The Impact of Youth-Friendly Structures of Care on Retention Among HIV-Infected Youth

Impacts of a multipronged initiative with community HIV clinics to support retention and re-engagement in HIV care

BACKGROUND

Despite advances in HIV treatment, gaps in care retention threaten the individual health of people with HIV (people) and public health efforts to end the HIV epidemic.

OBJECTIVE

This project aimed to identify and address gaps in retention and support re-engagement in care.

METHODS

A multipronged initiative at five community HIV clinics and community-based organizations (CBOs) included patient, healthcare professional (HCP), and community-focused interventions. Patient-oriented interventions included instructional videos for patients to view before appointments and conversation guides about barriers to care for patients to use with staff during appointments. HCP-oriented interventions included baseline surveys assessing clinic practices and challenges and audit-feedback sessions to review survey findings and devise plans to improve retention strategies. Community-oriented interventions included education sessions co-led by clinics and CBOs, micro-learning engagements at community events, and social media campaigns covering topics related to HIV care. Data were collected through surveys administered before and after patient- and HCP-oriented interventions and community education sessions, follow-up surveys administered after micro-learning engagements, and reach of social media campaigns.

RESULTS

Patient-oriented interventions led to improvements in patient-reported empowerment and confidence in their ability to remain in care. HCPs also reported improvements in patient intake and follow-up processes after audit-feedback sessions. Community interventions reached over 1,000 community members combined, with education sessions and micro-learning engagements uncovering key barriers to HIV care and leading to improvements in knowledge and awareness of local HIV services.

CONCLUSION

This multipronged initiative demonstrates how patient, HCP, and community-oriented education can support retention and re-engagement in care.

Characterizing adolescent and youth-friendly HIV services: a cross-sectional assessment across 16 global sites

INTRODUCTION

Adolescent and youth-friendly health services (AYFHS) have been promoted as a best practice for adolescents and young people living with HIV (AYLH). However, thorough descriptions of AYFHS for AYLH remain scarce. We sought to characterize adolescent-friendly HIV services in a global paediatric research consortium.

METHODS

Cross-sectional data were collected from 16 global sites in the Adolescent and Young Adult Network of IeDEA (AYANI) of the International epidemiology Databases to Evaluate AIDS consortium between August 2020 and October 2022 using a standardized site assessment tool that collected data on clinic, patient and provider characteristics, differentiated care, and transition to adult services processes. Descriptive analyses characterized the health services available across the participating sites, using frequencies and proportions for categorical variables and medians and interquartile range for continuous variables. Data were analysed using RStudio.

RESULTS

Overall, 13 of 16 sites (81%) reported having dedicated adolescent services, which most often consisted of dedicated clinic days (62%, n = 8/13), primarily offered on weekdays. Across all sites, nurses and counsellors delivered services to adolescents. Over half of all clinics (69%, n = 11/16) reported offering health education to adolescents to facilitate adolescent health literacy. Peer educators and navigators were involved in delivering services at 62% of sites, primarily in those with dedicated adolescent services (69%, n = 9/13). There was limited integration of sexual and reproductive health services into HIV clinics for adolescents. With 63% of clinics conducting pregnancy screening, 50% providing family planning methods and 38% providing cervical cancer screening. Under half of all HIV clinics screened for physical abuse or violence (44%, n = 7/16) and sexual abuse or rape (38%, n = 6/16). A low proportion of clinics screened for risk factors related to young key populations, including drug use (56%, n = 9/16), homelessness (38%, n = 6/16) young men having sex with men (31%, n = 5/16) and transactional sex (31%, n = 5/16). Mental health screening for concerns was variable.

CONCLUSIONS

Findings suggest gaps in AYFHS for AYLH across the HIV clinics included in this analysis. There is a vital need to design health services for AYLH that are accessible, equitable, and effective and meet the global standards for delivering high-quality healthcare to adolescents.

Transition experiences of young adults with perinatal HIV in the Netherlands

Introduction

The process of transition from paediatric to adult care is a crucial step towards self-management of healthcare for young adults with chronic health conditions. In the Netherlands, the On Your Own Feet program offers an extensive framework for supporting optimal transition. In this national study, we aimed to evaluate the transition experiences of young adults with perinatal HIV who transferred from a paediatric to an adult HIV treatment centre.

Methods

Participants who transferred to adult care less than six years ago received questionnaires on transition experiences, the validated On Your Own Feet - Transition Experiences Scale (OYOF-TES), and demographics. Demographic and healthcare-related variables were collected from patients' medical files. We explored correlations between OYOF-TES scores and other variables.

Results

Of 44 participants, 29 responded (65.1 %). Their median age was 20 (IQR 19-23). Overall, high scores were found on the subscales 'Reception in adult care' (median 4.8, IQR 4.0-5.0), 'Alliance paediatric and adult care' (median 4.0, IQR 3.4-4.4), and 'Transfer readiness' (median 4.2, IQR 3.8-4.8). The lowest scores were found in the subscales 'Preparation for transfer' (median 3.3, IQR 2.7-4.0) and 'Youth involvement' (median 3.5, IQR 2.5-4.5). Higher scores on transition experiences were correlated with younger age and female sex, while lower scores were correlated with those of whom one or both biological parents died during childhood.

Conclusion

Transition experiences in our population were positive. Younger participants felt better prepared for the transfer, which indicates that transition is increasingly becoming a joint effort between young adults and healthcare professionals and that pathways accustomed to individual needs improve the transition experience for young adults with perinatal HIV.

Differentiated care for youth in Zimbabwe: Outcomes across the HIV care cascade

Youth living with HIV are at higher risk than adults of disengaging from HIV care. Differentiated models of care such as community delivery of antiretroviral therapy (ART) may improve treatment outcomes. We investigated outcomes across the HIV cascade among youth accessing HIV services in a community-based setting. This study was nested in a cluster-randomised controlled trial (CHIEDZA: Clinicaltrials.gov, Registration Number: NCT03719521) conducted in three provinces in Zimbabwe and aimed to investigate the impact of a youth-friendly community-based package of HIV services, integrated with sexual and reproductive health services for youth (16-24 years), on population-level HIV viral load (VL). HIV services included HIV testing, ART initiation and continuous care, VL testing, and adherence support. Overall 377 clients were newly diagnosed with HIV at CHIEDZA, and linkage to HIV care was confirmed for 265 (70.7%, 234 accessed care at CHIEDZA and 31 with other providers); of these 250 (94.3%) started ART. Among those starting ART at CHIEDZA who did not transfer out and had enough follow up time (>6 months), 38% (68/177) were lost-to-follow-up within six months. Viral suppression (HIV Viral Load <1000 copies/ml) among those who had a test at 6 months was 90% (96/107). In addition 1162 clients previously diagnosed with HIV accessed CHIEDZA; 714 (61.4%) had a VL test, of whom 565 (79.1%) were virally suppressed. This study shows that provision of differentiated services for youth in the community is feasible. Linkage to care and retention during the initial months of ART was the main challenge and needs concerted attention to achieve the ambitious 95-95-95 UNAIDS targets.

Presence of Teen Clubs and its Association with Clinic Attendance among Adolescents Living with HIV in Tanzania: A Retrospective Cohort Study

Introduction

Adolescent's living with Human Immunodeficiency Virus (HIV) are widely reported to have poor adherence to antiretroviral therapy (ART) due to stigma and fear of discrimination. A "Teen club" is an adolescent centered intervention designed to reduce social stigma and improve adherence and retention in HIV care. In this study we determined how the availability of teen clubs within routine HIV care and treatment facilities affects adolescents' clinic attendance.

