Economic wellbeing and associated mediating pathways to improved antiretroviral therapy adherence among adolescents living with HIV: A prospective cohort study in South Africa

Background: Adolescents living with HIV exhibit lower levels of adherence to antiretroviral treatment (ART) than other age groups. Poverty is a key barrier to ART adherence. This study aims at understanding how alleviating poverty through structural and internal pathways can help increase ART adherence among adolescents. Setting: Eastern Cape province, South Africa. Methods: 1,046 adolescents living with HIV were recruited from 53 public healthcare facilities and interviewed at three data collection waves with a retention rate of 89% and a mortality rate of 3%.Data was collected via face-to-face, device-assisted interviews. Hybrid probit regressions and a structural equation path analysis were used to estimate the association between poverty reduction (increased access to basic necessities) and the pathways by which it could improve ART adherence. Results: Self-reported ART adherence ranged from an average of 66% (n=615) at baseline to 75% (n=700) in the last wave. Within- and between-person improvements in economic wellbeing were associated with significant increases in adolescent ART adherence. On average, adolescents with access to three additional basic needs experienced a four percentage-point increase in the probability of ART adherence. Structural pathways to improved ART adherence included participants having enough money to travel to the clinic andsufficient food to eat when taking medication. Internal pathways included improved psychological wellbeing and reduced internalised HIV stigma. Conclusion: Poverty reduction programmes such as HIV-sensitive social protection can address structural and psychological pathways to increase ART adherence among economically disadvantaged adolescents by incentivising demand-side interventions and the provision of quality essential services