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Introduction: As adolescents and young people living with HIV (AYLH) age, they face a 'transition cascade,' a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high-income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub-Saharan Africa, paediatric HIV care is mostly provided in decentralized, non-specialist primary care clinics, where 'transition' may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when 'transition' to autonomy might occur, we evaluated pre- and post-transition outcomes among AYLH. Methods: We included AYLH aged Results: A total of 5516 AYLH from 16 sites were included at 'transition' age 16 (transition-16y), 3864 at 18 (transition-18y), 1463 at 20 (transition-20y) and 440 at 22 years (transition-22y). At transition-18y in the 12 months pre- and post-transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (-1.0 to 6.5%)). The strongest predictor of being retained post-transition was having no gap in the preceding year, across all transition age thresholds (transition-16y adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition-18y: aRR 1.76 (1.61 to 1.92); transition-20y: aRR 1.75 (1.53 to 2.01); transition-22y: aRR 1.47; (1.21 to 1.78)). Conclusions: AYLH with gaps in care need targeted support to prevent non-retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood. Keywords: HIV; adolescents; youth; healthcare transition; retention; viral suppression; cascade of care, 1 | INTRODUCTION There is a growing cohort of adolescents and young adults living with HIV (AYLH), largely due to the increasing number of children with perinatally acquired HIV surviving [...]

: Introduction: As adolescents and young people living with HIV (AYLH) age, they face a “transition cascade,” a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high‐income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub‐Saharan Africa, paediatric HIV care is mostly provided in decentralized, non‐specialist primary care clinics, where “transition” may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when “transition” to autonomy might occur, we evaluated pre‐ and post‐transition outcomes among AYLH. Methods: We included AYLH aged Results: A total of 5516 AYLH from 16 sites were included at “transition” age 16 (transition‐16y), 3864 at 18 (transition‐18y), 1463 at 20 (transition‐20y) and 440 at 22 years (transition‐22y). At transition‐18y, in the 12 months pre‐ and post‐transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (−1.0 to 6.5%)). The strongest predictor of being retained post‐transition was having no gap in the preceding year, across all transition age thresholds (transition‐16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition‐18y: aRR 1.76 (1.61 to 1.92); transition‐20y: aRR 1.75 (1.53 to 2.01); transition‐22y: aRR 1.47; (1.21 to 1.78)). Conclusions: AYLH with gaps in care need targeted support to prevent non‐retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood., Introduction There is a growing cohort of adolescents and young adults living with HIV (AYLH), largely due to the increasing number of children with perinatally acquired HIV surviving into adolescence [...]

Paediatric antiretroviral treatment (ART) failure is an under-recognized issue that receives inadequate attention in the field of paediatrics and within HIV treatment programmes. With paediatric ART failure rates ranging from 19.3% to over 32% in resource limited settings, a comprehensive evaluation of the causes of failure along with approaches to address barriers to treatment adherence are urgently needed. In partnership with the local Department of Health, a pilot programme has been established by Medecins Sans Frontieres (MSF) in Khayelitsha, South Africa, to identify and support paediatric HIV patients with high viral loads and potential treatment failure. Through detailed clinical and psychosocial evaluations and adherence support with an innovative counselling model, treatment barriers are identified and addressed. Demographic and clinical characteristics from the cohort show a delayed median start date for ART, prolonged viraemia including a large number of patients who have never achieved viral load (VL) suppression, a low rate of regimen changes despite failure, and a high percentage of pre-adolescent and adolescent patients who have not gone through the disclosure process. Stemming this epidemic of paediatric treatment failure requires programmatic responses to high viral loads in children, starting with improved 'case finding' of previously undiagnosed HIV-infected children and adolescents. Viral load testing needs to be prioritized over CD4 count monitoring, and flagging systems to identify high VL results should be developed in clinics. Clinicians must understand that successful treatment begins with good adherence, and that simple adherence support strategies can often dramatically improve adherence. Moreover, appropriate adherence counselling should begin not when the child fails to respond to treatment. Establishing good adherence from the beginning of treatment, and supporting ongoing adherence during the milestones in these children's lives is key to sustaining treatment success in this vulnerable HIV-infected patient population. Keywords: HIV; treatment failure; Khayelitsha; paediatrics; viral load; primary care., While great progress has been made in the last 15 years in the field of paediatric HIV diagnosis and treatment, a growing problem has emerged that threatens to undermine much [...]