Introduction: In spite of progress in antiretroviral therapy (ART) programs, adolescents remain largely vulnerable to poor ART outcomes, due to non-adherence. In the frame of limited evidence on ART adherence during adolescence in resource-constrained settings, we aimed at evaluating the rate of adherence to ART among adolescents and associated factors in Cameroon. Methods: A cross-sectional study was conducted among 401 adolescents receiving ART in 13 health facilities of the Centre Region of Cameroon, from April through August 2018. Adherence was evaluated using a composite of both self-reported and pill count assessments. Risk factors of non-adherence were assessed using the socio-ecological model and p<0.05 were considered statistically significant. Results: Mean age was 14.63 (±2.89) and 55.9 % (224) were female. Rate of adherence was 25.2% (composite-assessment), 38.2% (pill-count) and 60.6% (self-reported). Following the composite-assessment, non-adherence was significantly higher in: vertically vs. horizontally infected adolescents (OR 4.24; 95% CI: 2.16-8.33, p<0.001); facilities with combined adult/adolescent vs. specialized adolescent care (0.32; 95% CI: 0.20-0.52, p<0.001); living beyond 5 km from the heath facility (OR 1.99; 95% CI: 1.26-3.15, p=0.003; inconvenient clinic appointments (OR 3.03; 95% CI: 1.78-5.16, p<0.001); Following multivariate analysis, non-adherence was associated with “living beyond 5 km from the heath facility” (OR 1.84, 95% CI: 1.01-3.33, p=0.045); “adolescents taking medication in the same service with adult” (OR 0.11, 95% CI: 0.03-0.35, p<0.001), managed at a rural health facility (OR 4.29, 95% CI: 1.84-9.96, p=0.001) and not counseled regularly (OR 0.02, 95% CI: 0.01-0.36, p=0.007). Conclusion: In the Centre region of Cameroon, about three-quarters of adolescents might be non-adherent to ART. Interventions towards improved adherence should focus on adolescents managed at the rural health facility and with vertical HIV-infection. Furthermore, convenient clinic appointments, creation of friendly adolescent healthcare centres and decentralising HIV-adolescent care in rural settings would improve adherence to ART program.
Of the estimated 36.3 million people living with HIV (PLHIV) worldwide, about 2.1 million adolescents are adolescents 1, 2, 3, 4, 5, of whom the majority (1.7 million) are living in sub‐Saharan Africa (SSA) 6, 7. Globally, HIV/AIDS is the second leading cause of adolescent mortality and the very first cause of mortality in Africa 7, 8. Of note, while AIDS‐related deaths has decreased by 30%, mortality among adolescents has increased up to 50%, making HIV/AIDS a major health concern during adolescence, especially in low and middle income countries (LMICs) that are disproportionately burdened by the pandemic 8, 9.
Adolescence (10-19 years) is known as the phase of physical growth and development, accompanied by sexual maturation, intimate relationships, changes in sexuality 6, 10, 11, 12, mental capacity 13, self-efficacy and independence. In this transition phase of life, adolescents are highly vulnerable to HIV/AIDS and other sexually transmitted infections (STIs), and those infected from birth encountered challenging in the continuum of care 14. Of note, adherence to ART, known as the footprint for therapeutic success, remains a major setback for adolescents receiving ART 14. Therefore, in order to meet the third pillar of the UNAIDS 90‐90‐90 targets (90% of PLHIV know their status, 90% of those who know their status are on treatment, and 90% of those on treatment are virally suppressed) among adolescents living with HIV (ALHIV) 15, it is essential to implement efficient measures for adherence assessment and to identify areas of specific interventions for the improved management and monitoring of adolescents receiving ART 14.
As a key component of adherence to ART program, retention in care has been extensively evaluated in several African countries, including Cameroon 16, 17, 18, 19. Nonetheless, there are fewer evidence on adherence levels among ALHIV, as well as methods and tools to ensure a thorough monitoring in routine clinical practice 14.
At country level, there is an urgent need of generating information on the number of ALHIV (10-19 years) in care and factors affecting their response to treatment, considering early and advanced age adolescence, as well as other socio-demographic, environmental and clinical factors 20, 21. Cameroon has endorsed in current UNAIDS 90-90-90 goals 19, 20, 21, with a preliminary report of 36% adherence rate among adolescents in an urban site of Yaoundé, which therefore call for informed policy-implementation that would contribute to the success of the ART program 22, 23, 24, 25, 26. We therefore sought to ascertain rate of adherence to ART of adolescents and factors associated with poor adherence in a typical Cameroonian context.
