 I thank you for the opportunity to present this research. This is a presentation of our expectations of perfect adherence and it's a finding from a qualitative study that we undertook to explore treatment failure among milception adolescents living with HIV. Is a study that was undertaken in partidisted pregnancy 20 in milertoared where MSF France has been supporting the Ministry of Health to deliver HIV care and treatment programs since 2001. Oherwydd ein bod yn fwy o ddych chi'n ymwneud am y pryd yn ein lleolau iawn, yn cynnwys, yn ymwneud yn wir iawn, a yn cael ei wneud am y mynd i'r adolytu'r pryd yn ein cyfnod corelliant o'r cyfrifol yn ei ddweud o'r rhai rai sydd yn iawn, yn ei ddweud i'r adolytu ar gyfer 30%. ydych chi'n gweithio ymweld o'r ysgolwch am ysgolwch ymweld o'r program? Felly mae'n ddifatodd o'r ddweud o'r fforddau sy'n gyffredinol a fydddi'n bod yn fwy gwaith yw'r ddechrau gyda'r idea o dyma hwn. Felly mae'r gweld ffشirio'n gaf polwgo o'r fforddau o gyffredinol yn gyffredinol ymlaen i'r fforddau o'r ffaisio ymddangos cynghoriadau a'r hynny a'n ffaisio ymddechrau sydd o'r cyfrifol o'r gwaith a'r gafodau. ac ymgyrchol gyda ffactorau cyd-refleithio ddim yn hyffordd iawn i yn ymddangos rhywun ar y terbyn m privileged to live with HIV to inform new interventions to to promote attenness in this setting. The particular analysis that I'll present today is just one component that aim to explore how the social interaction of young people in different settings such as the clinic, home, and community can influence their attenness to treatment. So this is a qualitative study and we collected our data through repeated in-depth ydy, yn ymlaen i agliadfaon beth sydd wedi rhoi hxiv. Rwy'n meddwl i'r meddwl sydd wedi'i gwaith y cyfrifau gyfo'r family wedi'i gwaith, os iddyn nhw i'r meddwl syd wedi'i minsau yn ystataethau ac yng nghyd-emwyntaeth. Yn mewn meddwl, ac rwy'n meddwl i'n meddwl i'r meddwl yn yourbwynydol ar y cyfaint i gael ei eisteddauheadd mewn hxiv i gael. ac iel nhw'n grannu ei wneud wrth i'r gwbl am gyda'u newydd yma. Rhaid i teimlo'n g listing i'r newid yma i'r newid a iddiwyd yma. Rwy'n lefrodu'r gweithio cynolio'r gweithredu cyffredin nhw'n ei bod nhw ym nid yw eu cyfrifysgwr ac eich veddordeb yn ei cynllun a fyddnoddiaid ei bod nhw hefyd i'r gweithredu meddwl. Rwy'n llei sy'n meddwl â'r slateau neu eu pariadau—ce wedi bod pesio'n lleol, eich mwy oedd gwylio'r llyfrifysgwr i'r llippydd, .. delivered data and felt like the numbers. We took the input in this ban of theRo-T-E-s Mountains ofこ. Read적으로, this is the list of countries with names to look at. Desk to a commonキrh Qinyslwmd Ysgrifeddial, people with strong power and values. There are many other districts with strong authority this year. i ddechrau nhw i bobl, a fe ddim ychydigol ystryd mewn dyma'r Fildredin Echydigor Gweithio Mhlau i Trofodaeth. Ond, mae'n cael eu chysylltu, ond ei gweithio'r ffordd higol yn gyffredig yr Adolesyn i'r Mhinga ar Ysgrifennidau, mae'n mhinga thysgol o'r Mhinga, mae'n mhinga ar bob amgylcheddau antirelfaenol, ac mae'n ddefnyddio myintill yn cael i gydigwyrmwys. Felly, efallai'n ddigwydd fydd yma hgor unig o'r Fhinga'r Mhinga. Dyma'r gwahodd y byddai'n eu cyd-ddiwedd fel hwnnw fydda i'r ochr o'i gaelion gyda wahanol y sgol yn ymgylchedd yma, ac mae'r llyfr o rhaglen o'r cyffredinol yw'r cyffredinol, neu'r cyfrifiadau o'r cyfrifiadau i'r cyfrifiadau i'r cyfrifiadau i'r cyfrifiadau. Mae'n gweithio ar y ddod, gwahodd yn cyfrifiadau ymgylchedd a'r gyfrifiadau o'r cyfrifiadau ac mae'n cyfrifiadau o'r cyfrifiadau i'r cyfrifiadau sy'n gwneud o gweithio disciplin a chynhyfydd o'r ddau'r gwaith a'r ddau'r gweithio. Dwi'n gweithio bod yma yw'r adeiladau o'r ddau cyfrifwyr o'r ddau. Mae'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r gweithio o'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau'r ddau. Felly, ar gyfer y rhannu hefyd, roedd ymgyrch gweithio bod y gweithiwyd y hifi yn gyffredig i'r cyfrifysgwyr ac yn gweithio. Rwy'r cyfrifysgwyr yn fwy o gweithio'r lluniau a dyfodol, ychydig o'r plwysoedd i'r cyfrifysgwyr i'r cyfrifysgwyr hynny. Felly, roedd y cyfrifysgwyr i'r lluniau a gweithio yn gwyliad. Mae'r cyfarffau yma yn cyfrifysgwyr, mwyaf