision to focus on the 10–15 age group was deliberate, as individuals aged 16–19 years were typically referred to adult OPC’s in residential settings, making it challenging to engage with them for the purposes of this study.

The adolescents included in the study regularly received ART in one of the five hospitals and consent to participate in the project was given by the patients and their caregives. The exclusion criteria included not providing consent to participate, patients from other settings who have temporarily undergone ART in the specified hospitals or who reside in orphanages or other public facilities that may influence the project’s intervention results.

Sample size

We conducted a comprehensive sampling of all eligible patients across five outpatient clinics within designated hospitals. In each hospital, patients were scheduled for regular check-up examinations and the administration of antiretroviral medications on a constant day each month. This synchronized scheduling ensured that patients living in the same area underwent follow-up check ups on the same day. Before participating in the study, all patients aged 10–15 years had undergone standard examinations and received medications. A total of 645 patients were receiving outpatient care across all five hospitals. However, following the initial screening and subsequent solicitations, 618 patients met the recruitment criteria and were enrolled in the study.

Data collection

The process of collecting initial, quarterly, and final data involved two components: (1) conducting interviews with patients and their caregivers and (2) gathering available information from their outpatient administrative medical records within the hospitals. The questionnaire was developed via Google Forms, enabling the collection and updating of data online through tablets and mobile phones. The questionnaire is found as a supplementary file.

Data collection initially

Nurses within the 5 hospitals’ OPC’s extracted the available information of participants from outpatient administrative medical records, subsequently completing the report forms. This information included procedures, demographics, socioeconomic data of patients and caregivers, medical history, clinical status, and treatment progress. At the first examination schedule, in addition to standard examining and administering medications, investigators gathered insufficient information and assessed ART adherence status. All that information was filled in Google Forms on mobile phones.

Data collection quarterly

The quarterly data collection included extracting information from medical records and interviewing patients and caregivers. Nurses updated the survey form every three months, providing treatment progress, laboratory test results, and patient outcomes. The interviews yielded insights into medication administration, ART adherence, challenges, barriers, and recent problems.

During the conclusive phase of data collection, we investigated the impact of the COVID-19 pandemic on the accessibility of health services and the eco-social aspects of patients and their families. Our research team developed a questionnaire regarding the influence of COVID-19, drawing inspiration from the American Center for Disease Control's report on the effects of COVID-19 on HIV patients, as well as the recent application of other survey tools to various population groups in the community.

Data analysis

For biostatistical algorithms for data analysis, the STATA 17.0 application was used. The results were conveyed through descriptive statistics, including frequency, ratio, mean, and standard deviation. To assess ratio differences, the chi square test was used when each cell of a cross table had an expected frequency of at least 5, or Fisher’s exact test was used when this assumption was not met. Bivariate analysis was used to check variables associated with the dependent variable. Those variables found to have a p value of ≤ 0.05 were fitted to multivariate logistic regression. Odds ratios with 95% CIs were computed, and variables with p values ≤ 0.05 in the multiple logistic regression models were considered significantly associated with the dependent variable.

Definition

Adherence is defined as good if it is ≥ 95% (< 2 doses of 30 doses or < 3 doses of 60 doses are missed), as documented by the ART healthcare provider. Poor if 85–94% (3–5 doses of 30 doses or 3–9 doses of 60 doses are missing), as documented by the ART healthcare provider.[18]

Ethical issues

Written consent to participate was obtained from the adolescent patients and their caregivers before participation in the study. The respondents could refuse or withdraw from the study at any time without any consequence. Adolescents were given a study identification number to ensure anonymity. The project received ethical approval from the Hanoi Medical University Institutional Review Board (Decision No HMUIRBI08/IBB-HDDDNCYSH-DHYHN, 29/04/2020). The ethical approval and consent given included approval to publish the study results. All potential ethical issues were discussed internally within the project team first and then, if needed, with the Hanoi Medical University Institutional Review Board. This is a sub study of ClinicalTrials.gov ID NCT02035969 “Assessment of Group Peer Support to Children With HIV in Vietnam”

The study results can be divided into 3 major sections: sociodemographic characteristics, status of adherence to antiretroviral therapy following the WHO classification and factors associated with nonadherence to antiretroviral therapy (see below).