Using a quantitative approach and a socio-ecological model, a cross-sectional study was conducted in the period ranging from April through August 2018 among ALHIV receiving ART in 13 health facilities (Mother-Child Centre of the Chantal BIYA Foundation, Yaounde Health Centre, Yaoundé Jamot Hospital, National Welfare Social Insurance Hospital, Ayos Regional Hospital, Cite Verte District Hospital, Efoulan District Hospital, Obala District Hospital, Olembe District Hospital, Mbalmayo District Hospital, Bikop Health Centre, Health and Social Animation Centre of Nkoldongo, Nkomo Medical Centre), coming from 8 health districts of the Centre Region of Cameroon.
2.2. Description of the Study SettingsThe Centre region of Cameroon has the national capital city, has 30 health districts for a total of 3,724,000 inhabitants. This region also has reference paediatric health facilities and the highest number of PLHIV on ART, including those at adolescence (25% national coverage) 22. In the entire region, a total of 105 health facilities provide ART of which 99 had adolescent healthcare services.
2.3. Sampling Method and ProcedureBased on a stratified random sampling from the total 99 adolescent healthcare facilities in the Centre region, 26 health facilities meet the eligibility criteria of having a minimum of 30 ALHIV receiving ART. From these 26 eligible sites, 50% (13) were randomly selected as study sites to ensure the regional representativeness.
In every study site, adolescents were enrolled based on the following criteria: aged 10-19 years, on ART for at least 6 months, registered for ART monitoring in the study site, and whose consent/assent was provided.
For the entire study, the minimum sample size was calculated based on the following statistical formula (Eq1):
 |
With P=0.36 (rate of 36% adherence in the aforementioned study conducted among adolescents in the city of Yaoundé in Cameroon) 26, Z=1.96 at 95% confidence interval (CI), with D=0.05 error rate. This resulted to a minimum sample size “n” of 354 participants to be enrolled in the study.
2.4. Data Collection and MeasurementsPrior to implementation, data collection tool was pretested and validated in one health facility. After pretesting, data collection was done by trained study investigators during routine clinic attendance of adolescents in each of the study site. Briefly, a structured questionnaire was administered eligible to each eligible ALHIV. This form entailed socio-demographic data as well as individual factors, health system factors, family and psychosocial factors, treatment history, biological parameters, and clinical factors that could influence adherence. Additionally, medical data were retrieved from existing medical records.
Adherence measurement was based on three different approaches: (1) self-report by the patient, (2) pharmacy pill count, and (3) composite of both self-reported and pill count. For the self-reported adherence, the Center for Adherence Support Evaluation (CASE) adherence index tool was used, consisting of three questions that summed to a total score of 19 points. Participants with a CASE Index score ≥10 were classified as good adherence compared to those with a CASE Index score <10 with poor adherence 23. Pharmacy pill count was calculated by subtracting the number of pills returned by a patient from the expected number of pills to be available. Good adherence based on pill count was defined as a score ≥95% of drug intake (i.e. corresponding to 29 out of 30 days intake for a single pill daily prescription). Finally, the composite adherence assessment was based on the combination of both methods (CASE index score and pill count), and good adherence by the composite method was defined as both a CASE Index score ≥10 and pill count ≥95%.
2.5. Data AnalysisStatistical analyses were done using STATA version 10.1. Chi-square test was used to evaluate differences in frequency distribution. Analysis of variance (ANOVA) was used to assess differences between group means. All p-values <0.2 from bivariate analyses were included in the multivariate logistic regression to determine the association of independent factors associated with adherence to ART. P-value less than 0.05 were considered as statistically significant at 95 % confidence level.
2.6. Ethical and Administrative ConsiderationsEthical Clearance for the study was obtained both from the Regional Delegation of Public Health of the Centre region - CE02243N°/CRERSHC/2017 and the Institutional Review Board of the Faculty of Health Sciences of the University of Buea - 2018/024/UB/SG/IRB/FHS. An administrative authorization was obtained from the Regional Delegation of Public Health, Centre region - 1902/L/MINSANTE/SG/DRSPC. A written informed consent was obtained each guardian as well as informed assent from each participant. For purpose of confidentiality and privacy, data were managed using specific identifiers and stored in a password-protected computer.
