People shifting from paediatric to adult HIV care have a high risk of ART failure

HIV-positive adolescents and young adults are especially likely to experience the virological failure of their antiretroviral treatment when they move from paediatric to adult HIV care, according to Dutch research published in the online edition of Clinical Infectious Diseases. The risk of virological failure was increased over four-fold at the time of care transition, 18 to 19 years of age. Risk factors associated with viral breakthrough were low educational attainment, poor knowledge of HIV and lack of independence regarding HIV treatment adherence.

“At the age of 18 years, an individual is still developing independence and self-consciousness, which increases the risk of suboptimal care,” comment the investigators.

Improvements in treatment and care mean that an increasing number of children living with HIV are surviving into adulthood. In the Netherlands and similar countries, adolescents living with HIV transition to adult HIV care at around the age of 18 years.

There are few data about outcomes among adolescents moving from paediatric to adult HIV care. Investigators in the Netherlands therefore designed a study monitoring rates of virologic failure and loss to follow-up among 59 people who entered HIV care as children and who subsequently transitioned to adult care. Data were also collected on the factors associated with adverse outcomes after transition.

All 59 participants received paediatric care at one of the four centres in the Netherlands specialising in the treatment of HIV-positive children. Around half (48%) were from sub-Saharan Africa. The median age at HIV diagnosis was 8 years and antiretroviral therapy (ART) was started at a median age of 10 years.

Many of the children were living in difficult circumstances. At baseline (age 12 to 13 years), half the children lived with one or both biological parents and a third with adoptive or foster parents. Child protection services were involved in the care of 36% of children.

Transition to adult care occurred at a median age of 18.8 years.

At the time of transition, 93% were assessed as having an adequate knowledge of HIV infection and its treatment and three-quarters were able to independently adhere to their ART.

After transitioning to adult care, eight individuals (14%) were lost to follow-up. The mean time after transition to dropping out of care was 1.5 years.

Virologic failure occurred most frequently in individuals aged 18 to 19 years and concentrated around the time of transition to adult care (OR, 4.26, 95% CI, 1.12-16.28, p = 0.03).

Individuals who were not able to independently adhere to their ART were especially likely to experience virologic failure (OR, 6.89; 95% CI, 2.57-18.5, p < 0.001), as were individuals with a poor knowledge of HIV (OR, 5.15; 95% CI, 2.16-12.3, p < 0.001), though only two individuals fell into this category. Low educational attainment was also identified as a risk failure for sustained viral breakthrough.

Half of participants experienced virologic failure as children, and a third of these individuals experienced a sustained rebound in viral load after transition. Only two individuals who did not experience treatment failure as children subsequently has virological breakthrough as adults.

As regards loss to follow-up after transition, individuals who had child protection services involved in their paediatric care were especially likely to drop out of care as adults (p = 0.02), as were those who lacked autonomy with their HIV therapy (p = 0.02).

“Supporting adolescents in the process of becoming autonomous regarding medication adherence should begin during pediatric care and requires continuous attention,” conclude the authors. “As education and employment are associated with better treatment adherence and success, addressing these topics during transition and providing additional support where necessary and possible, may further improve virological outcomes in this population.”