Where do HIV‐infected adolescents go after transfer? – Tracking transition/transfer of HIV‐infected adolescents using linkage of cohort data to a health information system platform

Abstract

Introduction: To evaluate long-term outcomes in HIV-infected adolescents, it is important to identify ways of tracking outcomes after transfer to a different health facility. The Department of Health (DoH) in the Western Cape Province (WCP) of South Africa uses a single unique identifier for all patients across the health service platform. We examined adolescent outcomes after transfer by linking data from four International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) cohorts in the WCP with DoH data.Methods: We included adolescents on antiretroviral therapy who transferred out of their original cohort from 10 to 19 years of age between 2004 and 2014. The DoH conducted the linkage separately for each cohort and linked anonymized data were then combined. The primary outcome was successful transfer defined as having a patient record at a facility other than the original facility after the transfer date. Secondary outcomes included the proportion of patients retained, with HIV-RNA <400 copies/ml and CD4 > 500 cells/µl at 1, 2 and 3 years post-transfer.Results: Of 460 adolescents transferred out (53% female), 72% transferred at 10–14 years old, and 79% transferred out of tertiary facilities. Overall, 81% of patients transferred successfully at a median (interquartile range) of 56 (27–134) days following transfer date; 95% reached the transfer site <18 months after transfer out. Among those transferring successfully, the proportion retained decreased from 1 to 3 years post-transfer (90–84%). There was no significant difference between transfer and 1–3 years post-transfer in the proportion of retained adolescents with HIV-RNA <400 copies/ml and CD4 > 500 cells/µl except for HIV-RNA <400 copies/ml at 3 years (86% vs. 75%; p = 0.007). The proportion virologically suppressed and with CD4 > 500 cells/µl was significantly lower at 1 and 2 years post-transfer in those transferring at 15–19 vs. 10–14 years of age. Using laboratory data alone over-estimated time to successful transfer.Conclusions: Linking cohort data to health information system data allowed efficient assessment of post-transfer outcomes. Although >80% of adolescents transferred successfully with nearly 85% of them retained for 3 years post-transfer, the decline in the proportion virologically suppressed and poorer outcomes in older adolescents are concerns.​

Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa

“…This highlights the difficulty with preparations for transition to adult care for older adolescents and young adults who often decrease engagement in care. [ 39 ] In our multivariate analysis, males had higher retention in care compared to females but there was no difference in viral suppression between the sexes. Sex differences in have been seen in other cohorts and are likely multifactorial and related to local socioeconomic factors.…”

Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART

“…This could mean inadequate ART retention in the face of significant scale‐up of ART services, and reflect challenges within health systems overwhelmed by an ever‐increasing ART population. It wasn't possible to account for undocumented transfers to other health facilities: this could have applied to some adolescents transitioning to adult care elsewhere . However, we expect that this would be a small proportion as all the health facilities in the analysis offered adolescent and adult care.…”

Tracking the transition of adolescents into adult HIV care: a global assessment

“…A key difficulty in studying post-transition outcomes is the inability in many national health systems to track patients as they move between facilities. Davies et al’s analysis linking cohort data with surveillance data from the Western Cape Province of South Africa to assess adolescent outcomes after transfer provides proof of concept that such linkages are possible in the context of strong health data systems and implementation of unique patient identifiers [ 3 ]. The investigators were able to confirm that 82% of their 451 transfers were successful, and report on retention of this group across three years post-transfer, with CD4 and HIV viral load test results from the national HIV lab database.…”