New Challenges for a Young Generation: Understanding Medication Adherence and Mental Health Impairments Among South African Perinatally Infected Youth in Early Adolescence

Background: The HIV epidemic has had devastating effects on adults and children in South Africa.  With one in five Black South African women infected with HIV in poverty-impacted townships, mother-to-child transmission of the virus during pregnancy and child birth was a frequent occurrence.  Further, prior to 2007, anti-retroviral therapy (ART) was not available to perinatally-infected children, thus the vast majority died prior to their fifth birthday.  Fortunately, this dire situation has improved in two important ways.  First, with aggressive prenatal care efforts, mother-to child transmissions have been reduced to 3.5%.  Next, with PEPFAR (President's Emergency Plan For AIDS Relief) support five years ago, ART became available to the first cohorts of HIV+ children making living to adolescence a real possibility. Each year, access to ART increases with thousand more children benefitting.  Today, there are approximately 330,000 HIV+ children living in South Africa. Seropositive children who were not previously expected to live past their childhood are maturing and will be forced to navigate a new set of challenges.  In the U.S., perinatally infected children frequently evidenced difficulties with medication adherence and mental health challenges as they approached adolescence. The lack of resources due to economic deprivation in South Africa can make these problems exponentially more severe.  This paper presentation focuses findings from a sample of one of the oldest cohorts of South African youth who received ART and is now aging into adolescence. These data are of high importance as they can alert South African care systems to needs of this new population.

Method: This paper draws on baseline data from a small-scale NIH-funded longitudinal pilot study of perinatally infected seropositive youth in KwaZulu Natal, South Africa (n=66).  The sample consists of boys (n=33) and girls (n=32) ages 10-13 years old (M=11.57, SD=1.2). Almost half lived with their mothers (47%), while others resided with relatives (father, aunt/uncle, grandparent). Their knowledge of their HIV diagnosis ranged from one week to 13 years. Multivariate analyses were used to examine the relationship between youth medication adherence, parent support in medication management and youth mental health challenges and prosocial strengths.  Standardized instruments, including the Strengths and Difficulties Questionnaire (Goodman, Meltzer, and Bailey, 1998) and the VUKA Adherence Questionnaire (Mellins et al., 2010) were used.

Results: Youth presented with serious mental health challenges (62% met criteria for impairments in behavioral and emotional functioning).  Parental medication monitoring was positively associated with youth ART adherence. Yet, youth conduct related difficulties significantly interfered with parental medication supports, while youth prosocial behavior was significantly associated with obtaining parental help with taking ART medications. 

Implications: Evidence-informed psychosocial interventions are needed to address youth health and behavioral outcomes in South Africa and globally. Family-focused models may be of particular utility and impact.  Integrating sustainable and effective interventions can help guide this young cohort's navigation through challenging developmental stages, reducing compromised behavioral health and transmission risk in complex real-world settings.