1. 1 Sumiyo Okawa 1, Sylvia Mwanza 2,3, Mwiya Mwiya 2, Kenichi Komada 4, Masamine Jimba 1, Naoko Ishikawa 4 The University of Tokyo, Tokyo, Japan Paediatric HIV Center of Excellence, University Teaching Hospital, Lusaka, Zambia The University of Zambia, Lusaka, Zambia National Center for Global Health and Medicine, Tokyo, Japan Emerging Challenges among Perinatally Infected Adolescents in Zambia: Poor Mental Health and Non-adherence to ART

2. Background 2 Adolescence Childhood Birth Multiple challenges among HIV-positive adolescents Sexual Reproductive health Mental health Adherence to ART Complications related to HIV infection and treatment Education and career development Mofenson, et al. 2013 Few epidemiological and social science researches of HIV-positive adolescents

3. Objectives of the study 3 Background of people living with HIV in Zambia:  12.4 % of adults (15-49 years)  100,000 of children (<15 years) HIV-positive children are moving into adolescence, and need to manage their treatment and well-being. This study aimed at assessing:  Mental health status of HIV-positive adolescents  Adherence to ART and its challenges (UNAIDS 2015)

4. Methods 4  Design: a cross-sectional study  Site: The Paediatric HIV Center of Excellence, University Teaching Hospital, Lusaka, Zambia  Period: April - July 2014  Participants: 190 HIV-positive adolescents aged 15 to 19 years known HIV-positive status  Data collection: Self-administered questionnaire  Ethical approval The University of Zambia The National Center for Global Health and Medicine, Japan

5. Measurements and Analyses 5  The Center for Epidemiological Studies Depression Scale (CES-D) short version  10 items  Score range: 0 to 30  Cut-off point for suspected depression ≥10  Cronbach’s alpha in this study: 0.74  Three-day recall - Adherent = Never missed ART - Non-adherence = missed ART at least once  Proportion of suspected depression  Associations between higher scores of depressive symptoms and participants’ characteristics by multiple linear regression  Proportion of adherence to ART  Factors associated with non- adherence to ART by multiple logistic regression 2. Adherence to ART 1. Mental Health (Depressive symptoms)

6. Basic characteristics 6 Characteristicsn% Sex Girl11057.9 Boy8042.1 Age 152814.7 164724.7 173920.5 184523.7 193116.3 Education Not completed basic school3417.9 Completed basic school9349.0 Completed secondary school or attending university6333.2 Orphan status Non orphan6735.3 Single orphan7640.0 Double orphan4724.7 HIV knowledge (5 items) Answered all correctly7740.5 Not answered correctly11359.5 ART status On ART17994.2 Not on ART115.8

7. Mental health status Scores of CES-D*n% NormalScore < 1014274.7 Suspected depression Score ≥ 104825.3 7 *CES-D: The Center for Epidemiological Studies Depression Scale

8. Associations between adolescents’ characteristics and higher scores of CES-D 8 Covariatesβp-value Sex (0=Girl, 1=Boy)-0.330.67 Age-0.230.55 Educatonal level0.330.63 Orphan status (0=non, 1=single, 2=double orphan) 0.190.71 Unsatisfied relationship with family0.460.30 Unsatisfied relationship with friends0.540.23 Unsatisfied relationship with health workers1.320.01 Unsatisfied relationship with HIV-positive peers 0.090.84 Answered all HIV-knowledge correctly-0.190.81 Ever felt bad for being stigmatized2.870.01 Ever learned how to disclose HIV status0.850.32 Ever disclosed HIV status to friends-0.320.70

9. Adherence to ART n% Never missed12972.1 Missed 1 day3117.3 Missed 2 days137.3 Missed 3 days63.4 9 28% were non-adherent

10. Factors associated with non-adherence to ART 10 CovariatesAdjusted OR95%CI Sex Girl1.00 Boy1.260.59-2.69 Age 151.00 161.450.43-4.89 171.530.42-5.62 181.620.36-7.27 192.240.44-11.38 Education Not completed basic school 1.00 Completed basic school 1.110.40-3.12 Completed secondary school or attending university 1.070.27-4.24 Orphan status Non-orphan1.00 Maternal orphan3.081.07-8.86 Paternal orphan1.830.68-4.97 Double orphan1.020.36-2.92 HIV knowledge (5 items) Answered all correctly 1.00 Not answered correctly 3.101.36-7.07

11. (continued) Adjusted OR95%CI Relationship with family Satisfied1.00 Unsatisfied1.850.69-4.96 Relationship with friends Satisfied1.00 Unsatisfied1.360.50-3.70 Relationship with health workers Satisfied1.00 Unsatisfied1.150.37-3.59 Relationship with HIV-positive peers Satisfied1.00 Unsatisfied1.000.41-2.43 Mental status Normal1.00 Suspected depression0.370.13-1.00 Management of ART By myself1.00 By caregiver1.810.81-4.04 11

12. 12 Challenges to retaining ART adherence “I feel shy to take medicine with those who do not take” "I just feel depressed to take them because it’s not my fault to that I am positive, I was just born like that." "When I go out, I sometimes come home late, and I forget to carry on extra dose” "When I want to take the drugs, I feel like vomiting." PRIVACY DEPRESSED OUT OF HOME SIDE- EFFECT

13. Discussion 28% were non-adherent to ART High risk groups for poor adherence to ART -Maternal orphan -Don’t have basic knowledge about HIV Various challenges to retain good adherence to ART 13 25 % of HIV-positive adolescents with suspected depression High risk groups for poor mental health - Unsatisfied relationship with health worker - Ever felt bad for being stigmatized regarding their HIV-positive status Mental Health Adherence to ART

14. Conclusions and Recommendations  Mental health and adherence to ART are key areas to address in adolescence HIV care treatment program.  Recommendations: [Mental health]  Develop rapport with health workers  Provide psychosocial support [Adherence to ART]  Educate on HIV infection, prevention, and treatment  Address issues of maternal orphan  Support personalized medication practices 14

15. Acknowledgements  Special thanks to: Participants of the study Staff of the Paediatric HIV Center of Excellence, University Teaching Hospital  This study was funded by Research Grant for International Health, the Ministry of Health, Labor and Welfare, Japan. 15

16. 16 Contacts for further information:  Sumiyo Okawa (sumuiyo@m.u-tokyo.ac.jp)  Naoko Ishikawa (n-ishikawa@it.ncgm.go.jp) “I know that I have a medication to make me better.” (Girl, age 17)