Sociodemographic characteristics

The study involved (Table 1) a total of 618 adolescents with HIV (referred to as patients) from outpatient clinics in five hospitals in Vietnam. The mean age (SD) of the patients was 12.8 (1.6) years. A greater percentage of males participated in the study, and the majority (91.9%) attended school. One-third of patients (29.3%) had to live in rented houses, and 3.9% were living with relatives. On average, the caregivers were 44.1 years old, with 72.6% having formal occupations and 60.5% being married. More than half of the caregivers had secondary/high school education (57.9%). Most caregivers knew their HIV status (64.6%), and the majority of them were receiving ARV treatment. Two-thirds of the caregivers (75.1%) faced difficulty caring for the child. Among the 535 caregivers who responded to their fatigue status, 51.8% reported having felt fatigued.

Table 1

Sociodemographic and household characteristics of the study participants and caregivers
I. Sociodemographic characteristics of patients
Characteristic	Study participants (n, %)
Age (mean, SD) (min/max: 10–15)	12,8 (1.6)
Gender (Female child)	299 (48.4)
Poor family (yes)	139 (22.5)
House ownership
Own house	437 (70.7)
Rented house	181 (29.3)
Studying status
No schooling	50 (8.1)
Go to school	568 (91.9)
Child’s health insurance status (n, %)	613 (99.2)
Number of household member (mean, SD)	41. (2.2)
Caregiver living with the child (yes)	587 (95.0)
Living with relative (n, %)	24 (3.9)
Other family member with HIV positive (n, %)	558 (90.3)
Number of other family member with HIV positive (mean, SD)	1.8 (1.6)
Family member died from HIV (n, %)	239 (42.8)
Number of family number died from HIV (mean, SD)	1.2 (0.4)
II. Sociodemographic characteristics of caregivers
Characteristic	Caregivers
Age (Mean, SD)	44.1 (11.3)
Have a formal occupation (yes)	471 (76.2)
Education level
Primary school	175 (28.3)
Secondary and high school	358 (57.9)
Higher high school	85 (13.8)
Caregiver’s HIV status
No	197 (31.9)
Yes	399 (64.6)
Don’t know	22 (3.5)
Caregiver’s ARV treatment (n = 399)	391 (98.0)
Marital status
Unmarried	244 (39.5)
Married	374 (60.5)
Fatigue status
Never	258 (48.2)
Sometimes	263 (49.2)
Often	14 (2.6)
Difficulty in taking care the child at baseline	464 (75.1)

Table 1

The study revealed that more than half of the patients who received an HIV-positive diagnosis (58.6%) started receiving ART (57.1%) between the ages of 1 and 5 years. Nearly half of the patients waited for 1–12 months before starting ARV treatment (44.3%). At baseline, most of the patients had been on ART for more than 10 years. Most of them were in clinical stage 1 (99.0%) and received a first-line ARV regimen (79.9%), with most ARV medication being an NNRTI-based regimen. Only a small number of patients (4.9%) changed their ART regimen during follow-up. The majority of patients were virologically suppressed below the detection threshold (86.4%) and had good immunocompetence, with a CD4 count over 500 (Table 2).

