Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom.
AIDS and Society Research Unit, University of Cape Town, Cape Town, South Africa.
J Acquir Immune Defic Syndr. 2019 Oct 1;82(2):166-174. doi: 10.1097/QAI.0000000000002125.
Research on adolescent transitions out of pediatric HIV care has focused on high-income countries, with limited understanding of transitions in sub-Saharan Africa's public health sector.
Patient file data were extracted through December 2017 for all 10- to 19-year olds ever initiated on antiretroviral therapy in a health district of the Eastern Cape, South Africa (n = 951). Pathways in HIV care were identified by tracing movements across facility care types and levels. Associations between pathways and viral failure, mortality, loss to follow-up, and viral load change were tested in sequential multivariable regressions. Analyses controlled for sociodemographic and treatment-related variables. Thematic analyses of semistructured health care provider interviews identified transition support at included facilities.
Only 57.8% of adolescents had initiated antiretroviral therapy in pediatric care, and 20.4% of the total cohort had transitioned out of pediatric HIV care. Among the 42.2% who had initiated in nonpediatric care, 93.8% remained exclusively in nonpediatric care. Median age at first transition was 14 years. Two main pathways were identified: classical transition to adult HIV care (43.3%) and down referral transition to primary health care clinics (56.7%). Across pathways, 27.3% experienced cyclical transition or repeated movement between pediatric and nonpediatric care. Independent of covariates, adolescents with down referral transition were less likely to demonstrate viral failure (adjusted odds ratio, 0.21; 95% confidence interval: 0.10 to 0.42; P < 0.001). Mortality and loss to follow-up were not associated with either pathway. Median posttransition viral load change was not clinically significant (median, 0.00; interquartile range: 0.00-0.35) or associated with transition pathways. Health care providers described informal "protocols" for mitigating risk of negative posttransition HIV outcomes.
This study proposes a contextually relevant model for transitions out of pediatric HIV care in South Africa. Feasible, scalable "protocols" may mitigate risk of worsening posttransition HIV outcomes.
青少年从儿科艾滋病护理过渡的研究主要集中在高收入国家，对撒哈拉以南非洲公共卫生部门的过渡情况了解有限。
通过追踪设施护理类型和水平的变化，提取了 2017 年 12 月前在南非东开普省一个卫生区接受过抗逆转录病毒治疗的所有 10-19 岁患者的病历数据（n=951）。通过分析艾滋病毒护理途径，确定了青少年过渡到成人艾滋病毒护理的最佳方案。采用序贯多变量回归分析了途径与病毒失败、死亡率、失访和病毒载量变化之间的关系。分析控制了社会人口统计学和治疗相关变量。对半结构化卫生保健提供者访谈的主题分析确定了纳入机构的过渡支持。
只有 57.8%的青少年在儿科护理中开始接受抗逆转录病毒治疗，总队列中有 20.4%的人已经从儿科艾滋病毒护理中过渡出来。在那些在非儿科护理中开始治疗的 42.2%的患者中，93.8%的患者仍然完全在非儿科护理中。首次过渡的中位年龄为 14 岁。确定了两种主要途径：经典过渡到成人艾滋病毒护理（43.3%）和下转过渡到初级保健诊所（56.7%）。无论在何种途径中，27.3%的青少年经历了周期性过渡或在儿科和非儿科护理之间反复移动。在不考虑协变量的情况下，进行下转过渡的青少年出现病毒失败的可能性较低（调整后的优势比为 0.21；95%置信区间：0.10 至 0.42；P<0.001）。死亡率和失访与任何途径都没有关系。中位过渡后病毒载量变化没有临床意义（中位数为 0.00；四分位距：0.00-0.35），也与过渡途径无关。卫生保健提供者描述了减轻过渡后艾滋病毒不良结局风险的非正式“方案”。
本研究提出了一个与南非儿科艾滋病毒护理过渡相关的、有意义的模型。可行的、可扩展的“方案”可以降低过渡后艾滋病毒不良结局的风险。
