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Pediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey.

ABSTRACT: INTRODUCTION:The period of transition from pediatric to adult care has been associated with poor health outcomes among 10-19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria's estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV. MATERIALS AND METHODS:This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up. RESULTS:All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the "clinic type" question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services. CONCLUSIONS:Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.

SUBMITTER: Badejo OA

PROVIDER: S-EPMC5997346 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children's hospitals. Despite multiple efforts to improve pediatric-adult healthcare transitions, little guidance exists for transitioning inpatient care. OBJECTIVE:This study sought to characterize pediatricadult inpatient care transitions across general pediatric services at US children's hospitals. DESIGN, SETTING AND PARTICIPANTS:National survey of inpatient general pediatric service leaders at US children's hospitals from January 2016 to July 2016. MEASUREMENTS:Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations between institutional characteristics, transition activities, and presence of an inpatient transition initiative. RESULTS:Ninety-six of 195 children's hospitals responded (49.2% response rate). Transition initiatives were present at 38% of children's hospitals, more often when there were dual-trained internal medicine-pediatrics providers or outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer. CONCLUSIONS:Relatively few inpatient general pediatric services at US children's hospitals have leaders or dedicated processes to shepherd transitions to adultoriented inpatient care. Across institutions, there is a wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.

Project description:BackgroundLittle data is available on the long-term psychosocial effects of disclosure of HIV status that may occur in late adolescence, even when disclosure is timely. Moreover, few studies have described the post-disclosure psychosocial needs of older adolescents who experience delayed disclosure. This study sought to address existing knowledge gaps in the post-disclosure experiences and psychosocial needs of older adolescents living with HIV (ALWHIV).MethodsWe conducted focus group discussions (FGDs) and in-depth interviews (IDIs) among older perinatally infected adolescents aged 16-19 years We collected socio-demographic data and baseline viral load (copies/ml) results for the preceding six months using interviewer-administered questionnaires and clinical notes abstraction. We analysed data inductively and deductively to identify themes related to the experiences and expectations of adolescents with the disclosure and post-disclosure period.ResultsAdolescents who reported having received timely disclosure expressed that as they grew older, they began to comprehend the lifelong repercussions of an HIV diagnosis and experienced a re-emergence of the negative feelings similar to those experienced during the post-disclosure period. Those who received the knowledge of their HIV status during late adolescence experienced prolonged periods of negative self-perception and anger at not receiving their HIV status earlier. They also expressed a need for more information during the disclosure process on the prevention of onward transmission of the virus, safe conception practices resulting in HIV negative children, and information on how to disclose their HIV status to sexual partners or peers. Anticipated stigma was experienced universally by these older adolescents and was a major barrier towards adherence and coping with an HIV status. Caregivers or siblings with a similar HIV status were a source of social support. Adolescents felt that the support of peers (ALWHIV) helped them to accept their HIV status and to learn how to develop a positive outlook on life.ConclusionProvision of psychosocial care in late adolescence during the transition to adult care is critical in ensuring the resolution of re-emergent negative emotions. Comprehensive information on HIV prevention and sexual reproductive health should be a crucial component of post-disclosure care for older adolescents. HIV Disclosure and adolescent transition guidelines should include these components to optimize psychosocial care for older adolescents.

Project description:OBJECTIVES:The objective of this study was to explore the access to, and perceived utility of, various simulation modalities by in-service healthcare providers in a resource-scarce setting. SETTING:Paediatric training workshops at a national paediatric conference in Nigeria. PARTICIPANTS:All 200 healthcare workers who attended the workshop sessions were eligible to participate. A total of 161 surveys were completed (response rate 81%). PRIMARY AND SECONDARY OUTCOME MEASURES:A paper-based 25-item cross-sectional survey on simulation-based training (SBT) was administered to a convenience sample of healthcare workers from secondary and tertiary healthcare facilities. RESULTS:Respondents were mostly 31-40 years of age (79, 49%) and women (127, 79%). Consultant physicians (26, 16%) and nurses (56, 35%) were in both general (98, 61%) and subspecialty (56, 35%) practice. Most had 5-10 years of experience (62, 37%) in a tertiary care setting (72, 43%). Exposure to SBT varied by profession with physicians more likely to be exposed to manikin-based (29, 30% physicians vs 12, 19% nurses, p<0.001) or online training (7, 7% physician vs 3, 5% nurses, p<0.05). Despite perceived barriers to SBT, respondents thought that SBT should be expanded for continuing education (84, 88% physician vs 39, 63% nurses, p<0.001), teaching (73, 76% physicians vs 16, 26% nurses, p<0.001) and research (65, 68% physicians vs 14, 23% nurses, p<0.001). If facilities were available, nearly all respondents (92, 98% physicians; 52, 96% nurses) would recommend the use of online simulation for their centre. CONCLUSIONS:The access of healthcare workers to SBT is limited in resource-scarce settings. While acknowledging the challenges, respondents identified many areas in which SBT may be useful, including skills acquisition, skills practice and communication training. Healthcare workers were open to the use of online SBT and expressed the need to expand SBT beyond the current scope for health professional training in Nigeria.

