Importance of Self-Motivation and Social Support in Medication Adherence in HIV-Infected Adolescents in the United Kingdom and Ireland: A Multicentre HYPNet Study

Abstract

Adolescents are a vulnerable population, not only to the acquisition of HIV, but also to poor adherence to antiretroviral therapy (ART) associated with disease progression and a increased risk of onward viral transmission. The aim of the study was to examine the factors that aid or act as barriers to adherence in a UK population of adolescents and young adults receiving ART. A cross-sectional survey was completed of 138 adolescents (12–24 years) across 14 clinical and community sites in the UK and Ireland. Analysis of results was undertaken using Chi-square testing in SPSS. Of the 138 patients, 48% were female, and 52% were born outside of the UK. Fifty-two of the 138 (43%) reported being on ART for at least 8 years. More than a third of the patients have ever interrupted treatment since initiating ART. One hundred four of the 138 (75%) patients self-reported being >85% adherent to medication for 7 day recall. Self-motivation (e.g., having a routine, specific goal) was cited as being most helpful in medication compliance (33%), followed by reminders by friends and family (25%), with 20% identifing no specific factor. Only 15% chose interventions such as an adherence diary or mobile phone reminders as helpful factors, and 1% chose healthcare professional input such as home visits. This study highlights the importance of self-motivation and social support in medication adherence in an HIV-infected adolescent population, in preference to healthcare professional input. Education and motivational strategies may confer the biggest impact on sustained ART adherence amongst this vulnerable group.

Introduction

Anti-retroviral therapy (ART) has dramatically improved survival for people living with HIV (PLWH). ART halts viral replication, reduces HIV viral load, and prevents disease progression, as well as onward transmission to partners and offspring. However, ART efficacy is dependent on lifelong sustained adherence above 90%¹ to daily oral dosing, although some regimens such as boosted protease inhibitors are more forgiving at lower rates of adherence.² A meta-analysis by Mills et al. showed that only 64% of adults on antiretroviral therapy are >90% adherent to treatment.³ Furthermore, the SMART study⁴ showed that treatment interruptions were associated with a higher risk of cardiovascular, renal, and hepatic disease and all-cause mortality compared to remaining on virally suppressive therapy even at a CD4 count of above 250 cells/μL and treatment interruptions are no longer recommended.

Adherence to ART is a complex issue for adolescents and young people living with HIV (defined as 10- to 19- and 20- to 24-year-olds, respectively).⁵ ART requiring lifelong adherence is a challenge for any adult but an even bigger challenge for those who are transitioning between childhood and adulthood. A meta-analysis of published studies of adolescent adherence to ART by Kim et al.⁶ showed that 62% of adolescents globally report >85% adherence to treatment, with similar rates reported within the European Union.⁶

Adolescents and young adults living with HIV can be divided into two main groups, those who have acquired infection horizontally and those infected perinatally who have survived to adolescence. Both have multiple, complex, overlapping, and different challenges. Whilst both perinatally and horizontally infected groups of young people have to live the rest of their lives with a potentially life threatening, stigmatized illness, the specific issues of living with HIV for each group differ. The perinatally infected group live with the family burden of disease—may have suffered multiple bereavements or grown up as parent carers, and many have fractured childhoods with migration and consequent educational and psychological challenges. In addition, many of these young people have received suboptimal ART in early childhood, due to poor availability of pediatric formulations and inadequate dosing regimens through their early childhood. Subsequently, due to the cumulative acquisition of HIV-1 associated resistance mutations, many young people with perinatally acquired HIV infection require more complex ART regimens presenting further challenges to adherence. Young people infected horizontally in adolescence are often from vulnerable groups with little peer or family support, and struggle with the diagnosis and its implications. In addition, they have to adjust their life styles to rigid adherence to therapy at a time often associated with uncertainty and disorganization. There may also be medical and biological reasons which compound the psychosocial factors threatening adherence, such as neurocognitive impairment⁷ and co-infections or co-morbidities that add complexity to antiretroviral adherence.

For the reasons outlined above, it may not always be relevant or appropriate to extrapolate the challenges and adherence support structures that have helped adults living with HIV to adolescents. A multidisciplinary group of practitioners who work with adolescents and young adults living with HIV collaborated to develop treatment adherence guidelines⁸ on behalf of the HIV in Young People network (HYPnet www.hypnet.org.uk). During the early stages of guideline development, the writing group felt that it would be valuable to obtain information from young people themselves regarding their adherence to ART. A comprehensive questionnaire was designed to assess their self-reported barriers to adherence to therapy and their suggested strategies to improve adherence. The questionnaire was distributed to fourteen UK sites, the majority through participation in HYPNet.

