AIDS and Behavior

, Volume 23, Issue 2, pp 475–488 | Cite as

Paediatric ART Adherence in South Africa: A Comprehensive Analysis

  • Sabine L. van ElslandEmail author
  • Remco P. H. Peters
  • Nelis Grobbelaar
  • Patiswa Ketelo
  • Maarten O. Kok
  • Mark F. Cotton
  • A. Marceline van Furth
Original Paper


Adherence to antiretroviral therapy (ART) remains a challenge for HIV-infected children. In this cross-sectional study, we used structured interview-administered questionnaires and medical records to measure adherence levels and factors associated with adherence and viral suppression. We included 195 South African children aged 2.1–12.9 on ART. Adherence levels ranged between 20.5% (pill count) and 89.1% (self-report). Boys were less adherent according to self-report, girls were less adherent according to pill count. Caregivers ensured medication was taken when the condition directly affected daily life. Well-functioning families and families with high SES provide a context supportive of adherence. Non-disclosure and difficulties administering medication negatively affected adherence and viral suppression. This study shows challenging levels of adherence impacting directly on viral suppression in a South African paediatric HIV program. Gender roles, non-disclosure and difficulty administering medication may undermine adherence and should be taken into account for clinical guidelines, policy design and inform strategies.


Adherence Child Paediatric HIV South Africa 



The authors thank the study participants, the staff at the clinical site, TC Newman Hospital and Anova Health Institute and also Mrs. H. Lesch for her assistance with the data collection.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflict of interest to declare.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Stellenbosch University’s human research ethics committee approved this study (reference number N11/11/329).

Informed Consent

All caregivers provided written informed consent for their and their child’s participation. In addition, all children (≥ 7 years) provided written informed assent for their participation.