Table 2

Clinical and treatment characteristics of the study participants
Characteristic	Study participants
Age of HIV diagnosis (mean, SD)	2.6 (2.8)
Below 1 year old	168 (27.2)
1–5 years old	362 (58.6)
Above 5 years old	88 (14.2)
Age of starting HIV treatment
Below 1 year old	127 (20.6)
1–5 years old	353 (57.1)
Above 5 years old	138 (22.3)
Waiting time for ARV treatment
1 month	200 (32.4)
From 1 to 12 months	274 (44.3)
Above 12 months	144 (22.3)
Years taking ART
Below 5 years	43 (7.0)
5–9 years	190 (30.7)
Above 10 years	385 (62.3)
Baseline CD4 count
Below 500	63 (10.2)
500–999	328 (53.1)
Over 1000	227 (36.7)
Baseline viral load
Below the detection threshold	534 (86.4)
< 1000	60 (9.7)
1000-100000	18 (2.9)
> 100000	6 (1.0)
Baseline WHO stage
Stage 1	612 (99.0)
Stage 2	6 (1.0)
Baseline ARV regimen (n,%)
First line	494 (79.9)
Second line	124 (20.1)
Number of daily ARV dose (n,%)
1 time	232 (37.5)
2 times	386 (63.5)
Baseline ARV medicines (n,%)
Boost PIs based	123 (19.9)
NNRTIs based	495 (80.1)
Change ARV regimen during follow-up (yes)	30 (4.9)

Table 2

The status of adherence to antiretroviral therapy according to the WHO classification

A majority of the 618 patients in the study were followed up (86.3%). The reasons for routine follow-up were the COVID-19 pandemic (69.4%), caregivers being busy (37.5%) and others (20.0%) (Table 3).

Table 3

Situation of monthly check-ups
Attributes	n,%
Routine follow-up status
On time	533 (86.3)
Late 1–2 days	26 (4.2)
Late 3–7 days	56 (9.1)
Late above 7 days	3 (0.4)
Cause of routine follow-up late (n = 85)
Due to COVID-19 pandemic	59 (69.4)
Due to caregiver busy	32 (37.5)
Others	17 (20.0)

Table 3

All patients (100%) indicated that they took the prescribed medication (Table 4), with the majority (87.7%) reporting no missed doses. Most patients (82.4%) adhered to a daily, on-time medication schedule.

Table 4

**Patient daily medication adherence**
Attributes	n,%
Taking the right ART dosage
Yes	618 (100)
No	0 (0)
Monthly ARV missed doses
No missed	542 (87.7)
Missed 1–2 doses	29 (4.7)
Missed 3–6 doses	26 (4.2)
Missed 7 doses and above	21 (3.4)
Monthly ARV late dose
Not late	509 (82.4)
Late 1–2 doses	59 (9.5)
Late 3–6 doses	39 (6.3)
Late 7 doses and above	11 (1.8)

Table 4

In this study, of the total participants, only 69.4% reported maintaining an adherence level of ≥ 95% in the previous month (Table 5). The reasons for nonadherence to ART included a lack of drugs at the check-up (42.9%), late check-up (37.0%), and missed doses (20.6%).

Table 5
**Adherence to antiretroviral therapy following WHO guidelines**
Attributes	n,%
Level of adherence to ART
Adherence	429 (69.4)
Nonadherence	189 (30.6)
Reason for nonadherence (n = 189)
Monthly heck-up late	70 (37.0)
Missed doses	39 (20.6)
Lack of drugs at the check-up	81 (42.9)

Table 5

Factors associated with nonadherence to antiretroviral therapy

In the bivariate analysis, the factors linked to nonadherence to ART included slow cognitive development, living in a rented house, not attending school, having HIV-positive confirmation between the ages of 1 and 5 years, initiating ART less than 1 month after receiving the HIV diagnosis, having a caregiver who was unemployed, being unmarried, and being sometimes fatigue

The multivariate logistic regression analysis included all characteristics that were significantly correlated with adherence to ART in the bivariable model. Patient-related and medication-related factors were not associated with ART adherence. We found that patients who started ART within the first month after HIV diagnosis demonstrated lower adherence than those who started ART after 1 month and beyond [OR = 1.85; 95% CI (1.15–2.94)]; [OR = 2.38; 95% CI (1.31–4.35)]. Patients whose caregivers were sometimes fatigued remained negatively associated with adherence to ART [OR = 1.65; 95% CI (1.08–2.50)] (Table 6).

