Search

Sustained viral suppression in adolescents and young adults living with HIV (AYALWH) is necessary for epidemic control. We evaluated facility and individual correlates of viral suppression using programmatic data from AYALWH between ages 10 and 24 years at 24 HIV clinics in Kenya. Binomial regression was used to evaluate correlates of viral load (VL) suppression (1,000 copies/ml). Of 5,316 AYALWH on antiretroviral therapy ≥6 months, 2,081 (39%) had VLs available in the medical record, of which 76% were virally suppressed. In multivariable analyses, antiretroviral therapy initiation among AYALWH older than 10 years was associated with higher viral suppression than initiation younger than 10 years (adjusted risk ratio [aRR] 10-14 = 1.03, 95% confidence interval [CI] 0.97-1.10; aRR 15-19 = 1.30, 95% CI 1.19-1.41; aRR 20-24 = 1.43, 95% CI 1.24-1.63). Facilities with both youth-friendly services (YFS) and trained providers had significantly higher VL suppression compared with facilities without YFS or trained providers (adjusted odds ratio: 2.07, 95% CI: 1.71-2.52). Viral suppression remains suboptimal among AYALWH. YFS and trained providers plus greater use of VL data may help increase viral suppression among AYALWH.

The health care transition (HCT) from pediatric to adult care is a potential contributor to poor clinical outcomes among adolescents living with HIV (ALHIV). In sub-Saharan Africa (SSA), there is limited information on effective tools and processes to prepare and support ALHIV through this transition. This study elicited perspectives of policy-makers regarding barriers and facilitators to successful HCT among ALHIV in Kenya. Twenty in-depth interviews (IDIs) were conducted with policy-makers using a semi-structured guide. Using the socio-ecological model (SEM) as an organizing framework, directed content and thematic network analyses methods were used to characterize themes related to key influences on HCT processes and to describe actionable recommendations for improved tools and resources. Policy-makers identified multilevel support, including the development of a triadic relationship between the caregiver, healthcare worker (HCW) and adolescent, as an essential strategy for improved HCT success. Across the SEM, policy-makers described the importance of actively engaging adolescents in their care to promote increased ownership and autonomy over health decisions. At the structural level, the need for more comprehensive HCT guidelines and improved HCW training was highlighted. Expanded HCT tools and guidelines, that emphasize supportive relationships and intensified adolescent engagement, may improve HCT processes and outcomes.

OBJECTIVES: To determine clinic-level and individual-level correlates of viral suppression among HIV-positive adolescents and young adult (AYA) aged 10–24 years receiving antiretroviral treatment (ART). DESIGN: Multilevel cross-sectional analysis using viral load data and facility surveys from HIV treatment programs throughout Kenya. METHODS: We abstracted medical records of AYA in HIV care, analyzed the subset on ART for more than 6 months between January 2016 and December 2017, and collected information on services at each clinic. Multilevel logistic regression models were used to determine correlates of viral suppression at most recent assessment. RESULTS: In 99 HIV clinics, among 10 096 AYA on ART more than 6 months, 2683 (27%) had unsuppressed viral load at last test. Among 16% of clinics, more than 80% of AYA were virally suppressed. Clinic-level correlates of individual viral suppression included designated adolescent spaces [aOR: 1.32, 95% CI (1.07–1.63)] and faster viral load turnaround time [aOR: 1.06 (95% CI 1.03–1.09)]. Adjusting for clinic-level factors, AYA aged 10–14 and 15–19 years had lower odds of viral suppression compared with AYA aged 20–24 years [aOR: 0.61 (0.54–0.69) and 0.59 (0.52–0.67], respectively. Compared with female patients, male patients had lower odds of viral suppression [aOR: 0.69 (0.62–0.77)]. Compared with ART duration of 6–12 months, ART for 2–5, above 5–10 or more than 10 years was associated with poor viral suppression (P < 0.001). CONCLUSION: Dedicated adolescent space, rapid viral load turnaround time, and tailored approaches for male individuals and perinatally infected AYA may improve viral suppression. Routine summarization of viral load suppression in clinics could provide benchmarking to motivate innovations in clinic-AYA and individual-AYA care strategies.