Methods

Ethical considerations

A discussion with the Imperial College Healthcare Research Ethics Committee concluded that this survey did not require an ethical review, as this was a voluntary anonymous survey to support the development of adherence guidelines to improve patient services.

A self-reported adherence questionnaire was designed to collect treatment adherence information from young people living with HIV (YPHIV) in the UK who were currently on ART. The paper questionnaire consisted of 25 questions which included multiple choice options, Likert scales, and free text (Appendix 1). It was originally designed by the lead author (S.M., HIV Clinical nurse practitioner) with input and review from the adherence guidelines multidisciplinary writing group, including representatives from the voluntary sector. An initial questionnaire was piloted by two HIV-positive young adolescents (aged 17 and 18 years old). They both reported the questionnaires were easy to follow, relevant, and not time consuming. Contacts of health care professionals working in HIV pediatric and young person clinics, the community, and voluntary sector were primarily found through HYPNet. Twenty eight sites were contacted across the UK between September 2009 and March 2010. Fourteen sites participated, which included four specialist adolescent HIV clinics, four tertiary pediatric HIV clinics, four pediatric district general hospitals, and two voluntary sector organizations. Twelve sites were in England (nine within Greater London), with single sites in Wales and Ireland. Questionnaires were handed out on site to be completed by the participants, and participation was anonymous and voluntary.

The inclusion criteria were as follows: age 12–24 years inclusive, HIV infection (any route of transmission), aware of HIV status, and currently on ART. The questionnaire included sections on general demographics (age, sex, ethnicity, country of birth) and ART regimens recieved. Questions were asked regarding adherence, factors associated with adherence, treatment interruption, and access to peer support groups. Likert scales were included to gauge patients' confidence in medication taking as well as their perceived importance of taking ART.

Co-ordinators for each site (key health care providers) distributed the questionnaires and returned the completed questionnaires by post to the main center for analysis.

Study analysis plans

Adherence was self-reported; no confirmatory laboratory viral load data was available. The goal was to determine correlates associated with self-reported good or poor ART adherence. To undertake this analysis, self-report of good adherence was arbitrarily defined as >85% of all doses taken and termed the “adherent group”. This estimated to missing ≤1 dose per week if on a once daily regime, or ≤2 doses missed per week if on a twice daily regime. Those who reported missing more than the doses defined above were determined the “non-adherent group”. The descriptive properties of the quantitative data are reported for each of the three domains investigated in the current study. Open-ended responses were transcribed and major themes were coded and grouped in categories of frequently expressed ideas. This qualitative information was analyzed in conjunction with the descriptive data to highlight factors affecting adherence.

Results

Demographic characteristics

Data were collected on 138 patients aged 12–24 years. There were 67 females (48%), with an age distribution of: 36 (26%) aged 12–14 years, 53 (38%) between 15–17, and 49 (36%) aged 18–24 years. The majority (81%) lived with their family and 46 (33.3%) were born in the UK. Within the sample, 9% had been on ART for <12 months, 23% for 1–4 years, 17% for 4–8 years, with 38% reporting more than 8 years of ART exposure (Table 1). There was no statistical difference in the self-reported duration on ART by different age groups (Table 2).

Table 1.

Selected Characteristics of Participants

	(%)
Female	67 (48)
Male	44 (32)
No response	27 (20)
Age (years)
12–14	36 (26)
15–17	53 (38)
18–24	49 (36)
Living with
Family	112 (81)
Friends	9 (7)
Alone	12 (9)
Partner	2 (1)
No response	3 (2)
Born in
UK	46 (33.3)
Outside UK	50 (36.2)
No response	42 (30.4)
Been on ART for
<12 months	12 (9)
1–4 years	32 (23)
4–8 years	24 (17)
>8 years	52 (38)
No response	18 (13)

Table 2.