Methods

We conducted a retrospective cohort study using secondary data from routine clinic records on adolescents (10-19 years) who started ART between 2010 and 2016, and had documented clinic visits between March 2017 and September 2017 at HIV care and treatment clinics (CTC) in northern and central Tanzania. Good clinic attendance was defined as attending at least four monthly clinic visits during the 7-month follow-up period. A Poisson model with robust standard errors was used to assess the relationship between presence of a teen club at health facilities and good clinic attendance adjusting for other factors including sex, age at ART initiation, duration on ART, WHO clinical stage and health facility level.

Results

Of the 2839 adolescents, 73.1% had good clinic attendance. Good clinic attendance was independently associated with availability of a teen club at the health facility (aRR=1.16, 95%CI:1.09-1.21) and been on ART for >2 years (aRR=1.15, 95%C1.02-1.30). Adolescents aged 15-19 years during this study were less likely to have good clinic attendance (aRR= 0.93, 95%CI:0.88-0.98) than those aged <15 years. Sex and WHO clinical stage were not associated with good clinic attendance.

Conclusion

Teen clubs improved visit adherence among adolescents in HIV care and treatment. Further qualitative research should be conducted to explore adolescents' perception of teen clubs as well as other enablers to clinic attendance.

Strategies to improve outcomes of youth experiencing healthcare transition from pediatric to adult HIV care in a large U.S. city

BACKGROUND

The healthcare transition (HCT) from pediatric to adult HIV care can be disruptive to HIV care engagement and viral suppression for youth living with HIV (YLH).

METHODS

We performed qualitative interviews with 20 YLH who experienced HCT and with 20 multidisciplinary pediatric and adult HIV clinicians to assess and rank barriers and facilitators to HCT and obtain their perspectives on strategies to improve the HCT process. We used the Exploration Preparation Implementation Sustainment Framework to guide this qualitative inquiry.

RESULTS

The most impactful barriers identified by YLH and clinicians focused on issues affecting the patient-clinician relationship, including building trust, and accessibility of clinicians. Both groups reported that having to leave the pediatric team was a significant barrier (ranked #1 for clinicians and #2 for YLH). The most impactful facilitator included having a social worker or case manager to navigate the HCT (listed #1 by clinicians and #2 by YLH); case managers were also identified as the individual most suited to support HCT. While YLH reported difficulty building trust with their new clinician as their #1 barrier, they also ranked the trust they ultimately built with a new clinician as their #1 facilitator. Factors reported to bridge pediatric and adult care included providing a warm handoff, medical record transfer, developing relationships between pediatric clinics and a network of youth-friendly adult clinics, and having the pediatric case manager attend the first adult appointment. Longer new patient visits, increased health communication between YLH and clinicians and sharing vetted clinician profiles with YLH were identified as innovative strategies.

CONCLUSION

In this multi-disciplinary contextual inquiry, we have identified several determinants that may be targeted to improve HCT for YLH.

Considerations to Improve Pediatric HIV Testing and Close the Treatment Gap in 16 African Countries

BACKGROUND

In 2019, South Africa, Nigeria, Tanzania, Democratic Republic of Congo, Uganda, Mozambique, Zambia, Angola, Cameroon, Zimbabwe, Ghana, Ethiopia, Malawi, Kenya, South Sudan and Côte d'Ivoire accounted for 80% of children living with HIV (CLHIV) not receiving HIV treatment. This manuscript describes pediatric HIV testing to inform case-finding strategies.

METHODS

We analyzed US President's Emergency Plan for AIDS Relief monitoring, evaluation, and reporting data (October 1, 2018 to September 30, 2019) for these 16 countries. Number of HIV tests and positive results were reported by age band, country, treatment coverage and testing modality. The number needed to test (NNT) to identify 1 new CLHIV 1-14 years was measured by testing modality and country. The pediatric testing gap was estimated by multiplying the estimated number of CLHIV unaware of their status by NNT per country.

RESULTS

Among children, 6,961,225 HIV tests were conducted, and 101,762 CLHIV were identified (NNT 68), meeting 17.6% of the pediatric testing need. Index testing accounted for 13.0% of HIV tests (29.7% of positive results, NNT 30), provider-initiated testing and counseling 65.9% of tests (43.6% of positives, NNT 103), and universal testing at sick entry points 5.3% of tests (6.5% of positives, NNT 58).

CONCLUSIONS

As countries near HIV epidemic control for adults, the need to increase pediatric testing continues. Each testing modality - PITC, universal testing at sick entry points, and index testing - offers unique benefits. These results illustrate the comparative advantages of including a strategic mix of testing modalities in national programs to increase pediatric HIV case finding.

Achieving Antiretroviral Therapy Uptake and Viral Suppression Among Children and Adolescents Living With HIV in the UNAIDS 90-90-90 Era Across Six Countries in Eastern and Southern Africa-Lessons From the BIPAI Network

BACKGROUND

Although achievements have been made globally since the UNAIDS 90-90-90 targets were announced, paediatric data remain sparse. We describe achievements toward antiretroviral therapy (ART) uptake and viral load (VL) suppression, existing gaps, and potential best practices among children and adolescents living with HIV (CALHIV) across 6 Eastern and Southern African countries.

SETTING

Baylor College of Medicine International Paediatric AIDS Initiative Network sites in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda.

METHODS

We performed retrospective data analysis among CALHIV ages 0-19 years between 2014 and 2019.

RESULTS

A total of 25,370 CALHIV received care, 85.8% (21,773/25,370) received ART, 84.4% (18,376/21,773) had documented VL results, and 74.6% (13,715/18,376) had VL < 1000 cps/mL. By 2019, the pooled proportion of CALHIV receiving ART and having viral suppression increased to 99.8% [95% confidence interval (CI): 98.1 to 100.0] and 89.8% (95 CI: 88.2 to 91.5) respectively. Lower rates of viral suppression and higher lost to follow-up (LTFU) were seen in the 0-4-year and 15-19-year cohorts. CALHIV on ART not achieving viral suppression were younger, received care in Malawi or Mbeya, had a history of tuberculosis, lower rates of integrase-strand inhibitor-based ART, and were on ART for shorter durations. Best practices reported included adopting universal ART, ART optimization with protease inhibitor-based and/or dolutegravir-based regimens, peer-supported activities, child/adolescent friendly services, community-supported activities, and technology-driven quality improvement activities and digital solutions.

CONCLUSIONS

High rates of CALHIV receiving ART and having viral suppression can be achieved in settings in Eastern and Southern Africa through using pediatric best practices. Increased efforts must be made to address LTFU and to support under-fives and adolescents.

Transitioning from paediatric to HIV adult care services for adolescents and young people living with HIV in the African region: a scoping review protocol

INTRODUCTION

The number of children living with HIV is increasing worldwide and is a major public health concern as they grow into adolescence and young adulthood with increasing access to antiretroviral therapy (ART) especially in the African region. There is a pressing need to transfer them from paediatric to adult care which has implications for their well-being. The objective of this scoping review is to systematically review published and unpublished literature to understand the extent and type of evidence in relation to the transition of adolescents to adult HIV clinics in the African region.