Transitioning youth living with HIV to adult care is a crucial step in the HIV care continuum; however, tools to support transition in sub-Saharan Africa are insufficient. We assessed the effectiveness of an adolescent transition package (ATP) to improve youth readiness for transition to independent HIV care.In this hybrid type 1, multicentre, cluster randomised clinical trial, we assessed the effectiveness of an ATP (administered by routine clinic staff, which included standardised assessments and chapter books to guide discussions at scheduled clinic visits) in four counties in Kenya, with HIV clinics randomly assigned 1:1 to ATP or control (standard-of-care practice). Clinics were eligible to participate if they had at least 50 youth (aged 10-24 years) living with HIV enrolled in care. We used restricted randomisation to achieve cluster balance and an independent biostatistician used computer-generated random numbers to assign clinics. We excluded very large clinics with more than 1000 youth, clinics with fewer than 50 youth, paediatric-only clinics, clinics with logistical challenges, and the smallest clinics in Homa Bay county. Youth were eligible for the transition intervention if they were enrolled in participating clinics, were aged 15-24 years, and were aware of their positive HIV diagnosis. Study staff assessed transition readiness scores overall and by four domains (HIV literacy, self-management, communication, and support) in youth with HIV, which were then compared between groups by use of mixed-effects linear regression models. Analysis was by intention-to-treat and was adjusted for multiple comparisons. This trial is registered with ClinicalTrials.gov, NCT03574129.We identified 35 clinics in four counties; of these, ten were assigned to the intervention group and ten to the control group. Of 1066 youth with HIV enrolled between Nov 1, 2019, and March 18, 2020, 578 (54%) were in intervention and 488 (46%) in control sites. Mean baseline transition readiness score was 12·1 (SD 3·4) in ATP sites and 11·4 (3·7) in control sites. At 1 year, adjusting for baseline scores, age, and months since HIV disclosure, participants in the ATP group had significantly higher overall transition readiness scores (adjusted mean difference 1·7, 95% CI 0·3-3·1, p=0·024), and higher scores in HIV literacy domain (adjusted mean difference 1·0, 0·2-1·7, p=0·011). At 12 months, 15 serious adverse events were recorded, none of which were thought to be related to study participation.Integrating ATP approaches could enhance long-term HIV care in youth with HIV as they age into adulthood.US National Institutes of Health.

Expansion of access to diagnosis and treatment for human immunodeficiency virus (HIV) and a high incidence of HIV infection in adolescence has resulted in a growing population of adolescents and young adults living with HIV. The prevalence of poor retention in care, insufficient viral suppression and loss to follow-up are higher among adolescents and young adults compared with other age groups. Poor outcomes could be attributed to psychosocial changes during adolescence, but also to poor transitional care from paediatric to adult HIV services. In many countries, transition processes remain poorly defined and unstructured, which may jeopardize treatment adherence and retention. We describe existing definitions of transition and transition frameworks, and key elements of transition as proposed by key national stakeholders in Kenya. Our consensus definition of transition is "a planned process by which adolescents and young adults living with HIV, and their caregivers, are empowered with knowledge and skills to enable them to independently manage their health." Transition should begin soon after disclosure of HIV status until an adolescent gains the necessary knowledge and skills and is willing to move to adult services, or by 25 years of age. Proposed key elements of transition are: target ages for milestone achievement; readiness assessment; caregiver involvement and communication with adult clinics; flexibility to return to adolescent or paediatric clinics; group transition; and considerations