STACKing the odds for adolescent survival: health service factors associated with full retention in care and adherence amongst adolescents living with HIV in South Africa

J Int AIDS Soc. 2018 Sep;21(9):e25176. doi: 10.1002/jia2.25176.


Introduction: There are two million HIV-positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self-reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)-initiated adolescents in South Africa.

Methods: We collected clinical records and detailed standardized interviews (n = 1059) with all 10- to 19 year-olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost-to-follow-up (90.1% of eligible adolescents interviewed). Associations between full self-reported retention in care (no past-year missed appointments and 85% past-week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility.

Results: About 56% of adolescents had self-reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention.

Conclusions: This study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV-positive adolescents.

Keywords: HIV; adolescent; adolescent health services; delivery of healthcare; medication therapy management; viral load.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adolescent Health Services*
  • Ambulatory Care Facilities
  • Anti-Retroviral Agents / therapeutic use
  • Child
  • Cross-Sectional Studies
  • Female
  • HIV
  • HIV Infections / drug therapy*
  • HIV Infections / epidemiology*
  • Humans
  • Male
  • Medication Adherence / statistics & numerical data
  • Pregnancy
  • Prenatal Care
  • Reproducibility of Results
  • Retention in Care
  • Rural Population
  • Self Report
  • Self-Help Groups
  • South Africa / epidemiology
  • Surveys and Questionnaires
  • Viral Load
  • Young Adult


  • Anti-Retroviral Agents