Transition Pathways Out of Pediatric Care and Associated HIV Outcomes for Adolescents Living With HIV in South Africa
Transition Pathways Out of Pediatric Care and Associated HIV Outcomes for Adolescents Living With HIV in South Africa
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DOI：
10.1097/qai.0000000000002125
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发表时间：
2019-10-01
影响因子：
3.6
通讯作者：
Bains, Anurita
中科院分区：
文献类型：
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作者：
Haghighat, Roxanna;Toska, Elona;Bains, Anurita
背景资料：对青少年从儿科艾滋病护理过渡的研究集中在高收入国家，对撒哈拉以南非洲公共卫生部门的过渡了解有限。方法：患者档案数据提取至2017年12月，所有10至19岁的青少年在南非东开普省的一个卫生区接受抗逆转录病毒治疗（n = 951）。艾滋病毒护理的途径是通过跟踪设施护理类型和级别的移动来确定的。在序贯多变量回归中检验了途径与病毒失败、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。主题分析的半结构化的医疗保健提供者的访谈确定过渡支持包括facility.Results：只有57.8%的青少年已开始抗逆转录病毒治疗的儿科护理，和20.4%的总队列已过渡出儿科艾滋病护理。在42.2%开始接受非儿科护理的患者中，93.8%的患者仅接受非儿科护理。第一次转变的中位年龄为14岁。确定了两个主要途径：向成人艾滋病毒护理的传统过渡（43.3%）和向初级卫生保健诊所的转诊过渡（56.7%）。在不同的路径中，27.3%的人经历了儿科和非儿科护理之间的周期性过渡或重复移动。独立于协变量，转介下降的青少年不太可能表现出病毒失败（调整后的比值比，0.21; 95%置信区间：0.10至0.42; P <0.001）。死亡率和失访与两种途径均无关。中位转换后病毒载量变化无临床意义（中位数，0.00;四分位数间距：0.00 - 0.35）或与转换途径相关。卫生保健提供者描述了非正式的“协议”，以减轻风险的负posttransition HIV outcomes.Conclusions：本研究提出了一个上下文相关的模式，在南非的儿科艾滋病护理的过渡。可行的、可扩展的"方案"可能会减轻过渡后艾滋病毒结果恶化的风险。
Background: 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.Methods: 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.Results: 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.Conclusions: 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.