for adolescents with special needs. Retention in care, linkage to care and viral suppression are important markers of transition success. Proposed definitions and key elements could provide a framework for structuring transition programmes in other countries.L'accès élargi au diagnostic et au traitement du virus de l'immunodéficience humaine (VIH) et l'incidence élevée de l'infection par le VIH à l'adolescence ont entraîné une hausse de la population d'adolescents et de jeunes adultes atteints du VIH. La prévalence de mauvais continuums de soins, de suppressions virales insuffisantes et d'interruptions du suivi est plus élevée chez les adolescents et les jeunes adultes que dans d'autres groupes d'âge. Ces mauvais résultats peuvent être attribués aux changements psychosociaux qui interviennent à l'adolescence, mais aussi à la médiocrité de la transition entre les services de soins pédiatriques et adultes du VIH. En Afrique subsaharienne, les processus de transition sont mal définis et peu structurés, ce qui peut nuire au respect et à la poursuite des traitements. Nous décrivons ici les définitions existantes de la transition et des cadres de transition, ainsi que les éléments clés de la transition proposés par les principales parties prenantes nationales du Kenya. Notre définition consensuelle de la transition est: « processus planifié qui permet aux adolescents et aux jeunes adultes atteints du VIH, ainsi qu'à leurs aidants, de disposer des connaissances et compétences nécessaires pour gérer leur santé de manière autonome ». La transition devrait débuter peu après la communication de la séropositivité et durer jusqu'à ce que l'adolescent ait acquis les connaissances et compétences nécessaires et qu’il souhaite passer à des services pour adultes, ou jusqu’à l'âge de 25 ans. Les éléments clés proposés de la transition sont: âges cibles pour le franchissement de certaines étapes; évaluation de la maturité; implication des aidants et communication avec les services pour adultes; possibilité de revenir à des services pédiatriques ou pour adolescents; transition de groupe; prise en compte des adolescents ayant des besoins spéciaux. Le continuum de soins, le lien entre les soins et la suppression virale sont d'importants marqueurs de la réussite de la transition. Les définitions et éléments clés proposés peuvent offrir un cadre pour structurer les programmes de transition dans d’autres pays.La ampliación del acceso al diagnóstico y tratamiento del virus de la inmunodeficiencia humana (VIH) y la alta incidencia de la infección por el VIH en la adolescencia han dado lugar a una población creciente de adolescentes y adultos jóvenes que viven con el VIH. La prevalencia de una retención inadecuada en la atención, la supresión viral insuficiente y la pérdida de seguimiento son mayores entre los adolescentes y los adultos jóvenes en comparación con otros grupos de edad. Los resultados negativos pueden atribuirse a cambios psicosociales durante la adolescencia, pero también a una atención de transición deficiente de los servicios pediátricos a los servicios para adultos con VIH. En África subsahariana, los procesos de transición siguen siendo mal definidos y desestructurados, lo que puede suponer un riesgo para el cumplimiento y la retención del tratamiento. Describimos las definiciones existentes de transición y los marcos de transición, así como los elementos clave de la transición propuestos por las principales partes interesadas a nivel nacional en Kenia. Nuestra definición consensuada de transición es “un proceso planificado mediante el cual los adolescentes y adultos jóvenes que viven con el VIH, y sus cuidadores, son capacitados con conocimientos y habilidades que les permiten manejar su salud de manera independiente”. La transición debe comenzar poco después de la revelación del estado serológico respecto al VIH hasta que el adolescente adquiera el conocimiento y las habilidades necesarias y esté dispuesto a trasladarse a los servicios para adultos, o a la edad de 25 años. Los elementos clave de la transición propuestos son: edades objetivo para el logro de los hitos; evaluación de la preparación; participación de los cuidadores y comunicación con las clínicas para adultos; flexibilidad para regresar a las clínicas para adolescentes o pediátricas; transición de grupos; y consideraciones para los adolescentes con necesidades especiales. La retención en la atención, la vinculación a la atención y la supresión viral son marcadores importantes del éxito de la transición. Las definiciones propuestas y los elementos clave podrían proporcionar un marco para estructurar los programas de transición en otros países.