Abstract: Mediators of the Impact of an Economic Empowerment Intervention on Adherence to Antiretroviral Therapy Among Adolescents Living with HIV in Uganda (Society for Social Work and Research 29th Annual Conference)

Schedule:

Sunday, January 19, 2025

Cedar B, Level 2 (Sheraton Grand Seattle)

* noted as presenting author

Samuel Kizito, MD, MS, Research fellow, Washington University in St. Louis, St Louis, MO

Fred Ssewamala, PhD, Professor, Washington University in Saint Louis, Saint Louis, MO

Proscovia Nabunya, MSW, PhD, Assistant Professor, Washington University in Saint Louis, St. Louis, MO

Josephine Nabayinda, Msc, Doctoral student, Washington University in Saint Louis, Saint Louis, MO

Torsten Neilands, PhD, Professor, University of California, San Francisco, CA

Ozge Sensoy Bahar, PhD, Research Associate Professor, Washington University in Saint Louis, St. Louis, MO

Kim Johnson, PhD, Professor, Washington University in Saint Louis, MO

Mary McKay, PhD, Vice Provost, Washington University in Saint Louis, St. Louis, MO

Background and Purpose

Adolescents living with HIV (ALHIV) have low adherence to Antiretroviral therapy (ART), with poverty remaining a major driver. Guided by the Health Belief Model and the Asset theory, we examined the mediators of the effect of an economic empowerment intervention on ART adherence among ALHIV.

Methods

W used data from a seven-year cluster-randomized controlled trial, the Suubi+Adherence study. We randomized 702 ALHIV (at the clinic level) from thirty-nine clinics into the control (n=344) or intervention group (n=358). At enrollment, participants were aged 10 - 16, living with HIV, taking ART, living with a family, and receiving care at the study clinics. Starting 2014, the intervention comprising matched savings account, financial literacy training, and micro-enterprise workshops was delivered over 24 months, and ALHIV followed up for seven years. We used sequential structural equation modeling in Mplus to examine how three mediators including barriers to medical care, adherence-self efficacy, and adolescent social transition (all measured at year six) influenced ART adherence at year seven, measured using self-reports and pill counts. (Registration at ClinicalTrials.gov: #NCT01790373).

Results

At baseline, the mean age was 12 years, and only 73.0% achieved good adherence (›90%). The intervention directly improved ART adherence, b=0.063 (95% CI: 0.001, 0.002), p=0.049. In other words, ALHIV who participated in the EE intervention had higher ART adherence levels compared to those in the control group. Also, there was a significant indirect effect of the intervention on ART adherence ß = -0.029 (95% CI: -0.054, -0.003), p = 0.027. The indirect effect was mediated through two pathways. First, through reducing barriers to medical care, ß=-0.028 (95% CI: -0.053, -0.003), p=0.027, and secondly, chained mediation through barriers to medical care and adherence self-efficacy, ß=0.006 (95% CI: 0.001, 0.012), p=0.045.

Conclusions and Implications

Providing ALHIV and their families with financial resources improved their ART adherence both directly and by reducing the barriers to medical care. Therefore, programs aimed at improving outcomes in ALHIV should consider incorporating interventions that address poverty.