Understanding the effects of the COVID-19 pandemic on HIV care among adolescents and young adults living with HIV in Kenya

Thesis (Master's)--University of Washington, 2022Background: The COVID-19 pandemic posed a considerable risk of disruption of clinical services, including HIV services. Mitigation measures mandated by governments limited movement and access to HIV clinics, which could impact clinical care. The impact of these measures among youth (10- 24) living with HIV (YLH) who were already a vulnerable group could result in exacerbation of poor outcomes. Using a mixed-methods design, we explored the effects of COVID-19 on HIV care among YLH in Kenya. Methods: We conducted a cross-sectional analysis of COVID-19 survey data collected in an ongoing clinical trial evaluating the impact of an Adolescent Transition Package (ATP) on readiness to transition to adult care. We used logistic regression models to estimate odds ratios and 95% confidence intervals for correlates of medication adherence, access to ART and clinical services, and mental health during the COVI9-19 pandemic period. Relevant correlates included age, gender, entry point to HIV services, and type of support person. Qualitative data from interviews with a subset of YLH was analyzed using a thematic analysis approach. Qualitative and quantitative results were triangulated to explore the effects of COVID-19 on HIV care among YLH. Results: A total of 1066 YLH, median age 20 years (17, 23), responded to the COVID-19 survey conducted June-October 2020. Most participants were female (n=770 [72%]) and were enrolled at Comprehensive Care Clinics (CCCs) (n= 711 [67%]). Of the 71 YLH who participated in the interviews, median age was 20 (18, 22) and 56% (n=37) were female. Overall self-reported medication adherence was high, with only 3% (n=29) of respondents reporting that they had missed ART doses for 2 or more days in the past week. Over a quarter (26% [n = 251]) of survey participants reported experiencing challenges accessing ART from clinics. Interview participants shared concerns about nationwide ART stockouts, noting challenges getting >1 month of medication at a time, and feared that stockouts would negatively impact adherence. Older YLH (20-25), and clients enrolled at CCC (vs. PMTCT) had higher odds of experiencing difficulties accessing ART (OR = 1.72, 95% CI: 1.21-2.44, p = 0.003; OR 1.67; 95% CI: 1.13-2.50; p= 0.011, respectively). Compared to male participants, female participants were more likely to face challenges accessing HIV clinical services (OR = 2.04; 95% CI: 1.13-3.86; p = 0.023). Participants who reported feeling loneliness were more likely to report challenges with adherence (OR= 0.19; 95% CI: 0.07-0.52; p = 0.001). Interviews revealed that COVID-19 disrupted social support networks for YLH and negatively impacted overall mental well-being. Conclusions: Self-reported adherence among YLH during COVID-19 was high, despite challenges accessing care. Fear of ART stockouts, disruption in social support and mental health well-being were important impacts of COVID-19. Efforts to optimize HIV care for YLH should consider strategies to strengthen the ART supply chain and integrate mental health services into the HIV care syste