Easing the transition of HIV-infected adolescents to adult care

The effect of late presentation on HIV related mortality among adolescents in public hospitals of north showa zone Oromiya, Ethiopia; 2022: a retrospective cohort study

BACKGROUND

Late human immunodeficiency virus (HIV) diagnosis is the most prominent cause of HIV/AIDS-related mortality and also increases the risk of transmission and spread of the disease in society. Adolescents are the most vulnerable population's age group for HIV infection in several settings, but expanding access to early HIV testing remains a challenge. Consequently, a significant proportion of adolescents are still dying of HIV-related causes, and the current study aimed at assessing the effect of late presentation on HIV-related mortality among adolescents living with HIV.

METHODS

An institutional-based retrospective cohort study was conducted from August 21-November 21, 2022, at selected public hospitals in the North Showa Zone of Oromiya, Ethiopia. All adolescents living with HIV who had received no ART and presented for ART follow-up at public hospitals from September 1, 2012, to August 31, 2021, were included in the study. Data entry was done by Epi-data version 3.1.1 software and exported to Stata version 16 for further analysis. Both bi-variable and multivariable analyses were performed using the Cox proportional hazard model to compare the HIV-related mortality of early and late-presented adolescents using an adjusted hazard ratio at a 95% confidence interval (CI).

RESULTS

A total of 341 medical records of adolescents were included in the study, contributing an overall incidence rate of 3.15 (95% CI: 2.21-4.26) deaths per 100 person-years of observation throughout the total follow-up period of 1173.98 person-years. Adolescents with late presentation for HIV care had three times the higher hazard of mortality (adjusted hazard ratio (aHR) = 3.00; 95% CI: 1.22-7.37) as compared to those with early presentation for HIV/AIDS care. Adolescents within the age range of 15-19 years old (aHR = 3.56; 95% CI: 1.44-8.77), rural residence (aHR = 2.81; 95% CI: 1.39-5.68), poor adherence to ART (aHR = 3.17; 95% CI: 1.49-6.76), and being anemic (aHR = 3.09; 95% CI: 1.52-6.29) were other independent predictors of HIV-related mortality.

CONCLUSION

The study found a substantial link between HIV late presentation to care and mortality among adolescents. Residence, age, antiretroviral therapy (ART) medication adherence, and anemia status were also found to be other independent predictors of HIV-related mortality. To achieve the ultimate aim of lowering mortality among adolescents living with HIV, rigorous emphasis must be placed on early presentation for HIV/AIDS care. In addition, counseling on adherence and prompt diagnosis and treatment of anemia are highly recommended to reduce mortality.

Intrapersonal predictors of internalized stigma among school going adolescents living with HIV in southwestern Uganda

We assessed the association between internalized HIV stigma, resilience, health locus of control, coping self-efficacy and empowerment among adolescents living with HIV in Uganda. We conducted a cross-sectional study between August and October 2020 among 173 adolescents aged 13-18 years attending Mbarara Regional Referral Hospital's HIV clinic. We used linear regression to determine the association between HIV stigma and intrapersonal factors adjusting for sociodemographic characteristics. The median age of the participants was 16 (IQR 3) years. There was a negative correlation between HIV stigma and resilience (β= -0.03, p < 0.001), internal health locus of control (β= -0.095, p < 0.001) and coping self-efficacy (β= -0.02, p < 0.001), while empowerment was positively correlated (β = 0.07, p < 0.001) with HIV stigma. After adjusting for the intrapersonal factors (resilience, health locus of control, coping self-efficacy and empowerment) and socio-demographic characteristics (education level and boarding school), only internal health locus of control (β=-0.044, p = 0.016) and coping self-efficacy (β=-0.015, p < 0.001) remained significantly correlated with HIV stigma. The findings suggest that interventions focusing on intrapersonal factors such as internal locus of control, empowerment and resilience may contribute towards reduction of HIV stigma among adolescents in boarding schools.

Human Immunodeficiency Virus (HIV) Care Continuum Outcomes After Transition to Adult Care Among a Prospective Cohort of Youth With HIV in Atlanta, Georgia

BACKGROUND

Healthcare transition from pediatric to adult-oriented clinical settings is often viewed as a high-risk time for care disengagement. However, there is a paucity of prospective, longitudinal research documenting human immunodeficiency virus (HIV) care outcomes after healthcare transition.

METHODS

We conducted a prospective, observational cohort study of healthcare transition among youth enrolled at an HIV care center in Atlanta, Georgia. Pediatric clinic patients (average age, 24 years) were enrolled up to 3 months before the expected transition and were followed up to determine linkage, retention, and viral suppression in adult care through electronic medical record abstractions at the baseline and at 6, 12, 18, and 24 months.

RESULTS

The majority of our cohort (n = 70) was male (88.6%) and black (92.9%) and acquired HIV horizontally (80%). Most of our cohort was linked to adult care by 12 months (84%) after enrollment. Of those who linked to adult care by 12 months, retention rates were 86% (95% confidence interval, 78%-94%) at 6 months, 76% (66%-86%) at 12 months, and 66% (55%-78%) at 18 and 24 months. Once in adult care, the proportion with viral suppression was stable (73% at baseline and 74%, 77%, 67%, and 78% at 6, 12, 18, and 24 months, respectively).

CONCLUSIONS

Although most youth successfully linked to adult care, retention rates decreased over the 24-month follow-up period. Rates of viral suppression were stable for those who remained in care. Strategies to support retention in adult care will be critical to optimizing this transition for youth with HIV.

Challenges and Fears of Adolescents and Young Adults Living with HIV Facing Transition to Adult HIV Care

Adolescents and young adults living with perinatally-acquired HIV (AYLPHIV) have poor outcomes along each step of the HIV care continuum due to challenges in seeking care and advocating for themselves. The transition from paediatric to adult HIV care is a particularly high-risk period for AYLPHIV in rural Uganda. We conducted in-depth interviews with AYLPHIV (n = 30), caregivers (n = 10), and healthcare providers (n = 10) to understand challenges facing AYLPHIV during the transition from paediatric to adult HIV care. Themes were identified by thematic content analysis. Transition-related challenges and fears included difficulty navigating the adult HIV clinic; loss of informational support; long wait times at the adult HIV clinic; lack of privacy, and fear of HIV status disclosure and stigma; and loss of support from caregivers, and health care providers. Before transitioning to adult HIV care, AYLPHIV should be adequately prepared and given appropriate information to help them navigate adult HIV care.

Health Insurance Coverage, Clinical Outcomes, and Health-Related Quality of Life Among Youth Born to Women Living With HIV

BACKGROUND

Although sustained access to health care is essential, little is known about the relationship between insurance coverage and health among people born to women living with HIV (WLHIV).

SETTING

Prospective cohort studies of youth and young adults born to WLHIV from 2007 to 2019.

METHODS

We used adjusted generalized estimating equation models to estimate mean differences in, and relative risks (RRs) of, health-related quality of life (HR-QoL) and HIV disease measures over time by insurance status. HR-QoL scales with limited variability were dichotomized. Modified Poisson models were used to estimate RRs.

RESULTS

Six hundred sixty-nine Adolescent Master Protocol (AMP) youth [66% living with perinatally-acquired HIV (PHIV), 72% Black] and 939 AMP Up/AMP Up Lite young adults (89% PHIV, 68% Black) reported insurance. Most were publicly insured (87% youth, 67% young adults). Privately insured young adults living with PHIV had lower risk of antiretroviral therapy nonadherence [adjusted RR (aRR): 0.82, 95% CI: 0.70 to 0.97] than those with public insurance. There was a lower risk of suboptimal role functioning for young adults with private insurance (aRR: 0.58, 95% CI: 0.35 to 0.97) and those unaware of their coverage (aRR: 0.41, 95% CI: 0.21 to 0.78). Young adults with private insurance had higher health perception scores than those with public insurance (adjusted mean difference: 3.87, 95% CI: 0.37 to 7.38). For youth, we observed no differences in HR-QOL and HIV disease measures by insurance.

