1. Barriers To Engagement In HIV Care Among Adolescents Females Participating In An HIV Prevention Intervention Tiarney D. Ritchwood, 1-2 Rushina Cholera, 2 & Audrey Pettifor 2-3 Medical University of South Carolina, 1 University of North Carolina at Chapel Hill, 2 University of the Witwatersrand 3 Presenting Author: Tiarney D. Ritchwood, PhD Assistant Professor Medical University of South Carolina

2. Introduction 15% of South African young women (15-24 years of age) and 5% of young men are currently infected with HIV. 1-2 South African adolescents often delay HIV care engagement until their CD4 counts are well below recommended rates for ART initiation. 3 Timely initiation of ART improves prognoses, decreases early mortality, and allows for communication of prevention messages that lead to risk reduction and decreased secondary transmission. 4-6 Loss to care can occur at any stage along this engagement in care continuum- a person may not initiate care after diagnosis or they may not maintain care after initiation. To improve the link between HIV testing and treatment among young people, modifiable barriers that might preclude HIV positive adolescents from accessing clinical services must be understood.

3. Aims Identify barriers to engagement in care among HIV positive South African female adolescents who had not sought care since the baseline intervention assessment Identify facilitators of engagement in care among HIV positive South African female adolescents reporting that they had sought care since the baseline assessment

4. Study Site: Agincourt Health and Socio-Demographic Surveillance Site (AHDSS) Kahn K, et al. IJE 2012.; Gomez-Olive X, et al AIDS Care 2013. Ehlanzeni District, Mpumalanga Province 28 villages, 115,000 people, 420 km 2 HIV Prevalence 46% and 45% among women and men 35-39 years.

5. Design: Study Design & Population A phase III RCT to determine whether the use of cash transfers conditional on school attendance leads to reduced sexual risk and subsequent HIV infection. Eligibility Criteria: Female Enrolled in grades 8, 9, 10 or 11 in participating high schools Age 13-20 years Not married or pregnant by self-report Parent/guardian living in household Able to complete a computer survey on her own Residing in study area * girls testing HIV positive at baseline were not excluded but rather stayed in the study and were randomized to the intervention

6. 2,533 young women were enrolled March 2011- December 2012. 2,448 were HIV uninfected at enrollment (81 HIV+, 4 unknown status). Results: HPTN 068 Baseline Baseline Age (Median, IQR)15 (14-17) Ever sex26.6% HIV3.2% HSV-24.4% Ever Pregnant8.9% Orphan28.6% Food insecurity34.3% HH receives CSG79.0%

7. Engage Study (N=38) Parental consent for Engagement in Care study Attends 1 year Swa Koteka camp CD4 collection visit scheduled At visit, adolescent consent or assent obtained Counselors administer questionnaire

8. Adolescents not engaged in Care (N=14)

9. Results: Barriers to Care

10. Adolescents engaged in Care (N=24)

11. Top Facilitators for engagement in Care for HIV+ Young Women

12. Strongly agree AgreeDisagre e Strongly disagree Spent plenty of time with you. 8.769.617.44.3 Treated you in a friendly manner. 13.069.613.04.3 Made you feel embarrassed about being HIV+. --13.060.926.1 Listened carefully to what you had to say. 17.478.34.3-- Made you feel better than before. 26.165.24.3 Criticized you. --9.168.222.7 Guided you as to what you must do. 26.173.9-- Clinic Experiences of Adolescents engaged in HIV Care

13. Summary & Conclusions: Barriers Barriers to engagement in care among HIV+ young South African women in rural villages focused on four main areas: Perception of illness (i.e., don’t need treatment, not ill, can wait) Clinic accessibility (i.e., money for transportation, distance) Stigma (i.e., fear of someone finding out) Awareness (i.e., where to go, treatment side effects) To combat such challenges, should consider: Public Health campaigns promoting the importance of early engagement in care marketed towards youth Mobile health options Community outreach aimed at increasing awareness and decreasing stigma

14. Summary & Conclusions: Facilitators Facilitators to engagement in care among HIV+ young South African women in rural villages focused on two main areas Clinic accessibility (i.e., affordable transportation, proximity, positive experiences, & convenient hours) Most appreciated the services provided by their specific clinic providers and felt that they were receiving proper guidance, adequate information, and that staff were friendly Family support was the most frequently cited facilitator to engagement in care Important, developmentally, for adolescents and transitioning adults How can we engage families in care?

15. ACKNOWLEDGEMENTS Engage Study Principal Investigators Rushina Cholera (UNC) Bill Miller (UNC) HPTN 068 Study Investigators Audrey Pettifor (UNC) Kathleen Kahn (MRC/Wits Agincourt) Catherine MacPhail (WrHI/UNE) Xavier Gomez-Olive (MRC/Wits Agincourt) UNC Amanda Selin Aimee Julien Cheryl Marcus Mary Jane Hill Lisa Albert Suchindran Chirayath Harsha Thirumurthy Sudhanshu Handa Joseph Eron Tamu Daniel WrHI Nomhle Khoza Sinead Delaney Helen Rees HPTN Laboratory Center Susan Eshleman Estelle Piwowar-Manning Oliver Laeyendecker Yaw Agyei LeTanya Johnson-Lewis HPTN LOC at FHI360 Phil Andrew Erica Hamilton Rhonda White NIMH Susannah Allison Dianne Rausch NIAID Sheryl Zwerski Ellen Townley Paul Sato Jenese Tucker HPTN SDMC Jim Hughes Jing Wang Diana Lynn Laura McKinstry Lynda Emel LSHTM James Hargreaves MRC/Wits- Agincourt Ryan Wagner Stephen Tollman Rhian Twine Wonderful Mabuza Immitrude Mokoena Tsundzukani Siwelane Simon Mjoli Dumisani Rebombo Edwin Maroga Senamile Ndlovu Audrey Khosa

16. The HIV Prevention Trials Network is sponsored by the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the National Institute on Drug Abuse, all components of the U.S. National Institutes of Health. ACKNOWLEDGEMENTS This project was funded by the National Institute of Mental Health (F30MH096664, PI: Cholera)