A total of 401 adolescents were enrolled from the 13 study health facilities in the Centre region of Cameroon. The mean age was 14.63 (±2.89) and 55.9% (224) were female; the majority [243(60.6%)] of the adolescents were at the secondary level of education. Almost all the adolescents [394(98.3%)] were single and more than half of them (56.6%) living with their parents at the time of study. A non-negligible number [49 (12.2%)] of these adolescents reported to be alcohol consumers and 13 (3.2%) were cigarette smokers. About half them lived around their respective health facilities (Table 1).
According to each adherence assessment method, the rate of adolescents reported with good adherence was 60.6%, 38.2% and 25.2% by the self-reported, the pill count and the composite methods, respectively (Figure 1).
3.3. Factors Associated of Non-adherence to ART among Study ParticipantsAccording to marital status, single adolescents were 19 times more at risk of non-adherence compared their married peers (OR 18.88; 95% CI: 2.25-158-84; p=0.007). Living more than 5 kilometers away from the health facility had 2 times more at risk of poor adherence as compared to those who lived less than 5 kilometers away (OR 1.99; 95% CI: 1.26-3.15; p=0.003), and those involved in sexual activities had two times less risk of non-adherence (OR 0.50; 95% CI: 0.31-0.83; p=0.007), as shown in Table 2.
Compared to faith-based centres, adolescents receiving ART in private health facilities were about 21 times more at risk of non-adherence (OR 20.87; 95% CI: 2.57- 169.40; p=0.004), those in parastatal health facilities had 3 times more risk of non-adherence (OR 33.06; 95% CI: 1.446- 6.44; p=0.003). Adolescents taking their treatment at the same centres with adults were at higher risk of non-adherence score as compared to those in the centres without adult care (OR 0.32; 95% CI: 0.20-0.52; p<0.001), as shown in Table 3.
According to transmission mode, vertically infected adolescents had 4 times more risk of non-adherence compared to those infected horizontally (OR 4.24; 95% CI: 2.16-8.33; p<0.001); those on ART beyond 12 months had 3-10 times more risk of non-adherence (see Table 4). Disclosure of HIV status before 10 years of age had 3 times more risk of non-adherence compared to disclosure between at 15-19 years old. Unsuppressed viral load had 5 times more risk of non-adherence compared to those with suppressed viral load result (OR 4.99; 95% CI: 2.56-9.73; p<0.001) in Table 4.
Failure to take treatment on time had 3 times more risk of being non-adherence to ART (OR 3.71, 95% CI: 1.64-8.40 p=0.002), and not taking medication as prescribed due to side effects also had a slight higher risk of being non-adherent (1.17; 95% CI: 1.08-2.74, p=0.023), as shown in Table 5.
No environmental factor was found to be associated with non-adherence, as shown in Table 6.
Regarding healthcare delivery services, having an inconvenient clinic appointment date (OR 3.03, 95% CI: 1.78-5.16, p<0.000) and not attending hospital adherence awareness workshops (OR 2.38, 95% CI: 1.28-4.41, p=0.006) were significantly associated with non-adherence to ART, as detailed in Table 7.
In multivariate analysis, factors significantly associated with non-adherence were (a) “being single” (OR17.59, 95% CI: 1.89-163-67, p=0.012) and (b) “living far from the health facility” (OR1.84, 95% CI: 1.01-3.33, p=0.045), as shown in Table 8.
In multivariate analysis, factors significantly associated with non-adherence were: (a) “being managed in a private health facility” (OR17.59, 95% CI: 181.17-1984.99, p<0.001); (b) “being managed in the same health facility with adults (OR0.11, 95% CI: 0.03-0.35, p<0.001); and (c) being managed at a rural health facility (OR4.29, 95% CI: 1.84-9.96, p=0.001); as detailed in Table 9.
In multivariate analysis, factor significantly associated with non-adherence was have a viral load unsuppressed (OR 4.71, 95% CI: 1.88-11.79, p=0.001); as detailed in Table 10.
In multivariate analysis, factor significantly associated with non-adherence was being Not counseled regularly (OR0.02, 95% CI: 0.01-0.36, p=0.007); as detailed in Table 11.
With the goal to contribute in achieving the third pillar of the 90-90-90 targets through improved adherence among the most disproportionally affected population by HIV/AIDS, our present study focused on evaluating adherence to ART and associated factors among adolescents living with HIV/AIDS in the Centre Region of Cameroon.