o Gwylodraeth rwy'n meddwl i'w meddwl i'r ffordd hifi ac ar y taw, ac mae'r gweithio gyda'r gwahanol yn rhoi'r gweithio'r adeiladau i'r gwahanol i'r adeiladau. Felly, mae'r gweithio'r adeiladau yn y cyfaroedau yma o'r bod yn dod. Rwy'n meddwl i'r gwahanol i'r cyfrifiadau yn cyfrifiadau ar y twyd yw'r gweithio'n meddwl i'r gweithio'r adeiladau a'r gweithio'r gweithio'r adeiladau. Felly, yw'r ein nod o yr adeiladolweddau, efallai y meddwl yn ymweld yn ymmwyaf ar gyfer y 658, ac yn ystod y cyfnodd yma ar 630, yr adeilad yn ymwyaf rydyn ni os ymwyaf yn gwneud yn y porfodon i fyrwyr, ac yn ymweld yn ymwyaf ag i'r ffordd. Rydyn ni coloured yn ymwyaf ar y gyfresDonald, ac mae ydw ymweld yn ymwyaf yn y cair o'r gwylliant sy'n rydyn ni bod ni'n gwybwysig o'r cyfeiwch ar y gaelau Eliswn i chi'n ei wneud ei bod yn ffordd y gallwn gyma'r piliol ac ydych chi yn ei wneud y cael y gweithydd sy'n mynd i'r awdur fod yn y cychwyneth ar fy mhent yn ei wneud gyda'r awdur yn gweithio yn ôl, mae'n ffwg i'r awdur gyda'r awdur. Diolch am ffio'r piliolaethau yn ffun o'ch gyrshodau a'i g boothi'r cyflwnu ar gyfer awdur, mae'n oed i gael cyfredu cyn y gallu gweld o sightsiaid, a fyddai'n gweithio i gael cymdeithasolion hynny. Mae'r hyn yn ei gwybod'i un o'r ffagurhau gyda yma yn ymwneud eich gwybod hefyd o gyd, a mae'r hyn o'r pwyllt o'r drws iawn, sy'n gallu drws iawn, o'r cyfrifysgol, o'r drws iawn, o'r drws iawn o'r llwstdachau o'r gwybod. Mae'n cael eich gwybod, mae'r drws iawn er mwyn o'r cyfrifysgol, ond mae'n cael ei wneud o'r ddechrau fel y gallwn cyffredinol o'r problemau. Rwy'n gweithio i chi i ei hyn o'r dylannu. Mae'r gwirioneddau yma sy'n dwi'n meddwl y pethau'r wych yn ei ddweud yr ysgol yw'r ysgolol. Mae'r ysgol yw'r ysgol, a'r ysgol, a'r ysgol, a'r ysgol yn ei ddweud yr ysgol. Felly mae'n ffordd ychydig yn ddiweddol â'r ysgol, yn y mae'r ysgol yn ysgol, mewn ysgol, yn ei ddweud, yn eu ddweud. Mae'n ddweud yma, a'r ysgol eich bod yn gallu'n meddwl yma, I wish the health worker could try to encourage the patient other than just giving medicine names. I wish he could engage the patient in a dialogue, ask the patient how he's feeling, how he thinks the medicine will work and even involve him in deciding the best time to take the medicine. This is something that was clearly very absent in the narratives of all of our participants. We also found that some of the measures that were put in place to support adherents were actually perceived to be very punitive by adolescents and that could also really undermine their adherence. So, for example, additional pill counts to see if people who were suspected of poor adherence were actually taking those drugs, sometimes going so far as make people wait longer because they hadn't been adherent, going to the back of the queue having to come for extra appointments. These were things that were sort of supposed to well-intentioned help for young people, but they were perceived to be punitive. And one young boy said, if you come and get medicine for two months in advance, they would deliberately give you medicine only worth one month so as to punish you. And so we went at wasting our transport money and other costs. But we found that these attitudes weren't just in the HIV clinics, but were also quite prevalent in the other health services around. So, for example, we saw this notice on the door of a youth-friendly sexual and reproductive health clinic, and it says translated, to all use, this is not a meeting place for you and your lovers. If found doing that you have broken our law, you will not be tolerated but given a punishment proportional to the crime you committed. This is a reproductive and sexual health clinic, a youth-friendly sexual and reproductive health clinic, in one of the health centres where one of the HIV clinics that MSF is supporting. We similarly found that even in people's homes, young people faced a range of challenges. Their caregiving arrangements were often fluid. There were precarious people being passed around in many cases, particularly for those who were orphans. And in many cases we found that children were being instructed to hide their HIV status, to hide their pills, to hide their pill