CONCLUSION

These findings suggest meaningful differences in antiretroviral therapy adherence and some HR-QoL outcomes by health insurance coverage among young adults born to WLHIV.

Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries

Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed.

Adolescent retention in HIV care within differentiated service-delivery models in sub-Saharan Africa

Adolescents and young people living with HIV are at risk of disengaging from HIV care at all stages of the care cascade. Differentiated models of care offer simplified HIV-service delivery options in the hope of improving treatment outcomes, including retention on antiretroviral therapy. However, it remains unclear how successful and widespread these models are for adolescents in sub-Saharan Africa, where the burden of HIV is the greatest. Very few differentiated models of care specifically targeted to adolescents can be found and this priority group are currently ineligible from several models that exist. Where differentiated care has been made available to adolescents, data on the implementation and effectiveness of these interventions remain scarce. Despite this scarcity of evidence on the effectiveness of differentiated care among adolescent populations, several interventions, particularly community-based groups with peer navigators or supporters, might have potential to increase the reach, effectiveness, and adoption of differentiated care in adolescent HIV-care programmes.

Community-based accompaniment for adolescents transitioning to adult HIV care in urban Peru: a pilot study

We piloted a community-based intervention to improve outcomes among adolescents living with HIV who were transitioning to adult-oriented care in Lima, Peru. We assessed feasibility and potential effectiveness, including within-person changes in self-reported adherence, psychosocial metrics (NIH Toolbox), and transition readiness (“Am I on TRAC” questionnaire, “Got Transition” checklist). From October 2019 to January 2020, we enrolled 30 adolescents (15–21 years). The nine-month intervention consisted of logistical, adherence and social support delivered by entry-level health workers and group sessions to improve health-related knowledge and skills and social support. In transition readiness, we observed within-person improvements relative to baseline. We also observed strong evidence of improvements in adherence, social support, self-efficacy, and stress, which were generally sustained three months post-intervention. All participants remained in treatment after 12 months. The intervention was feasible and potentially effective for bridging the transition to adult HIV care. A large-scale evaluation, including biological endpoints, is warranted.

The Role of Self-Efficacy in HIV treatment Adherence and its interaction with psychosocial factors among HIV Positive Adolescents in Transition to Adult Care in Kenya

Adolescents and young adults (15-24 yrs.) have poorer HIV clinical outcomes than adults. Despite this, there is minimal data on individual-level factors such as self-efficacy towards antiretroviral adherence among perinatally infected adolescents living with HIV in sub-Saharan Africa. Our study examined the interaction between antiretroviral treatment adherence self-efficacy and other psychosocial factors among adolescents receiving care in Nairobi, Kenya. We enrolled perinatally infected Adolescent Living with HIV (ALWHIV) 16-19 yrs. who were accessing care routinely at the HIV clinic. We measured self-reported ART adherence (7-day recall) and defined optimal adherence as >95%, and conducted a regression analysis to identify independently associated factors. Mediation analysis explored interactions between the psychosocial variables. We enrolled 82 ALWHIV median age 17 (IQR 16,18) who had been on ART for a median age of 11 yrs. (IQR 7,13). Sixty-four per cent (52) of the ALWHIV reported optimal adherence of >95%, and 15% reported missing doses for three or more months. After controlling for the other covariates, self-esteem, high viral load and an adherence level > 95% were significantly associated with adherence self-efficacy. Self-esteem was significantly associated with adherence self-efficacy and social support (p<0.001 and p=0.001), respectively. The paramed test indicated that the association between self-efficacy and adherence was mediated by self-esteem with a total effect of OR 6.93 (bootstrap 95% CI 1.99-24.14). Adherence self-efficacy was also mediated by self-esteem in developing adherence behavior. Interventions focused on increasing adherence among ALWHIV should include self-esteem building components.

Transitioning from pediatric to adult care and the HIV care continuum in Ghana: a retrospective study

Background

In Sub-Saharan Africa, there are now a significant number of adolescents living with HIV (ALHIV), due to increased access to effective antiretroviral therapy. However, these adolescents are at high risk of dying during the transition to adult care due to various reasons, including lack of preparation for the transition and poor transition arrangements. More knowledge about this issue will lead to a better planned healthcare transition process and preparation for transition from pediatric care to adult care. The aim of this study was to explore the healthcare transitional experiences of ALHIV as they moved from pediatric to adult care.

Methods

A descriptive exploratory qualitative study was conducted. Purposive sampling method was used to recruit adolescents between 12 and 19 years old. Saturation was realized by the 10th participant. Data were analyzed using thematic content analysis.

Results

Four main themes emerged from the interview data: the transition process, factors facilitating the transition experience, challenges and coping mechanisms of the ALHIV during transition, and suggestions for improvement based on perceptions on the current transitioning approach. A key finding of this study was the sudden preparation for transition, linked to the absence of a structured transition protocol. Even though age was the main reason for transferring the participants from the pediatric to adult clinic, participants’ age did not influence whether they attended clinic appointment on their own or accompanied by a care provider; it was dependent on the availability of their parents or caregivers. Participants’ parents and adult family caregivers were also integrated into the transition process to some extent. We also found that most of the participants had good patient-provider relationship with their health care providers in both pediatric and adult clinics.

Conclusion

Findings support the need to develop a structured healthcare transition policy and age-appropriate transition within the clinic environment. There is also a need for social and community support as ALHIV transition from pediatric to adult care.

Stepping up: retention in HIV care within an integrated health care transition program

Strategies are needed to optimize HIV health care transition (HCT). We describe HCT outcomes within the University of Maryland STEP Program, which is built upon integration of an adult HIV provider and navigator into the pediatric clinic, and coordinated collaboration between pediatric and adult HIV multi-disciplinary care teams. These outcomes were compared to a historical institutional HCT cohort (N = 50) which attempted transition in an earlier time period (2004-2012). Fifty-eight patients were enrolled during the study period, and 34 attempted HCT. In total, 84 patients underwent attempted HCT. In the STEP cohort, linkage to adult care was 94% and 12 month retention in adult care (95%) was statistically higher compared to the historical cohort. Rates of viral suppression did not differ pre- and post-HCT among STEP Program patients. These results support the concept of an integrated pediatric and adult HIV HCT model though the ability to achieve sustainable HCT success will require further study.

An Intervention for the Transition From Pediatric or Adolescent to Adult-Oriented HIV Care: Protocol for the Development and Pilot Implementation of iTransition

Background

In the United States, adolescents and young adults are disproportionately affected by HIV and have poorer HIV-related health outcomes than adults. Health care transition (HCT) from pediatric or adolescent to adult-oriented HIV care is associated with disruptions to youths’ care retention, medication adherence, and viral suppression. However, no evidence-based interventions exist to improve HCT outcomes for youth living with HIV.

Objective

There are 2 phases of this project. Phase 1 involves the iterative development and usability testing of a Social Cognitive Theory–based mobile health (mHealth) HIV HCT intervention (iTransition). In phase 2, we will conduct a pilot implementation trial to assess iTransition’s feasibility and acceptability and to establish preliminary efficacy among youth and provider participants.