In this study with a slightly higher proportion of female adolescents (similar to previous reports) 24, 25, 26, 27, in a population of adolescents mainly infected vertically 28, the rate of adherence appeared very low (i.e. one quarter). This finding underscores the fact that adolescents constitute a vulnerable population in the field of HIV/AIDS, and therefore deserve specialised care to ensure their successful transition from pediatric to adult care. Moreover, adherence level varies decreasingly from the self-reported method, pill count, to the combined method. This observation is similar to a systematic review conducted in 2014 reporting a varying range of 16% to 99% adherence rates amongst ALHIV from LMICs 9. In a study conducted in a single health facility in Yaoundé, 36% of ALHIV were reported adherent to ART following self-reporting 26, as compared to 60% from our present investigation. The discrepancy observed highlights the lack of reliability of self-reported adherence in assessing compliance to ART. Furthermore, the former study was conducted only in an urban health facility while our study was conducted in several health facilities of both rural and urban areas, thereby giving a better appraisal of the local context 9, 26.
Adolescents thus face several challenges in accepting their status and in gaining autonomy towards treating their infection, as most of them are in denial, afraid, misinformed or lack familial or social 9. Thus, to ensure a successful transition to adult care, identifying risk factors of non-adherence are essential for ALHIV receiving ART.
Regarding socio-demographic features, neither sex nor age ranges of adolescents were not found to be associated with adherence. However, single adolescents were about 18 times at risk of non-adherence when compared to those who were married. This is similar to the study 7, likely due to the fact that married adolescents have support towards adherence from their partners, coupled to adherence motivated by the needs to avoid infecting their partner and to achieving suppressed viremia as a prerequisite for procreation 7.
Beyond 12 months after ART initiation, adherence becomes very concerning, and is known as the driven factor of the high mortality amongst ALHIV, with varying adherence in Africa as compared to the western world 25, 29, 30, 31. This suggests the need for active patient involvement mediated by healthcare provider’s support 32.
Adolescents receiving ART in faith-based health facilities were more adherent compared to their peers in parastatal and private facilities. This should be due to the fact that in religious health facilities, prayer, as a form of psychosocial support through spiritual belief, is an important and integral part of patient care. Adolescents taking their treatment at the same centers with adults were more likely to be non-adherent rather than those in centers without adult care. This should be due to the fact that adolescents still feel belonging to the pediatric population and, coupled to their aforementioned peculiarity, need of a separate service for clinical monitoring. Nonetheless, familiarising adolescents gradually with adult care service, could help in facilitating transition to adult care, pending findings on effective implementation strategies.
It has been found that adolescents taking their medication in the facilities located in the rural zone were 5 times likely to be non-adherent rather than those in the urban zone. This should be due to the fact that most of the activities relating to the care of adolescents living with HIV are centred at the level of health facilities.
On a separate note, adolescents with unsuppressed viral load were 5 times at risk of being non-adherent compared to those with suppressed viral load. This supports the use of viremia as an indicator of adherence in the absence of HIV drug resistance 7, 16.
Among the health care delivery factors, not counselled regularly by health care providers, was predictors of non-adherence to ART, suggesting the need for caregivers to pay attention to patient’s need/preference 3.
Although our investigation contributes to knowledge on ART adherence and associated factors during adolescence in the Centre region of Cameroon, the current design was limited to quantitative data analysis. Qualitative assessments are henceforth needed for in-depth understanding of barriers to adherence and mitigating factors.
This study identified 7 predictors of non-adherence to ART among adolescents across 13 health facilities. Following the composite approach, the adherence rate appears very low, and varies between self-reported and pill-count measurements. Thus, in the Centre region of Cameroon, about three quarter of adolescents might be non-adherent to ART. Interventions towards improved adherence should focus on adolescents living more than 5 km from the health facility, in rural areas, and within the private and public health facilities. Furthermore, creation of adolescent healthcare centres and enhance counselling would improve adherence to ART program in resource-constrained countries facing similar challenges like Cameroon.
The study was conducted with support from the investigative team.
AK, FA, FM and MNN: designed and implemented the study; AK collected the data; AK, EA and JF: analysed and interpreted the data; AK: initiated the manuscript; FA and JF: revised the initial version of the manuscript; All authors: revised and approved the final version of the manuscript.