METHODS AND ANALYSIS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Review) guidelines for conducting a scoping review, we will systematically search online bibliographic databases including PubMed, EMBASE, Google Scholar and bibliographies of pertinent articles. This will be supplemented by searches in grey literature databases. Two reviewers will independently review all articles to determine if they meet eligibility criteria. Any conflicts will be resolved after discussion with a third reviewer to ensure accurate and reliable data collection. Both quantitative and qualitative results will be extracted from all included articles and synthesised in a narrative form in response to the review questions.

ETHICS AND DISSEMINATION

The scoping review does not require ethics approval as we will collect and review existing literature and materials. The results will be disseminated through a peer-reviewed publication, conference presentations and stakeholder meetings to support clinicians, health experts and policy makers develop guidelines and evidence-based transition protocols favourable for the populations in the African region to minimise challenges associated with the transition process.

Individual and contextual factors affect the implementation fidelity of youth-friendly services, northwest Ethiopia: A multilevel analysis

BACKGROUND

The evaluation of all potential determinants of implementation fidelity of Youth-Friendly Services (YFS) is crucial for Ethiopia. Previous studies overlooked investigating the determinants at different levels. Therefore, this study aimed to assess the determinants of implementation fidelity of YFS considering individual and contextual levels.

METHODS

This study was conducted among 1,029 youths, from 11 health centers that are implementing the YFS in Central Gondar Zone. Data were collected by face to face interview and facility observation using a semi-structured questionnaire. A Bivariable multi-level mixed effect modelling was employed to assess the main determinants. Four separate models were fitted to reach the full model. The fitness of the model was assessed using Akaike Information Criterion (AIC) and level of significance was declared at p-values < 0.05. The results of fixed effects were presented as adjusted odds ratio (AOR) at their 95% CI.

RESULTS

Four hundred one (39.0%) of the respondents got the YFS with high level of fidelity. Had high level of involvement in the YFS provision (AOR = 1.35, 95% CI: 1.15, 1.57), knew any peer educator trained in YFS (AOR = 1.60, 95% CI: 1.36, 1.86), and involved as a peer educator (AOR = 1.46, 95% CI: 1.24, 1.71), were the individual level determinants. Whereas, got capacity building training; (AOR = 1.93, 95% CI (1.12, 3.48), got supportive supervision, (AOR 2.85, 95% CI (1.99, 6.37), had a separate waiting room (AOR = 9.84, 95%CI: 2.14, 17.79), and system in place to provide continuous support to staff (AOR = 2.81, 95%CI: 1.25, 6.34) were the contextual level determinants.

CONCLUSIONS

The level of implementation fidelity remains low. Both individual and contextual level determinants affect the implementation fidelity of YFS. Therefore, policy makers, planners, managers and YFS providers could consider both individual and contextual factors to improve the implementation fidelity.

Group counselling for adherence support among young people failing first-line antiretroviral therapy in Zimbabwe

Background

Sub-optimal adherence to antiretroviral therapy (ART) is reportedly worse amongst young people living with HIV (YPLHIV). Group adherence counselling can be useful to improve adherence.

Objectives

We evaluated an enhanced adherence counselling group intervention (EACGI) amongst YPLHIV failing a non-nucleoside reverse transcriptase (NNRTI)-based first-line ART regimen.

Method

This was a retrospective cohort study using routinely collected data of YPLHIV failing NNRTI-based first-line ART. Patients with confirmed virological failure were referred for EACGI, a 12-week curriculum of weekly, 1.5-h sessions accommodating 8–15 people per group. It aimed to facilitate readiness to switch to second-line ART and improve adherence through a mental health intervention. Viral loads of HIV were measured pre-EACGI; at baseline; 3, 6 and 12 months post switch.

Results

Fifty-seven patients aged 13–25 years were invited to EACGI and followed for up to 48 weeks. Thirty-three (58%) patients attended at least four sessions, whilst 24 (42%) attended none. Amongst those who attended none, two (8%) were transferred out, three (13%) were lost to follow-up and two (8%) had died by week 48 of follow-up, whilst all who attended were still in care. By week 48, amongst patients still in care, 29%, 44% and 67% of those who attended no sessions, 4–9 and 10–12 sessions, respectively, had viral loads of < 50 copies/mL.

Conclusion

An EACGI is a promising intervention for YPLHIV failing ART prior to treatment switch, leading to improved adherence. This study’s findings support the need for further enquiry into rigorous, evidence-based multilevel adherence interventions that are acceptable and effective for YPLHIV.

Loss to follow up after pregnancy among mothers enrolled on the option B+ program in Uganda

Objective

Option-B+ programs in Uganda have reported high levels of loss to follow up (LTFU) after cessation of breastfeeding, and this remains unknown beyond this period. In this study, we assessed the incidence and factors associated with LTFU two to four years after delivery among Option-B+ mothers.

Study design

Retrospective cohort.

Methods

We reviewed files of 452 mothers who enrolled on Option-B+ between January 1st, 2013 and December 31st, 2014 ​at Kisenyi Health Centre IV in Kampala district. We assessed factors associated with LTFU using Cox proportional hazards regression. We also explored the reasons for LTFU using three focus group discussions, five in-depth and three key informant interviews.

Results

Of the 452 mothers, 131(29%) were LTFU after delivery. The incidence of LTFU after delivery was 17/1000 person months (95% CI, 14–30/1000) with a median follow up of 32 months. The risk of LTFU was higher among mothers who started ART on the day they tested HIV positive (aHR ​= ​1.66, 95% CI; 1.25–2.20, p-value< 0.001). Reasons for LFTU included transport costs, stigma, poor human resource policies and non-disclosure.

Conclusion

LTFU after delivery among Option-B+ mothers is higher than the global target of 15%. ART initiation on the day a mother tests positive increases the risk of LTFU. The major reasons for LTFU were stigma and non-disclosure. To reduce the risk of LTFU, we recommend approaches that encourage disclosure to sexual partners and ongoing specific support to mothers who are initiated on ART-the day of positive test.

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Loss to follow up (LTFU) among Option-B+ mothers after delivery is high.

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ART initiation on the day a mother tests positive increases the risk of LTFU.

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Non-disclosure is a major contributor to LTFU among Option-B+ mothers.

How Can Clinical Outcomes among Adolescents Living with HIV in Ethiopia be Improved? Healthcare Professionals' Perspectives

While successes in the prevention of mother-to-child transmission program are believed to lead to substantial reductions in new perinatal infections, new sexually acquired infections among the older adolescent group seem to fuel the HIV epidemic. That is why adolescents are the only age group in which an increase in new HIV infections was reported in the latest global HIV progress update. Increase in the number of perinatally HIV infected children growing to adolescence adds to this pool. However, there is limited evidence on the specific needs of adolescents in resource-limited settings. The objective of this study was to assess the experiences and suggestions of health-care providers regarding clinical services for adolescents living with HIV in Ethiopia. The study was conducted in two regions of Ethiopia. An inductive qualitative approach, including focus group interviews among health-care professionals working with adolescents living with HIV was conducted between November 2015 and March 2016. Fifteen health-care professionals participated in three focus group discussions. The interviews were analyzed using qualitative content analyses. The health-care professionals' experiences are described in three categories: Youth specific support needed; Manifold support from and within society; and Adults' fear of stigma. This led to the main theme: To see what is needed but not always being able to give. The main theme described that the health-care professionals were aware that the adolescents had specific health-care needs which they were not able to fulfill. They were also aware of the adolescents' need and support from the society and from their family, but they were not in control of it. Adolescents living with HIV have unique care needs which need to be met through evidence-guided introduction of adolescent-friendly services. This study further substantiates earlier findings that poor adherence to treatment and appointment schedules remains a critical challenge that needs interventions.

