Transition to independent care for youth living with HIV: a cluster randomised clinical trial

Transition to Adult Care for Young People Living with HIV

PURPOSE OF REVIEW

The purpose of this narrative review is to delineate the challenges of transitioning young people living with HIV (YPLHIV) to adult-based care and to review recent literature including both qualitative and interventional studies focused on the process of transitioning.

METHODS

A search in PubMed and Embase was conducted using the key words "adolescent." "young adult," "transition to adult care," "HIV," and "AIDS," including only articles published from 2019 onwards. Conference proceedings from major peer-reviewed conferences focused on YPLHIV were manually searched for studies from January 2021 to December 2023. Data extraction included variables such as study type, participant ages, location, and, for intervention studies, detailed descriptions and outcomes, which were further categorized into themes. Results are included in Table 1 and Table 2.

RECENT FINDINGS

Experts still debate about what a successful transition means which makes studying it harder. Challenges to successful transition include heterogeneity of the population, inconsistency with transition timing, mobility, and stigma. Recent qualitative studies that elicit feedback from stake holders reveal individual barriers such as lack of self-efficacy and fears of successive disclosures. A major facilitator to successful transition is having youth-friendly services in the adult clinic. Interventional studies emphasize the evidence for transition readiness assessments, transition protocols, mobile health engagement, transition clinics, and health care transition navigation. Health care teams who care for YPLHIV before, during, and after transition need to recognize how vulnerable this population can be. Therefore, transition must be formally addressed and grounded in the local settings and needs. Simple interventions have the potential to improve transition outcomes.

Cross-Cultural Validation of the HIV Adolescent Readiness for Transition Scale (HARTS) in China

For adolescents infected with the Human Immunodeficiency Virus (HIV), transitioning from pediatric to adult healthcare requires thorough preparation to maintain care continuity and optimal health outcomes. In China, a dedicated scale for assessing their transition readiness is lacking. The HIV Adolescent Readiness for Transition Scale (HARTS) addresses this by evaluating transition readiness across vital domains, with its 15-item design predicting post-transition viral suppression-a key indicator of a successful transition. With no equivalent tool in China, the HARTS's cross-cultural adaptation holds significant potential for enhancing personalized transition strategies and health management. To validate the HIV Adolescent Readiness for Transition Scale (HARTS) among adolescents with HIV in China, the validation was conducted from October 2023 to February 2024, following a five-step process: translation and back-translation; content validity examination by 13 experts; pre-survey with 30 adolescents with HIV; test-retest reliability assessment with 40 adolescents with HIV over a 10-day interval; and structural validation using exploratory factor analysis, including principal component analysis and varimax orthogonal rotation, among 170 adolescents with HIV. The average content validity index of the scale was 0.99. The Cronbach's alpha value for the pre-survey was 0.767, and for test-retest reliability, the intra-class correlation coefficient (ICC) was 0.901. With a total of 15 items, the four factors that made up the scale-"Disclosure," "Health Navigation," "Self-Advocacy," and "Health Literacy"-explained 81.73% of the variation. With alpha values of 0.940, 0.917, 0.929, and 0.888 for each of the four domains, the scale's overall Cronbach's alpha value was 0.943. The Chinese version of HARTS demonstrates good reliability and validity, serving as a tool for assessing the medical transition readiness level of adolescents with HIV in China.

Sustainability of an evidence-based intervention supporting transition to independent care for youth living with HIV in Kenya

Integrating and sustaining evidence-based interventions (EBIs) in routine care is crucial to improving HIV treatment outcomes among youth living with HIV (YLH). However, EBIs are often not sustained post clinical trial. An Adolescent Transition Package (ATP) delivered by health care workers (HCWs) and tested in Kenya in 2021 significantly improved YLH readiness to transition to independent care. Post-trial, participating clinics could continue using the ATP. We conducted 30 in-depth interviews with health care workers to evaluate determinants of continued ATP implementation one-year post-trial. Interviews used semi-structured guides, informed by the Consolidated Framework for Implementation Research version 2.0 (CFIR v2.0). Transcripts were analyzed thematically to identify key influences of ATP sustainment and fidelity post-trial. Effective training during and after the trial, and continued internal and external support for implementation, were crucial for sustained acceptability and feasibility. In contrast, staff shortages and high turnover, lack of integration into the existing electronic medical system, and maintaining staff motivation were barriers to ATP sustainment. Implementation fidelity was limited by workforce constraints and HCW beliefs about the importance of individualizing content and delivery to be responsive to individual client needs. ATP adaptability afforded optimization of delivery to overcome workforce constraints and meet client needs, increasing HCW perceptions of feasibility and motivating continued use. Alignment between observed impact and care provision goals further motivated ongoing ATP utilization. Strategies to ensure continued training and integration of tools into existing systems have the potential to further enhance ATP sustainability.

Mapping the Transition of Adolescents to Adult HIV Care: A Mixed-Methods Perspective from the Cape Town Metropole, South Africa

(1) Background: Globally, an estimated 1.7 million adolescents (aged 10-19 years) were living with HIV in 2023, with 82% residing in sub-Saharan Africa. For ALHIV, transitioning to adult care involves assuming responsibility for their own health and disease management, posing significant challenges to persistent engagement in care. There is a paucity in health policies guiding this transition in many sub-Saharan African countries. Overburdened and poorly functioning health systems struggle to provide optimal care for ALHIV amidst the rising HIV pandemic in this priority population. (2) Methods: This study employed a mixed-methods design, comprising a descriptive qualitative study with healthcare workers and managers and a cross-sectional survey to examine the practices and pathways in which the transition to adult HIV care occurs in the Cape Town Metropole, South Africa. (3) Results: We delineate three distinct ways in which transition occurs (transfer-only, adolescent-friendly, and supportive transition). A successful transition involves a sufficient level of self-management of their chronic condition and healthcare journey, which is preceded by adequate preparation pre-transition, and the monitoring of engagement post-transition. This ideally requires developing relevant health policies and implementing guidelines signaling political will and providing the impetus and agency of implementation at the service level in South Africa.