Table 6

Factors associated with nonadherence to antiretroviral therapy
Variables		Adherence to ART		OR (95% CI)
Variables		Adherence	Nonadherence	OR (95% CI)
Studying status	No attending school	121 (57.9)	88 (42.1)	1
Studying status	Attending school	308 (75.3)	101 (24.7)	0.66 (0.31–1.44)
House ownership	Own house	320 (73.2)	117 (26.8)	1
House ownership	Rented house	109 (60.2)	72 (39.8)	1.36 (0.88–2.10)
Age of HIV positive confirmation	Below 1 year old	108 (64.2)	60 (35.7)	1
	1–5 years old	270 (74.6)	92 (25.4)	0.67 (0.42–1.08)
	Above 5 years old	51 (58.0)	37 (42.0)	1.05 (0.55-2.00)
Waiting time for ARV treatment	1 month	116 (58.0)	84 (42.0)	1.85 (1.15–2.94)*
	From 1 to 12 months	201 (73.4)	73 (26.6)	2.38 (1.31–4.35)*
	Above 12 months	112 (77.8)	32 (22.2)	1
Mental develop	Normal	426 (70.1)	182 (29.9)	1
Mental develop	Slow	3 (30.0)	7 (70.0)	1.50 (0.28–7.99)
ARV regimen	Boosted PIs based	86 (69.9)	37 (30.1)	1
ARV regimen	NNRITs based	343 (69.3)	152 (30.7)	1.08 (0.65–1.79)
Caregiver’s occupation status	Have a formal occupation	342 (72.6)	129 (27.4)	1
Caregiver’s occupation status	Have no occupation	87 (59.2)	60 (40.8)	1.61 (0.65–1.80)
Caregiver’s marital status	Unmarried	155 (63.5)	89 (36.5)	1
Caregiver’s marital status	Married	274 (73.3)	100 (26.7)	0.68 (0.45–1.03)
Caregiver’s fatigue status (n = 535)	Never	204 (79.1)	54 (20.9)	1
	Sometimes	170 (64.6)	93 (35.4)	1.65 (1.08–2.50) *
	Often	9 (64.3)	5 (35.7)	1.42 (0.41–4.96)
Education of caregiver	Primary school	109 (62.3)	66 (37.7)	1
	Secondary and high school	252 (70.4)	106 (29.6)	0.99 (0.62–1.61)
	Above high school	68 (80.0)	17 (20.0)	0.72 (0.35–1.45)
* p < 0.05, OR = odds ratio, CI = confidence interval

Table 6

A majority of the 618 patients in the study were followed up on schedule (86.3%). This finding was similar to findings from previous studies. A study at Vietnam National Children’s Hospital reported that 86.4% of patients had their examinations on time [19], whereas another study reported that 91.36% of infants were follow-up on time [20]. Notably, while our study was carried out during an outbreak of the COVID-19 pandemic, the proportion of reported timely follow-up was higher in studies conducted before the COVID-19 pandemic. The COVID-19 pandemic disruptions as lockdowns was the most common cause of late regular check-ups (69.4%), followed by caregivers’ busy schedules (37.5%) and other factors (20.0%).

The study team assessed ART adherence among adolescents through three aspects, namely, the number of doses missed in the past month, whether the medication were taken at the correct time, and whether correct doses of medication were taken. This study revealed that all patients in this study reported that they were taking the prescribed medication. The reported adherence in this study was higher than that of many other studies [11, 14, 18, 21], however lower then reported in some Vietnamese studies such as 99.6% [19] and 96.35% [20]. This finding demonstrated high level of reported ART adherence among adolescents’, which indicate that Vietnam has been successful in providing pediatric and adolescent HIV care services. The majority (87.7%) of patients reported taking the right number of ARV doses. However, in this study, the adherence rate to a daily, on-time medication schedule was 82.4%, which was lower than the findings of some studies, such as 98.34% [20] and 92.2% [19].

