Evaluation of the Psychosocial and Clinical Outcomes After Life Skills Provision among Perinatally HIV-Infected Older Adolescents at Mbagathi Hospital, Nairobi, Kenya

Abstract

HIV-related deaths account for the highest mortality among older adolescents and young people in Africa. Studies evaluating the most effective interventions to support disclosure in sub-Saharan Africa have not focused on life-skills provision aimed at empowering adolescents living with HIV (ALWHIV) to navigate the health system after transition to adult care. The overall objective of this study was to evaluate the effect of the introduction of a life skills curriculum as a transition to adult care support tool among perinatally infected adolescents receiving care at Mbagathi hospital, Nairobi, Kenya. The study employed a randomized clinical trial design and utilized a mix-methods approach to conduct the study in two phases between December 2018 and September 2019 among 140 ALWHIV aged 16-18 yrs. For the first phase of the study which utilized a formative qualitative approach, 58 adolescents were enrolled and eight focus group discussions (FGDs) and ten in depth interviews (IDIs) were conducted. Based on the qualitative data, the Baylor’s curriculum was adapted and contextualized to include identified additional topics and exclude those that did not emerge as relevant to the adolescents The curriculum was pilot tested among an additional 82 HIV positive adolescents randomized to an intervention arm (n=42); receiving the life-skills utilizing the modified curriculum and standard care) and a control arm (n=40); receiving standard of care consisting of psychosocial support for adolescents with virological failure and ad hoc unstructured support groups). Viral load, Antiretroviral therapy (ART) adherence self-efficacy and self-esteem were measured at baseline and 12 weeks post the intervention Viral load suppression was the primary clinical outcome defined as ≤1000copies (results abstracted from patient files from latest blood sample result within the past one year), while ART adherence self –efficacy (measured by the HIV-Adherence self-efficacy assessment survey (HIV ASES) utilizing ≥60 as cut-off) and self –esteem (measured by the Rosenberg scale; utilizing ≥35 as cut-off)) were secondary outcomes. Data were also collected on sociodemographic and self-reported adherence to ART. Thematic analysis with an inductive-deductive approach was conducted for the analysis of qualitative data. Regression analysis was conducted to identify determinants of adherence while difference in difference analysis was utilize to analyse outcomes between the two study arms. The qualitative results revealed that adolescents’ experiences challenges in antiretroviral adherence and struggled with psychosocial distress post-disclosure of their HIV status. They also expressed that they had many informational needs including how to set goals, reach their aspirations and utilize HIV prevention service such as Pre-exposure prophylaxis (PrEP). The RCT found that odds of increased self-reported adherence were 8.1 times higher among adolescents with higher ART Adherence self-efficacy (95% CI [2.31- 28.18]) and 3.8 times higher (95% CI [1.11-12.72]). The self-reported adherence ≥95% had a high correlation with viral loads of <1000 copies ml (Kappa= 0.87). ART adherence self-efficacy was significantly higher among the adolescents in the intervention group (p=0.012). Viral suppression (p=0.003) and self-esteem (p=0.04) were also higher in the intervention group. The study reported unmet psychosocial needs among older ALWHIV, particularly during disclosure of their own HIV status and when they disclosed to others. The contextualization of the life skills intervention in this study improved psychosocial and clinical outcomes among ALWHIV. The finds indicate a gap in tailored psychosocial support and psychosocial care training content targeting used older adolescents’ unique needs. Further research into adherence self-efficacy as a potential indicator of transition readiness assessment to adult care for ALWHIV is warranted to meet the needs of older adolescents.