Mixed Methods Evaluation of a Youth-Friendly Clinic for Young People Living with HIV Transitioning from Pediatric Care

(1) Background: Adolescents and young adults face challenges when transitioning to adult care due to emerging adulthood and changing providers and insurance. Young people living with HIV (YPLHIV) have additional obstacles with mental health and stigma. During transition, only 55% of YPLHIV are retained in care, and 65% are virally suppressed. To address these challenges, the Adolescent and Young Adult Health Care Transition Clinic (AYAHCTC) was created at Vanderbilt University Medical Center in 2017. This mixed methods study evaluates the initial cohort and solicits YPLHIVs' perspectives on transition barriers and facilitators. (2) Methods: Quantitative analyses (n = 21) characterized patients' demographics, clinical engagement, and retention. Qualitative interviews (n = 5) captured patients' transition experiences. (3) Results: This study, conducted in the Southeastern USA, included a cohort where 47.6% were born abroad, with all participants being US citizens by birth or naturalization. Patients' mean age at first visit was 19.6 years. The average AYAHCTC duration was 2.21 years. First-year engagement and retention were 100% and 95.5%, respectively. Viral suppression rates improved from 66.7% at the first visit to 81.0% at the last visit. Eleven patients transitioned out of AYAHCTC. Qualitative analyses indicate that barriers to transition include leaving trusted providers, reduced parental guidance, developing autonomy, and perceived loss of confidentiality in adult clinic environment. Transition was facilitated by youth-friendly services, clear communication, and strong relationships with AYAHCTC providers. (4) Conclusions: YPLHIV positively viewed AYAHCTC experiences. Future directions include optimizing services to build YPLHIVs' independence, supporting YPLHIV experiencing stigma, assuaging concerns about switching providers, collaborating with adult clinics to maintain confidentiality, and designing interventions focused on adherence during transition.

Estimating the costs of adolescent HIV care visits and an intervention to facilitate transition to adult care in Kenya

INTRODUCTION

Adolescents with HIV in sub-Saharan Africa face challenges transitioning to adult HIV care, which can affect long-term HIV care adherence and retention. An adolescent transition package (ATP) focused on transition tools can improve post-transition clinical outcomes, but its implementation costs are unknown.

METHODS

We estimated the average cost per patient of an HIV care visit and ATP provision to adolescents. Data was collected from 13 HIV clinics involved in a randomized clinical trial evaluating ATP in western Kenya. We conducted a micro-costing and activity-driven time estimation to assess costs from the provider perspective. We developed a flow-map, conducted staff interviews, and completed time and motion observation. ATP costs were estimated as the difference in average cost for an HIV care transition visit in the intervention compared to control facilities. We assessed uncertainty in costing estimates via Monte Carlo simulations.

RESULTS

The average cost of an adolescent HIV care visit was 29.8USD (95%CI 27.5, 33.4) in the standard of care arm and 32.9USD (95%CI 30.5, 36.8) in the ATP intervention arm, yielding an incremental cost of 3.1USD (95%CI 3.0, 3.4) for the ATP intervention. The majority of the intervention cost (2.8USD) was due ATP booklet discussion with the adolescent.

CONCLUSION

The ATP can be feasibly implemented in HIV care clinics at a modest increase in overall clinic visit cost. Our cost estimates can be used to inform economic evaluations or budgetary planning of adolescent HIV care interventions in Kenya.

HIV epidemiology, prevention, treatment, and implementation strategies for public health

The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.

Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach

BACKGROUND

The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker (HCW)-delivered disclosure and transition intervention - the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP.

METHODS

We conducted continuous quality improvement (CQI) meetings with HCWs involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest, or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience, and outcomes.

RESULTS

We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n = 38), content (49%, n = 35), and evaluation processes (13%, n = 9). Context adaptations primarily featured changes to personnel, format, and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n = 69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n = 60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%).

CONCLUSION

Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility.

TRIAL REGISTRATION

Trial registered on ClinicalTrial.gov as NCT03574129.

Interventions to Improve Adolescent HIV Care Outcomes

PURPOSE OF REVIEW

This review of recent studies evaluating interventions to improve HIV care outcomes among adolescents with HIV (AHIV) was conducted to provide a comprehensive overview of the recent evidence, highlight promising approaches, and suggest directions for future research.

RECENT FINDINGS

Our scoping review revealed 65 studies evaluating a variety of interventions and using a range of study designs at various stages of research. Effective approaches included community-based, integrated service delivery models with case management, trained community adolescent treatment supporters, and consideration of social determinants of health. Recent evidence also supports the feasibility, acceptability, and preliminary efficacy of other innovative approaches, including mental health interventions as well as technology-delivered approaches; however, more research is needed to build the evidence base for these interventions. Our review's findings suggest that interventions providing comprehensive, individualized support are essential to improving HIV care outcomes among adolescents. More research is needed to build the evidence base for such interventions and ensure effective, equitable implementation to support the global target of ending the AIDS epidemic by 2030.