إن التقدم في التوصل إلى تشخيص، والحصول على علاج لفيروس نقص المناعة البشرية (HIV)، وكذلك ارتفاع نسبة الإصابة بهذا الفيروس في مرحلة المراهقة، إلى تزايد عدد السكان من المراهقين والشباب المصابين بفيروس نقص المناعة البشرية. إن انتشار سوء البقاء في الرعاية ومكافحة الفيروس غير الكافية والافتقار إلى المتابعةـ يظهر بشكل أعلى بين المراهقين وشباب البالغين، مقارنة بالفئات العمرية الأخرى. يمكن أن تعزى النتائج الضعيفة إلى التغيرات النفسية والاجتماعية خلال فترة المراهقة، ولكن أيضًا إلى سوء الرعاية الانتقالية في خدمات فيروس نقص المناعية البشرية من الأطفال إلى البالغين. في جنوب الصحراء الكبرى الأفريقية، تظل العمليات الانتقالية غير واضحة وغير واضحة المعالم، وهو ما قد يعرض الالتزام بالعلاج والاحتفاظ به للخطر. نحن نصف التعريفات القائمة للانتقال وأطر الانتقال، والعناصر الرئيسية للانتقال، وفقاً لما اقترحه أصحاب المصلحة الوطنيون الرئيسيون في كينيا. كان تعريفنا بالإجماع لعملية الانتقال هو "عملية مخطط لها تعمل على دعم المراهقين وشباب البالغين المصابين بفيروس نقص المناعة البشرية ومقدمي الرعاية، بالمعرفة والمهارات اللازمة لتمكينهم من إدارة صحتهم بشكل مستقل". يجب أن يبدأ الانتقال على الفور بعد الكشف عن حالة الإصابة بفيروس نقص المناعة البشرية، حتى يكتسب المراهق المعرفة والمهارات اللازمة، ويرغب في الانتقال إلى خدمات البالغين، أو عند سن 25 عامًا. العناصر الرئيسية المقترحة للانتقال هي: الأعمار المستهدفة لتحقيق الإنجاز؛ وتقييم الجاهزية، ومشاركة مقدمي الرعاية وتواصلهم مع عيادات البالغين؛ والمرونة في العودة إلى عيادات المراهقين أو الأطفال؛ والانتقال الجماعي؛ واعتبارات للمراهقين ذوي الاحتياجات الخاصة. يعد البقاء في الرعاية، والارتباط بالرعاية، ومكافحة الفيروس، هي مكونات مهمة لنجاح عملية الانتقال. يمكن أن توفر التعريفات المقترحة والعناصر الأساسية إطارًا لهيكلة برامج الانتقال في البلدان الأخرى.人类免疫缺陷病毒 (HIV) 诊断与治疗途径的扩大以及青春期 HIV 感染的高发病率导致越来越多的青少年和年轻人被确诊为 HIV 感染者。与其他年龄组相比,青少年和年轻人中普遍存在护理保留率低、病毒抑制不足和失访率较高的现象。结果不良可归因于青春期在社会环境影响下的个人心理变化,也可归因于从儿科过渡到成人 HIV 服务的转诊护理不良。在撒哈拉以南非洲地区,过渡进程仍然定义不明确且结构不合理,这可能会影响治疗依从性和保留率。我们描述了现有的过渡和过渡框架定义,以及肯尼亚主要国家利益相关者所提出的过渡的关键因素。我们达成共识的过渡定义是“感染艾滋病毒的青少年和年轻人及其护理者通过一个有计划的过程获得知识和技能,从而具备保持身体健康的自主能力。”在披露 HIV 状况之后不久就应开始过渡,直到青少年获得必要的知识和技能并愿意转向成人服务,或者年满 25 岁。现已提出的过渡关键因素为:完成主要阶段性成就的目标年龄;准备程度评估;护理者参与以及与成人诊所的沟通;重返青少年或儿科诊所的灵活性;团体过渡;以及针对有特殊需求的青少年的考量因素。护理保留率、护理联动和病毒抑制是过渡成功的重要标志。对于撒哈拉以南非洲地区和其他资源匮乏地区而言,提出的定义和关键因素能够为在其他国家构建过渡计划提供一个框架。.Расширение доступности диагностики и лечения вируса иммунодефицита человека (ВИЧ) и высокая заболеваемость ВИЧ-инфекцией в подростковом возрасте привели к увеличению количества людей молодого возраста и подростков, живущих с ВИЧ. По сравнению с другими возрастными группами у подростков и молодежи чаще встречается несоблюдение назначенного режима лечения, недостаточная супрессия вирусной нагрузки и неявка для последующего наблюдения. Неблагоприятные исходы лечения могут быть связаны с психосоциальными переменами, характерными для подросткового возраста, а также с плохим качеством медицинского обслуживания при переходе от педиатрической схемы лечения ВИЧ к взрослой. В странах Африки, расположенных к югу от Сахары, процесс такого перехода остается плохо определенным и бессистемным, что может угрожать соблюдению назначенного режима лечения и удержанию пациентов. Авторы описывают существующие определения перехода и его рамки, а также ключевые элементы перехода, предложенные основными национальными партнерами в Кении. Общепринятое определение перехода звучит так: «Это спланированный процесс, в ходе которого подростки и молодежь, живущие с ВИЧ, а также лица, обеспечивающие им уход, получают знания и навыки, которые позволяют им заботиться о здоровье без посторонней помощи». Переход должен начинаться вскоре после предоставления информации о ВИЧ-статусе и продолжаться до тех пор, пока подросток не получит