In this study, adherence to ART following the WHO classification was assessed. Accordingly, the level of adherence among adolescents aged 10–15 years in Vietnam was quite low, with 629 patients adhering to ART, accounting for 69.4%. This result was consistent with findings from other studies conducted in sub-Saharan Africa (65%)[11] and England (69%)[21]. SH Kim et al. (2014) estimated that 62.3% of adolescents and young adults globally were adherent to ART by using a pooled analysis of all eligible studies.

This result was lower than those of previous studies in Ethiopia, with 88.7% 7-day adherence and 93.7% 3-day adherence[12], Ghana (93.2%)[22], and Brazil (94%)[23] as well as Vietnam where when receiving timely and sufficient ARV doses and checked on schedule the level of ART adherence was 91.1% [19], 78.9% ([24], and 91.36% [20]. This distinction between our findings and others might be partly because of the difference in recall time, in this study one month prior to the interview, while the other studies 7 days prior. The rate of adherence with shorter in recall time was higher than that reported in the longer, which has been noted in other studies [12, 25]. These low results suggest poorer adherence to ART among adolescents in Vietnam, possibly influenced by the COVID-19 pandemic, which has led to late follow-up and temporary lack of medications, especially in southern provinces of Vietnam. Due to this finding policy makers and healthcare providers have implementated interventions to improve ART adherence.

The most common reason for nonadherence to ART in our study was a lack of drugs at the check-up (42.9%). As mentioned before, it was obvious that the COVID-19 pandemic negatively affected access to HIV care services globally. Physical distancing and lockdown during the COVID-19 pandemic period decreased the spread of the pandemic across borders. However, this has led to inadequate human resources in ARV manufacturing facilities and, subsequently, a lack of ARV medicines.[15] In particular, when we analyzed a subgroup of ART nonadherent patients due to the unavailability of ARVs at follow-up, we found that most of them (67/81 patients) came late to follow up visits. Gultie et al. (2015) noted that drug side effects and child illness were the two most common reasons for nonadherence [26].

In this study, adherence to ART was significantly associated with the initiation of ARV treatment following HIV-positive confirmation. Patients who started treatment within the first month or had a duration of pre-ARV treatment preparation of less than 1 month demonstrated lower adherence to ART than did those who initiated treatment after 1 month of confirmation and beyond [OR = 0.53; 95% CI (0.33–0.84)]; [OR = 0.41; 95% CI (0.22–0.75)]. A study in Nepal similarly identified nonadherence among patients who initiated ART within 24 months after diagnosis [27]. Delayed ARV treatment initiation was defined as starting treatment more than 30 days after diagnosis and was associated with poor HIV outcomes. Although the WHO recommended initiating ARV treatment as soon as possible after HIV diagnosis, patient education regarding the benefits of ART and the deployment of strategies to optimize care engagement and treatment adherence before the initiation of therapy are needed[7, 28]. A lack of information about HIV or ART or the experience of ART side effects might increase the risk for nonadherence to treatment[26]. Pre-ART counseling and providing information on the ART regimen with patients and caregivers facilitates adherence[7]. Many authors have also noted an association between good adherence to ART and strong awareness of the benefits of ARV treatment[23]. Therefore, the keys to success in HIV treatment are education and adherence counseling. Another reason is that adolescents and their caregivers who experienced HIV complications might possess a heightened awareness of the benefits of ARV treatment, consequently fostering adherence to HIV care.

The family and caregivers of patients play important roles in enhancing the level of adherence to ART among adolescents and children who still need caregiver care and administration.[29] This study highlighted the association between the adherence to ART among adolescents and their caregiver’s fatigue status. The patients whose caregivers experienced occasional fatigue had significantly lower adherence to ART than did the other patients did [OR = 1.59; 95% CI (1.04–2.44)]. A qualitative study in Cuba found that emotional symptoms were more common among caregivers of nonadherent children[30]. This finding clearly suggests the importance of implementing psychological support solutions for families and caregivers of HIV-infected adolescents to positively influence adherence rates.

