Abstract
INTRODUCTION: Supporting and improving antiretroviral therapy (ART) adherence and preventing the evolution of HIV drug resistance remain major challenges for children and adolescents living with HIV globally. In a large global HIV clinical data consortium, we sought to describe how global HIV care programs measure and support pediatric ART adherence, as well as patient-level measures of adherence. METHODS: We prospectively collected site-level data between June 2014-March 2015 using a site assessment survey and retrospectively examined patient-level data collected during routine clinical care, to provide a comprehensive assessment of pediatric ART adherence across the International Epidemiology Databases to Evaluate AIDS (IeDEA) cohort, in six global regions. All regions capturing patient-level data on adherence by any measure for children living with HIV aged less than 14 years between 2000-2015 were asked to contribute data. ART adherence was conceptualized as a binomial variable of "good" (greater than 90%) or "poor" (90% or less) adherence per visit. RESULTS: Clinical staff from 180 pediatric sites in 45 countries completed the adherence survey. Clinician adherence assessment (used at 87% of sites) and pharmacy refills (86% of sites) were the most common adherence measurement methods used globally. Counseling focused on adherence was the most commonly available support service, (94% of sites). 28,664 pediatric patients had at least one adherence measurement, to be included for adherence analyses. In East Africa and Southern Africa, higher baseline CD4 counts were associated with a greater likelihood of viral suppression; however, in Central and South America and the Caribbean (CCASAnet) and Asia-Pacific, we did not find a consistent relationship between baseline CD4 count and the likelihood of viral suppression. We found evidence that very young children (< 2 years of age), older children (> 10 years of age), and males were less likely to experience viral suppression in East Africa and Southern Africa. CONCLUSION: These findings indicate that the majority of global pediatric HIV care services routinely measure ART adherence for children living with HIV; however, few sites use objective or validated measures. Identifying subgroups of children and youth at highest risk for non-adherence allows care programs to target those most in need of adherence support or resistance monitoring.