Methods

The iterative phase 1 development process will involve in-person and virtual meetings and a design team comprising youth living with HIV and health care providers. The design team will both inform the content and provide feedback on the look, feel, and process of the iTransition intervention. In phase 2, we will recruit 100 transition-eligible youth across two clinical sites in Atlanta, Georgia, and Philadelphia, Pennsylvania, to participate in the historical control group (n=50; data collection only) or the intervention group (n=50) in a pilot implementation trial. We will also recruit 28 provider participants across the pediatric or adolescent and adult clinics at the two sites. Data collection will include electronic medical chart abstraction for clinical outcomes as well as surveys and interviews related to demographic and behavioral characteristics; Social Cognitive Theory constructs; and intervention feasibility, acceptability, and use. Analyses will compare historical control and intervention groups in terms of HCT outcomes, including adult care linkage (primary), care retention, and viral suppression (secondary). Interview data will be analyzed using content analysis to understand the experience with use and acceptability.

Results

Phase 1 (development) of iTransition research activities began in November 2019 and is ongoing. The data collection for the phase 2 pilot implementation trial is expected to be completed in January 2023. Final results are anticipated in summer 2023.

Conclusions

The development and pilot implementation trial of the iTransition intervention will fill an important gap in understanding the role of mHealth interventions to support HCT outcomes for youth living with HIV.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24565

HIV-related stigma among young people living with HIV transitioning to an adult clinic in a public hospital in Rio de Janeiro, Brazil

This study analyzes how experiences of HIV-related stigma are expressed among HIV-positive young people transitioning to an adult clinic, the health service, the family, the affective-sexual interactions, and their relationship with inequalities and social hierarchies. This research included 31 young people (median age 21) transitioning to an adult clinic (G1) and 12 young people (median age 30) who had already made this transition (G2), both monitored at a health service in Rio de Janeiro. Seventy percent of the 43 young people were women and 65% were infected by mother-to-child transmission. Young people answered questionnaires and participated in focus groups on AIDS stigma and transition to adulthood. Most reported discrimination associated with HIV stigma in daily life and health care. G1 young people showed more significant concern about the consequences of HIV disclosure and difficulties with treatment. The G2 accounts suggest that establishing marital relationships, including HIV-negative partners and children, linked to treatment access allowed resignifying the fear of stigmatization. The findings aim to guide the training and action of professionals involved in the prevention and care of young people living with HIV.

Healthcare Transition Outcomes Among Young Adults With Perinatally Acquired Human Immunodeficiency Virus Infection in the United States

BACKGROUND

Young adults with perinatally acquired HIV (YPHIVs) living in the United States are transitioning to adult clinical care, yet there is little information on factors that affect transition outcomes.

METHODS

YPHIVs aged ≥18 years in the Pediatric HIV/AIDS Cohort Study (PHACS) AMP Up cohort approaching or having completed transition from pediatric to adult healthcare were included. Demographic and clinical characteristics and self-reported ability to self-manage healthcare were compared by transition status, and multivariable logistic regression models examined factors associated with satisfaction with, and retention in, adult clinical care (clinic visit within the previous 6 months).

RESULTS

Most of the 455 YPHIVs, regardless of transition status, reported satisfaction with their clinic and care provider, but many reported antiretroviral medication nonadherence. Of the 124 YPHIVs who had transitioned, 56% had periods of unsuppressed HIV-1 RNA in the year before transition. Those who had transitioned were more likely to report high ability to self-manage their healthcare (ability to manage ≥7 of 8 skills) than those not transitioned. High self-management was associated with retention after transition (odds ratio, 3.40; 95% confidence interval, 1.33-9.12). Higher perceived emotional social support was also associated with retention. Older age at transition was associated with greater satisfaction with provider and clinic.

CONCLUSIONS

YPHIVs have positive associations with their clinical care around the time of their transition to adult care, but unsuppressed viral load and suboptimal adherence are a concern. Strengthening skills that increase ability to self-manage care and enhance social support may increase retention in care and improve clinical health.

"It was not okay because you leave your friends behind": A prospective analysis of transition to adult care for adolescents living with perinatally-acquired HIV in South Africa

OBJECTIVE

To determine facilitators and barriers to successful transition to adult care for adolescents living with perinatally-acquired HIV in South Africa.

METHODS

We prospectively enrolled 30 adolescents living with perinatally-acquired HIV after their pediatrician deemed them ready for transition to adult care but prior to their transition. Eighteen months after enrollment, we measured transition status, engagement in care (i.e., viral load within 12 months of transition), and viral suppression (<200 copies/ml). Additionally, we conducted in-depth interviews with adolescents before and after transition to explore facilitators and barriers to successful transition.

RESULTS

A total of 19/30 (63%) adolescents transitioned to adult care. Of those who transitioned, 11 (58%) were retained in care and 7 (37%) were virally suppressed one year after transition to adult care. Insufficient staff training, lack of availability of pediatric ART formulations in adult clinics, and insufficient clinical monitoring contributed to delayed transition. Rigid clinical scheduling that interfered with school and loss of clinic relationships with peers and clinical staff were major factors in contributing to poor engagement in care after transition. Maturity of the adolescent, reduced distance to clinic, and reduced length of time in the clinic were seen as facilitators to transition to adult care.

CONCLUSION

Improved preparation for transition by pediatric and adult clinical staff, including restructuring of care delivery, may improve successful transition of adolescents living with perinatally acquired HIV to adult care. Transition readiness assessments are needed to determine optimal timing of transition and which adolescents are ready to transition to adult care.

Impending Transition From Pediatric to Adult Health Services: A Qualitative Study of the Experiences of Adolescents With Eating Disorders and Their Caregivers

Background: There is a dearth of research that identifies pediatric to adult health care transition practices that yield positive outcomes for young people with eating disorders (EDs). Further, adolescent and caregiver perspectives are poorly understood and underrepresented in the literature. The purpose of this study, focused on the impending transition from pediatric to adult health services, was twofold: (a) to identify adolescent and caregiver perspectives of barriers and facilitators of a successful transition for adolescents with EDs; and (b) to understand adolescent and caregiver suggestions of interventions for a successful transition. Design/Method: We recruited five adolescents with EDs who were about to be transferred out of pediatric care as well as their caregivers. We conducted a qualitative study in accordance with the principles of interpretive description. Through conducting semi-structured, in-depth interviews with adolescents and caregivers, we investigated their knowledge about health system transitions and anticipated experiences. We identified participants' perceptions of barriers and facilitators regarding a successful transition, as well as their recommendations to improve the transfer of care. Results: Participants possessed a limited understanding of transition processes despite the fact that they were about to be transferred to adult care. From our analyses, the following themes were identified as barriers during the transition process: re-explaining information to adult healthcare providers, lack of professional support while waiting for uptake into the adult health system, and late timing of transition of care discussions. Both adolescents and caregivers expressed that involvement of parents and the pediatric healthcare team helped to facilitate a successful transfer of care. In addition, participants expressed that the implementation of a Transition Coordinator and Transition Passport would be helpful in facilitating a seamless transfer between systems of care. Discussion: These findings demonstrate a significant gap in the system and highlight the importance of developing interventions that facilitate a successful transition. The themes that emerged from this study can inform the development of interventions to facilitate a coordinated transition from pediatric to adult health services for adolescents with EDs.

Disclosure, Social Support, and Mental Health are Modifiable Factors Affecting Engagement in Care of Perinatally-HIV Infected Adolescents: A Qualitative Dyadic Analysis

Adolescents living with perinatally acquired HIV in South Africa face significant barriers to successful transition from pediatric to adult care. We performed in-depth qualitative interviews with 41 adolescents living with HIV and 18 of their caregivers to investigate modifiable factors to improve engagement in care prior to transition to adult care. Based on dyadic, inductive content analysis, findings suggest that HIV status disclosure, social support, and mental health are targets for improvement in engagement in care. Early disclosure and a sense of belonging facilitated engagement in care, while barriers included delayed or inadequate disclosure, denial, and lack of disclosure to others. Adherence support improved by having a biological mother as a direct supervisor. Barriers to care included changing caregivers, abandonment, undiagnosed mental health problems and learning difficulties. Despite these factors, the majority of adolescents showed resilience and remained engaged in care despite difficult circumstances.

