Teenagers not taking HIV drugs, says report

A growing number of adolescents living with HIV are not taking the antiretroviral drugs (ARVs) that prevent the onset of Aids and minimise infecting other people, a new report warns.
 
The Annual Health Sector Performance report covering July 2022 to June 2023 shows that antiretroviral retention rates, which measures the number of people who continue to take the life-prolonging medications after they start on them, remain generally high.
 
However, the study found that one in five patients who started on anti-retroviral therapy (ART) had dropped out a year later, with the highest drop-out rate among adolescents.  
 
Taking antiretrovirals as directed by health workers is a key element in preventing the onset of Aids on top of reducing the risk of transmission to others, and death, according to health guidelines from the World Health Organisation.
 
The report shows significant variation in compliance across the country, with some districts retaining only half of the people who started on ARVs 12 months later. 

“ART retention rate at 12 months declined by six percent from 83 percent in 2021/2022 financial year to 77 percent by the fourth quarter of 2022/2023 financial year. Only six out of 146 [district]local governments achieved the target of 95 percent,” the report notes. 
 
The six districts that achieved the target were Rubirizi, Mitooma and Kaabong at 100 percent, Abim at 99 percent, and Rubanda at 97 percent. Adherence was lowest in Karenga (59 percent), Kibuku (55 percent), Kween (52 percent), Kalungu (51 percent) and Nakapiripirit (48 percent), according to the report.
 
The regions with the highest ART retention were West Nile, Tooro, Ankole, Lango, and Bukedi. The worst-performing regions were Kampala and Bugisu, according to the report. 

About 1.4 million Ugandans are living with HIV, of whom 1.2 million are on ART.
 
Dr Nelson Musoba, the director general of the Uganda Aids Commission (UAC), blamed stigma for the declining adherence to treatment.
 
“Stigma and discrimination are the key factors that affect adherence and the more you give information and provide services, then that gets reduced,” he told this newspaper. 
 
Dr Musoba called for renewed efforts to address high infection rates and declining adherence among young people, particularly women. 

“Out of the 52,000 new infections that we had last year, women accounted for 30,000, and 70 percent of those new infections for women were adolescent girls and young women between the ages of 15 and 25. So they are clearly more affected by HIV and this is because of factors such as lack of information on how to protect themselves,” he noted.

Dr Musoba added: “We are failing to achieve viral suppression. When you look at who is defaulting, it is again young people – those aged 0-10, and 10-19, we are not doing well at all.” 

Adherence
Declining adherence to treatment is a challenge to Uganda’s plan to end Aids as a public health threat by 2030, as more people die because of failure to adhere to medication or spread the infections because their viral load is not suppressed.
 
A total of 17,000 Aids-related deaths and 52,000 new HIV infections were recorded in Uganda last year, according to UAC figures.
 
The findings come amid increasing concern from healthcare officials and donors over the rising cost of HIV care due to drug resistance. 

Financial burden
Ms Sarah Nakku, an adviser at the joint United Nations Programme on HIV/Aids (Unaids), said low adherence is increasing the burden on donors and the government.

She said: “The cost of fighting HIV keeps increasing because although we are seeing a reduction in prices for ARVs, that is first-line treatment, at a cost of approximately Shs60,000 per person per month, we are seeing an increase where we register a failure of adherence to treatment because second-line treatment costs Shs250,000 per person per month and third-line treatment costs  Shs800,000.”

Ninety-six percent of Ugandans on ART are on first-line therapy and less than one percent on third-line therapy. Adolescents make up 4.3 percent of those on first-line therapy but 20 percent of those on third-line, which could be driven by the start-stop approach to medication. Some 61,804 Ugandans aged 10-19 are on the three lines of ART, according to UAC.
 
“The more they drop off, the more they can’t [respond] to first-line treatment,” Ms Nakku said. 

She added: “It means you have to shift them when they decide to come back. They call it a drug holiday. They need to live and they still have hope in life, so if they decide to come back, we start them on second-line treatment which is more costly. We are seeing that constant drug resistance, which is not good.” 
 
The report shows that between July 2022 and September 2022, ART retention among children stood at 75 percent, 57 percent for adolescents and 74 percent for adults. 

During April 2023 to June 2023, it had risen to 82 percent among children and adults but had increased slower among adolescents, to 73 percent. It was not clear what caused the variations.
 
Access rights
A section of young people living with HIV who spoke with our reporter on condition of anonymity because of fear of stigma, said they face many barriers in accessing care and adhering to treatment.
 
“There is pill burden, especially for people who are unsuppressed,” a teenage girl living with HIV said. “Taking one or more tablets a day makes us feel tired. The people living with HIV are considered marginalised, have no jobs, or are unemployed, and so they start blaming themselves because of their status and start thinking that there is no reason to live and so they ask themselves why they have to continue taking the medicine and so they give themselves a break – a drug holiday.”
 
Another teenager living with HIV said they feel unwelcome and judged whenever they go to health facilities for HIV care. 

“The attitude of health workers in the facilities is not good. When you air out your issue to them, they will become harsh and start focusing on your age. This makes one to not adhere to medication.” 
 
Dr Musoba said long-acting injectable ARVs, which Uganda is piloting alongside other countries, would improve adherence to treatment because it is more convenient and reduces stigma associated with taking oral pills.
 
Reducing the number of visits to health facilities would also help. 

In a study conducted in Ibanda in 2023 and published by the National Library of Medicine, Ms Christine Nimwesiga from the Kampala-based Infectious Diseases Institute found that ART retention fell to as low as 35 percent for adolescents three years after starting treatment. 
 
The study examined clinical data from 84 adolescent girls living with HIV enrolled from 2019 to 2020 in eight health facilities in Ibanda District. “Factors associated with retention in care found that 66.7 percent of the respondents whose ART clinic day was once a month were retained in care as compared to the 33 percent retention among those 2–3 days,” the study found.
 
The researcher also noted that up to 96.7 percent of the respondents who had “treatment supporters” had retention in HIV care unlike those who did not. Furthermore, retention in HIV care was found at 90 percent among respondents without any medical condition, and 100 percent among those that tested negative for TB.
 
The study also found that respondents who had access to psychosocial support and those who had disclosed their HIV status to a friend or a family member were more likely to stick to their treatment regimes.