необходимые навыки и знания и не выразит желание перейти на взрослую схему лечения, или до достижения пациентом возраста 25 лет. Были предложены следующие ключевые элементы переходного процесса: деление на целевые возрастные группы для достижения определенных промежуточных этапов; оценка готовности; привлечение лица, осуществляющего уход, и общение с представителями клиник для взрослых; гибкая возможность возвращения в клинику для детей или подростков; групповой переход и учет особенностей подростков с особыми потребностями. Обеспечение непрерывности лечения, привязка к уходу и супрессия вирусной нагрузки — вот важные маркеры успешного перехода. Предложенные определения и ключевые элементы могут служить в качестве основных принципов для структурирования программ перехода и в других странах.

Objectives Adolescents and young adults (AYA) have poorer retention, viral suppression, and survival than other age groups. We evaluated correlates of initial AYA engagement in HIV care at facilities participating in a randomized trial in Kenya. Design Retrospective cohort study. Methods Electronic medical records from AYA ages 10-24 attending 24 HIV care facilities in Kenya were abstracted. Facility surveys assessed provider trainings and services. HIV provider surveys assessed AYA training and work experience. Engagement in care was defined as return for first follow-up visit within 3 months among newly enrolled or recently re-engaged (returning after >3 months out of care) AYA. Multilevel regression estimated risk ratios and 95% confidence intervals (CIs), accounting for clustering by facility. Final models adjusted for AYA individual age and median AYA age and number enrolled per facility. Results Among 3662 AYA records at first eligible visit, most were female (75.1%), older (20-24 years: 54.5%), and on antiretroviral therapy (79.5%). Overall, 2639 AYA returned for care (72.1%) after enrollment or re-engagement visit. Engagement in care among AYA was significantly higher at facilities offering provider training in adolescent-friendly care (85.5 vs. 67.7%; adjusted risk ratio (aRR) 1.11, 95% CI: 1.01-1.22) and that used the Kenyan government's AYA care checklist (88.9 vs. 69.2%; aRR 1.14, 95% CI: 1.06-1.23). Engagement was also significantly higher at facilities where providers reported being trained in AYA HIV care (aRR 1.56, 95% CI: 1.13-2.16). Conclusion Adolescent-specific health provider training and tools may improve quality of care and subsequent AYA engagement. Health provider interventions are needed to achieve the '95-95-95' targets for AYA.

Background Repeat HIV viral load (VL) testing is required after unsuppressed VL to confirm treatment failure. We assessed proportion of adolescents and young adults living with HIV (AYALHIV) in Kenya with a confirmatory VL test and time to repeat testing. Design A retrospective analysis of longitudinal data abstracted from Kenya's national VL database. Methods VL data for AYALHIV who were 10-24 year old between April 2017 and May 2019 were abstracted from 117 HIV care clinics. Records were eligible if at least one VL test was performed ≥6 months after antiretroviral therapy (ART) initiation. The proportion of unsuppressed AYALHIV (≥1000 copies/mL) and time in months between first unsuppressed VL and repeat VL was determined. Results We abstracted 40,928 VL records for 23,969 AYALHIV; of whom, 17,092 (71%) were eligible for this analysis. Of these, 12,122 (71%) were women, median age of 19 years [interquartile range (IQR): 13-23], and median ART duration of 38 months (IQR: 16-76). Among eligible AYALHIV, 4010 (23%) had an unsuppressed VL at first eligible measurement. Only 316 (8%) of the unsuppressed AYALHIV had a repeat VL within 3 months and 1176 (29%) within 6 months. Among 2311 virally unsuppressed AYALHIV with a repeat VL, the median time between the first and the repeat VL was 6 months (IQR: 4-8), with 1330 (58%) having confirmed treatment failure. Conclusions One-quarter of AYALHIV on ART had unsuppressed VL, with less than a third receiving a repeat VL within 6 months. Strategies to improve VL testing practices are needed to improve AYALHIV's outcomes.