Transition from pediatric to adult care for adolescents living with HIV in South Africa: A natural experiment and survival analysis

OBJECTIVE

To determine rates of retention and viral suppression among adolescents living with perinatally-acquired HIV who remained in pediatric care compared to those who transitioned to adult care.

METHODS

We evaluated a natural experiment involving adolescents living with perinatally-acquired HIV who were attending a government-supported antiretroviral clinic in KwaZulu-Natal, South Africa. Prior to 2011, all adolescents transitioned to adult care at 12 years of age. Due to a policy change, all adolescents were retained in pediatric care after 2011. We analyzed adolescents two years before and two years after this policy change. Outcomes were retention in care and HIV viral suppression one year after transition to adult care or the 13th birthday if remaining in pediatric care.

RESULTS

In the natural experiment, 180 adolescents who turned 12 years old between 2011 and 2014 were evaluated; 35 (20%) transitioned to adult care under the old policy and 145 (80%) remained in pediatric care under the new policy. Adolescents who transitioned to the adult clinic had lower rates of retention in care (49%; 17/35) compared to adolescents remaining in the pediatric clinic (92%; 134/145; p<0.001). Retention in care was lower (ARR 0.59; 95%CI 0.43-0.82; p = 0.001) and viral suppression was similar (ARR = 1.06, 95%CI 0.89-1.26; p = 0.53) for adolescents who transitioned to adult care compared to adolescents remaining in pediatric care.

CONCLUSION

Adolescents living with perinatally-acquired HIV appear to have higher retention in care when cared for in pediatric clinics compared to adult clinics. Longer-term follow-up is needed to fully assess viral suppression.

Longitudinal evaluation of adherence, retention, and transition patterns of adolescents living with HIV in Nigeria

Introduction

Adherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic.

Setting

The Jos University Teaching Hospital, United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria.

Methods

We conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ≥95% MPR and the proportion with virologic suppression (viral load ≤400 copies/mL) within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed.

Results

A total of 476 patients received at least one dose of ART as an adolescent (ages 10–19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ≥95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%–64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression.

Conclusions

Our evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ≥95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals.

Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa

BACKGROUND

Long-term retention of adolescents aged 10 -19 years on antiretroviral therapy (ART) is crucial to achieve viral load suppression. However, it is reported globally that adolescents have lower retention in care (RiC) on ART, compared with children and adults.

OBJECTIVES

To determine the prevalence and predictors of RiC of adolescents over 2 years following initiation onto ART in public health facilities in the Metropole District Health Services of the Western Cape province in 2013.

METHODS

Data of 220 adolescent patients who were newly initiated on ART in 2013 were extracted from the provincial electronic database, and subjected to univariate and bivariate analyses using SPSS.

RESULTS

The rate of RiC post-initiation was low throughout the study period, that is, 68.6%, 50.5% and 36.4% at 4, 12 and 24 months, respectively. The corresponding post-initiation viral load suppression levels on ART of those remaining in care and who had viral loads monitored were 84.1%, 77.4% and 68.8% at 4, 12 and 24 months, respectively. Retention in care after initiation on ART was higher amongst younger adolescents (10-14 years), compared with older adolescents (15-19 years). Male adolescents were significantly more likely to be retained, compared with females. Pregnant adolescents were significantly less likely to be retained compared with those who were not pregnant.

CONCLUSION

Key interventions are needed to motivate adolescents to remain in care, and to adhere to their treatment regimen to achieve the target of 90% viral load suppression, with specific emphasis on older and pregnant adolescents.

HIV Care Among Elderly Population: Systematic Review and Meta-Analysis

Elderly people living with HIV are increasing. At present in the United States, nearly half of newly diagnosed HIV-infected people are aged >50 years. Diagnosis and treatment of HIV-infected elderly patients tends to be delayed by several health care factors as several life-threatening diseases are common in elderly people. This study aimed to find the pooled HIV prevalence in elderly population and the present situation of continuum care for the elderly HIV patients through systematic review and meta-analysis. All previously published articles from 2000 to 2018 are retrieved using MEDLINE, PUBMED, Cochrane Library, EMBASE, and Google Scholar. DerSimonian and Laird Random Effects model are used to critically appraise articles. STATA 13.0 is used to perform the meta-analysis and quantum-geographic information system (Q-GIS) is used to prepare desired map. I² statistics has been used to test heterogeneity and publication biases. Results have been presented using forest plots. A total of 28 studies are included in this meta-analysis. Present analysis revealed pooled prevalence of HIV in elderly population as 15.79% with a lower rate of viral suppression as 11.524% (95% confidence interval, CI: 11.199-11.855), where a moderate number 38.643% (95% CI: 38.289-38.997) of elderly patients received antiretroviral therapy (ART) globally. The ART retention rate was 12.769% (95% CI: 12.540-13.001) with 6.15% (95% CI: 6.089-6.212) mortality. Despite successful administration of ART in developing part of the world that have relatively higher retention rates among HIV-infected elderly patients only a small percentage are virally suppressed, largely due to elderly drugs interact with ART and several comorbidities reduce the life span of the elderly people.

Characteristics and Care Outcomes Among Persons Living With Perinatally Acquired HIV Infection in the United States, 2015

BACKGROUND

Medical advancements have improved the survival of persons with perinatally acquired HIV infection (PHIV). We describe persons living with diagnosed PHIV and assess receipt of HIV care, retention in care, and viral suppression.

METHODS

Data reported to the National HIV Surveillance System through December 2017 were used to characterize persons living with diagnosed PHIV by year-end 2015 in the United States and 6 dependent areas. National HIV Surveillance System data from 40 jurisdictions with complete laboratory reporting were used to assess receipt of HIV care (≥1 CD4 or viral load during 2015), retention in HIV care (≥2 CD4 or viral load tests ≥3 months apart during 2015) and viral suppression (<200 copies/mL during 2015) among persons with PHIV diagnosed by year-end 2014 and alive at year-end 2015.

RESULTS

By year-end 2015, 11,747 persons were living with PHIV and half were aged 18-25 years. Of 9562 persons with HIV diagnosed by year-end 2014 and living with PHIV at year-end 2015 in the 40 jurisdictions, 75.4% received any care, 61.1% were retained in care, and 49.0% achieved viral suppression. Persons aged ≤17 years had a significantly higher prevalence of being retained in care (prevalence ratio = 1.2, 95% confidence interval = 1.2 to 1.3) and virally suppressed (prevalence ratio = 1.4, 95% confidence interval = 1.3 to 1.5) than persons aged 18-25 years.

CONCLUSIONS

Efforts to improve care outcomes among persons with PHIV are needed. Enhanced collaboration between pediatric and adult medical providers may ensure continuity of care during the transition from adolescence to adulthood.

Transition from Pediatric to Adult HIV Care for Young Women Living with HIV

Transitioning from pediatric to adult care is a complicated process for youth with chronic illnesses. This study elucidates the unique factors affecting transition preparedness and perception of adult HIV care among a cohort of young women with HIV. Between 2013 and 2015, 48 women with HIV, who had experience with pediatric HIV care, were enrolled in a large Canadian cohort study. Variables were self-reported during peer-administered surveys. Only 60% reported feeling prepared for transition. Having never had contact with child protection services (P = .049), never been in foster care (P = .011), never been in a group home (P = .036), reporting a higher current CD4 count (P = .033), and reporting a younger ideal age for transition (P = .041) were associated with transition preparedness. Eighty-four percent reported equivalent or better HIV care following transition. Correlates of equivalent/better care following transition included lower personal income (P = .023), higher CD4 count (P = .021), care by an adult infectious diseases specialist (P = .002), and transition preparedness (P = .005). Our findings highlight the importance of adequate transition preparation and its effect on perception of care following transition.