Limitations of the study

This study has several limitations that should be considered when the results are interpreted. First, the participants lacked consistency in their clinical characteristics. Additionally, the research was not conducted simultaneously across all participating hospitals, and particularly due to the challenges posed by the COVID-19 pandemic, there were delays, leading to an extended period of data collection.

In this study, the level of adherence to antiretroviral therapy was low among adolescents aged 10–15 years in Vietnam. The most common reason for nonadherence was late routine follow-up. The factors associated with nonadherence included initiation of ART within 1 month after HIV-positive confirmation, the caregiver’s fatigue status and the caregiver’s marital status. More efforts should be dedicated to psychological preparation, pre-ARV counseling for patients, and reducing the physical and mental burden on caregivers.

Ethics approval and consent to participate

Consent for publication

All the authors provided consent for publication.

Availability of data and materials

The data presented in this study are available upon request from the corresponding author. The data are not publicly available due to ethical application and approval.

Competing interests

None of the authors have any competing or conflicts of interest.

Funding

The study was supported by the Swedish Research Council (330--2014--6356). In-kind contributions were made by the authors.

Authors' contributions

Conceptualization: Toan Khanh Tran(T.L.T.), Chuc Thi Kim Nguyen(C.T.K.N.), Mattias Larsson M.L., and Linus Olson(L.O.); funding acquisition: C.T.K.N., M.L., and L.O.; methodology: T.L.T., C.T.K.N., M.L., and L.O.; formal analysis: An Van Pham(A.V.P.),T.L.T,and M.L.;investigation: An Van Pham(A.V.P),T.L.T., Trang Quynh Pham(T.Q.P.), Linh Huynh Dinh(K.H.D.), M.L. and L.O.; resources, C.T.K.N., T.L.T., Huong Thu Tram(H.T.T.),Thy Chau Tieu(T.C.T.), An Thien Vu(A.T.V.),Tan Nhat Pho(T.N.P.), Dinh Thi Le(D.T.L.), M.L., and L.O.; data curation, A.V.P.,T.L.T., and T.Q.P.; supervision, T.L.T., C.T.K.N., M.L., and L.O.; project administration, T.L.T., C.T.K.N., M.L., and L.O.; validation, A.V.P.,T.L.T., T.Q.P. K.H.D. and L.O.; writing—original draft preparation, A.V.P. and T.L.T.; Writing—review and editing, all authors; All authors have read and agreed to the published version of the manuscript.

Acknowledgment

The authors would like to thank all the participants who participated in the study. We would like to acknowledge and thank the following people: Lam Van Nguyen (Vietnam National Children’s Hospital, Hanoi), Quy Tuan Du (Children’s Hospital 1, HCMC), Viet Chau Do (Children’s Hospital 2, HCMC), Loc Thi Nguyen (Hai Phong CDC, Hai Phong), Dung Kim Khuong (Quang Ninh General Hospital, Quang Ninh), and others who contributed to the data collection and implementation of the project. We would like to acknowledge all the OPC and trial teams in Vietnam and the hospital boards for their contributions and help. We also thank the Swedish Research Councils for their funding.

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No competing interests reported.

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Antiretroviral Therapy Adherence and Associated Factors Among Hiv Patients Aged 10--15: A Cross-Sectional Study at Five Hospitals in Vietnam

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Abstract

Introduction

I. Subject and methods

Study design and setting

Participants

Sample size

Data collection

Data collection initially

Data collection quarterly

Data analysis

Definition

Ethical issues

II. Results

Sociodemographic characteristics

The status of adherence to antiretroviral therapy according to the WHO classification

Factors associated with nonadherence to antiretroviral therapy

III. Discussion

Limitations of the study

IV. Conclusion

Declarations

References

Additional Declarations

Status:

Version 1