Our gratitude goes to the HIV/AIDS adolescents and their parents/caregivers for their voluntary participation and collaboration throughout the study. We also thank all the Directors and staff of the health facilities in the Centre Region who took part in the study, for their technical collaboration. We also acknowledge Pr Zoung-Kanyi Bissek Anne Cecile, Dr Zeh Kakanou Florence, Dr Elat Nfetam Jean Bosco, Dr Nelly Kamgaing, M. Kembou Etienne, Dr Amando Frank, Dr Andreas Frambo, M. Choffo Eugène, Forteh Emmanuela and Ms. Takam Arrey for providing assistance in the better implementation of this study.
The authors have no potential conflict of interest to declare.
| [1] | Davies M-A, Pinto J. Targeting 90–90–90 – don't leave children and adolescents behind. Journal of the International AIDS Society. 2015; 18(7Suppl 6):20745. | ||
| In article | View Article | ||
| [2] | UNAIDS. 2016. Fact sheet, world AIDS day. Available at: https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf. assessed on 27th September 2018. | ||
| In article | |||
| [3] | Ammon N, Mason S, Corkery J. Factors impacting antiretroviral therapy adherence among human immunodeficiency virus-positive adolescents in Sub-Saharan Africa: a systematic review. Public health. 2018;157:20. | ||
| In article | View Article PubMed | ||
| [4] | UNAIDS. 2017. Global HIV & AIDS statistics fact sheet. Available at: https://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf Assessed on 2th November 2018. | ||
| In article | |||
| [5] | Bell M. Care of the HIV-positive adolescent. Developmental stages and provider sensitivity play a special role: Posit Aware. Indian J Sex Transm Dis AIDS. 2006; 17(4):36-9. | ||
| In article | |||
| [6] | Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. Lancet. 2012; 379(9826):1641-52. | ||
| In article | View Article | ||
| [7] | Biressaw S, Abegaz, W. E., Abebe, M., Taye, W. A., & Belay,M. Adherence to antiretroviral therapy and associated factors among HIV infected children in Ethiopia:. BMC Pediatrics. 2013. | ||
| In article | View Article PubMed PubMed | ||
| [8] | UNAIDS. 2016. Global AIDS Update. Geneva, Switzerland: The Joint United Nations Programme on HIV/AIDS. Available at: https://www.unaids.org/en/resources/documents/2016/Global-AIDS-update-2016. Assessed on 3th November 2018 | ||
| In article | |||
| [9] | Hudelson C, Cluver L. Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low- and middle-income countries: a systematic review. AIDS Care. 2015; 27(7):805-16. | ||
| In article | View Article PubMed | ||
| [10] | UNAIDS.2016. ALL IN to end the adolescent AIDS epidemic — A progress report. Available at: https://www.unaids.org/en/resources/documents/2016/ALLIN2016ProgressReport.Assessed on 5th December 2018. | ||
| In article | |||
| [11] | UNICEF. 2015. Progress for children. New York. Available at: https://www.google.com/search?q=UNICEF.+Progress+for+children.+New+York:+UNICEF. Assessed on 7th October 2018. | ||
| In article | |||
| [12] | UNAIDS.2016.All in: end adolescent AIDS. Available at: https://wwwunaidsorg/sites/default/files/media_asset/20150217_ALL_IN_brochurepdf. Assessed on 18th October 2018. | ||
| In article | |||
| [13] | Mburu G, Hodgson I, Teltschik A, Ram M, Haamujompa C, Bajpai D, et al. Rights-based services for adolescents living with HIV: adolescent self-efficacy and implications for health systems in Zambia. Reprod Health Matters. 2013; 21(41):176-85. | ||
| In article | View Article | ||
| [14] | Napierala Mavedzenge S, Newman JE, Nduwimana M, Bukuru H, Kariyo P, Niyongabo T, et al. HIV infection among children and adolescents in Burundi, Cameroon, and the Democratic Republic of Congo. AIDS Care. 2017;29(8):1026-33. | ||
| In article | View Article PubMed | ||
| [15] | UNAIDS. 2014. 90‐90‐90: an ambitious treatment target to help end the AIDS epidemic. Available at: https://www.unaids.org/en/resources/documents/2017/90-90-90. Assessed on 12th November 2018. | ||
