Association for Public Policy Analysis & Management

An estimated 2.1 million adolescents are living with HIV worldwide, with more than 80% in sub-Saharan Africa. Research has shown that early initiation of antiretroviral therapy (ART) and continued adherence to ART can achieve viral load suppression, extend life expectancy, and reduce the risk of HIV transmission. Yet, poverty remains a threat to adherence and the potential effectiveness of ART. Limited resources to pay for costs related to treatment, lost employment due to illness, and food insecurity have all been shown to perpetuate treatment avoidance or disruptions. A limited number of economic interventions have been evaluated to address adherence to ART in low-resource settings. This literature has identified significant improvements in adherence for individuals receiving some form of financial incentive, assistance, or training. These studies, however, are limited to non-experimental designs and none have targeted adolescents as the primary study population. To address this gap, this study assessed whether HIV-infected adolescents who were randomized to receive a Child Savings Account (CSA) were as adherent to ART treatment, based on viral load suppression at 12 and 24 months, as adolescents in a comparison grouped randomized to receive a bolstered standard of care (BSOC).

Using a two-arm group randomized trial method, 39 participating clinics were randomly assigned to either the intervention or the control group. Adolescents in the control arm received a BSOC which included clinical care and psychosocial support complemented by six information sessions on ART adherence. Adolescents in the intervention group received the BSOC as well as a 1:1 matched Child Savings Account (CSA), withdrawals conditional upon use towards secondary education or microenterprise development. As part of the CSA package, the intervention arm also received financial literacy trainings, mentorship, and life-skills workshops.

The primary outcome of analysis was adherence to ART as measured by HIV RNA viral load. Cluster-adjusted comparisons of means and proportions were used to descriptively analyze changes in adherence between study arms while multi-level modelling was used to estimate treatment efficacy after adjusting for fixed and random effects. Analysis of pre-intervention viral load data demonstrated no statistically significant difference between study arms in regard to the proportion of participants with suppressed viral load (+6.3, p=0.182). At 24-months post intervention initiation, the proportion of virally suppressed participants in the intervention cohort increased tenfold (Δ_T2-T0=+10.0, p=0.001) relative to the control group (Δ_T2-T0=+1.1, p=0.733). In adjusted mixed models, simple main effects tests identified significantly lower odds of intervention adolescents having a detectable viral load at both 12- and 24-months.

These findings suggest that interventions addressing financial insecurity may be beneficial to increase ART uptake. This supports prior research demonstrating the ability of economic initiatives to improve ART adherence and extends this evidence base to an adolescent population. Such results prompt important policy questions when aiming to address the public health challenge of HIV, necessitating a dialogue on the intersections of financial security and HIV prevention and treatment.