Transition from paediatric to adult care of adolescents living with HIV in sub‐Saharan Africa: challenges, youth‐friendly models, and outcomes

Abstract

Introduction: The number of adolescents with perinatally or behaviourally acquired HIV is increasing in low-income countries, and especially in sub-Saharan Africa where HIV prevalence and incidence are the highest. As they survive into adulthood in the era of antiretroviral therapy, there is a pressing need to transfer them from paediatric to adult care, known as the transition of care. We conducted a narrative review of recent evidence on their transition outcomes in Africa, highlighting the specific needs and challenges in these populations and settings, and the different models of care for transition.Areas covered: We searched PubMed bibliographic database, HIV conference content, and grey literature from January 2000 to August 2016 with the following keywords: HIV infections AND (adolescents or youth) AND transition AND Africa. All qualitative and quantitative, experimental and observational studies including HIV-infected patients aged 10–24 years with information on transition were eligible.Results: Few data on transition outcomes for HIV-infected adolescents are available from Africa settings. Studies mainly from Southern and East Africa reported on the barriers to successful transition, highlighting several gaps. These included lack of adequate infrastructure, staff training and communication between paediatric and adult clinicians as well as the fear of stigma of adolescents and youth living with HIV. Most countries have no specific national guidelines on when to disclose HIV status or when and how to transition to adult care. Several models of care adapted to the adolescent transition question have been implemented in specific settings. These models include teen clinics, peer educators or the use of social media. However, regardless of the model, services are increasingly overburdened and have insufficient human resources. Furthermore, very high attrition has been observed among adolescents and youth compared to younger children or older adults. There is a need to identify sub-groups at higher risk of loss to follow-up for targeted care and peer support.Expert commentary: Although the available HIV-related data on adolescent transition outcomes are limited, there is evidence of their increased vulnerability during this period. Standardized data gathering, analysis, and reporting systems specific to adolescent transition are essential to improve understanding and adolescent outcomes in Africa.

Patterns of detectable viral load in a cohort of HIV‐positive adolescents on antiretroviral therapy in South Africa

“…Detectable VL was not sustained throughout the follow‐up period in a majority of adolescents, and showed a dynamic pattern of adherence and virological outcomes. The extremely high rate of detectable VL in the older adolescents within this cohort is of concern, as this occurs at the time prior to transition to adult care, which has been associated with poor health outcomes in both high and LMIC settings .…”

Challenges and facilitators of transition from adolescent to adult HIV care among young adults living with HIV in Moshi, Tanzania

“…The main healthcare system barrier, like other studies in low‐resource settings, was the overwhelmed adult clinic with long waiting times and few physicians . Healthcare facilities lack adequate resources to address structural barriers to transition.…”

The effectiveness and cost‐effectiveness of community‐based support for adolescents receiving antiretroviral treatment: an operational research study in South Africa

“…Challenges faced by the CBS programme include the rural context of many patients' homes with long travel distances and inadequate transport, and inconsistent availability of some adolescents for follow‐up counselling sessions. CBS is not a panacea, and other important facets of comprehensive care include youth‐friendly clinical management, peer‐support groups, and integrated management of the transition from child to adult care services .…”

“…ART programmes retention in SSA is poor, being only 56% after five years . The barriers to retention amongst adolescents and youth are numerous and diverse, and include the burden of multiple vulnerabilities, barriers to healthcare access, mental health needs, a lack of psychosocial support, a lack of trained healthcare workers focusing on adolescent‐specific care, and lack of support during the transition from paediatric to adult care . Appropriate, individualized, holistic and durable interventions that support adolescent's clinical, psychosocial and nutritional care have been suggested .…”