| In article | |||
| [16] | Fonsah JY, Njamnshi AK, Kouanfack C, Qiu F, Njamnshi DM, Tagny CT, et al. Adherence to antiretroviral therapy (ART) in Yaoundé-Cameroon: association with opportunistic infections, depression, ART regimen and side effects. PloS one. 2017; 12(1): e0170893. | ||
| In article | View Article PubMed PubMed | ||
| [17] | O’Bryan G. Factors associated with ART non-adherence and contributing influence of stock shortages at Nkongsamba Regional Hospital, Cameroon.Global health. 2015; [264]. | ||
| In article | |||
| [18] | Pefura Yone EW, Soh E, Kengne A, Balkissou A, Kuaban C. Non-adherence to antiretroviral therapy in Yaounde: Prevalence, determinants and the concordance of two screening criteria. PLoS One. 2017; 12(1). | ||
| In article | |||
| [19] | Meresse M, March L, Kouanfack C, Bonono RC, Boyer S, Laborde-Balen G, et al. Patterns of adherence to antiretroviral therapy and HIV drug resistance over time in the S tratall ANRS 12110/ESTHER trial in C ameroon. HIV medicine. 2014; 15(8): 478-87. | ||
| In article | View Article PubMed | ||
| [20] | NACC. 2014. Global Aids Response Progress (GARP). Available at: https://wwwunaidsorg/sites/default/files/country/documents/CMR_narrative_report_2014pdf. Assessed on 6th October 2018. | ||
| In article | |||
| [21] | Maddali MV, Gupta A, Shah M. Epidemiological impact of achieving UNAIDS 90-90-90 targets for HIV care in India: a modelling study. BMJ Open. 2016;6(7):e011914. | ||
| In article | View Article PubMed PubMed | ||
| [22] | CNLS. 2016. Annual report. Available at: https://wwwcnlscm. Assessed on 2th December 2018. | ||
| In article | |||
| [23] | Rongkavilit C, Wright K, Chen X, Naar-King S, Chuenyam T, Phanuphak P. HIV stigma, disclosure and psychosocial distress among Thai youth living with HIV. Int J STD AIDS. 2010;21(2):126-32. | ||
| In article | View Article PubMed | ||
| [24] | Marima R. The Prevalence and factors associated with nonadherence with ARV treatment and cotrimoxazole preventive therapy among HIV infected adolescents attending out-patient HIV clinics in Kenya. Aku institutional repositiry. 2011. | ||
| In article | |||
| [25] | Naswa S, Marfatia YS. Adolescent HIV/AIDS: Issues and challenges. Indian J Sex Transm Dis AIDS. 2010;31(1):1-10. | ||
| In article | View Article PubMed PubMed | ||
| [26] | {Chhim, 2018 #371} | ||
| In article | |||
| [27] | MINSANTE. Cameroon Population-Based HIV Impact Assessment. Available at: https://phia.icap.columbia.edu/wp-content/uploads/2018/07/3471CAMPHIA_Cameroon- SS_A4_v13_requests_7.25.18.pdf. Assessed on 7th November 2018. | ||
| In article | |||
| [28] | Joshi KS, Bhaware BD, Pazare AR. Indian Adolescent Living with HIV-AIDS: Current Clinical Scenario. Journal of The Association of Physicians of India. 2017;65:41. | ||
| In article | |||
| [29] | Mellins CA, Tassiopoulos K, Malee K, Moscicki AB, Patton D, Smith R, et al. Behavioral health risks in perinatally HIV-exposed youth: co-occurrence of sexual and drug use behavior, mental health problems, and nonadherence to antiretroviral treatment. AIDS Patient Care STDS. 2011;25(7):413-22. | ||
| In article | View Article PubMed PubMed | ||
| [30] | MacPherson P, Munthali C, Ferguson J, Armstrong A, Kranzer K, Ferrand RA, et al. Service delivery interventions to improve adolescents' linkage, retention and adherence to antiretroviral therapy and HIV care. Tropical Medicine & International Health. 2015; 20(8): 1015-32. | ||
| In article | View Article PubMed PubMed | ||
| [31] | Kim SH, Gerver SM, Fidler S, Ward H. Adherence to antiretroviral therapy in adolescents living with HIV: systematic review and meta-analysis. Aids. 2014;28(13):1945-56. | ||
| In article | View Article PubMed PubMed | ||