Individual and neighborhood predictors of retention in care and viral suppression among Florida youth (aged 13-24) living with HIV in 2015

Youth aged 13‒24 are less likely to be retained in HIV care and be virally suppressed than older age groups. This study aimed to assess predictors of retention in HIV care and viral suppression among a population-based cohort of youth (N = 2872) diagnosed with HIV between 1993 and 2014 in Florida. We used generalized estimating equations to estimate prevalence ratios (PRs). Retention in care was defined as evidence of engagement in care (at least one laboratory test, physician visit, or antiretroviral therapy prescription refill), two or more times, at least three months apart during 2015. Viral suppression was defined as having evidence of a viral load <200 copies/ml among those in care during 2015. Among the 2872 youth, 65.4% were retained in care, and among those in care, 65.0% were virally suppressed. Older youth (18‒24 years old) and non-Hispanic Blacks (NHBs) were less likely to be retained in care, whereas those men who have sex with men, perinatal HIV transmission, living in low socioeconomic neighborhoods, and those diagnosed with AIDS before 2016 were more likely to be retained in care. Those diagnosed with AIDS before 2016 and NHBs were less likely to be virally suppressed, whereas those men who have sex with men and foreign-born persons were more likely to be virally suppressed. Results suggest the need for targeted retention and viral suppression interventions for NHB youth and older youth (18‒24 years-age).

A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV

A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.

Evaluating a patient-centred intervention to increase disclosure and promote resilience for children living with HIV in Kenya

OBJECTIVE

We evaluated the impact of a patient-centred, culturally and age-appropriate disclosure counselling intervention on HIV disclosure rates among Kenyan children living with HIV.

DESIGN

A prospective, clinic-cluster randomized trial.

METHODS

We followed 285 child-caregiver dyads (children ages 10-14 years) attending eight HIV clinics (randomized to intervention or control) in Kenya. Participants at intervention clinics received intensive counselling with trained disclosure counsellors and culturally tailored materials, compared with control clinics with standard care. Disclosure was treated as a time-to-event outcome, measured on a discrete time scale, with assessments at 0, 6, 12, 18 and 24 months. Mental health and behavioural outcomes were assessed using standardized questionnaires.

RESULTS

Mean age was 12.3 years [standard deviation (SD) 1.5], 52% were girls, with average time-on-treatment of 4.5 years (SD 2.4). Between 0 and 6 months, disclosure prevalence increased from 47 to 58% in the control group and from 50 to 70% in the intervention group. Differences in disclosure were not sustained over the following 18 months. The prevalence of depression symptoms was significantly higher in the intervention than in the control group at 6 months (odds ratio 2.07, 95% confidence interval 1.01-4.25); however, there was no evidence that these differences were sustained after 6 months.

CONCLUSION

The clinic-based intervention increased disclosure of HIV status to children living with HIV in the short-term, resulting in earlier disclosures, but had less clear impacts longer-term. Although well tailored interventions may support disclosure, children may still experience increased levels of depression symptoms immediately following disclosure.

Healthcare Transition for Youth Living With HIV: Outcomes from a Prospective Multi-site Study

PURPOSE

Youth living with HIV (YLHIV) in the United States (U.S.) account for nearly one-third of new HIV infections and face significant barriers to care engagement; only 25% are virally suppressed. Healthcare transition (HCT) from pediatric/adolescent to adult-oriented care can be particularly disruptive. Accordingly, we prospectively examined HCT processes at 14 distinct geographical sites across the U.S.

METHODS

We collected Audio Computer-Assisted Self-Interviews data and abstracted electronic medical records from 135 HCT-eligible YLHIV at baseline and 9-month follow-up. Descriptive analyses and multilevel modeling were conducted. Data also included qualitative interviews with 28 adolescent and 30 adult providers across 14 adolescent and 20 adult clinics, respectively. Interviews were analyzed using the constant comparative method; this analysis focused on specific HCT recommendations.

RESULTS

At baseline, youth were primarily age 24 (78.8%), male (76.8%), black (78.0%), identified as a sexual minority (62.9%), had attended an HIV appointment in the past 3 months (90.2%), had Medicaid for insurance (65.2%), and were always or mostly always adherent to their antiretroviral therapy (65.9%). At the 9-month follow-up only 37% of YLHIV successfully transitioned to adult care. Both individual-level (insurance status and disclosure-related stigma) and clinic-level (adolescent clinic best practices) factors were significant. Adolescent and adult clinic staff offered recommendations to support HCT; these focused primarily on clinical changes.

CONCLUSIONS

This study highlights the complex set of individual- and clinic-level factors associated with HCT. Addressing these key factors is essential for developing streamlined, comprehensive, and context-specific HCT protocols to support continuous care engagement for YLHIV.

Factors that Motivated Otherwise Healthy HIV-Positive Young Adults to Access HIV Testing and Treatment in South Africa

The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm³ who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.

Health-care transition from adolescent to adult services for young people with HIV

HIV-related care and treatment engagement are crucial steps to improve individual and population-level health; yet, many young people (18-25 years old) with HIV are not maintained in, or disengage from, care. Health-care transition and the transfer to adult care are particularly vulnerable points in the care and treatment of young people with HIV. In this Review, we explore barriers and facilitators to health-care transition, evaluate existing health-care transition programmes, and identify best practices for the improvement of health-care transition outcomes and health. Although we examine health-care transition across a range of geographical regions, most examples are from the settings in which the most research has been done-the USA and western Europe.

What is it going to take to move youth-related HIV programme policies into practice in Africa?

Introduction: HIV has been reported to be the leading cause of mortality amongst adolescents in Africa. This has brought attention to the changes in service provision and health management that many adolescents living with HIV experience when transferring from specialized paediatric- or adolescent-focused services to adult care. When transition is enacted poorly, adherence may be affected and the continuum of care disrupted. As the population of HIV-infected adolescents grows, effective and supported transition increases in significance as an operational imperative.

Discussion: Considerable gaps remain in moving policy to practice at global, national, and local levels. Policies that give clear definition to transition and provide standard operating procedures or tools to support this process are lacking. National guidelines tend to neglect transition. Beyond transition itself, there has been slow progress on the inclusion of adolescents in national policies and strategies. Guidance often overlooks the specific needs and rights of adolescents, in particular for those living with HIV. In some cases, prohibitive laws can impede adolescent access by applying age of consent restriction to HIV testing, counselling and treatment, as well as SRH services. Where adolescent-focused policies do exist, they have been slow to emerge as tangible operating procedures at health facility level. A key barrier is the nature of existing transition guidance, which tends to recommend an individualized, client-centred approach, driven by clinicians. In low- and middle-income settings, flexible responses are resource intensive and time consuming, and therefore challenging to implement amidst staff shortages and administrative challenges. First, national governments must adopt transition-specific policies to ensure that adolescents seamlessly receive appropriate and supportive care. Second, transition policies must form part of a broader adolescent-centred policy landscape and adolescent-friendly orientation and approach at health system level. Third, national actors must ensure that transition policies are supported at implementation level. Fourth, youth involvement and community mobilization are essential. Finally, further implementation research is urgently needed to better understand how to support young people and providers in achieving smooth transitions.

