Adolescent HIV treatment in South Africa's national HIV programme: a retrospective cohort study

Abstract

Background: The number of South African adolescents receiving HIV care and treatment in South Africa is growing. By use of routinely collected laboratory data from South Africa's National HIV Programme, we aimed to quantify the numbers of adolescents accessing HIV care and treatment over time, characterise the role of perinatal infection in these trends, and estimate proportions of adolescents seeking HIV care and antiretroviral therapy (ART) in South Africa's public sector.

Methods: We did a retrospective, descriptive cohort study of children and adolescents aged 1-19 years accessing care in South Africa's public sector HIV treatment programme from 2005 to 2016 with a CD4 cell count or viral load recorded in South Africa's National Health Laboratory Service database. We estimated the total number of children and adolescents entering HIV care with a CD4 cell count or viral load test result by calendar period, as well as the proportion in care and receiving ART with at least one viral load test result. We stratified analyses by gender and by whether the patient entered care at younger than 15 years (probably perinatally infected) or at 15-19 years (probably infected in adolescence).

Findings: We identified 730 882 patients aged 1-19 years at entry to care between Jan 1, 2005, and Dec 31, 2016. 209 205 (54%) of 388 439 patients entering care younger than 15 years and 301 242 (88%) of 342 443 patients entering care aged 15-19 were female. During the study period, the number of virologically monitored patients aged 15-19 years receiving ART increased from 7949 in 2005-08 to 80 918 in 2013-16. 92 783 (66%) of 140 028 patients aged 15-19 years seeking care started ART by 2016, well below UNAID's target of ART for 90% of those diagnosed. We project that the number of adolescents on ART will continue to rise.

Interpretation: The many adolescents aged 15-19 years receiving ART reflect the ageing of children entering care at ages 1-14 years, and increases in care-seeking among horizontally infected adolescents aged 15-19 years. However, many adolescents seeking care do not start ART, suggesting an urgent need for interventions to increase uptake of ART and improve services for this population.

Funding: US National Institutes of Health, and the President's Emergency Plan for AIDS Relief through the US Agency for International Development.

Figure 1:

Flow chart of patients included in analysis

Figure 2:

Gender distribution by age in years at entry to HIV care program

Figure 3:

National distribution of current age among children and adolescents in care in 2016 in South Africa’s public sector HIV program stratified by probable mode* of infection. *Note: age <15 years at entry to care classified as probable vertical/perinatal transmission; age 15+ years at entry to care classified as probable incident horizontal infection. The figure depicts the current age distribution of all patients in care in 2016 who entered care aged 1-19 years at any point during the period 2005-2016.

Figure 4:

National distribution of age among children and adolescents on ART in South Africa’s public sector HIV program, stratified by calendar year

Figure 5:

Projected estimated numbers on ART* among adolescents aged 15-19 years *Notes:

1. The solid black line above the columns for 2005-2016 reflects observed trends in numbers on ART

2. All data beyond 2016 are projections of numbers on ART based on assumptions in the text:

   1. Columns from 2016-2021 reflects projected numbers on ART stratified by mode of infection assuming no improvement in ART uptake or retention

   2. Dashed line from 2016-2021 reflects projected numbers on ART assuming 90% annual rate of retention

   3. Dashed/dotted line from 2016-2021 reflects projected numbers on ART assuming 90% uptake of ART and annual rate of retention at 90%