| [32] | Davies MA, Boulle A, Fakir T, Nuttall J, Eley B. Adherence to antiretroviral therapy in young children in Cape Town, South Africa, measured by medication return and caregiver self-report: a prospective cohort study. BMC Pediatr. 2008; 8(34): 1471-2431. | ||
| In article | View Article PubMed PubMed | ||
Published with license by Science and Education Publishing, Copyright © 2019 Alice Ketchaji, Felix Assah, Joseph Fokam, Elvis Asangbeng Tanue, Francisca Monebenimp and Marcelin Ngowe Ngowe
This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit
https://creativecommons.org/licenses/by/4.0/
| [1] | Davies M-A, Pinto J. Targeting 90–90–90 – don't leave children and adolescents behind. Journal of the International AIDS Society. 2015; 18(7Suppl 6):20745. | ||
| In article | View Article | ||
| [2] | UNAIDS. 2016. Fact sheet, world AIDS day. Available at: https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf. assessed on 27th September 2018. | ||
| In article | |||
| [3] | Ammon N, Mason S, Corkery J. Factors impacting antiretroviral therapy adherence among human immunodeficiency virus-positive adolescents in Sub-Saharan Africa: a systematic review. Public health. 2018;157:20. | ||
| In article | View Article PubMed | ||
| [4] | UNAIDS. 2017. Global HIV & AIDS statistics fact sheet. Available at: https://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf Assessed on 2th November 2018. | ||
| In article | |||
| [5] | Bell M. Care of the HIV-positive adolescent. Developmental stages and provider sensitivity play a special role: Posit Aware. Indian J Sex Transm Dis AIDS. 2006; 17(4):36-9. | ||
| In article | |||
| [6] | Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. Lancet. 2012; 379(9826):1641-52. | ||
| In article | View Article | ||
| [7] | Biressaw S, Abegaz, W. E., Abebe, M., Taye, W. A., & Belay,M. Adherence to antiretroviral therapy and associated factors among HIV infected children in Ethiopia:. BMC Pediatrics. 2013. | ||
| In article | View Article PubMed PubMed | ||
| [8] | UNAIDS. 2016. Global AIDS Update. Geneva, Switzerland: The Joint United Nations Programme on HIV/AIDS. Available at: https://www.unaids.org/en/resources/documents/2016/Global-AIDS-update-2016. Assessed on 3th November 2018 | ||
| In article | |||
| [9] | Hudelson C, Cluver L. Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low- and middle-income countries: a systematic review. AIDS Care. 2015; 27(7):805-16. | ||
| In article | View Article PubMed | ||
| [10] | UNAIDS.2016. ALL IN to end the adolescent AIDS epidemic — A progress report. Available at: https://www.unaids.org/en/resources/documents/2016/ALLIN2016ProgressReport.Assessed on 5th December 2018. | ||
| In article | |||
| [11] | UNICEF. 2015. Progress for children. New York. Available at: https://www.google.com/search?q=UNICEF.+Progress+for+children.+New+York:+UNICEF. Assessed on 7th October 2018. | ||
| In article | |||
| [12] | UNAIDS.2016.All in: end adolescent AIDS. Available at: https://wwwunaidsorg/sites/default/files/media_asset/20150217_ALL_IN_brochurepdf. Assessed on 18th October 2018. | ||
| In article | |||
| [13] | Mburu G, Hodgson I, Teltschik A, Ram M, Haamujompa C, Bajpai D, et al. Rights-based services for adolescents living with HIV: adolescent self-efficacy and implications for health systems in Zambia. Reprod Health Matters. 2013; 21(41):176-85. | ||
| In article | View Article | ||
| [14] | Napierala Mavedzenge S, Newman JE, Nduwimana M, Bukuru H, Kariyo P, Niyongabo T, et al. HIV infection among children and adolescents in Burundi, Cameroon, and the Democratic Republic of Congo. AIDS Care. 2017;29(8):1026-33. | ||
| In article | View Article PubMed | ||
| [15] | UNAIDS. 2014. 90‐90‐90: an ambitious treatment target to help end the AIDS epidemic. Available at: https://www.unaids.org/en/resources/documents/2017/90-90-90. Assessed on 12th November 2018. | ||
| In article | |||