Conclusions: Only by moving from policy to practice through supportive policies and their implementation will we be closer to including adolescents in the 2030 goal of ending AIDS.

Adolescent and Adult HIV Providers' Definitions of HIV-Infected Youths' Successful Transition to Adult Care in the United States

It is important for both individual- and population-level health that HIV-infected individuals progress through the Care Continuum. However, HIV-infected youth frequently disengage from care during transition from pediatric/adolescent to adult care; only 50% remain in adult care after 1 year. Understanding how providers define and approach a successful healthcare transition can improve the delivery of HIV-related services during critical years of HIV treatment. We conducted 58 staff interviews across 14 Adolescent Trials Network clinics (n = 30) and 20 adult clinics (n = 28). We used the constant comparative method to examine how providers defined and approached youths' successful transition. Providers identified four components critical to successful transition: (1) clinical outcomes (e.g., medication adherence and viral suppression); (2) youth knowing how to complete treatment-related activities (e.g., refilling prescriptions and making appointments); (3) youth taking responsibility for treatment-related activities and their overall health (e.g., "when they stop reaching out to the adolescent [clinic] to solve all their problems."); and (4) youth feeling a connection and trust toward the adult clinic (e.g., "they feel safe here"), with some providers even prioritizing connectedness over clinical outcomes (e.g., "Even if they're not taking meds but are connected [to care], …that's a success."). The identification of key components of successful transition can guide focused interventions and resources to improve youth maintenance in the HIV Care Continuum as they transition to adult care. Identifying what facilitates successful transitions, and the gaps that interventions can target, will help to ensure HIV-infected youth remain healthy across their lifespan.

Adolescent to Adult HIV Health Care Transition From the Perspective of Adult Providers in the United States

PURPOSE

The HIV Care Continuum highlights the need for HIV-infected youth to be tested, linked, and maintained in lifelong care. Care engagement is important for HIV-infected youth in order for them to stay healthy, maintain a low viral load, and reduce further transmission. One point of potential interruption in the care continuum is during health care transition from adolescent- to adult-centered HIV care. HIV-related health care transition research focuses mainly on youth and on adolescent clinic providers; missing is adult clinic providers' perspectives.

METHODS

We examined health care transition processes through semi-structured interviews with 28 adult clinic staff across Adolescent Trials Network sites. We also collected quantitative data related to clinical characteristics and transition-specific strategies.

RESULTS

Overall, participants described health care transition as a "warm handoff" and a collaborative effort across adolescent and adult clinics. Emergent transition themes included adult clinical care culture (e.g., patient responsibility), strategies for connecting youth to adult care (e.g., adolescent clinic staff attending youth's first appointment at adult clinic), and approaches to evaluating transition outcomes (e.g., data sharing). Participants provided transition improvement recommendations (e.g., formalized protocols).

CONCLUSIONS

Using evidence-based research and a quality improvement framework to inform comprehensive and streamlined transition protocols can help enhance the capacity of adult clinics to collaborate with adolescent clinics to provide coordinated and uninterrupted HIV-related care and to improve continuum of care outcomes.

Growing up with perinatal human immunodeficiency virus-A life not expected

AIM AND OBJECTIVES

To describe the lived experience of young adults with perinatally acquired HIV (PaHIV).

BACKGROUND

With the advancement of the highly active antiretroviral treatment, PaHIV infection has transformed into a chronic lifelong illness that is faced by young adults who grew up with HIV. The known challenges that are associated with HIV are poverty, stigma and social and emotional isolation.

DESIGN

This was a qualitative single-interview study of a convenience sample of PaHIV-infected young adults receiving care at a large metropolitan pediatric hospital.

METHODS

The participants had individual face-to-face interviews which were audio-taped and transcribed verbatim. Themes were developed to describe their living space, and Max Van Manen's lifeworld guide was used to describe their lived experience.

FINDINGS

Seventeen participants (eight males/nine females) were enrolled. Four major themes emerged: (i) limited social capital, especially when orphaned participants reflected on a life void of parental guidance; (ii) incomplete education and unemployment, participants described an idle existence; (iii) a harsh life, described as participants facing difficulties meeting their life's milestones; (iv) unanticipated adult issues, where participants described their limited ability to care for themselves and their children. Van Manen lifeworld themes also described the space they occupied, their memories growing up with PaHIV, their health care and relationships.

CONCLUSION

Our study provides a valuable insight into the social and emotional difficulties faced by youth with PaHIV. The findings underscore the importance of extensive support and coordination of services between adult and pediatric providers to optimize long-term outcomes among young adults with PaHIV.

RELEVANCE TO CLINICAL PRACTICE

The young adults with PaHIV require close attention and support from the healthcare providers, who can offer them a safe space to discuss lived experiences and support their ability to achieve full lives.

Transitioning HIV-infected adolescents to adult care at 14 clinics across the United States: using adolescent and adult providers' insights to create multi-level solutions to address transition barriers

HIV-infected adolescents have disproportionately low rates of care retention and viral suppression. Approximately half disengage from care while transitioning to adult clinics, in part due to fragmented care systems and lack of streamlined protocols. We conducted 58 qualitative interviews with social service and health care providers across 14 Adolescent Trials Network clinics (n = 28) and 20 adult clinics that receive transitioning adolescents (n = 30) from August 2015-June 2016. We used the constant comparative approach to examine processes, barriers, and facilitators of adult care transition. Transition barriers coalesced around three levels. Structural: insurance eligibility, transportation, and HIV-related stigma; Clinical: inter-clinic communication, differences in care cultures, and resource/personnel limitations; and Individual: adolescents' transition readiness and developmental capacity. Staff-initiated solutions (e.g., grant-funded transportation) were often unsustainable and applied individual-level solutions to structural-level barriers. Comprehensive initiatives, which develop collaborative policies and protocols that support providers' ability to match the solution and barrier level (i.e., structural-to-structural), are sorely needed. These initiatives should also support local systematic planning to facilitate inter-clinic structures and communication. Such approaches will help HIV-infected adolescents transition to adult care and improve long-term health outcomes.

Growing up with perinatal HIV: changes in clinical outcomes before and after transfer to adult care in the UK

INTRODUCTION

With improved survival, adolescents with perinatal HIV (PHIV) are transitioning from paediatric to adult care, but there are few published data on clinical outcomes post-transfer. Using linked data from patients in the national UK/Ireland paediatric cohort (CHIPS) and an adult UK cohort of outpatient clinics (UK CHIC), we describe mortality and changes in immunological status post-transfer.

METHODS

Participants in CHIPS aged ≥13 years by the end of 2013 were linked to the UK CHIC database. Mixed effects models explored changes in CD4 count before and after transfer, including interactions between time and variables where interaction p < 0.05.

RESULTS

Of 1,215 paediatric participants aged ≥13 years, 271 (22%) had linked data in UK CHIC. One hundred and forty-six (53%) were female, median age at last visit in paediatric care was 17 [interquartile range, IQR 16,18] years, median duration in paediatric care was 11.8 [6.6,15.5] years, and in adult care was 2.9 [1.5,5.9] years. At last visit in paediatric care, 74% (n = 200) were on ART, increasing to 84% (n = 228, p = 0.001) at last visit in adult care. In the 12 months before leaving paediatric care, 92 (47%) had two consecutive viral loads >400 copies/mL or one viral load >10,000 copies/mL, and likewise 102 (52%) in the 12 months post-transfer (p = 0.79). Seven (3%) people died in adult care. In multivariable analysis, CD4 declined as patients approached transition with a greater decline in those with higher nadir CD4 count (mean rates of decline of 3, 13, 15, 30 cells/mm3 per year for those with nadir CD4 < 100, 100-199, 200-299 and ≥300 cells/mm3, respectively). Post-transition, CD4 continued to decline in some groups (e.g. black males, -20 (-34, -5) cells/mm3 per year post transition, p = 0.007)) while it improved in others. Overall CD4 was higher with later year of birth (14 (7, 21) cells/mm3 per later year). There was no effect of age at transfer or changing hospital at transfer on CD4.