Adolescents and young adults with early acquired HIV infection in the united states: unique challenges in treatment and secondary prevention

INTRODUCTION

Worldwide, children who acquired human immunodeficiency virus (HIV) at an early age, either perinatally or through blood transfusion, are reaching adolescence and adulthood due to successful antiretroviral treatment (ART). While many are thriving, a significant proportion face unprecedented multilevel challenges that can affect their long-term outcomes. Specifically, longstanding and poorly controlled HIV resulting from inadequate early regimens and nonadherence, along with the toxicities of some ART agents, can predispose them to sequelae including HIV-associated complications and other comorbidities.

AREAS COVERED

This paper reviews and summarizes the unique issues facing adolescents and young adults with early acquired HIV (AYA-EAHIV), including ART challenges, emerging comorbidities, and complications, including mental health comorbidities, secondary prevention, and transition from pediatric/adolescent to adult care.

EXPERT OPINION

AYA-EAHIV are a special population that have lived their entire lives with the physical and psychological toll of HIV mandating targeted and purposeful approaches to optimize their management and outcomes. Multifaceted inclusive and context-specific approaches focusing on heightened research, risk reduction interventions, and 'outside the box' thinking will be required to optimize treatment and reduce morbidity and mortality.

Healthcare Transition Outcomes Among Young Adults With Perinatally Acquired Human Immunodeficiency Virus Infection in the United States

BACKGROUND

Young adults with perinatally acquired HIV (YPHIVs) living in the United States are transitioning to adult clinical care, yet there is little information on factors that affect transition outcomes.

METHODS

YPHIVs aged ≥18 years in the Pediatric HIV/AIDS Cohort Study (PHACS) AMP Up cohort approaching or having completed transition from pediatric to adult healthcare were included. Demographic and clinical characteristics and self-reported ability to self-manage healthcare were compared by transition status, and multivariable logistic regression models examined factors associated with satisfaction with, and retention in, adult clinical care (clinic visit within the previous 6 months).

RESULTS

Most of the 455 YPHIVs, regardless of transition status, reported satisfaction with their clinic and care provider, but many reported antiretroviral medication nonadherence. Of the 124 YPHIVs who had transitioned, 56% had periods of unsuppressed HIV-1 RNA in the year before transition. Those who had transitioned were more likely to report high ability to self-manage their healthcare (ability to manage ≥7 of 8 skills) than those not transitioned. High self-management was associated with retention after transition (odds ratio, 3.40; 95% confidence interval, 1.33-9.12). Higher perceived emotional social support was also associated with retention. Older age at transition was associated with greater satisfaction with provider and clinic.

CONCLUSIONS

YPHIVs have positive associations with their clinical care around the time of their transition to adult care, but unsuppressed viral load and suboptimal adherence are a concern. Strengthening skills that increase ability to self-manage care and enhance social support may increase retention in care and improve clinical health.

"It was not okay because you leave your friends behind": A prospective analysis of transition to adult care for adolescents living with perinatally-acquired HIV in South Africa

OBJECTIVE

To determine facilitators and barriers to successful transition to adult care for adolescents living with perinatally-acquired HIV in South Africa.

METHODS

We prospectively enrolled 30 adolescents living with perinatally-acquired HIV after their pediatrician deemed them ready for transition to adult care but prior to their transition. Eighteen months after enrollment, we measured transition status, engagement in care (i.e., viral load within 12 months of transition), and viral suppression (<200 copies/ml). Additionally, we conducted in-depth interviews with adolescents before and after transition to explore facilitators and barriers to successful transition.

RESULTS

A total of 19/30 (63%) adolescents transitioned to adult care. Of those who transitioned, 11 (58%) were retained in care and 7 (37%) were virally suppressed one year after transition to adult care. Insufficient staff training, lack of availability of pediatric ART formulations in adult clinics, and insufficient clinical monitoring contributed to delayed transition. Rigid clinical scheduling that interfered with school and loss of clinic relationships with peers and clinical staff were major factors in contributing to poor engagement in care after transition. Maturity of the adolescent, reduced distance to clinic, and reduced length of time in the clinic were seen as facilitators to transition to adult care.

CONCLUSION

Improved preparation for transition by pediatric and adult clinical staff, including restructuring of care delivery, may improve successful transition of adolescents living with perinatally acquired HIV to adult care. Transition readiness assessments are needed to determine optimal timing of transition and which adolescents are ready to transition to adult care.

Viral load care of HIV-1 infected children and adolescents: A longitudinal study in rural Zimbabwe

INTRODUCTION

Maintaining virologic suppression of children and adolescents on ART in rural communities in sub-Saharan Africa is challenging. We explored switching drug regimens to protease inhibitor (PI) based treatment and reducing nevirapine and zidovudine use in a differentiated community service delivery model in rural Zimbabwe.

METHODS

From 2016 through 2018, we followed 306 children and adolescents on ART in Hurungwe, Zimbabwe at Chidamoyo Christian Hospital, which provides compact ART regimens at 8 dispersed rural community outreach sites. Viral load testing was performed (2016) by Roche and at follow-up (2018) by a point of care viral load assay. Virologic failure was defined as viral load ≥1,000 copies/ml. A logistic regression model which included demographics, treatment regimens and caregiver's characteristics was used to assess risks for virologic failure and loss to follow-up (LTFU).

RESULTS

At baseline in 2016, 296 of 306 children and adolescents (97%) were on first-line ART, and only 10 were receiving a PI-based regimen. The median age was 12 years (IQR 8-15) and 55% were female. Two hundred and nine (68%) had viral load suppression (<1,000 copies/ml) and 97(32%) were unsuppressed (viral load ≥1000). At follow-up in 2018, 42/306 (14%) were either transferred 23 (7%) or LTFU 17 (6%) and 2 had died. In 2018, of the 264 retained in care, 107/264 (41%), had been switched to second-line, ritonavir-boosted PI with abacavir as a new nucleotide analog reverse transcriptase inhibitor (NRTI). Overall viral load suppression increased from 68% in 2016 to 81% in 2018 (P<0.001).

CONCLUSION

Viral load testing, and switching to second-line, ritonavir-boosted PI with abacavir significantly increased virologic suppression among HIV-infected children and adolescents in rural Zimbabwe.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

Adhering to antiretroviral therapy: A qualitative analysis of motivations for and obstacles to consistent use of antiretroviral therapy in people living with HIV

Objectives:

Based on the 2015 U.S. Centers for Disease Control and Prevention data, 40% of people living with HIV in the United States with an HIV diagnosis and 18.5% of people living with HIV in HIV care in the United States are not virally suppressed. Many HIV care clinics have implemented recommendations to improve the percentage of people living with HIV on antiretroviral therapy. To understand what more could be done, we examine patients’ motivations and obstacles to maintaining adherence to antiretroviral therapy.

Methods:

We conducted qualitative analysis using a qualitative description framework of in-depth interviews with people living with HIV receiving care at an urban HIV care clinic in the midwestern United States.

Results:

We found that while many traditional barriers to care have been addressed by existing programs, there are key differences between those consistent with antiretroviral therapy and those inconsistent with antiretroviral therapy. In particular, self-motivation, diagnosis acceptance, treatment for depression, spiritual beliefs, perceived value of the HIV care team, and prior experience with health care distinguish these two groups. Most significantly, we found that people living with HIV consistent with antiretroviral therapy describe their main motivation as coming from themselves, whereas people living with HIV inconsistent with antiretroviral therapy more often describe their main motivation as coming from the HIV care team.

