Wagner Anjuli D, Augusto Orvalho, Njuguna Irene N, Gaitho Douglas, Mburu Nancy, Oluoch Geoffrey, Carimo Naziat, Mwaura Peter, Cherutich Peter, Oyiengo Laura, Gimbel Sarah, John-Stewart Grace C, Nduati Ruth, Sherr Kenneth
Department of Global Health, University of Washington, Box 359931, Seattle, WA, 98104, USA.
Universidade Aduardo Mondlane, Maputo, Mozambique.
Implement Sci Commun. 2022 May 10;3(1):49. doi: 10.1186/s43058-022-00272-8.
Children and adolescents lag behind adults in achieving UNAIDS 95-95-95 targets for HIV testing, treatment, and viral suppression. The Systems Analysis and Improvement Approach (SAIA) is a multi-component implementation strategy previously shown to improve the HIV care cascade for pregnant women and infants. SAIA merits adaptation and testing to reduce gaps in the pediatric and adolescent HIV cascade.
We adapted the SAIA strategy components to be applicable to the pediatric and adolescent HIV care cascade (SAIA-PEDS) in Nairobi and western Kenya. We tested whether this SAIA-PEDS strategy improved HIV testing, linkage to care, antiretroviral treatment (ART), viral load (VL) testing, and viral load suppression for children and adolescents ages 0-24 years at 5 facilities. We conducted a pre-post analysis with 6 months pre- and 6 months post-implementation strategy (coupled with an interrupted time series sensitivity analysis) using abstracted routine program data to determine changes attributable to SAIA-PEDS.
Baseline levels of HIV testing and care cascade indicators were heterogeneous between facilities. Per facility, the monthly average number of children/adolescents attending outpatient and inpatient services eligible for HIV testing was 842; on average, 253 received HIV testing services, 6 tested positive, 6 were linked to care, and 5 initiated ART. Among those on treatment at the facility, an average of 15 had a VL sample taken and 13 had suppressed VL results returned. Following the SAIA-PEDS training and mentorship, there was no substantial or significant change in the ratio of HIV testing (RR: 0.803 [95% CI: 0.420, 1.532]) and linkage to care (RR: 0.831 [95% CI: 0.546, 1.266]). The ratio of ART initiation increased substantially and trended towards significance (RR: 1.412 [95% CI: 0.999, 1.996]). There were significant and substantial improvements in the ratio of VL tests ordered (RR: 1.939 [95% CI: 1.230, 3.055]) but no substantial or significant change in the ratio of VL results suppressed (RR: 0.851 [95% CI: 0.554, 1.306]).
The piloted SAIA-PEDS implementation strategy was associated with increases in health system performance for indicators later in the HIV care cascade, but not for HIV testing and treatment indicators. This strategy merits further rigorous testing for effectiveness and sustainment.
儿童和青少年在实现联合国艾滋病规划署提出的艾滋病病毒检测、治疗和病毒抑制95-95-95目标方面落后于成年人。系统分析与改进方法（SAIA）是一种多组件实施策略，此前已证明可改善孕妇和婴儿的艾滋病病毒治疗流程。SAIA值得进行调整和测试，以缩小儿童和青少年艾滋病病毒治疗流程中的差距。
我们对SAIA策略组件进行了调整，使其适用于内罗毕和肯尼亚西部的儿童和青少年艾滋病病毒治疗流程（SAIA-PEDS）。我们测试了这种SAIA-PEDS策略是否改善了5家医疗机构中0至24岁儿童和青少年的艾滋病病毒检测、与护理的联系、抗逆转录病毒治疗（ART）、病毒载量（VL）检测以及病毒载量抑制情况。我们使用抽象的常规项目数据进行了实施前6个月和实施后6个月的前后分析（并结合中断时间序列敏感性分析），以确定SAIA-PEDS带来的变化。
各医疗机构之间艾滋病病毒检测和治疗流程指标的基线水平存在差异。每个医疗机构中，每月平均有842名符合艾滋病病毒检测条件的儿童/青少年接受门诊和住院服务；平均有253人接受了艾滋病病毒检测服务，6人检测呈阳性，6人与护理建立了联系，5人开始接受抗逆转录病毒治疗。在该医疗机构接受治疗的患者中，平均有15人采集了病毒载量样本，13人的病毒载量检测结果得到抑制。在接受SAIA-PEDS培训和指导后，艾滋病病毒检测率（相对风险：0.803[95%置信区间：0.420，1.532]）和与护理的联系率（相对风险：0.831[95%置信区间：0.546，1.266]）没有实质性或显著变化。抗逆转录病毒治疗启动率大幅上升且有显著趋势（相对风险：1.412[95%置信区间：0.999，1.996]）。病毒载量检测率有显著且大幅提高（相对风险：1.939[95%置信区间：1.230，3.055]），但病毒载量抑制率没有实质性或显著变化（相对风险：0.851[95%置信区间：0.554，1.306]）。
试点的SAIA-PEDS实施策略与艾滋病病毒治疗流程后期指标的卫生系统绩效提升相关，但与艾滋病病毒检测和治疗指标无关。该策略值得进一步严格测试其有效性和可持续性。
