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Patients shifting from paediatric to adult HIV care have a high risk of ART failure
Michael Carter, 2016-08-09 07:40:00
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,
18-19 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.
treatment and care mean that an increasing number of HIV-positive children are
surviving into adulthood. In the Netherlands and similar countries,
HIV-positive adolescents transition to adult HIV care at around the age of 18
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 patients 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.
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
ART was started at a median age of 10 years.
Many of the
children were living in difficult circumstances. At baseline (age 12-13 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.
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
transitioning to adult care, eight patients (14%) were lost to follow-up. The
mean time after transition to dropping out of care was 1.5 years.
occurred most frequently in patients aged 18-19 years and concentrated around
the time of transition to adult care (OR, 4.26, 95% CI, 1.12-16.28, p = 0.03).
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
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
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.”