Title: Adherence to antiretroviral therapy among adolescents and young adults living with HIV in Haiti
Description: Adolescents and young adults represent a growing proportion of people living with HIV around the world and have worse outcomes than all other age groups. Retention along each step of the HIV care cascade is essential for optimal care, but importantly, achieving sustained adherence to antiretroviral therapy (ART) and subsequent viral suppression is necessary for decreasing morbidity and mortality and reducing further transmission. The overarching goal of this dissertation was to assess health-services interventions aimed at improving ART adherence among adolescents and young adults living with HIV, and prospectively evaluate one such intervention – point-of-care viral load testing – in a randomized control trial. First, a systematic review was conducted to assess and synthesize recent research on interventions aimed at improving ART adherence among adolescents and young adults living with HIV in a resource-limited setting. Evidence from the review indicated that comprehensive models of HIV care, re-structuring how HIV services were delivered to patients, which included increased monitoring of adolescents and young adults through home visits or case management in addition to standard clinical care improved ART adherence.

Second, a randomized control trial was conducted to evaluate the implementation and effect of point-of-care viral load testing compared to standard laboratory-based testing. The trial had two primary objectives: 1) to assess the efficiency of point-of-care viral load testing, and 2) evaluate the effect of point-of-care viral load testing on health outcomes including ART adherence and viral suppression. The research protocol is described including study design, the point-of-care viral load testing intervention, analysis plan, and outcome definitions. Lastly, the results of this trial are reported which indicate that point-of-care viral load testing can be feasibly integrated into a low-resource, clinical setting. A majority of point-of-care viral load test results (81.8%; 148/181) were processed and returned the same day, with a mean time between blood collection and participant receipt of results of 2.7 hours (IQR: 2.5-3.2; range 1.7-6.0). Point-of-care viral load testing also appeared to improve the accuracy of reported ART adherence, an unanticipated finding.

In the point-of-care arm, participants who reported sub-optimal ART adherence on any of 3 adherence questions were more likely to have a VL >1,000 copies/mL (OR: 6.57; 95% CI: 2.12-25.21), compared to participants in the standard arm among whom the association was weaker (OR: 2.62; 95% CI: 0.97-7.44). There was no difference in viral load outcomes between arms. Overall, this dissertation addresses gaps in our knowledge about interventions aimed at improving ART adherence among adolescents and young adults living with HIV. The key finding is that point-of-care viral load testing can simplify the viral load monitoring process and help clinicians accurately identify adolescents and young adults with a high viral load in order to provide enhanced adherence counseling or make clinical decisions regarding appropriate treatment options faster. Point-of-care viral load testing could be used in concert with other interventions which address additional barriers to ART adherence among adolescents and young adults such as forgetfulness, stigma, or lack of social support.

As the public health field continues to focus on improving HIV outcomes among this vulnerable age group, these findings can guide the optimization of HIV services and the development of combination interventions which could increase the number of adolescents and young adults who achieve sustained ART adherence and viral suppression.