Tailored services for adolescents and young adults (AYA) living with HIV may improve treatment outcomes. We surveyed HIV clinics throughout Kenya to determine AYA clinic practices, disclosure and transition services.We deployed a mobile team to conduct surveys in a random sample of 102 public HIV clinics with 300 total clients. Data were collected from healthcare workers offering AYA services who had6 months of experience delivering AYA care.Of 102 surveyed HIV clinics, almost all (101/102) had the same staff to provide services to all age groups. AYA-specific services included dedicated clinic days (91%), the majority being on weekends (57%) and designated clinic spaces (20%). Activities to support AYA retention and adherence were common (support groups [97%] and HIV literacy meetings [93%]). Fewer clinics offered more holistic care, including psychosocial support (16%) and career education (2%), posted additional staff during the AYA day (17%), provided food (17%) or had sporting activities (10%) as incentives. Tracking of disclosure of HIV status to AYA was common (87%). In 40% of clinics, disclosure discussions with caregivers or AYA occurred a median of 2 years later in practice than stated in clinic policy. Transition was not routinely tracked, and definitions were heterogeneous. Median age at transition was reported as 20 years (range: 14-30 years).HIV programmes have implemented varied approaches to enhance AYA services that could be leveraged to support transition to adult services. Research on the impact of these services on health outcomes is needed.Des services taillés sur mesure pour les adolescents et les jeunes adultes (AJA) vivant avec le VIH peuvent améliorer les résultats du traitement. Nous avons mené une surveillance des cliniques VIH à travers le Kenya pour déterminer les pratiques, la divulgation et les services de transition dans les cliniques AJA. MÉTHODES: Nous avons déployé une équipe mobile pour mener des enquêtes sur un échantillon aléatoire de 102 cliniques publiques du VIH avec300 patients au total. Les données ont été recueillies auprès d'agents de santé offrant des services AJA qui avaient6 mois d'expérience dans la prestation de soins AJA. RÉSULTATS: Sur 102 cliniques VIH surveillées, presque toutes (101/102) avaient les mêmes personnels pour fournir des services à tous les groupes d'âge. Les services spécifiques AJA comprenaient des journées de clinique dédiées (91%), la majorité étant le week-end (57%) et des espaces de clinique désignés (20%). Les activités visant à soutenir la rétention et l'adhésion à l'AJA étaient courantes (groupes de soutien [97%] et réunions d’éducation sur le VIH [93%]). Peu de cliniques offraient de soins plus holistiques, y compris un soutien psychosocial (16%) et une formation professionnelle (2%), détachaient du personnel supplémentaire pendant la journée AJA (17%), fournissait de la nourriture (17%) ou pratiquaient des activités sportives (10%) comme des incitations. Le suivi de la divulgation du statut VIH aux AJA était courant (87%). Dans 40% des cliniques, les discussions de divulgation avec les soignants ou AJA ont eu lieu en moyenne 2 ans plus tard dans la pratique que ce qui est indiqué dans la politique de la clinique. La transition n'était pas systématiquement suivie et les définitions étaient hétérogènes. L'âge médian au moment de la transition était de 20 ans (intervalle: 14-30 ans).Les programmes de lutte contre le VIH ont mis en œuvre diverses approches pour améliorer les services AJA qui pourraient être exploitées pour soutenir la transition vers les services pour adultes. Des recherches sur l'impact de ces services sur les résultats de santé sont nécessaires.