Reported Duration on ART by Different Age Groups (%)

	Duration on ART (no data: 18)
Percentage of each age group on the duration of ART	<12 months	1–4 years	4–8 years	>8 years
12–14	15	26	11	48
15–17	13	25	27	35
18–24	10	27	17	46

Medication interruption

127 patients gave an answer regarding medication interruption of which 54 patients (39%) reported ever taking a treatment interruption, with a third reporting less than 3 months off therapy, a third more than a year, and 22% did not know duration of treatment interruption. Reported reasons for stopping ART were external (part of a trial or doctor stopped it) in 22% and personal such as “didn't want to take it”, “treatment side effects,” and “fed up taking treatment” for the remaining 78%.

Adherence

104/138 patients (75.4%) self-reported weekly adherence to ART of greater than 85%. Pearson Chi-square test showed no statistically significant difference in self-reported adherence between once daily and twice daily regimes. Furthermore, there was no significant difference in reported adherence with regards to the duration of time on ART (p=0.498).

Older age groups showed higher rates of reported adherence compared to younger age groups. The rates of reported adherence dropped from 88% in 18–24 year group (n=43) to 69% in 12–17 year group (n=61), (Pearson Chi-square test, p<0.05).

When asked to grade the importance of taking treatment on a Likert scale from 0–10, where 0 was not important at all and 10 was extremely important, both adherent and non-adherent groups rated taking medication as important. Those who were non-adherent had a lower mean report of the importance placed on taking ART of 8.3±2.22 compared to a mean of 9.0±1.96 for the adherent group. However the differences were not statistically significant (p=0.077).

Participants were again asked to grade their confidence in taking medication and not missing doses. This allowed comparisons of how much confidence they placed on their own management of their HIV treatment with how adherent they reported being. Greater confidence in the ability to take ART was seen for those reporting good adherence (Likert mean, 8.32±2.05) compared with those reporting less adherence (6.06±2.65) which was statistically significant (p<0.01).

Factors reported to affect adherence

When patients were asked what aids their medication taking, 33.4% of all responses were related to self-motivation including “carry them with me all the time,” “I know it helps me to look after my health,” “having a routine,” “having a specific goal,” “I keep them in a place that reminds me to take them.” Support from friends and family were next most frequent response with 27.7%, followed by 19.6% of the respondents identifying no specific support. Only 1.4% of responses identified healthcare professional involvement such as home visits and care plans by professionals as helpful (Table 3). The rates of finding professional input helpful did not differ between adherent and non-adherent groups. 57% of all respondents in the adherent group identified self-motivation and/or no specific support compared to 40% from the non-adherent group. The most frequent response from the non-adherent group was support from friends and family (36%) compared to 25% in the adherent group. Younger patients were significantly more likely to choose “parents remind me” as a factor that aids adherence (65% of 12- to 14-year-olds, 50% of 15- to 17-year-olds, and 22% of 18- to 24-year-olds, p<0.01) (Table 4).

Table 3.

Factors Reported as Facilitators and Barriers to Adherence

Factors that help adherence (%)		Factors that act as barriers to adherence (%)		Factors that may improve adherence (%)
Self-motivation	33.4	Impractical	38.1	Medication related	55.9
Support from friends and family	27.7	Forgot	23.9	Reduction in stigma	17.1
Nothing	19.6	Other^b	11.6	Reminders	8.9
Specific Interventions^a	16.2	Treatment fatigue	10.1	Education	5.3
Other	1.7	Stigma	9.0	Self- motivation	3.9
Healthcare professional involvement	1.4	Medication related	7.5	Peer support	3.9
				Other	2.8
				External input	2.1

Adherence diary, mobile phone, pill box, other alarm system.

^bDon't know; I don't want to take this treatment; Not sure why I am taking this treatment; Don't believe in taking HIV medication; Difficult to take treatment when well; People were nagging me too much.

Table 4.

Age Disaggregated Reports of Factors that Improve Adherence (%)

	12–14 years (n=36)	15–17 years (n=53)	18–24 years (n=49)
Nothing	17.1	19.8	20.9
Self-motivation	25.7	31.0	40.9
Friends and family	40.0	31.0	16.4
Interventions	15.7	15.5	17.3
Healthcare professionals	0.0	0.9	2.7
Other	1.4	1.7	1.8

Patients were also asked “why do you think you missed doses?” Practical reasons such as being busy with other activities and being with friends or family were most frequently chosen (38.1%), followed by simply forgetting to take medication (23.9%). Other reasons cited included “I don't want to,” “it doesn't matter,” and “difficult to take treatment when well”.

