Study identifies serious gaps in treatment and care of HIV-positive adolescents in sub-Saharan Africa

Healthcare providers in sub-Saharan Africa are struggling to provide services for HIV-positive adolescents, investigators report in the Journal of the International AIDS Society. 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.
• 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 2.1 million 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.

Twenty-seven percent 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.