Antiretroviral Therapy Adherence Did Not Differ between Thai Children with Biological and Those with Nonbiological Parents

TO THE EDITOR—In Thailand, an estimated 20,000 children are living with HIV infection, at least one-half of whom have lost one or both parents. Caring for an HIV-infected child is complex, especially when there is a need to administer antiretroviral therapy (ART). Caregivers play a major role in assuring that children adhere to therapy. We investigated whether adherence to ART was different for Thai children with biological parents (BPs) versus nonbiological parents (NBPs).

From February through June 2004, the study enrolled 29 primary caregivers whose children were attending their scheduled visits at a university hospital in Bangkok: 16 consecutive BPs, defined as biological fathers or mothers; and 13 consecutive NBPs, including biological relatives, foster parents, and others. All caregivers signed informed consent forms. Data were collected from pill counts, the children's medical charts, and questionnaires administered to caregivers about adherence to ART and basic knowledge about HIV infection. Full adherence to ART was defined as no missed doses in the past month. Institutional ethics committees approved the study.

Characteristics of children were the same in both groups. The median age of children was 6.1 years, 48% were female, and all were receiving ART. The median CD4 cell percentage was 12%. Both BPs and NBPs cared for a similar number of children and had a similar number of adults living in their households. The caregivers' characteristics are presented in table 1. BPs were more likely to be HIV infected themselves. NBPs were older, reported significantly lower income, tended to be less educated, and did not score as well on the questionnaire about basic knowledge regarding HIV infection. All caregivers reported that the children had full adherence to ART on the questionnaire. The rates of adherence, as by determined by the pill count, were 99.3% and 98.2% in the BP and NBP groups, respectively (P > .05). In such a small sample size, significant differences may not be detected. However, we were concerned that we would see significant differences in the rates for children of BPs versus the children of NBPs.

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Table 1

Characteristics of caregiver groups.

Little is known about how the relationship of the caregiver with the child impacts adherence to treatment. A Ugandan study found that most older NBPs lacked resources, knowledge, and skills sufficient to provide proper care for children and concluded that the NBPs need support to meet their economic needs and child-rearing responsibilities [1]. In contrast, an Italian study reported the children of NBPs—in this case, foster parents—had higher rates of adherence to ART than did children raised by BPs or other relatives [2]. ART adherence was found to be similar in orphans and nonorphans in a Kenyan study [3].

The dynamics of these relationships and their impact on ART adherence appear to vary across cultures. Although adherence rates did not differ between BPs and NBPs in our study, additional attention is necessary to ascertain whether being elderly, less educated, and poorer can hinder Thai caregivers' efforts to meet both the children's needs and their own. As access to ART for children increases around the globe, an effort to compare results across countries, leading to the development of global guidance, is a necessary next step.

• © 2007 Infectious Diseases Society of America