taking from other family members, including their siblings. And this was often related to parents' fears of disclosing their own HIV status if the child's HIV status was known. People would go to extraordinary lengths to hide their pills in the home. One caretaker told us, OK, this is how I hide. There's a drum and inside that drum there are books and that's where we get these chairs and I'll be interested to remove all those things in such a place. I also place the mattress on top, normal step of foot in there. So people are going to extraordinary lengths to hide pill taking in the home. We also found that caretakers didn't engage in conversations about HIV in the home and this really reinforced it as something that was a very shameful experience for many of those young people. And even talk about reminders to take pills were often very directive. There were sometimes accompanied by threats or reprimands or punishments and this often led to young people hiding the fact that they hadn't been able to take their pills as they'd wanted to and even throwing away some of those pills. So overall we found that some of these issues contributed to young people feeling isolated. There was secrecy, there was silence in the home around their HIV status and their ability to take their pills. It led to them feeling anxious and confused and all of these things undermined their pill taking. Within the wider community as well we found that influential community members held strong views about people's social lives and their behaviours in general including adherence and we found that many of them felt responsibility at a certain role to help address stigma and to encourage adherence to ART and they actually had a range of powers through which they could influence and regulate some of these social behaviours. So for example they could impose curfews or fines for example if someone was found to discriminate against someone with HIV. They could organise social events for young people but they could also cancel them if they felt there was inappropriate behaviours and these attempts also sometimes undermined people's adherence behaviours. One community member told us there are others who when they take their medicine and see that they are good they stay without taking the medicine, they just stop. So when we find such things we give them threatening advice that if they do that they won't be received at the hospital so we won't write those letters, referral letters to groups and so on. So overall we found that treatment failure couldn't really be explained by a lack of knowledge about HIV and ART but it was far more likely to be undermined by an inability of young people to conform to some of the unnecessarily strict rules and expectations of adherence in this setting. We found that young people were fearful of the consequences if they were seen to be non-adherent and this led to a lack of opportunities to talk frankly about those challenges a lack of safe spaces in which they could discuss the challenges and pill taking strategies. Based on these findings we think that interventions should also move outside of the clinic and occur where the pill taking occurs. So for example in the home and this could be supported through home visits. We feel that interventions need to be more family focused giving support to caregivers as well as the young people to support disclosure within the household, address stigma within the household. We feel that there's further evidence to support MSF's advocacy for a counselling cadre to help support adherence particularly amongst young people. We feel that there's also a need to move away from ART literacy and move towards problem solving skills in young kids and efforts to build their resilience and in this particular setting more better and more peer clubs for them to get involved in. We also think that there's a need for supporting health workers to think about the messages that they're delivering and the impact that they can have on young people the style and the way in which they deliver those. As a result of the study and others a revised model of care is being developed now into a Zulu and will be rolled out later this year. Thank you.