Project description:BackgroundAntimicrobial resistance (AMR) is a global problem compromising the effective treatment of infectious diseases. The World Health Organization (WHO) is encouraging and promoting awareness creation among health workers as one of its strategies to reduce the rate of emergence and transmission of AMR. Available data on the prescribing behavior of healthcare workers (HCWs) in Nigeria remains incomplete. This study was designed to provide an up-to-date estimate of the knowledge, attitude and antibiotic prescribing behavior of HCWs in Nigeria.MethodsThis is a cross-sectional study. Self-administered questionnaires were distributed to healthcare workers selected from six states, one each from the 6 geopolitical zones in Nigeria. A multi-stage sampling technique was used to reflect the three tiers of healthcare: primary, secondary and tertiary levels. Quantitative data was summarized using descriptive statistics. All data analysis was done using the Statistical package for social sciences version 26.0.ResultsOf the 420 questionnaires distributed, 358 (85.2%) responded. The mean year of practice of the respondents was 9.32 ± 7.8 years. About a half (50.3%) agreed that their prescribing behavior could promote antimicrobial resistance. 49.2% had a good knowledge of AMR and physicians had significantly better knowledge than other HCWs (X2 = 69.59, P < 0.001). Several participants prescribed antibiotics for common viral infections such as sore throats (75.7%), measles (37.7%), common cold and flu (21.2%). Over 60.3% admitted prescribing antibiotics just to be on the safe side. In general, 70.9% of the respondents frequently or moderately use practice guidelines while 25.7% often apply the delayed antibiotic prescription (DAP) strategy to reduce antimicrobial prescription.ConclusionThis study reveals an overall moderate level of knowledge of AMR and attitude towards minimizing the emergence of antimicrobial resistance though this did not translate significantly to practice. Further efforts must be made in order to improve rational prescription of antimicrobials among HCWs in Nigeria.

Project description:INTRODUCTION:As adolescents and young people living with HIV (AYLH) age, they face a "transition cascade," a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high-income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub-Saharan Africa, paediatric HIV care is mostly provided in decentralized, non-specialist primary care clinics, where "transition" may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when "transition" to autonomy might occur, we evaluated pre- and post-transition outcomes among AYLH. METHODS:We included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for "transition to autonomy," we compared the outcomes: no gap in care (?2 clinic visits) and viral suppression (HIV-RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log-binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post-transition. RESULTS:A total of 5516 AYLH from 16 sites were included at "transition" age 16 (transition-16y), 3864 at 18 (transition-18y), 1463 at 20 (transition-20y) and 440 at 22 years (transition-22y). At transition-18y, in the 12 months pre- and post-transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (-1.0 to 6.5%)). The strongest predictor of being retained post-transition was having no gap in the preceding year, across all transition age thresholds (transition-16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition-18y: aRR 1.76 (1.61 to 1.92); transition-20y: aRR 1.75 (1.53 to 2.01); transition-22y: aRR 1.47; (1.21 to 1.78)). CONCLUSIONS:AYLH with gaps in care need targeted support to prevent non-retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood.

Project description:INTRODUCTION:Adherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic. SETTING:The Jos University Teaching Hospital, United States President's Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria. METHODS:We conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ?95% MPR and the proportion with virologic suppression (viral load ?400 copies/mL) within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed. RESULTS:A total of 476 patients received at least one dose of ART as an adolescent (ages 10-19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ?95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%-64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression. CONCLUSIONS:Our evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ?95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals.

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Pediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey.

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