The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
J Int AIDS Soc. 2021 Apr;24(4):e25695. doi: 10.1002/jia2.25695.
There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement.
We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care.
Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care.
Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.
目前全球有大约 170 万感染艾滋病毒的青少年（年龄在 10 至 19 岁之间的青少年感染者，即 ALHIV），其中包括肯尼亚的 11 万。虽然 ALHIV 在接受护理方面的保留率较差，但关于导致其脱离护理的因素的数据有限。我们调查了肯尼亚西部脱离护理的 ALHIV 所承受的创伤负担，并研究了其在 HIV 护理脱离方面的潜在作用。
我们于 2018 年至 2020 年，在两个地点对已脱离护理的 ALHIV 及其护理人员以及来自 10 个地点的医疗保健工作者（HCW）进行了深入的定性访谈。脱离护理的定义是在错过预约后 60 天以上未到诊所就诊。通过电话和家访追踪 ALHIV 和他们的护理人员。访谈确定了青少年在 HIV 护理中保留的障碍和促进因素。专门的问题引出了围绕创伤经历的叙述，以及这些经历对护理保留的影响或没有影响的方式。通过主题分析，出现了一个从青少年经历创伤到脱离 HIV 护理的连续模型。
共对 42 名脱离护理的 ALHIV、34 名护理人员和 28 名 HCW 进行了访谈。ALHIV 经历了多种压力源造成的沉重的创伤负担，包括艾滋病毒披露或诊断、父母去世、经历污名化、身体或性暴力等。一系列因素——创伤、污名化和孤立以及缺乏社会支持——导致了绝望和抑郁。这些因素相互作用，导致了复杂的心理健康负担、抗逆转录病毒药物依从性差和护理脱离。HCW 的方法与该模型中的因素一致，这表明这些领域是干预和提供创伤知情护理的目标。
创伤是肯尼亚青少年脱离 HIV 护理的一个主要因素。我们描述了一个从 HIV 护理脱离的因素连续体，代表了支持心理健康和 HIV 护理保留的干预领域。这不仅包括提供精神保健，还包括预防或解决暴力、创伤和污名化，以及加强围绕弱势青少年的社会和家庭支持。在这种概念化中，支持 HIV 护理保留需要采用创伤知情方法，既要为 ALHIV 提供个性化护理，又要制定支持青少年健康结果的战略和政策。
