Impact of a youth‐friendly HIV clinic: 10 years of adolescent outcomes in Port‐au‐Prince, Haiti

Abstract

IntroductionAdolescents account for over 40% of new HIV infections in Haiti. This analysis compares outcomes among HIV-positive adolescents before and after implementation of an adolescent HIV clinic in Port-au-Prince, Haiti.MethodsWe conducted a cohort study using programmatic data among HIV-positive adolescents aged 13 to 19. Data from 41,218 adolescents who were HIV tested from January 2003 to December 2012 were included. Outcomes across the HIV care cascade were assessed before and after implementation of an adolescent clinic (2009), including HIV testing, enrolment in care, assessment for antiretroviral therapy (ART) eligibility, ART initiation and 12-month retention. Pre-ART outcomes were assessed 12 months after HIV testing. Factors associated with pre-ART and ART attrition were identified through multivariable competing risk and Cox proportional hazards regression modelling.ResultsCumulatively, 1672 (4.1%) adolescents tested HIV positive (80% female, median age 16 years). Retention by cascade step comparing pre- and post-clinic included the following: 86% versus 87% of patients enrolled in care, 61% versus 79% were assessed for ART eligibility, 85% versus 92% initiated ART and 68% versus 66% were retained 12 months after ART initiation. Pre-ART attrition decreased from 61% pre-clinic to 50% post-clinic (p<0.001). Pre-ART attrition was associated with being female (sub-distributional hazard ratio (sHR): 1.59; CI: 1.31–1.93), syphilis diagnosis (sHR: 1.47; CI: 1.16–1.85) and slum residence (sHR: 0.84; CI: 0.72–0.97). ART attrition was associated with syphilis diagnosis (hazard ratio (HR): 2.23; CI: 1.35–3.68) and CD4 <50 cells/µL (HR: 1.88; CI: 1.15–3.06).ConclusionsImplementation of a youth-friendly adolescent clinic improved retention in HIV care among adolescents, particularly in the assessment of ART eligibility and ART initiation. Additional interventions are needed to improve retention among pre-ART patients and support long-term retention among ART patients.

Adolescents with HIV and transition to adult care in the Caribbean, Central America and South America, Eastern Europe and Asia and Pacific regions

“…Programmatic data from Haiti demonstrate the positive impact of youth-friendly adolescent HIV services on the proportion of young people initiating ART [56]. A proportion of youth living with HIV in CCASA are already parents [57], most of whom are still being followed at adolescent clinics, where they have, many times, built strong bonds.…”

“…In CCASA, many paediatric HIV clinics have established dedicated clinical settings for the adolescent population and most provide care for adolescents regardless of mode of acquisition with many BHIV adolescents referred from sexually transmitted disease and pregnancy clinics. Programmatic data from Haiti demonstrate the positive impact of youth-friendly adolescent HIV services on the proportion of young people initiating ART [56]. A proportion of youth living with HIV in CCASA are already parents [57], most of whom are still being followed at adolescent clinics, where they have, many times, built strong bonds.…”

STACKing the odds for adolescent survival: health service factors associated with full retention in care and adherence amongst adolescents living with HIV in South Africa

“…They also suggest that economic and psychosocial services may be valuable in supporting health system use and treatment adherence . Two ongoing randomized trials in South Africa and Uganda examine family‐based and economic strengthening approaches to adherence support, and successful pilots suggest likely positive impacts .…”

Retention and adherence

“…In recent years, older adolescents (15-19 years) are the only age group with increasing HIV mortality, at a time of massive scale-up of treatment programs, and when mortality is declining in all other age groups [2,3**]. High adolescent HIV mortality reflects critical gaps in the HIV care cascade, including low rates of retention in care, and complex challenges with adherence to ART [4][5][6][7][8][9][10][11][12][13][14][15]. The adolescent years (10-19 years) encompass significant physiological and psychosocial changes that confer particular vulnerability for adolescents living with either perinatally (PHIV) or behaviorally acquired HIV infection (BHIV) [4,5,[16][17][18].…”