  1. 1.
    World bank. World development indicators. 2017. Accessed July 10, 2018.
  2. 2.
    Joint United Nations Programme on HIV/AIDS (UNAIDS), AIDSinfo. Global factsheets 2016.,0&qla=G&qls=AllCountries. Accessed July 10, 2018.
  3. 3.
    Joint United Nations Programme on HIV/AIDS (UNAIDS), AIDSinfo. Country factsheets South Africa 2016.,0&qla=C&qls=ZAF. Accessed July 10, 2018.Google Scholar
  4. 4.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). Global AIDS update 2016. Geneva, Switzerland: UNAIDS; 2016. Accessed July 10, 2018.
  5. 5.
    National Department of Health South Africa and South African National AIDS council. Guidelines for the Management of HIV in Children 2nd Edition 2010. National Department of Health, Pretoria, South Africa 2010. Accessed July 10, 2018.
  6. 6.
    Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009;374:817–34.CrossRefGoogle Scholar
  7. 7.
    National Department of Health South Africa. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMCTC) and the management of HIV in children, adolescents and adults. National Department of Health, Pretoria, South Africa 2015. Accessed July 10, 2018.
  8. 8.
    Muller AD, Bode S, Myer L, Stahl J, von Steinbüchel N. Predictors of adherence to antiretroviral treatment and therapeutic success among children in South Africa. AIDS Care. 2010;23(2):129–38.CrossRefGoogle Scholar
  9. 9.
    Davies MA, Boulle A, Fakir T, Nuttall J, Eley B. Adherence to antiretroviral therapy in young children in Cape Town South Africa, measured by medication return and caregiver self-report: a prospective cohort study. BMC Pediatr. 2008;8(1):34.CrossRefGoogle Scholar
  10. 10.
    Joint United Nations Programme on HIV/AIDS (UNAIDS), AIDS info. AIDS-related deaths in South Africa 1990–2016—all ages, children (0–14) and adolescents (10–19). 2016.,0&gid=55815a8db9568074415370b4,55815ac7b9568074415370b6,5975fcaf749d6b134fc968e9&gr=ZAF. Accessed July 10, 2018.Google Scholar
  11. 11.
    Lall P, Lim SH, Khairuddin N, Kamarulzaman A. Review: an urgent need for research on factors impacting adherence to and retention in care among HIV-positive youth and adolescents from key populations. JIAS. 2015;18(1):41–53.Google Scholar
  12. 12.
    Bernheimer JM, Patten G, Makeleni T, Mantangana N, Dumile N, Goemaere E, Cox V. Paediatric HIV treatment failure: a silent epidemic. JIAS. 2015;18:20090.CrossRefGoogle Scholar
  13. 13.
    Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet. 2009;374:921–33.CrossRefGoogle Scholar
  14. 14.
    World Health Organization (WHO). Adherence to long-term therapies, evidence for action, section III—disease-specific reviews, chapter XII—HIV/AIDS. WHO and chapter XV—tuberculosis, Geneva, Switzerland: 2003; 95–106, and 123–132. Accessed July 10, 2018.
  15. 15.
    The United Nations Children’s Fund (UNICEF) and Joint United Nations Programme on HIV/AIDS (UNAIDS), a call to action—children, the missing face of AIDS. New York, USA: The United Nations Children’s Fund; 2005. Accessed July 10, 2018.
  16. 16.
    Haberer J, Mellins C. Pediatric adherence to HIV antiretroviral therapy. Curr HIV AIDS Rep. 2009;6:194–200.CrossRefGoogle Scholar
  17. 17.
    van Dyke RB, Lee S, Johnson GM, et al. Reported adherence as a determinant of response to highly active antiretroviral therapy in children who have human immunodeficiency virus infection. Pediatrics. 2002;109(4):e61–7.CrossRefGoogle Scholar
  18. 18.
    Quittner AL, Modi AC, Lemanek KL, Levers-Landis CE, Rapoff MA. Evidence-based assessment of adherence to medical treatments in pediatric psychology. J Pediatr Psychol. 2008;33(9):916–36.CrossRefGoogle Scholar
  19. 19.
    La Greca MA. Adherence to pediatric treatment regimens. In: Roberts MC, editor. Handbook of pediatric psychology. New York: The Guilford Press; 2003. p. 119–40.Google Scholar
  20. 20.
    Varni JW. How young can children reliably and validly self-report their health-related quality of life?: An analysis of 8591 children across age subgroups with the PedsQLTM 4.0 generic core scales. Health Qual Life Outcomes. 2007;5(1):1.CrossRefGoogle Scholar
  21. 21.
    Varni JW, Limbers CA, Burwinkle TM. Parent proxy-report of their childrenʼs health-related quality of life: an analysis of 13,878 parents’ reliability and validity across age subgroups using the PedsQLTM 40 generic core scales. Health Qual Life Outcomes. 2007;5(1):2.CrossRefGoogle Scholar
  22. 22.
    Varni JW, Sherman SA, Burwinkle TM, Dickinson PE, Dixon P. The PedsQLTM family impact module: preliminary reliability and validity. Health Qual Life Outcomes. 2004;2(1):55.CrossRefGoogle Scholar
  23. 23.
    Statistics South Africa. Census 2011 statistical release P0301.4. Pretoria, South Africa: Statistics South Africa; 2012. Accessed July 10, 2018.
  24. 24.
    National Department of Health South Africa. Disclosure guidelines for children and adolescents in the context of HIV, TB and non-communicable diseases. Pretoria, South Africa: South African national department of health; 2016. Accessed July 10, 2018.
  25. 25.
    Simoni JM, Montgomery A, Martin E, New M, Demas PA, Rana S. Adherence to antiretroviral therapy for pediatric HIV infection: a qualitative systematic review with recommendations for research and clinical management. Pediatrics. 2007;119(6):e1371–83.CrossRefGoogle Scholar
  26. 26.
    Mellins CA, Brackis-Cott E, Dolezal C, Abrams EJ. The role of psychosocial and family factors in adherence to antiretroviral treatment in human immunodeficiency virus-infected children. Pediatr Infect Dis J. 2004;23(11):1035–41.CrossRefGoogle Scholar
  27. 27.
    Reda AA, Biadgilign S. Determinants of adherence to antiretroviral therapy among HIV-infected patients in Africa. AIDS Res Treat. 2012. Scholar
  28. 28.
    Mori M, Adland E, Paioni P, Swordy A, Mori L, Laker L, et al. Sex differences in antiretroviral therapy initiation in pediatric HIV infection. PLoS ONE. 2015;10(7):e0131591.CrossRefGoogle Scholar
  29. 29.
    Strebel A, Crawford M, Shefer T, Cloete A, Nomvo DH, Kaufman M, Simbayi L, Magome K, Kalichman S. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. SAHARA J. 2006;3(3):516–28.CrossRefGoogle Scholar
  30. 30.
    Vreeman RC, Wiehe SE, Pearce EC, Nyandiko WM. A systematic review of pediatric adherence to antiretroviral therapy in low- and middle-income countries. Pediatric infect Dis J. 2008;27:686–91.CrossRefGoogle Scholar
  31. 31.
    van Elsland, SL, Peters RPH, Grobbelaar N, Ketelo P, Kok MO, Cotton MF, van Furth AM. Disclosure of HIV status to children in South Africa: a comprehensive analysis. Submitted for publication.Google Scholar
  32. 32.
    Duong M, Piroth L, Peytavin G, Forte F, Kohli E, Grappin M, Buisson M, Chavanet P, Portier H. Value of patient self-report and plasma human immunodeficiency virus protease inhibitor level as markers of adherence to antiretroviral therapy: relationship to virologic response. Clin Infect Dis. 2001;33:386–92.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Sabine L. van Elsland
    • 1
    • 2
    Email author
  • Remco P. H. Peters
    • 3
  • Nelis Grobbelaar
    • 3
  • Patiswa Ketelo
    • 3
  • Maarten O. Kok
    • 4
  • Mark F. Cotton
    • 5
  • A. Marceline van Furth
    • 1
  1. 1.Department of Paediatric Infectious Diseases and ImmunologyVU University Medical CentreAmsterdamThe Netherlands
  2. 2.Department of Paediatrics and Child HealthTygerberg Children’s Hospital and Stellenbosch UniversityCape TownSouth Africa
  3. 3.Anova Health InstituteJohannesburgSouth Africa
  4. 4.Department of Health Care GovernanceErasmus School of Health Policy and Management at Erasmus University RotterdamRotterdamThe Netherlands
  5. 5.FAM-CRU, Department of Paediatrics and Child HealthStellenbosch University and Tygerberg Children’s HospitalCape TownSouth Africa

Personalised recommendations