CONCLUSIONS

Our findings suggest that CD4 in adolescents with perinatal HIV in the UK was declining in the period before transition to adult care, and there was some reversal in this trend post-transfer in some groups. Across the transition period, CD4 was higher in those with later birth years, suggesting improvements in clinical care and/or transition planning over time.

Mental health challenges among adolescents living with HIV

INTRODUCTION

Mental health is a critical and neglected global health challenge for adolescents infected with HIV. The prevalence of mental and behavioural health issues among HIV-infected adolescents may not be well understood or addressed as the world scales up HIV prevention and treatment for adolescents. The objective of this narrative review is to assess the current literature related to mental health challenges faced by adolescents living with HIV, including access to mental health services, the role of mental health challenges during transition from paediatric to adult care services and responsibilities, and the impact of mental health interventions.

METHODS

For each of the topics included in this review, individual searches were run using Medline and PubMed, accompanied by scans of bibliographies of relevant articles. The topics on which searches were conducted for HIV-infected adolescents include depression and anxiety, transition from paediatric to adult HIV care and its impact on adherence and mental health, HIV-related, mental health services and interventions, and the measurement of mental health problems. Articles were included if the focus was consistent with one of the identified topics, involved HIV-infected adolescents, and was published in English.

RESULTS AND DISCUSSION

Mental and behavioural health challenges are prevalent in HIV-infected adolescents, including in resource-limited settings where most of them live, and they impact all aspects of HIV prevention and treatment. Too little has been done to measure the impact of mental health challenges for adolescents living with HIV, to evaluate interventions to best sustain or improve the mental health of this population, or to create healthcare systems with personnel or resources to promote mental health.

CONCLUSIONS

Mental health issues should be addressed proactively during adolescence for all HIV-infected youth. In addition, care systems need to pay greater attention to how mental health support is integrated into the care management for HIV, particularly throughout lifespan changes from childhood to adolescence to adulthood. The lack of research and support for mental health needs in resource-limited settings presents an enormous burden for which cost-effective solutions are urgently needed.

HIV healthcare transition outcomes among youth in North America and Europe: a review

INTRODUCTION

The transition from paediatric to adult care poses risks to the health of young adults living with HIV if unsuccessful, including interruptions in care and poor health outcomes. Evolving best practices in HIV healthcare transition should ideally be informed by real-world qualitative and quantitative clinical healthcare transition outcomes. There has been a recent proliferation of HIV healthcare transition outcome research, largely from Europe and North America.

METHODS

A literature search was undertaken using the online databases PubMed, Web of Science, and Google Scholar. Medical subject and text word searches were combined for terms relating to HIV, paediatric transition outcomes, and internal and external factors were used to identify peer-reviewed articles.

RESULTS

In this paper, we review data on HIV healthcare transition outcomes in North America and Europe. Internal and external factors which may impact the success of HIV healthcare transition are examined. We describe ongoing research efforts to capture transition outcomes in the North America and Europe. Clinical, operational, and implementation science research gaps that exist to date are highlighted. Efforts to improve HIV healthcare transition research through country-level surveillance networks and large multicentre cohorts, including data integration and linkage between paediatric and adult cohorts are discussed.

CONCLUSIONS

We identified the need for a comprehensive approach to implementing empirically supported protocols to support healthcare transition for ALHIV. While there is limited prospective longitudinal cohort data available at this time, cohorts linking the paediatric and adolescent with ongoing surveillance into adulthood are being developed. Through a review of existing qualitative and quantitative healthcare transition outcomes studies, we identify emerging areas of consensus surrounding healthcare transition research implementation. Successful healthcare transition programmes in Europe and North America often share several characteristics, including implementation of a youth friendly multidisciplinary approach, consistent communication and integration between paediatric and adult care teams, and an individualized approach which is attuned the adolescent's transition readiness. Moving forward, the voices of youth and young adults living with HIV should be included in the development and evaluation of healthcare transition protocols to ensure that the definition of successful transition reflects all of the stakeholders in the transition process.

Transition of Care for Youth with HIV

Remarkable advances have been made in the treatment of HIV. Despite progress in reducing perinatal HIV transmission, there is a growing number of adolescents and emerging adults with HIV who will require transfer of care from pediatric to adult providers. Adolescents with HIV have poorer retention in care and viral suppression compared to other age groups with HIV. Barriers to successful care of youth with HIV include mental health disorders, poor medication adherence, socioeconomic instability, and HIV-related stigma. Transfer of care to adult providers is often met with reluctance on the part of the adolescent. Recommendations for effective transfer of care include clear communication between adult and pediatric providers, early initiation of a transition planning discussion, a multidisciplinary team approach, and meeting the adult provider prior to the transfer of care. Adult HIV care may be more fragmented than adolescents are familiar with, but thoughtful transition approaches can foster development of health and life skills among youth with HIV. [Pediatr Ann. 2017;46(5):e198-e202.].

Insights into Adherence among a Cohort of Adolescents Aged 12-20 Years in South Africa: Reported Barriers to Antiretroviral Treatment

Adolescents experience disproportionately high rates of poor ART outcomes compared to adults despite prolonged use of antiretroviral therapy in Southern African treatment programs, presenting a significant challenge to national attempts to meet the UNAIDS 90-90-90 targets for 2020. This cohort study among adolescents aged 12-20 years accessing ART care at two urban public-sector clinics in Johannesburg between September and November 2013 aimed to identify factors potentially associated with poor attendance at clinic visits. Patients were followed up through routine medical records to identify missed visits (failing to attend clinic within 30 days of scheduled visit date) up to 2 years after enrolment. We enrolled 126 adolescents on ART for a median of 6.3 years (IQR: 2.7-8.4). A total of 47 (38%) adolescents missed a scheduled visit within 24 months of enrolment. Older adolescents (18-20 years) were more likely to miss a visit compared to adolescents aged 12-14 years (risk ratio (RR) = 1.72; 95% CI: 1.00-2.95). Those who were identified to have difficulty in taking medication (RR = 1.57; 95% CI: 1.13-2.18) as a barrier to care were more likely to miss a visit compared to adolescents who did not. Awareness of treatment fatigue, challenges to taking ART, and caregiver difficulties is important when considering interventions to improve treatment outcomes among adolescents.

Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave

CONTEXT

South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression.

OBJECTIVE

To determine the adolescent HIV continuum of care in South Africa.

DATA SOURCES

We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015.

DATA EXTRACTION

We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15-24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression.

RESULTS

Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed.

LIMITATIONS

This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents.

CONCLUSIONS

Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.

Children and young people with perinatal HIV in Europe: epidemiological situation in 2014 and implications for the future

Accurate ascertainment of the number of children living with human immunodeficiency virus (HIV) is important to plan paediatric and adolescent health services. In Europe, the first generation of perinatally HIV-infected survivors are transferring to adult care and their health needs are unknown. We undertook an online survey of HIV cohort studies participating in the EuroCoord Network of Excellence to ascertain the number of perinatally HIV-infected (pHIV) patients included, to compare it with those published by the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) and to assess the ability of countries to follow up pHIV patients after transfer to adult care. At the end of 2013, 16 countries in EuroCoord reported 8,229 pHIV patients in follow-up in cohorts, compared with 5,160 cumulative diagnoses reported by the ECDC in the same area. Follow-up of pHIV patients after transfer to adult care varied. It is likely that the number of diagnoses of perinatal HIV reported to ECDC is an underestimate, although this varies by country. Further work is needed to refine estimates and encourage follow-up in adult HIV cohorts to investigate long-term outcomes and improve the care of the next generation of children with HIV.