Conclusion:

Our results highlight the importance of the HIV care team’s encouragement of maintaining antiretroviral adherence, as well as encouraging treatment for depression.

TB and TB-HIV care for adolescents and young adults

SETTING: Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana.OBJECTIVE: To evaluate the challenges encountered, healthcare worker (HCW) approaches, and supported interventions in TB and TB-HIV (human immunodeficiency virus) care for adolescents and young adults (AYA, aged 10-24 years).DESIGN: Semi-structured interviews with HCW in TB clinics, analyzed using thematic analysis.RESULTS: Sixteen HCWs were interviewed. AYA developmental needs included reliance on family support for care, increasing autonomy, attending school or work, building trust in HCWs, and intensive TB education and adherence support. Stigma strongly influenced care engagement, including clinic attendance and HIV testing. Health system barriers to optimal AYA TB care included limited staffing and resources to follow-up or support. HCWs utilized intensive education and counseling, and transitioned AYA to community-based directly observed therapy whenever feasible. HCWs supported implementation of youth-friendly services, such as AYA-friendly spaces or clinic days, training in AYA care, use of mobile applications, and peer support interventions, in addition to health system strengthening.CONCLUSION: HCWs utilize dedicated approaches for AYA with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment. Further work is needed to study interventions to improve AYA TB care and outcomes.

Community perspectives of South African adolescents' experiences seeking treatment at local HIV clinics and how such clinics may influence engagement in the HIV treatment cascade: a qualitative study

Despite having the largest antiretroviral treatment (ART) program in the world, only 14% of South African adolescents living with HIV (ALWH) are on ART. The purpose of this study was to identify aspects of the clinic environment that either improve or inhibit ALWH's ability to engage in HIV care. We conducted fifty-nine semi-structured, in-depth interviews with ALWH (n = 20; 13-19 years of age), their caregivers (n = 19), and local stakeholders (n = 20) in Cape Town, South Africa. Data were coded and analyzed using inductive and deductive approaches to content analyses. Codes were grouped into positive and negative aspects of the HIV clinic environment, and into suggestions on how clinic practices could be improved to facilitate ALWH treatment retention and ART adherence. Positive clinic factors included: community co-location; familiarity with clinic staff; and adolescent only/adolescent-friendly clinic spaces. Negative clinic factors included: clinic visit frequency; overcrowding and long wait times; discrimination and stigma; lack of confidentiality; inflexible appointment-scheduling; and staff attitudes. ALWHs' clinic experiences affect their ability to remain in care and adhere to their treatment regimens. These findings support a call for innovative approaches that improve ALWH's clinic experiences and support them as they progress along the HIV treatment cascade.

Exploring the Sexually Transmitted Infection Testing Experiences of Young People through Creative Visual Mapping

BACKGROUND

Innovative solution-focused research with youth is needed to improve sexually transmitted infection (STI) testing among adolescents and young adults (AYA). We sought to identify moments that matter to AYA during the STI testing experience.

METHODS

Five social design graduate students and five youth advisory council (YAC) members independently received STI testing and created journey maps documenting their experience. Social design students assisted YAC members in their map creation during group workshops and one-on-one worktime. Participants completed interviews about their experience using their maps to facilitate responses. We used thematic content analysis to synthesize textual interview data.

RESULTS

Participants experienced stress and discomfort throughout the testing process, with three main sources of stress identified: finding a clinic, completing registration forms, and general lack of clarity during the clinical experience. Friendly interactions with providers and staff improved the experience, however. Finally, the physical environment of the clinic space could positively or negatively impact the overall experience.

CONCLUSIONS

Journey mapping may be an important tool for identifying solutions to improve STI testing among AYA.

Impact of a Youth-Focused Care Model on Retention and Virologic Suppression Among Young Adults With HIV Cared for in an Adult HIV Clinic

BACKGROUND

Young adults with HIV (YAHIV) are less likely to be retained in care or achieve viral suppression (VS) when seen in adult clinics. We assessed the outcomes of a youth-focused care model versus standard of care (SOC) within a large adult HIV clinic.

SETTING

The Accessing Care Early (ACE) program for YAHIV is embedded within an adult clinic. Eligibility for ACE includes age 18-30 years with ≥1 criteria: transfer from pediatric care, mental health diagnosis, substance use, or identified adherence barriers. Ineligible patients receive SOC.

METHODS

Retrospective analysis of patients entering ACE versus SOC from 2012 to 2014. Multivariable logistic regression assessed variables associated with retention and VS <200 copies per milliliter, and in separate analysis, clinical services utilization.

RESULTS

One hundred thirty-seven YAHIV entered care (2012-2014), 61 ACE and 76 SOC. Despite higher risk factors, ACE YAHIV were less likely to be lost to follow-up compared with SOC (16% versus 37%, P < 0.01). At 24 months, 49% in ACE versus 26% in SOC met the retention measure (P < 0.01). In adjusted analysis, ACE was associated with retention in care [AOR 3.26 (1.23-8.63)]. Of those meeting the retention measure, 60% of ACE versus 89% of SOC had VS [AOR 0.63 (0.35-1.14)]. Retention was associated with more frequent social work visits, nurse phone calls, and peer navigator interactions.

CONCLUSIONS

Higher risk ACE YAHIV had better retention than SOC YAHIV in an adult clinic. Improved retention did not lead to improved VS, underscoring the need for additional interventions to optimize VS for YAHIV.

Outcomes of a Comprehensive Retention Strategy for Youth With HIV After Transfer to Adult Care in the United States

BACKGROUND

The retention of youth living with HIV (YLHIV) in adult care after transfer from pediatric care in the United States is a challenge. A targeted comprehensive retention strategy (CRS) may improve retention among YLHIV.

METHODS

A retrospective cohort study of YLHIV after transfer from pediatric to adult care for patients with at least 1 adult visit at 2 urban HIV care programs in the United States employing CRSs with internal medicine/pediatrics-trained providers, peer navigators, social workers and mental health resources. Primary outcomes were successful retention in care after transfer (≥2 provider visits in the adult clinic ≥90 days apart within 1 year of transfer) and successful transition (successful retention plus a stable HIV viral load (VL) defined as VL 1 year after transfer that was less than or equal to the VL obtained at or immediately before transfer). Logistic regression assessed factors associated with successful transition. A subgroup analysis was performed to examine rates of successful transfer and linkage from pediatric to adult clinics (attending at least 1 adult visit after transition).

RESULTS

Of the 89 patients included in the study, 79 (89%) patients had successful retention and 53 (60%) had successful transition to the adult program. Factors associated with successful transition included non-African American race [adjusted odds ratio (aOR) = 11.26, 95% confidence interval (CI): 1.32-95.51], perinatal HIV (aOR = 8.00, 95% CI: 1.39-46.02) and CD4 count > 500 cells/mm (aOR = 5.22, 95% CI: 1.54-17.70). Of those who were retained, 53/79 (67%) had stable or improved virologic control at 1 year after transition. In a subgroup analysis, 54/56 (96%) patients who were targeted to transition successfully linked to adult care.

CONCLUSIONS

Overall, YLHIV in the United States engaged in a CRS program appear to have high retention rates but suboptimal virologic control after transfer from pediatric HIV care.