When patients were asked “what do you think could improve taking your HIV medications?” over half of responses (55.9%) indicated medication-related factors (reducing the pill burden, smaller tablets, reduced side effects). Reduction in stigma, was identified by 17.1% of respondents, reporting “if I didn't have to keep it a secret” and “if I was able to share this with my friends.” 2.1% responses identified that they felt external input such as home visits by nurses and plan making with family or staff as factors that could be helpful in improving medication adherence.

When patients were asked to tick individual factors that impacted on their adherence, significantly more good-adherers chose “I know it helps me to look after my health” (p=0.02), and poor adherers were more likely to list “side effects” as a factor that makes adherence to medication challenging (p<0.01).

Fifty-seven patients (42%) reported currently accessing peer support groups (51% of poor adherers and 38% of good adherers). There was no statistical evidence that access to peer support groups had a significant impact on self-reported adherence in this cohort (p=0.129). Of those who accessed peer support groups, 50/57 (88%) reported it to be helpful. Furthermore, when asked “In peer support do you think talking to other young people who are going through similar things has helped you in terms of taking your treatment?” 46/57 respondents said yes with 70% and 30% of the good and poor adherers agreeing respectively (p=0.62).

Discussion

Overall, three-quarters of the 138 adolescents and young people living with HIV reported greater than 85% adherence to ART, whilst only a quarter reported less than 85% adherence. This is a higher rate of self-reported adherence than previously documented in a meta-analysis of published studies of adolescent ART adherence, assessed by both self-report and viral load where the global pooled rate was 62.3%,⁶ with a quarter of the studies being conducted within the in European Union. Several potential reasons may explain this discrepancy. In the UK, the NHS provides ART free at the point of access, which maybe in contrast compared with other country health providers. Furthermore, this study only used self-reported adherence measures without viral load correlates, resulting in potential reporting bias with higher rates of self-reported adherence. However, self-report has been shown in some studies to be a reliable tool for measuring adherence with strong association with development of viralogical failure in pedaitric cohorts.⁹ Other studies including adolescents on ART conducted in UK report adherence rates between 47–64%.^10
–12 The surveyed population in this analysis only included those currently on ART, thereby excluding adolescent and young adults currently interrupting therapy or those not engaged in care. A large number of those responding were either attending specialist adolescent transition centers or voluntary sector services and therefore may not be representative of the adolescent cohort across the whole of the UK and Ireland.

Older age groups reported better adherence with the 18- to 24-year group having 19% more adherent patients when compared to those aged 12–17 years. As a young person ages, increasing self reliance and independence results in taking more responsibility for their own healthcare, whilst younger patients were more likely to rely on family support and selected “parents remind me” as a factor that helps adherence. Furthermore, the results are in keeping with the other studies reporting lower ART adherence rates in 15- to 18-year-olds compared with younger children,¹³ where their parents are often still responsible for care provision. The 15- to 18-year age group is likely to be undergoing the peak of transition, from having been dependent on others in managing HIV treatment to having to take ownership of their own health. A similar phenomenon has been reported in medication adherence in adolescents with asthma, where a negative correlation between adherence and age is reported with improved adherence in older adolescents/young adults.¹⁴ In our cohort, although mode of infection was not reported, the older group will include a higher proportion of horizontally infected young people with a shorter duration on ART who are not yet experiencing pill fatigue. However, no association was found between duration of ART exposure and adherence in this study.

Over a third of the cohort reported interruptions to ART, the majority self-initiated. This is nearly double the rate recorded in a US study¹⁵ of 72 children and adolescents mean age 12.4 years with ART exposure for ≥6 months, where 17.8% reported treatment interruptions, with an average time off ART of 14 months. However, the age range and duration of ART exposure in this study is lower, suggesting that perhaps our cohort, because they are older, are more likely to have experienced treatment interruption. Although treatment interruption has been shown to have adverse effects in adults,⁴ a European pediatric study of CD4 count-driven treatment interruptions of less than 12-month duration did not result in serious adverse clinical outcomes.¹⁶ Despite treatment interruptions not being recommended in global pediatric and adolescent guidelines,¹⁷ adolescents frequently reported taking treatment interruptions. Further research is needed in how best to manage this, particularly in light of a global roll-out of efavirenz-based FDC first line therapy where an unstructured treatment interruption is likely to result in high rates of NNRTI resistance mutations due to the long half-life of efavirenz.¹⁸

