Challenges and Facilitators of Transition from Adolescent to Adult HIV Care among Youth Living with HIV in Moshi, Tanzania
Background: AIDS is the leading killer of adolescents in Africa, the continent most impacted by the AIDS pandemic. The East African nation of Tanzania is one of the top five countries with the highest burden of HIV in the world. Despite these challenges, scale up of anti-retroviral therapy (ART) has enabled millions of children infected with HIV to survive into adolescence and adulthood. These children attend family-centered and adolescent clinics where they not only receive HIV care, but also form close knit bonds with their healthcare providers and peers. As patients age into adulthood, they require to transition to the adult HIV clinic. Failure to transition results in an adolescent treatment bulge and strain on capacity in the family centered and adolescent clinics. This adolescent to adult transition period is a point of frequent loss to follow-up in the HIV care continuum, which may be partially due to fear and anxiety about the change. As clinics seek guidance on how best to manage the transition, few established protocols exist, and those available were primarily written for well-resourced settings. This study examined challenges and facilitators of the transition of care among youth living with HIV in Moshi, Tanzania.
Methods: Purposive sampling methods were used to recruit youth living with HIV who attended an adolescent specific clinic, Teen Club, and the adult HIV clinic at Kilimanjaro Christian Medical Centre. Two native Swahili speaking research assistants trained in qualitative research conducted in-depth interviews. Medical records were reviewed retrospectively to collect data on factors associated with HIV outcomes. Preliminary results were presented to key stakeholders. Youth and key stakeholders separately suggested solutions to identified challenges associated with transition of care. Results: 19 youth participated in the study. A slight majority were female (53%) and on first-line ART. Participants’ age of HIV diagnosis ranged from 5 to 18 years with a mean ART duration of 9.8 years. Barriers and facilitators of transition were categorized into four domains based on the Health Care Transition Research Consortium (HCTRC) framework. Individual domain: Barriers included long ART duration and financial constrains due to low socio-economic status. Facilitators to care were a positive perspective on living with HIV, high sense of maturity and responsibility, and good health maintenance. Family/Social Support Domain: Barriers were stigma and lack of social events in the adult clinic. Facilitators were family and peer support. Health care system domain: Barriers were lack of preparation for transition and concern about the quality of care in the adult clinic which entailed payment for services, few physicians, long waiting times and poor patient-provider communication. Environment domain: Barriers were lack of national guidelines for transition and inadequate investment in adolescent health and education by the government.
Conclusion: Transition is a complex, dynamic process influenced by many factors. With projections indicating that the number of youth living with HIV in Tanzania is likely to increase in the coming years, it is vital to develop a transition protocol that addresses the challenges identified and is feasible to implement in low resource settings. A strong protocol may influence the use of health system resources, facilitate continuity of care, and improve long term disease outcomes.
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