 not itself because majority of poor economic migrants actually utilize antibiotics for a quick fix and they're just trying to get back to work and it's very interesting I must say for a lot of people who work in urban poor economic migrant settings. I'm going to go over to the next presenter she's from epicenter and she's going to cover HIV and adolescence again perhaps one of the few conferences that has looked at adolescence so much and that's that's actually a welcome this thing please we have Rose Burns. Good afternoon everyone thank you for the opportunity to present our study today this presentation will explore treatment failure and expectations of perfect adherence to antiretroviral therapy through a qualitative study conducted with adolescents living with HIV in rural Malawi. So the study took place in Chua Zulu which is a rural district in the south of Malawi where MSF and Ministry of Health are running a HIV program which has included access to antiretroviral therapy since 2001. It's a well-supported HIV program and it has very good outcomes amongst adult patients however we've seen that adolescents have high rates of treatment failure on first line ART in the order of 30%. There's limited evidence to design an intervention that can support adherence amongst adolescents so in this context we've conducted a qualitative study which had the overall aim of exploring how individual social and programmatic factors could influence ART adherence amongst adolescents. Within this broader study this analysis looks at expectations that are put on to adolescents within clinics, families and the community to consider how they can influence adolescents adherence to treatment. So we conducted in-depth interviews with adolescents living with HIV aged between 10 and 19 years old as well as people who influence their health-seeking behavior. So that included caregivers, parents, aunties, uncles, community members such as traditional authorities and football coaches, also health workers. We did group activities using participatory methods that could generate discussion around HIV and treatment. These were conducted with adolescents who are inside our HIV program as well as adolescents from the wider community. We had a total of 99 participants in the study. As is standard we recorded transcribed verbatim and translated our interviews and group discussions. These were coded inductively meaning we went through the text systematically to develop categories. These categories were distilled further leading to the emergence of key themes and ideas that related to this research aim. We had ethical approval from institutional review boards in Malawi and the UK. Moving on to our key findings we found that adolescents had really good knowledge about HIV and treatment so they understood that it was important to take their drugs every day and they wanted to do so to maintain their health. But these good intentions were often undermined by social norms and expectations of young people. These were manifest in the social spaces that young people inhabited such as HIV clinics, homes and communities. In each of these settings we found that adolescents' behaviors were regulated by strict rules and obligations and there were threats of punishment for non-compliance. So attempts to exert control over adolescents' behaviors could actually undermine their adherence intentions. Within clinics we saw a major focus on treatment literacy and imparting information about HIV and ART. Accounts from patients, health workers and caregivers revealed that the messages that were received about treatment were unnecessarily strict, for example regarding the timing of doses, taking doses with meals. Patients often missed a dose or gave up if they couldn't follow these instructions and, as one caregiver told us, for example the medicine is supposed to be taken at 6.15 and instead one takes at 6.30. The medicine in this case does not work properly, the viruses keep multiplying and the medicine does not work at all. Patients also perceived different clinic approaches as punitive such as pill counts, longer waits or extra appointments that they were given if they couldn't follow clinic instructions. Other clinics also had similar approaches. In this case we have a sign that was on the door of a so called youth friendly sexual and reproductive health clinic and the translation reads, to all use this is not a meeting place for you and your lovers. If found doing that then you have broken our law. You will not be tolerated but given a punishment proportional to the crime you have committed. So that's a sexual and reproductive health clinic for youth. So adolescents appreciated emotional support that they received from staff, particularly counsellors, but there was also certain staff attitudes which undermined their engagement with care they reported being scolded or shouted at. In the group discussions we had adolescents draw a doctor seen here in the picture and described as fat frowning and grumpy and wearing expensive sunglasses. When talking about this doctor one participant explains other doctors are better off but the kind we've drawn are those that cannot manage to stay for 10 minutes while explaining to them about your problems. They would even shout at you for delaying them. So as a result adolescents were often afraid of discussing everyday challenges they faced with adherence. In households caretakers rarely talked about HIV. It was a shameful topic and when they did have a discussion it was often to relay clinic instructions on adherence and to focus on the dire consequences of non-adherence. At the same time actually adhering was challenging when adolescents were told to hide pill taking and their HIV status from other family members and this often happened because of fears of inadvertently disclosing parents status given that vertical infection was the most common. One caretaker explained the extraordinary lengths that they went to to hide medication in the house. They say can you tell me where you hid the medicine? Okay this is how I hide. There's a drum and inside that drum there are books and that is where we get these chairs so that no one will be interested to remove all those things in such a place. I also place the mattress on top no one will step a foot in there. In this context adolescents were left confused, anxious and isolated. There was a group of adolescents who appeared to comply and did what they were told, a small group who openly rebelled and another group who hid their failure by secretly skipping doses by throwing pills into the garden or into the rubbish. In the wider community we found that community leaders had held strong views about young people in terms of their expected roles and behaviour. Community leaders had far reaching powers to influence social behaviour. They could impose fines or curfews or cancel social events. They often felt responsibility to address HIV related stigma or to ensure that patients had good health seeking behaviour. One community member describes threats to withhold healthcare from non adherent HIV patients. He says there are others they stay without taking medication they just stop. So when we find such things we give them the threatening advice that if they do that they won't be received at the hospital. These threats often disempowered adolescents yet again. Limitations of this study were that it was challenging to collect information on socially undesirable behaviour like treatment adherence. The strengths of using a qualitative approach were that we could tap into a diversity of perspectives on the issue. To summarise we found really good patient treatment literacy but an absence of safe spaces to admit problems in following instructions or falling short of impossible expectations. Therefore we propose moving beyond ART literacy which is necessary but it's not the be all and end all of adherence. We think it's important to work on life skills and problem solving through peer clubs developing a counselling cadre inside of Ministry of Health. Secondly we found that unnecessarily strict rules were communicated to adolescents about treatment. Therefore we think it's important to prioritise more health worker training and adopt patient centred approaches. And thirdly we found that adherence happens inside families. So we need to work outside of clinical settings where children are taking their pills and support disclosure inside families as well as family level stigma through interventions that include social workers, counsellors, home visits. So following this study there's a new model of care that's under development in Tradzulu in MSF France project for adolescents. Lastly I'd like to thank everyone involved in the study. Thank you Rose. So questions?