Ratings for perceived importance in medication taking and perceived confidence in medication taking were higher in the adherent group (9.0, 8.3, respectively) compared to the non-adherent group (8.3, 6.1). The adherent group put higher emphasis on self-motivation as a factor that helps adherence than the non-adherent group, the latter identified external support from friends and family as greater importance. An association between good adherence, self-motivation, and greater perceived confidence in ability to take medication was identified by many, suggesting a shift of responsibility; from dependence on others to self-reliance. It is likely that positive reinforcement occurs with self-motivation assisting adherence, which increases self-confidence in health management, in turn reinforcing self-motivation. This suggests that behavioral interventions such as motivational interviewing that aims to identify and resolve ambivalence and strengthen self-efficacy may be a useful adherence tool. Early pilot studies have shown encouraging outcomes for motivational interviewing in reducing viral load and unprotected sex and warrant well powered, age stratified randomized controlled trials.^19
–21

Practical reasons such as holidays or being busy with other activities were frequently identified as a barrier to adherence, and medication-related factors such as once daily regimens and smaller pill sizes were most commonly identified as factors that may improve adherence. Both factors are related to the convenience of taking the medication and suggest efforts to ease medication at a younger age, whilst adherence is still maintained, such as simplification to once daily regimens and FDCs may prove to be beneficial and are welcomed by adolescents.

Amongst this group, only 9% of responses cited that poor adherence was linked to stigma. However, when asked “what do you think could improve taking your HIV medications?” reducing stigma was the second most frequently identified factor that may improve adherence (17.1%) after medication-related factors. Secrecy, whether in families, between friends and partners, or even between siblings was perceived to impact on adherence. Secrecy is a consequence of stigma and in many of the perinatally infected young people, is driven from an early age by patterns of disclosure within families. A study of 29 French adolescents living with HIV found that secrecy and silence regarding their HIV diagnosis and treatment was seen as a major barrier to adherence.²² Patients perceived that their adherence would be better if they didn't have to keep it a secret and were able to share with others. For many perinatally infected young people, HIV is often a taboo subject within the family with added layers of complexity due to family ill-health, maternal HIV, and potential carer role since childhood. Additionally, onward disclosure of their HIV status also discloses that of their mother and potentially other family members.

Nearly a quarter of respondents said simply forgetting to take medication is a barrier to adherence, which may indicate that there may be a role for interventions that aim to remind patients to take their medication such as text alerts. A randomized controlled trial (n=431) of text reminders in adults have been shown to improve adherence to ART,²³ and requires further investigation in adolescents and young adults. Another smaller randomized controlled trial (n=28)²⁴ showed improved adherence with a smartphone adherence application, demonstrating the potential for innovative technological approaches in improving medication compliance.

In adult populations, peer support groups have been shown to be an effective intervention to improve adherence to ART²⁵ and are recommended by the CDC as an evidence-based intervention.²⁶ In this survey, patients reported finding peer support groups helpful (69%), although no differences in self-reported adherence was seen in patients who accessed peer support and those who did not. However, as only 57 patients attended peer support groups, the sample size may have been too small to detect a difference. Peer support comes in many forms, from one-to-one to group meetings and lack of standardization makes interpretation difficult. Peer support addresses much more than just adherence to ART, and whilst we did not observe a correlation between reported adherence and accessing peer support, this has been shown to provide other benefits, such as psychological support for HIV disclosure to friends and partners.²⁷

It is estimated that there are around 3000 YHIV aged between 12–24 years in the UK (Health Protection Agency estimate 3291 (age 0–24), Collaborative HIV Paediatric Study (CHIPS) database, 1835). This makes our cohort of 138 patients representing roughly 5–10% of the YHIV population in UK. Whilst the WHO definitions are of adolescence (10–19 years) and young adulthood (20–24 years), disaggregated data in this study is presented in age bands characteristic of UK clinical services. Twelve years delineates the lower age limit as the majority of children are aware of their HIV diagnosis by this age (12- to 14-year grouping—early adolescence), the median age of transition from paediatric to adult services in the UK is 17.5 years and determined the age bandings 15–17 and 18–24 years. Lack of global standardized definitions and age banding limit interpretation and comparison between studies and limits the interpretation of this individual study.

