Characterizing the double‐sided cascade of care for adolescents living with HIV transitioning to adulthood across Southern Africa

Abstract

Introduction As adolescents and young people living with HIV (AYLH) age, they face a “transition cascade,” a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high‐income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub‐Saharan Africa, paediatric HIV care is mostly provided in decentralized, non‐specialist primary care clinics, where “transition” may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when “transition” to autonomy might occur, we evaluated pre‐ and post‐transition outcomes among AYLH. Methods We included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA‐SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for “transition to autonomy,” we compared the outcomes: no gap in care (≥2 clinic visits) and viral suppression (HIV‐RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log‐binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post‐transition. Results A total of 5516 AYLH from 16 sites were included at “transition” age 16 (transition‐16y), 3864 at 18 (transition‐18y), 1463 at 20 (transition‐20y) and 440 at 22 years (transition‐22y). At transition‐18y, in the 12 months pre‐ and post‐transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (−1.0 to 6.5%)). The strongest predictor of being retained post‐transition was having no gap in the preceding year, across all transition age thresholds (transition‐16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition‐18y: aRR 1.76 (1.61 to 1.92); transition‐20y: aRR 1.75 (1.53 to 2.01); transition‐22y: aRR 1.47; (1.21 to 1.78)). Conclusions AYLH with gaps in care need targeted support to prevent non‐retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood.

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria

“…Adolescents and youths are an important group in global efforts to eliminate HIV. Compared with adults, adolescents and youths engage less with healthcare services and have lower viral suppression rates, [1][2][3][4][5] resulting in increases in AIDS-related deaths despite a global reduction of AIDS mortality among other age groups. [6][7][8] Under current circumstances, the global optimism to eliminate HIV by 2030 does not appear to hold for adolescents and youths.…”

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

“…However, Davies et al found that South African adolescents in Cape Town who transferred care at an older age (15–19 years) had higher risk of virologic failure compared to adolescents who transferred at a younger age (10–14 years) [ 19 ]. An analysis of the IdDEA cohort in sub-Saharan Africa found that the biggest predictor of being retained in care post transition among age groups of 16, 18, 20 and 22 years was gaps in care the year prior to transition [ 28 ]. Neurocognitive, developmental, and social differences among perinatally-HIV infected adolescents makes age-based transition problematic [ 29 , 30 ].…”

Patient and provider perceptions of a community‐based accompaniment intervention for adolescents transitioning to adult HIV care in urban Peru: a qualitative analysis

“…Care transition is a process lasting months or years, and, if unsuccessful, poses risks to HIV care engagement, retention [ 6 ] and mental health [ 7 ]. Ideally, ALWH are virally suppressed before, during and after transition [ 8 ]. Viral suppression pre‐transition is vital; a 2020 systematic review ( N = 24 studies) of ALWH's care transition experiences found the worst health outcomes among those with unsuppressed viremia [ 9 ].…”