Abstract
Adolescents living with HIV (ALHIV) have low adherence to antiretroviral therapy (ART). Poverty and mental health challenges remain major drivers of this poor ART adherence. We explored the mediators of the impact of an economic empowerment intervention on ART adherence among ALHIV and assessed the moderating effects of depression. We randomized 39 clinics (702 participants) into the control or intervention groups. Participants were aged 10-16, living with HIV and taking ART. The intervention comprising matched savings account, financial literacy training, and microenterprise workshops. We fitted a sequential structural equation model to examine how the three mediators-HIV stigma, barriers to medical care, and healthcare transition readiness-influenced ART adherence at year seven. Depression was included as a moderator. At baseline, the mean age was 12 years, and only 73.0% achieved good adherence (≥ 90%). The intervention directly improved ART adherence, β = 0.060 (95% CI: 0.038, 0.081), p < 0.001. Also, there was a significant indirect effect of the intervention on ART adherence, mediated through barriers to medical care, β = - 0.036 (95% CI: - 0.041, - 0.032), p < 0.001, and HIV stigma, β = - 0.011 (- 0.016, - 0.007), p < 0.001. Depression reduced the effect of the intervention on ART adherence β = - 0.114 (- 0.123, - 0.104), p < 0.001. Our results showed that providing ALHIV with financial resources improved their ART adherence; however, this was affected by depression. Therefore, programs aimed at improving outcomes in ALHIV should consider incorporating interventions that address mental health challenges in addition to poverty.