Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand.
J Int AIDS Soc. 2020 Jan;23(1):e25447. doi: 10.1002/jia2.25447.
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.
We included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for "transition to autonomy," we compared the outcomes: no gap in care (≥2 clinic visits) and viral suppression (HIV-RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log-binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post-transition.
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)).
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.
随着青少年和青年艾滋病毒感染者（AYLH）年龄的增长，他们面临着“过渡级联”，这是一系列与他们在照顾自己的医疗保健方面的转变相关的步骤。在高收入国家，这通常包括从主要为儿科/青少年向成人诊所的转移。在撒哈拉以南非洲，儿科艾滋病毒护理主要在分散的、非专科的基层保健诊所提供，在这些诊所，“过渡”不一定包括护理的转移，而是需要对自己的艾滋病毒护理更加自主。我们使用不同的年龄阈值作为“过渡”到自主可能发生的代理，评估了 AYLH 的过渡前后的结果。
我们纳入了在 IeDEA-SA 地点（2004 年至 2017 年）登记时年龄<16 岁、正在接受抗逆转录病毒治疗（ART）、且无护理转移史的 AYLH。我们使用 16、18、20 和 22 岁作为“过渡到自主”的年龄代理，比较了在每个年龄阈值前后 12 个月内的无护理差距（≥2 次就诊）和病毒抑制（HIV-RNA<400 拷贝/ml）情况。我们使用对数二项式回归分析了与过渡后 12 个月内无护理差距（保留）相关的因素。
共有来自 16 个地点的 5516 名 AYLH 在 16 岁（过渡-16y）、3864 名在 18 岁（过渡-18y）、1463 名在 20 岁（过渡-20y）和 440 名在 22 岁（过渡-22y）时发生了过渡。在 18 岁过渡时，在过渡前后的 12 个月内，83%的 AYLH 与 74%的 AYLH 相比没有护理差距（差异为 9.3（95%置信区间（CI）为 7.8 至 10.9））；而 65%与 62%相比病毒得到抑制（差异为 2.7（-1.0 至 6.5%））。在所有过渡年龄阈值中，过渡后保持保留的最强预测因素是在前一年没有护理差距（过渡-16y：调整后的风险比（aRR）为 1.72（95%CI（1.60 至 1.86））；过渡-18y：aRR 为 1.76（1.61 至 1.92））；过渡-20y：aRR 为 1.75（1.53 至 2.01））；过渡-22y：aRR 为 1.47（1.21 至 1.78））。
有护理差距的 AYLH 需要有针对性的支持，以防止因承担更大的医疗保健责任而失去联系。所有过渡到成年的 AYLH 都需要增加病毒学抑制率的干预措施。