Recent Interventions to Improve Retention in HIV Care and Adherence to Antiretroviral Treatment Among Adolescents and Youth: A Systematic Review

Adolescents represent a growing proportion of people living with HIV worldwide and the highest risk population group for treatment attrition and AIDS-related mortality. There is an urgent need to design, implement, and test interventions that keep young people in HIV treatment and care. However, previous systematic reviews show scarce and inconclusive evidence of effective interventions for this age group. Recent years have seen an increase in focus on adolescent health and a rapidly changing programmatic environment. This systematic review article provides an evidence update by synthesizing empirical evaluations of interventions designed to improve antiretroviral therapy adherence and retention among adolescents (10-19) and youth (15-24) living with HIV, published between January 2016 and June 2018. A search of 11 health and humanities databases generated 2425 citations and 10 relevant studies, the large majority conducted in sub-Saharan Africa. These include six clinic-level interventions, one individual-level m-Health trial, and three community- or household-level interventions. Implications of their findings for future programming and research with young adults are discussed, in relation to previous reviews and the broader empirical evidence in this area. Findings highlight the need to further develop and test multi-faceted interventions that go beyond health facilities, to address broader social barriers to adherence and retention. In particular, further intervention studies with adolescents (10-19) should be a priority, if we are to retain these young people in treatment and care and aspire to achieve the United Nation's Sustainable Development Goals and 90-90-90 targets.

Engagement in care among youth living with parenterally-acquired HIV infection in Romania

Transition from adolescent to adult care can be challenging for youth living with HIV. We conducted a cohort study of youth born between 1985 and 1993 and infected with HIV parenterally, followed by the same medical team from age 15 years or first clinic visit until age 25 years or 30 November 2016. A longitudinal continuum-of-care was constructed, categorizing individuals' status for each month of follow-up as: engaged in care (EIC); not in care (NIC: no clinic visits within past year); lost-to-follow-up (LTFU: NIC and did not return to clinic); or died. Five hundred and forty-five individuals (52% male) were followed for 4775 person-years. At age 15, 92% were EIC, decreasing to 84% at age 20 and 74% at age 25. Of those EIC, HIV outcomes improved with age: 79% and 52% had a CD4 ≥200 cells/µl and VL <400 cps/ml at age 15; increasing to 86% and 73% at age 20 and 87% and 80% at age 25. We conclude that youth infected during early childhood tended to disengage from care, even when followed by the same medical team for a lengthy period of time. For those that did engage in care, HIV-related outcomes improved from adolescence through adulthood.

Barriers to Retention in Care are Overcome by Adolescent-Friendly Services for Adolescents Living with HIV in South Africa: A Qualitative Analysis

To assess facilitators and barriers to retention in care for adolescents living with HIV, we conducted in-depth, semi-structured interviews with adolescents ages 13 to 24 years who were living with HIV and being cared for in either an adolescent-friendly or standard government-supported clinic in KwaZulu-Natal, South Africa. We used inductive content analysis approach based on grounded theory derived from reviewing, coding, and interpreting data. We interviewed 28 adolescents living with HIV (16 in the adolescent clinic and 12 from the pediatric clinic) and 14 of their caregivers. Barriers to retention in care included having to attend clinic during school hours, fear of disclosure to others, social isolation, and conflict with clinical staff. Facilitators to retention in care seen in the adolescent-friendly services clinic included after school clinic hours, peer support, and connection to the clinical staff. Adolescent-friendly services are facilitators of HIV care and warrant prioritization in treatment programs.

Young people in HIV care in Ukraine: a national survey on characteristics and service provision

Background: Ukraine's perinatally HIV-infected (PHIV) young people are ageing into adolescence/young adulthood and, alongside those with horizontally-acquired HIV infections, require transitional and other support services. We aimed to map this population and policies/service provision at specialist HIV centres, to inform future service development. Methods: A national survey was conducted of 28 HIV/AIDS centres on number, characteristics (age group, HIV acquisition mode) and care setting (paediatric/adult) of 10-24 year olds in HIV care in each of 24 regions in January 2016. Information was collected on policies/service provision at each centre. Results: Of 13,286 young people aged 10-24 years registered for HIV care nationally in Ukraine in January 2016, 1,675 were aged 10-18 years. Three-quarters of ≤19 year olds were PHIV, while 72% of 20-24-year-olds had sexually-acquired infection. Five regions accounted for two-thirds of 10-18 year olds in paediatric and 85% of 19-24 year olds in adult services. In 2015, 97 young people transitioned from paediatric to adult services nationally, typically at 18 years although with flexibility in timing at 17/28 centres. At 27/28 centres, horizontally HIV-infected young people aged <18 years began their HIV care in paediatric services sometimes (5) or always (22). Transition support most commonly consisted of a joint appointment with paediatrician and adult doctor, and support from a psychologist/social worker (both at 24/28 centres). Only 5/28 centres offered routine HIV care during the evening or weekend, and availability of integrated sexual/reproductive health and harm reduction services was uneven. Of 16/28 centres selectively following-up patients who did not attend for care, 15 targeted patients in paediatric services. Conclusions: Heterogeneity in the population and in service availability at the main regional/municipal HIV/AIDS centres has implications for potential structural barriers to HIV care, and development of services for this group.

Young people in HIV care in Ukraine: a national survey on characteristics and service provision

Background: Ukraine's perinatally HIV-infected (PHIV) young people are ageing into adolescence/young adulthood and, alongside those with behaviourally-acquired infections (BHIV), require transitional and other support services. We aimed to map this population and policies/service provision at specialist HIV centres, to inform future service development. Methods: A national survey was conducted of 28 HIV/AIDS centres on number, characteristics (age group, HIV acquisition mode) and care setting (paediatric/adult) of 10-24 year olds in HIV care in each of 24 regions in January 2016. Information was collected on policies/service provision at each centre. Results: Of 13,286 young people aged 10-24 years registered for HIV care nationally in Ukraine in January 2016, 1,675 were aged 10-18 years. Three-quarters of ≤19 year olds were PHIV, while 72% of 20-24-year-olds had sexually-acquired infection. Five regions accounted for two-thirds of 10-18 year olds in paediatric and 85% of 19-24 year olds in adult services. In 2015, 97 young people transitioned from paediatric to adult services nationally, typically at 18 years although with flexibility in timing at 17/28 centres. At 27/28 centres, BHIV young people aged <18 years began their HIV care in paediatric services sometimes (5) or always (22). Transition support most commonly consisted of a joint appointment with paediatrician and adult doctor, and support from a psychologist/social worker (both at 24/28 centres). Only 5/28 centres offered routine HIV care during the evening or weekend, and availability of integrated sexual/reproductive health and harm reduction services was uneven. Of 16/28 centres selectively following-up patients who did not attend for care, 15 targeted patients in paediatric services. Conclusions: Heterogeneity in the population and in service availability at the main regional/municipal HIV/AIDS centres has implications for potential structural barriers to HIV care, and development of services for this group.

Retention and adherence: global challenges for the long-term care of adolescents and young adults living with HIV

PURPOSE OF REVIEW

Adolescents living with HIV are the only age group with increasing HIV mortality at a time of global scale-up of access to antiretroviral therapy (ART). As a 'treat all' strategy is implemented worldwide, it is critically important to optimize retention and adherence for this vulnerable group.

RECENT FINDINGS

Adolescents and young adults living with HIV have poorer outcomes when compared with adults at each stage of the HIV care cascade, irrespective of income setting. Rates of viral suppression are lowest for adolescents living with HIV, and adherence to ART remains an enormous challenge. High-quality studies of interventions to improve linkage to, and retention in, care on suppressive ART are starkly lacking for adolescents and young adults living with HIV across the globe. However, examples of good practice are beginning to emerge but require large-scale implementation studies with outcome data disaggregated by age, route of infection, and income setting, and include young pregnant women and key populations groups.

