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PLoS One. 2018 Feb 21;13(2):e0191848. doi: 10.1371/journal.pone.0191848. eCollection 2018.

Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa.

Author information

Indiana University School of Medicine, Indianapolis, IN, United States of America.
Regenstrief Institute, Inc, Indianapolis, IN, United States of America.
Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.
R.M. Fairbanks School of Public Health, Indianapolis, IN, United States of America.
University of California San Francisco, San Francisco, CA, United States of America.
City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, NY, United States of America.
Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda.



To describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium.


This study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis.


In East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]).


Self-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.

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