From pediatric to adolescent HIV: mortality, viral suppression and transition to adult care
Global scale-up of prevention of mother to child transmission (PMTCT) programs and expansion of pediatric HIV testing and treatment have dramatically changed the course of pediatric HIV. Fewer infants are born with HIV, and early treatment significantly improves survival, growth, neurodevelopment and prevents morbidity. However, challenges with early diagnosis and achieving treatment goals during adolescence exist. A majority of HIV infected children present for care while severely ill, and experience high morbidity and mortality despite initiation of treatment. For children surviving to adolescence, maintaining viral suppression remains challenging, and mortality during adolescence is high. As children grow into adulthood, how to support them transition to adult care and gain independence in their own care remain unanswered questions. Methods: The aims of the dissertation address the following questions: Chapter 1) what are the common diagnoses at death and what are the correlates of viral suppression among severely ill, hospitalized, antiretroviral therapy (ART) naÃ¯ve HIV-positive children aged 0-12 years in Kenya? Using data from a randomized controlled trial (RCT) on urgent versus post–stabilization antiretroviral treatment (ART) (PUSH trial), we use survival analysis methods examined sociodemographic and clinical correlates of mortality. Chapter 2) What is the prevalence of viral suppression and what clinic and individual level factors are associated with viral suppression among HIV-positive adolescents and young adults (AYA) age 10-24 years, on ART for more than 6 months and enrolled in HIV care programs in Kenya? We used multilevel logistic regression methods to estimate association of viral suppression with hypothesized individual and clinic level factors. Chapter 3) What are the current adolescent transition practices in Kenya, and how can we define transition and its success in programmatic settings in Kenya. We used descriptive statistics to describe adolescent HIV care practice, disclosure and transition services in Kenya and a user-centered design workshop to develop transition definitions and key elements for programmatic use in Kenya. Results: Chapter 1: Overall 39/181 (22%) of hospitalized HIV-positive children enrolled in the PUSH RCT died. Pneumonia or suspected tuberculosis, and gastroenteritis were the most common diagnoses at the time of death. Young age (<2 years) and being an orphaned or vulnerable child (OVC) were independently associated with mortality. Chapter 2: Among 9921 AYA enrolled in 99 facilities, 2664 (27%) had unsuppressed viral load. Adjusting for clinic and individual factors, young age (10-24 and 15-19), perinatal HIV infection, male sex and increasing duration on ART were associated with poor viral suppression. Adolescents in clinics with separate adolescent spaces, lower-level clinic, and faster viral load turnaround time were more likely to have viral suppression. Chapter 3: The majority of HIV clinics in Kenya had included models of care to meet specific adolescent needs. Adolescent days, most on weekend days were common. Transition definitions were heterogeneous, and tracking systems had limited ability to monitor individual progress or assess outcomes. Conclusions: The findings of this dissertation emphasize on the need to develop strategies to identify HIV infected children early and link them to care, and to optimize hospital management for severely ill children. As children grow into adolescence, strategies to aggressively identify and manage virologic failure are needed particularly for perinatal infected AYA. At program level, consistent transition definitions and defining measures of success are first steps in studying transitional care. Tools to support HIV disclosure services and support adolescents gain skills and knowledge they need to independently manage their care are needed.