Further limitations include the study set up; questionnaires were handed out in clinics or voluntary sector organizations, with a potential selection bias towards patients who are engaged in services and those more open about their status and would have missed those who are out of care and/or do not attend peer support. It also excluded adolescents and young adults currently interrupting therapy. Furthermore, the nature of self-reported adherence implies that there is likelihood that there may be reporting bias as patients have a tendency to want to be perceived to a “good patient” with good adherence level. We have tried to reduce this by adding in recruitment through public sector and making the questionnaire anonymous, although this precludes correlation with viral load suppression data.

An additional limitation is that there are no data on the number of people who were asked to complete the questionnaire but failed to. This may exclude those with low literacy and recent migration with limited English language. Furthermore, this study did not differentiate those who were perinatally infected and those who were horizontally infected. These two groups have overlapping but different sets of challenges that may impact on adherence. For example, those who were perinatally infected would have been on ART for longer, more likely to have acquired resistance, and have higher pill burden regimens. Conversely, young adults with recent horizontally acquired HIV may still be adjusting to their diagnosis and disclosure to partners, friends, and family.

Conclusion

Self-motivation and social support were the key factors in enhancing adherence to ART amongst a large cohort of adolescents and young adults living with HIV. Regimen simplification with a reduced pill burden was perceived to improve adherence in this age group, but peer and health care provider support was not associated with enhanced adherence. Strategies that build up confidence resilience and facilitate self-motivation together with practical tools that reduce the risk of simply forgetting ART, and prevention of unplanned treatment interruptions require further investigation in large well-powered age dissagregated randomized controlled trials. Improving adherence to ART, reducing the risk of onward transmission of HIV, and the need for movement to second line therapy is critical as the global population of adolescents and young adults living with HIV continues to rise.

Self-motivation and social support were the key factors in enhancing adherence to ART amongst a large cohort of adolescents and young adults living with HIV. Regimen simplification with a reduced pill burden was perceived to improve adherence in this age group, but peer and health care provider support was not viewed as enhancing adherence. Reliance on family to support adherence in earlier adolescence would suggest that, while young people are transitioning into adulthood and becoming more independant, involving the family in their care remains important. Strategies that build up self efficacy and facilitate self-motivation together with practical tools that reduce the risk of simply forgetting ART, and prevention of unplanned treatment interruptions require further investigation in large well-powered age dissagregated randomized controlled trials. Improving adherence to ART, reducing the risk of onward transmission of HIV and the need for movement to second line therapy is critical as the global population of adolescents and young adults living with HIV continues to rise.

Footnotes

Acknowledgments

The authors would like to thank Christine Norton, Imperial College Healthcare NHS Trust, for her support with the initial data analysis. We thank the young people who completed the questionnaires, the HIV Young Person's Network (HYPNet) members for all of their support with designing the questionnaires, the members of the HYPNet adherence guidelines group; Alice Armstrong, Jackie Flynn, Jayne Griffiths, Debbie Levitt, Djamel Hamadache, Nimisha Tanna, and the participating hospitals and charities. They are listed in alphabetical order below along with the co-ordinators for each site. Jill Hellings, Barnardos HIV Support (Manchester, UK), Nimisha Tanna, Body and Soul HIV Charity (London, UK), Tricia Gardiner, Cardiff and Vale NHS Trust Hospital (Cardiff, UK), Djamel Hamadache and Paula Seery, The Family Clinic Chelsea and Westminster NHS Trust Hospital (London, UK), Breda Patterson, The Kobler Clinic Chelsea and Westminster NHS Trust Hospital (London, UK), Robyn Cross, Evalina Children's Hospital, Guys and St Thomas' NHS Trust (London, UK), Jacquie Flynn and Margaret Clapson, Great Ormond Street Hospital (London, UK), Ailsa Pickering, Newcastle Upon Tyne Hospitals, (Newcastle, UK), Jayne Griffiths, Newham General Hospital, (London, UK), Michelle Goode, Our Lady's Children's Hospital, Dublin (Ireland), Katia Prime, St Georges NHS Trust Hospital (London, UK), Christina Hanley and Clare Monrose, The Family Clinic Imperial College Healthcare NHS Trust, (London UK), Susan McDonald, The 900 Clinic Imperial College Healthcare NHS Trust 900 Clinic (London UK) and Alice Armstrong and Karen Gurney, Mortimer Market Centre, Central and North West London NHS Trust, (London, UK).

Author Disclosure Statement

No conflicting financial interests exist.

Appendix 1

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