SUMMARY

There is an urgent need for evidence-based interventions addressing gaps in the adolescent HIV care cascade, including supporting retention in care and adherence to ART.

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

INTRODUCTION

There are two million HIV-positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self-reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)-initiated adolescents in South Africa.

METHODS

We collected clinical records and detailed standardized interviews (n = 1059) with all 10- to 19 year-olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost-to-follow-up (90.1% of eligible adolescents interviewed). Associations between full self-reported retention in care (no past-year missed appointments and 85% past-week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility.

RESULTS

About 56% of adolescents had self-reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention.

CONCLUSIONS

This study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV-positive adolescents.

Identifying Solutions to Improve the Sexually Transmitted Infections Testing Experience for Youth Through Participatory Ideation

Sexually transmitted infection (STI) services, including screening, treatment, and counseling among youth, remain suboptimal. In the midst of increasing incidence of bacterial STIs, alarming STI disparities, and persistently low testing rates among youth, solution-focused and action-oriented research with youth is needed. To identify solutions to STI testing barriers, we conducted three participatory ideation workshops with 18 youth, 10 key stakeholders who work with youth, and 8 social design graduate students. In response to prompt questions asking "How might we" address a testing barrier, participants generated as many ideas as they could on small pieces of paper. The brainstorming sessions produced 702 brainstorm idea sheets that were then qualitatively analyzed through pile sorting by three team members (including two youth) with each pile representing a priori themes (from the "How might we" probe) or emergent themes. Ten themes were identified corresponding to three domains: (1) improving the testing experience (improving transparency in the testing process, increasing trust in privacy, alternative testing options, and providing incentives/rewards for testing), (2) addressing the clinic space (multi-service spaces, appealing physical clinical space, and providing waiting room activities), and (3) reframing STI testing (normalizing STI testing, the clinic as a supportive environment, and youth leadership to promote and support STI testing). These findings move beyond identifying barriers and motivators to STI testing among youth and focus on the generation of possible solutions. By engaging youth in the development of solutions to STI testing, solutions that may be better-utilized and more acceptable to youth may be developed.

Adolescent transition among young people with perinatal HIV in high-income and low-income settings

PURPOSE OF REVIEW

To summarize evidence for health outcomes among adolescents and young people living with HIV (AYLHIV) who have transitioned to adult care/adulthood, views of AYLHIV and providers on the transition process, and the effect of adolescent and youth friendly services (AYFS) on outcomes.

RECENT FINDINGS

A total of 43 studies were identified [n = 13 high-income countries (HICs), n = 30 low-/middle-income countries (LMICs)]. In HICs, around 75% of patients were retained in care at approximately 4 years posttransition. In LMICs, retention worsened from older adolescence into young adulthood. Across both contexts, comparisons of mortality, immunological, and virological outcomes were hampered by a limited number of studies and/or different definitions and study durations. AYLHIV and providers reported several factors that could aid transition and AYFS had generally positive outcomes.

SUMMARY

Overall, outcomes varied by study and context; direct comparison was severely hampered by the inclusion of different populations of AYLHIV (sometimes with small numbers and a lack of comparison groups), the use of different outcome definitions, varying follow-up duration, and the lack of a specific transition process in LMICs. Future studies need to consider harmonizing definitions and implementing unique patient identifiers, and data linkage techniques to improve the evidence base on long-term outcomes.

The Clinic Environment as a Form of Social Support for Adolescents and Young Adults Living with HIV

Adolescents and young adults living with HIV (YLHIV) face numerous stresses that affect their care and medication adherence. The clinic social environment may play an important supportive role for YLHIV, influencing health outcomes. The aim of this article is to explore how YLHIV in Baltimore, Maryland understand the various forms of social support provided within the social environment of their HIV clinic. We used qualitative research methods including iterative, semi-structured in-depth interviews with 20 YLHIV interviewed up to three times each to explore HIV stressors, support systems, and medication adherence. We employed thematic content analysis to systematically code and synthesize textual interview data. We found that YLHIV experienced social embeddedness with their healthcare teams and through clinic activities. Participants largely perceived these social connections as support, acknowledging that these supports are available to them when needed. Support was enacted through the provision of instrumental support for issues outside of the young person's medical care (i.e., finding a crib for a participant's baby), appraisal (i.e., through respect of the young person's agency and decision making), and information about their HIV care and medication. Support was not always well received, however, as some young people found the support from clinicians demeaning. Limitations of the clinic social support environment included concerns about trust and privacy, and perceiving support as inappropriate or unwanted. Participants identified a number of ways in which the clinic provided meaningful social support. Future research should explore how these supports may improve care and medication adherence of YLHIV.

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

Objective

To determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site.

Design

Retrospective cohort analysis.

Setting

Government supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa.

Participants

Two hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015.

Intervention

Attendance in an adolescent-friendly clinic compared to a standard pediatric clinic.

Outcomes measures

Retention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml.

Results

Overall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2–11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3–32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1–5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5–9.7; p = 0.005).

Conclusion

Adolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.

Project nGage: Results of a Randomized Controlled Trial of a Dyadic Network Support Intervention to Retain Young Black Men Who Have Sex With Men in HIV Care

HIV-positive young black MSM (YBMSM) experience poor outcomes along the HIV care continuum, yet few interventions have been developed expressly for YBMSM retention in care. Project nGage was a randomized controlled trial conducted across five Chicago clinics with 98 HIV-positive YBMSM aged 16-29 between 2012 and 2015. The intervention used a social network elicitation approach with index YBMSM (n = 45) to identify and recruit a support confidant (SC) to the study. Each index-SC dyad met with a social worker to improve HIV-care knowledge, activate dyadic social support, and develop a retention in care plan. Each index and SC also received four mini-booster sessions. Control participants (n = 53) received treatment as usual. Surveys and medical records at baseline, 3-, and 12-months post-intervention assessed visit history (3 or more visits over 12 months; primary outcome), and sociodemographic, network, social-psychological, and behavioral factors. At baseline, there were no differences in age (M = 23.8 years), time since diagnosis (M ≤ 2 years), clinic visits in the previous 12 months (M = 4.1), and medication adherence (68.6 ≥ 90% adherence). In multivariate logistic regression analysis, intervention participants were 3.01 times more likely to have had at least 3 provider visits (95% CI 1.0-7.3) than were control participants over 12 months. Project nGage demonstrates preliminary efficacy in improving retention in care among YBMSM. Results suggest that engaging supportive network members may improve key HIV care continuum outcomes.

Health Technology-Enabled Interventions for Adherence Support and Retention in Care Among US HIV-Infected Adolescents and Young Adults: An Integrative Review

The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13-29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005-March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.

