Healthcare providers in sub-Saharan Africa are struggling to provide services for HIV-positive adolescents, found a multi-country situational analysis.
Facilities in 23 countries, which collectively provide care to over 80,000 adolescents (defined as 10-19 years) participated in the study.
Four major service limitations or challenges were identified by the researchers: mechanisms to support adherence and retention in care; service gaps, especially transitioning from paediatric to adult care; poor integration of sexual and reproductive health services; and insufficient disaggregation of health outcome monitoring data by age.
"This multi-country situational analysis provides key insights into the status of HIV treatment and care services for adolescents in sub-Saharan Africa," comment the authors. "Overall, the analysis highlighted a wide variety of approaches in the region. Additionally, it flags critical areas for research and intervention in adolescent adherence to ART (antiretroviral therapy) and engagement in care from perspectives of frontline health providers."
Latest global estimates suggest 2.1m adolescents are living with HIV, with 83% located in sub-Saharan Africa. Data are limited on the provision and type of adolescent-specific HIV services, especially in sub-Saharan Africa.
Investigators from the Paediatric-Adolescent Treatment Africa (PATA) network therefore surveyed 218 clinics in 23 countries enquiring about their adolescent services and the challenges they experienced providing treatment and care to this population. The survey took place in 2014 – 27% of participating clinics were located in West and Central Africa, 38% in Southern Africa and 35% in East Africa. Half the facilities were in urban areas, 17% in peri-urban areas and 33% in rural districts.
The most commonly reported adolescent treatment and care challenges were adherence to therapy (40%) and non-disclosure (30%). Socio-economic barriers to care were also widespread (25%), including poverty, transport costs and food insecurity.
Just over a third of facilities (35%) reported looking after their adolescent patients separately from their adult and/or paediatric patients. When present, adolescent services typically consisted of specially allocated clinic times (88%), staff dedicated to the care of adolescents (10%) or spaces specifically allocated to adolescents (8%). However, 25% of clinics did not have an official definition of adolescence, and even when definitions did exist the age range for adolescence varied widely, from 8 to 21 years.
As regards monitoring of treatment outcome, only 43% of facilities checked viral load and 80% of facilities did not disaggregate outcomes by age.
The majority of facilities (87%) reported that they offered adherence counselling. This largely focused on the negative outcomes of non-adherence. Two-thirds of clinics reported offering services to improve adherence among adolescents, most-commonly peer support (49%). However, 39% of respondents reported having no guidelines or protocols to manage adolescents with adherence challenges and many clinics also stated they had no mechanism for assessing adherence, or defined cut-offs for determining non-adherence.
Only 61% of facilities reported having services targeted at retaining adolescents in long-term follow-up. Moreover, just 41% said they had guidelines or protocols for managing adolescents who were struggling to remain in care. When services were offered, the most common approaches were peer support (34%) or home visits (31%).
Approximately two-thirds of facilities provided sexual and reproductive health services for adolescents. When offered, services most commonly consisted of family planning and distribution of contraceptives (72%). Only 31% of clinics offered screening and treatment for sexually transmitted infections, with 14% providing cervical cancer screening and 10% prevention of mother-to-child transmission services or antenatal care.
Counselling or support when transitioning to adult services was provided by 63% of facilities, with 51% having protocols or guidelines for the management of this process. A quarter of facilities reported transitioning patients when they reached the age of 18 years, but 14% of clinics said this took place when patients reached the age of 10 years.
Pregnancy led to transition to adult services at 12% of clinics, with only two facilities reporting that patients went back to adolescent care post-pregnancy. Support for pregnant adolescents was limited, with only 46% reporting offering services such as prevention of mother-to-child transmission, antenatal care, case management or support groups for this sub-set of patients.
"New initiatives to address the urgent needs of the growing adolescent population must be put in place to reach global treatment targets," the authors conclude.
Abstract
Introduction: In 2013, an estimated 2.1 million adolescents (age 10–19 years) were living with HIV globally. The extent to which health facilities provide appropriate treatment and care was unknown. To support understanding of service availability in 2014, Paediatric-Adolescent Treatment Africa (PATA), a non-governmental organisation (NGO) supporting a network of health facilities across sub-Saharan Africa, undertook a facility-level situational analysis of adolescent HIV treatment and care services in 23 countries.
Methods: Two hundred and eighteen facilities, responsible for an estimated 80,072 HIV-infected adolescents in care, were surveyed. Sixty per cent of the sample were from PATA’s network, with the remaining gathered via local NGO partners and snowball sampling. Data were analysed using descriptive statistics and coding to describe central tendencies and identify themes.
Results: Respondents represented three subregions: West and Central Africa (n = 59; 27%), East Africa (n = 77, 35%) and southern Africa (n = 82, 38%). Half (50%) of the facilities were in urban areas, 17% peri-urban and 33% rural settings. Insufficient data disaggregation and outcomes monitoring were critical issues. A quarter of facilities did not have a working definition of adolescence. Facilities reported non-adherence as their key challenge in adolescent service provision, but had insufficient protocols for determining and managing poor adherence and loss to follow-up. Adherence counselling focused on implications of non-adherence rather than its drivers. Facilities recommended peer support as an effective adherence and retention intervention, yet not all offered these services. Almost two-thirds reported attending to adolescents with adults and/or children, and half had no transitioning protocols. Of those with transitioning protocols, 21% moved pregnant adolescents into adult services earlier than their peers. There was limited sexual and reproductive health integration, with 63% of facilities offering these services within their HIV programmes and 46% catering to the special needs of HIV-infected pregnant adolescents.
Conclusions: Results indicate that providers are challenged by adolescent adherence and reflect an insufficiently targeted approach for adolescents. Guidance on standard definitions for adherence, retention and counselling approaches is needed. Peer support may create an enabling environment and sensitize personnel. Service delivery gaps should be addressed, with standardized transition and quality counselling. Integrated, comprehensive sexual reproductive health services are needed, with support for pregnant adolescents.
Authors
Daniella Mark, Alice Armstrong, Catarina Andrade, Martina Penazzato, Luann Hatane, Lina Taing, Toby Runciman, Jane Ferguson
[link url="http://www.aidsmap.com/Study-identifies-serious-gaps-in-treatment-and-care-of-HIV-positive-adolescents-in-sub-Saharan-Africa/page/3151096/"]Aidsmap material[/link]
[link url="http://www.jiasociety.org/index.php/jias/article/view/21591"]Journal of the International Aids Society abstract[/link]