| [16] | Fonsah JY, Njamnshi AK, Kouanfack C, Qiu F, Njamnshi DM, Tagny CT, et al. Adherence to antiretroviral therapy (ART) in Yaoundé-Cameroon: association with opportunistic infections, depression, ART regimen and side effects. PloS one. 2017; 12(1): e0170893. | ||
| In article | View Article PubMed PubMed | ||
| [17] | O’Bryan G. Factors associated with ART non-adherence and contributing influence of stock shortages at Nkongsamba Regional Hospital, Cameroon.Global health. 2015; [264]. | ||
| In article | |||
| [18] | Pefura Yone EW, Soh E, Kengne A, Balkissou A, Kuaban C. Non-adherence to antiretroviral therapy in Yaounde: Prevalence, determinants and the concordance of two screening criteria. PLoS One. 2017; 12(1). | ||
| In article | |||
| [19] | Meresse M, March L, Kouanfack C, Bonono RC, Boyer S, Laborde-Balen G, et al. Patterns of adherence to antiretroviral therapy and HIV drug resistance over time in the S tratall ANRS 12110/ESTHER trial in C ameroon. HIV medicine. 2014; 15(8): 478-87. | ||
| In article | View Article PubMed | ||
| [20] | NACC. 2014. Global Aids Response Progress (GARP). Available at: https://wwwunaidsorg/sites/default/files/country/documents/CMR_narrative_report_2014pdf. Assessed on 6th October 2018. | ||
| In article | |||
| [21] | Maddali MV, Gupta A, Shah M. Epidemiological impact of achieving UNAIDS 90-90-90 targets for HIV care in India: a modelling study. BMJ Open. 2016;6(7):e011914. | ||
| In article | View Article PubMed PubMed | ||
| [22] | CNLS. 2016. Annual report. Available at: https://wwwcnlscm. Assessed on 2th December 2018. | ||
| In article | |||
| [23] | Rongkavilit C, Wright K, Chen X, Naar-King S, Chuenyam T, Phanuphak P. HIV stigma, disclosure and psychosocial distress among Thai youth living with HIV. Int J STD AIDS. 2010;21(2):126-32. | ||
| In article | View Article PubMed | ||
| [24] | Marima R. The Prevalence and factors associated with nonadherence with ARV treatment and cotrimoxazole preventive therapy among HIV infected adolescents attending out-patient HIV clinics in Kenya. Aku institutional repositiry. 2011. | ||
| In article | |||
| [25] | Naswa S, Marfatia YS. Adolescent HIV/AIDS: Issues and challenges. Indian J Sex Transm Dis AIDS. 2010;31(1):1-10. | ||
| In article | View Article PubMed PubMed | ||
| [26] | {Chhim, 2018 #371} | ||
| In article | |||
| [27] | MINSANTE. Cameroon Population-Based HIV Impact Assessment. Available at: https://phia.icap.columbia.edu/wp-content/uploads/2018/07/3471CAMPHIA_Cameroon- SS_A4_v13_requests_7.25.18.pdf. Assessed on 7th November 2018. | ||
| In article | |||
| [28] | Joshi KS, Bhaware BD, Pazare AR. Indian Adolescent Living with HIV-AIDS: Current Clinical Scenario. Journal of The Association of Physicians of India. 2017;65:41. | ||
| In article | |||
| [29] | Mellins CA, Tassiopoulos K, Malee K, Moscicki AB, Patton D, Smith R, et al. Behavioral health risks in perinatally HIV-exposed youth: co-occurrence of sexual and drug use behavior, mental health problems, and nonadherence to antiretroviral treatment. AIDS Patient Care STDS. 2011;25(7):413-22. | ||
| In article | View Article PubMed PubMed | ||
| [30] | MacPherson P, Munthali C, Ferguson J, Armstrong A, Kranzer K, Ferrand RA, et al. Service delivery interventions to improve adolescents' linkage, retention and adherence to antiretroviral therapy and HIV care. Tropical Medicine & International Health. 2015; 20(8): 1015-32. | ||
| In article | View Article PubMed PubMed | ||
| [31] | Kim SH, Gerver SM, Fidler S, Ward H. Adherence to antiretroviral therapy in adolescents living with HIV: systematic review and meta-analysis. Aids. 2014;28(13):1945-56. | ||
| In article | View Article PubMed PubMed | ||
| [32] | Davies MA, Boulle A, Fakir T, Nuttall J, Eley B. Adherence to antiretroviral therapy in young children in Cape Town, South Africa, measured by medication return and caregiver self-report: a prospective cohort study. BMC Pediatr. 2008; 8(34): 1471-2431. | ||
| In article | View Article PubMed PubMed | ||