Longitudinal Viral Suppression Among a Cohort of Adolescents and Young Adults with Behaviorally Acquired Human Immunodeficiency Virus

Youth living with HIV (YLWH) are less likely than older adults to achieve and sustain viral suppression. While treatment guidelines recommend decreased viral load (VL) monitoring in individuals with well-controlled HIV, the appropriateness of this strategy for adolescents is unknown. We conducted a retrospective cohort study to describe longitudinal viral suppression and identify incidence of, and risk factors for, virologic failure among YLWH at a US adolescent HIV clinic from 2002 to 2015. We utilized Cox proportional hazards modeling to compare hazard ratios (HRs) for virologic failure stratified by baseline characteristics. Study participants (n = 365) were predominately African American (87%) and cisgender men and transgender women who have sex with men (80%) and the majority (79%) entered care from 2002 to 2012. Of antiretroviral therapy (ART)-treated participants (n = 201), 88% achieved viral suppression, with 29% subsequently developing virologic failure at a median 12.0 months [interquartile range (IQR) 6.9-22.4] after suppression. The cohort incidence rate of virologic failure was 200 (confidence interval [95% CI]: 151-264) per 1000 person years (PY), with a rate after ≥2 years sustained suppression of 113 (95% CI: 57-227) per 1000 PY. After adjusting for time to ART initiation, initial regimen class, and year of cohort entry, cisgender women had increased hazards of virologic failure (HR 3.2 95% CI: 1.3-7.9, p = 0.01). In conclusion, youth remained at high risk of virologic failure throughout their treatment course, with higher hazards of virologic failure among cisgender women compared with other youth. Maintaining frequent VL monitoring in YLWH may be warranted, even after prolonged viral suppression.

Interventions to improve treatment, retention and survival outcomes for adolescents with perinatal HIV-1 transitioning to adult care: moving on up

PURPOSE OF REVIEW

There is an increasing number of deaths among adult survivors of perinatal HIV. Multiple and complex factors drive this mortality, including problems with retention in care and adherence during adolescence, coupled with the critical period of transition from paediatric to adult care, increasing their risk of treatment failure and severe immunosuppression. We reviewed studies that evaluated the impact of service delivery interventions to improve the health of perinatally infected adolescents living with HIV (P-ALHIV) to gain insight into what might help them survive the vulnerable period of adolescence.

RECENT FINDINGS

Youth-focused health services and individual-level interventions may improve P-ALHIV adherence and retention in care. However, there have been few studies, many with small sample sizes and with short durations of follow-up that end before the transition period. Studies from other childhood-onset chronic diseases are similarly limited.

SUMMARY

Further studies are urgently needed to identify optimal intervention strategies to reduce mortality and poor outcomes as the adolescent population expands and ages into adult care. Until we have a more robust evidence base, programmes can develop transition plans based on best practice recommendations to optimize the health and longevity of ALHIV in adulthood.

HIV testing in nonhealthcare facilities among adolescent MSM

Objectives:

To describe the extent to which Centers for Disease Control and Prevention (CDC)-funded HIV testing in nonhealthcare facilities reaches adolescent MSM, identifies new HIV infections, and links those newly diagnosed to medical care.

Methods/design:

We describe HIV testing, newly diagnosed positivity, and linkage to medical care for adolescent MSM who received a CDC-funded HIV test in a nonhealthcare facility in 2015. We assess outcomes by race/ethnicity, HIV-related risk behaviors, and US geographical region.

Results:

Of the 703 890 CDC-funded HIV testing events conducted in nonhealthcare facilities in 2015, 6848 (0.9%) were provided to adolescent MSM aged 13–19 years. Among those tested, 1.8% were newly diagnosed with HIV, compared with 0.7% among total tests provided in nonhealthcare facilities regardless of age and sex. The odds of testing positive among black adolescent MSM were nearly four times that of white adolescent MSM in multivariable analysis (odds ratio = 3.97, P < 0.001). Among adolescent MSM newly diagnosed with HIV, 67% were linked to HIV medical care. Linkage was lower among black (59%) and Hispanic/Latino adolescent MSM (71%) compared with white adolescent MSM (88%).

Conclusion:

CDC-funded nonhealthcare facilities can reach and provide HIV tests to adolescent MSM and identify new HIV infections; however, given the low rate of HIV testing overall and high engagement in HIV-related risk behaviors, there are opportunities to increase access to HIV testing and linkage to care for HIV-positive adolescent MSM. Efforts are needed to identify and address the barriers that prevent black and Hispanic/Latino adolescent MSM from being linked to HIV medical care in a timely manner.

HIV healthcare transition outcomes among youth in North America and Europe: a review

INTRODUCTION

The transition from paediatric to adult care poses risks to the health of young adults living with HIV if unsuccessful, including interruptions in care and poor health outcomes. Evolving best practices in HIV healthcare transition should ideally be informed by real-world qualitative and quantitative clinical healthcare transition outcomes. There has been a recent proliferation of HIV healthcare transition outcome research, largely from Europe and North America.

METHODS

A literature search was undertaken using the online databases PubMed, Web of Science, and Google Scholar. Medical subject and text word searches were combined for terms relating to HIV, paediatric transition outcomes, and internal and external factors were used to identify peer-reviewed articles.

RESULTS

In this paper, we review data on HIV healthcare transition outcomes in North America and Europe. Internal and external factors which may impact the success of HIV healthcare transition are examined. We describe ongoing research efforts to capture transition outcomes in the North America and Europe. Clinical, operational, and implementation science research gaps that exist to date are highlighted. Efforts to improve HIV healthcare transition research through country-level surveillance networks and large multicentre cohorts, including data integration and linkage between paediatric and adult cohorts are discussed.

CONCLUSIONS

We identified the need for a comprehensive approach to implementing empirically supported protocols to support healthcare transition for ALHIV. While there is limited prospective longitudinal cohort data available at this time, cohorts linking the paediatric and adolescent with ongoing surveillance into adulthood are being developed. Through a review of existing qualitative and quantitative healthcare transition outcomes studies, we identify emerging areas of consensus surrounding healthcare transition research implementation. Successful healthcare transition programmes in Europe and North America often share several characteristics, including implementation of a youth friendly multidisciplinary approach, consistent communication and integration between paediatric and adult care teams, and an individualized approach which is attuned the adolescent's transition readiness. Moving forward, the voices of youth and young adults living with HIV should be included in the development and evaluation of healthcare transition protocols to ensure that the definition of successful transition reflects all of the stakeholders in the transition process.

Missed Initial Medical Visits: Predictors, Timing, and Implications for Retention in HIV Care

HIV disproportionately affects racial/ethnic minorities and individuals living in the southern United States, and missed clinic visits account for much of this disparity. We sought to evaluate: (1) predictors of missed initial HIV medical visits, (2) time to initial visit, and (3) the association between initial visit attendance and retention in HIV care. Chart reviews were conducted for 200 consecutive HIV-infected patients (100 in Dallas, 100 in San Antonio) completing case management (CM) intake. Of these, 52 (26%) missed their initial visit, with 22 (11%) never presenting for care. Mean age was 40 years, 85% were men, >70% were of minority race/ethnicity, and 28% had a new HIV diagnosis. Unemployment (OR [95% CI] = 2.33 [1.04-5.24], p = 0.04) and lower attendance of CM visits (OR = 3.08 [1.43-6.66], p = 0.004) were associated with missing the initial medical visit. A shorter time to visit completion was associated with CD4 ≤ 200 (HR 1.90 [1.25-2.88], p = 0.003), Dallas study site (HR = 1.48 [1.03-2.14], p = 0.04), and recent hospitalization (HR = 2.18 [1.38-3.43], p < 0.001). Patients who did not complete their initial medical visit within 90 days of intake were unlikely to engage in care. Initial medical visit attendance was associated with higher proportion of visits attended (p = 0.04) and fewer gaps in care (p = 0.01). Missed medical visits were common among HIV patients initiating or reinitiating care in Texas. Employment and CM involvement predicted initial medical visit attendance, which was associated with retention in care. New, early engagement strategies are needed to decrease missed visits and reduce HIV health disparities.