Transitioning HIV-Positive Adolescents to Adult Care: Lessons Learned From Twelve Adolescent Medicine Clinics

To maximize positive health outcomes for youth with HIV as they transition from youth to adult care, clinical staff need strategies and protocols to help youth maintain clinic engagement and medication adherence. Accordingly, this paper describe transition processes across twelve clinics within the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) to provide lessons learned and inform the development of transition protocols to improve health outcomes as youth shift from adolescent to adult HIV care.

DESIGN AND METHODS

During a large multi-method Care Initiative program evaluation, three annual visits were completed at each site from 2010-2012 and conducted 174 semi-structured interviews with clinical and program staff (baseline n=64, year 1 n=56, year 2=54).

RESULTS

The results underscore the value of adhering to recent American Academy of Pediatrics (AAP) transition recommendations, including: developing formal transition protocols, preparing youth for transition, facilitating youth's connection to the adult clinic, and identifying necessary strategies for transition evaluation.

CONCLUSIONS

Transitioning youth with HIV involves targeting individual-, provider-, and system-level factors. Acknowledging and addressing key barriers is essential for developing streamlined, comprehensive, and context-specific transition protocols.

PRACTICE IMPLICATIONS

Adolescent and adult clinic involvement in transition is essential to reduce service fragmentation, provide coordinated and continuous care, and support individual and community level health.

Stigma, sexual risks, and the war on drugs: Examining drug policy and HIV/AIDS inequities among African Americans using the Drug War HIV/AIDS Inequities Model

The relationship between drug policy and HIV vulnerability is well documented. However, little research examines the links between racial/ethnic HIV disparities via the Drug War, sexual risk, and stigma. The Drug War HIV/AIDS Inequities Model has been developed to address this dearth. This model contends that inequitable policing and sentencing promotes sexual risks, resource deprivation, and ultimately greater HIV risk for African-Americans. The Drug War also socially marginalizes African Americans and compounds stigma for incarcerated and formerly incarcerated persons living with HIV/AIDS. This marginalization has implications for sexual risk-taking, access to health-promoting resources, and continuum of care participation. The Drug War HIV/AIDS Inequities Model may help illuminate mechanisms that promote increased HIV vulnerability as well as inform structural intervention development and targeting to address racial/ethnic disparities.

Health outcomes and the transition experience of HIV-infected adolescents after transfer to adult care in Québec, Canada

Background

Little is known on outcomes after transition to adult care among adolescents with perinatal HIV infection. Though there is data from other chronic pediatric diseases suggesting increased morbidity and mortality following transfer to adult care, this has not well been studied among the first wave of survivors of perinatal HIV infection. The primary objective of this study was to determine outcomes after transition to adult care among a cohort of HIV-infected adolescents in Québec, Canada. Secondary objectives were to document participant experiences with the transition process, identify barriers to successful transition, and potential changes to improve the transition process.

Methods

Clinic records were reviewed to identify all perinatally-infected youth who transitioned from the Centre Maternel et Infantile sur le Sida pediatric HIV clinic (Montreal) at age 18 to an adult care provider between 1999 and 2012. Transitioned patients were contacted using last available patient or parental listed phone number on hospital record, internet based telephone directory, or social media. A standardized questionnaire was administered by telephone or in-person interview, and copies of current medical records obtained from treating physicians.

Results

Forty-five patients were transferred between 1999 and 2012, among whom 25 consented to the study, eight were lost to follow-up, eight refused participation, and four were deceased. Overall 76 % of patients remained engaged in care, defined by at least one physician visit within 6 months of the interview. Over 50 % reported difficulty with adherence to their current drug regimens. At one-year post-transfer, there was a decrease in the proportion of patients with CD4 count >500 cells/mm³ from 64 to 29 %, and a statistically significant decrease in absolute CD4 count (mean 370 vs 524 cells/mm³, p = 0.04.). The majority (92 %) of participants felt that 18 was too young an age to transfer to adult care, and provided suggestions for improving the transition process.

Conclusions

This group of perinatally-infected youth remained engaged in care after transition, however difficulties with adherence and assuming responsibility for their own care were identified as issues in their post-transition care. The high rate of mortality among them and the changes to their health status post-transition suggest that further work is necessary to document the health outcomes of this group in larger, more diverse cohort settings.

Parenting Among Adolescents and Young Adults with Human Immunodeficiency Virus Infection in the United States: Challenges, Unmet Needs, and Opportunities

Given the realistic expectations of HIV-infected adolescents and young adults (AYA) to have children and start families, steps must be taken to ensure that youth are prepared to deal with the challenges associated with their HIV and parenting. Literature reviews were conducted to identify published research and practice guidelines addressing parenting or becoming parents among HIV-infected AYA in the United States. Research articles or practice guidelines on this topic were not identified. Given the paucity of information available on this topic, this article provides a framework for the development of appropriate interventions and guidelines for use in clinical and community-based settings. First, the social, economic, and sexual and reproductive health challenges facing HIV-infected AYA in the United States are summarized. Next, family planning considerations, including age-appropriate disclosure of HIV status to those who are perinatally infected, and contraceptive and preconception counseling are described. The impact of early childbearing on young parents is discussed and considerations are outlined during the preconception, antenatal, and postnatal periods with regard to antiretroviral medications and clinical care guidelines. The importance of transitioning AYA from pediatric or adolescent to adult-centered medical care is highlighted. Finally, a comprehensive approach is suggested that addresses not only medical needs but also emphasizes ways to mitigate the impact of social and economic factors on the health and well-being of these young parents and their children.

Psychosocial needs of perinatally HIV-infected youths in Thailand: lessons learnt from instructive counseling

Identifying psychosocial needs of perinatally HIV-infected (pHIV) youth is a key step in ensuring good mental health care. We report psychosocial needs of pHIV youth identified using the "Youth Counseling Needs Survey" (YCS) and during individual counseling (IC) sessions. pHIV youth receiving care at two tertiary-care hospitals in Bangkok or at an orphanage in Lopburi province were invited to participate IC sessions. The youths' psychosocial needs were assessed using instructive IC sessions in four main areas: general health, reproductive health, mood, and psychosocial concerns. Prior to the IC session youth were asked to complete the YCS in which their concerns in the four areas were investigated. Issues identified from the YCS and the IC sessions were compared. During October 2010-July 2011, 150 (68.2%) of 220 eligible youths participated in the IC sessions and completed the YCS. Median age was 14 (range 11-18) years and 92 (61.3%) were female. Mean duration of the IC sessions was 36.5 minutes. One-hundred and thirty (86.7%) youths reported having at least one psychosocial problem discovered by either the IC session or the YCS. The most common problems identified during the IC session were poor health attitude and self-care (48.0%), lack of life skills (44.0%), lack of communication skills (40.0%), poor antiretroviral (ARV) adherence (38.7%), and low self-value (34.7%). The most common problems identified by the YCS were lack of communication skills (21.3%), poor health attitude and self-care (14.0%), and poor ARV adherence (12.7%). Youth were less likely to report psychosocial problems in the YCS than in the IC session. Common psychosocial needs among HIV-infected youth were issues about life skills, communication skills, knowledge on self-care, ARV adherence, and self-value. YCS can identify pHIV youths' psychosocial needs but might underestimate issues. Regular IC sessions are useful to detect problems and provide opportunities for counseling.