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Transition Program of HIV-infected adolescents to Adult HIV care in

Buenos Aires, Argentina

S. Arazi Caillaud1, D. Mecikovsky1, A.Bordato1, J.Lattner2, L.Spadaccini2, C.Rodríguez3, R. Posada4, P.Cahn2, R. Bologna1

1Hospital de Pediatría Dr J. P. Garrahan, Buenos Aires, Argentina2Hospital Fernández, Buenos Aires, Argentina3 Hospital Cosme Argerich, Buenos Aires, Argentina4 Mount Sinai School of Medicine, New York, USA

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Background With advances in ARV therapy most HIV-infected

children survive into adulthood Optimal health care includes a formal plan for the

transition of care from primary pediatric care to adult health-care providers

Transitioning difficulties include changes of puberty, factors related to HIV infection (disclosure, stigma, parental loss, poor treatment adherence, poverty, sexual life), family resistance, and limited training of health professionals

Scal P,. J Adolesc Health. 1999;24:259-264

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Background

Facilitators: • Transition planning • Introduction of concept of transition to patient

and family • Education and empowerment: Independence, autonomy, and decision

making Health education: disease understanding Ways to obtain solutions from health

professionals Rationale of antiretroviral treatment Psychosocial support Committee on Pediatric AIDS Pediatrics 2013; 132: 192-197

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ARGENTINA

Buenos Aires

Hospital de Pediatría Garrahan 507 HIV-infected children in

follow-up Median age: 12 years (0.3-21)

Transition Program in Buenos Aires, Argentina

Argentina has a prevalence of 130,000 HIV cases, with 100 (70-120) children newly infected per year

Free access to HIV treatment (ART + care)

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Transition Program • Pilot project: 2007 (cross- sectional review)• Transition program: 2008-2013

Phase 1: • Team activities (local team, identification of

potential adult-care centers, development of guidelines, communication plan, registry)

• Patient and family activities (Transition Clinic, workshops, peer support groups): risk reduction, empowerment, autonomy, how to “navigate” the new hospital )

Phase 2: Actual transition to adult care Phase 3: Monitoring and Evaluation

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Pilot Study: Baseline characteristics (N:85)

Median age, years (IQR) 18.2 (16.5-19.6)

Sex N (%) females 37 (43.5)

males 48 (56.5)

Median age at diagnosis years (IQR)

3.8 (0.9-8.7)

Duration of treatment, years (IQR) 14 (8.8-15.6)

HIV transmission category N (%)

Perinatal 72 (84.7)

Transfusion

7 (8.3)

Others 6 (7.0)

CDC Category C events N (%) 54 (63.5)

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Transition Program • Pilot project: 2007 (cross- sectional review)• Transition program: 2008-2013

Phase 1: • Team activities (local team, identification of

potential adult-care centers, development of guidelines, communication plan, registry)

• Patient and family activities (Transition Clinic, workshops, peer support groups): to provide support and risk reduction counseling, help them to “navigate” the new hospital

Phase 2: Actual transition to adult care Phase 3: Monitoring and Evaluation

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Workshops – Peer support groups

• Multimedia sessions: • Interactive activities • Videos

• Different means of communication (SMS, dropbox, telephone calls)

• Transition clinic with more flexible appointments • Medical and social history was communicated to

accepting provider by a physician • Guide to “navigate” the new hospital has been

designed

Welcome to the Infectious Diseases Unit

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• Prospective, observational study• Setting: Hospital de Pediatría Dr J.P.Garrahan Adult centers(receptors): Hospital Fernández

Hospital Argerich • Population: adolescents HIV infected as children > 16

years enrolled at the pediatric hospital, and transferred to adult health-care centers between 06/2007 and 12/2013

• Aim of the study: to evaluate the transition program Transition was considered successful when at least 2

clinic visits and 1 viral load testing took place at an adult-care center within 6 months after referral

Demographic, clinical, virological, and social characteristics of adolescents at the time of transition were evaluated

To evaluate the contingency tables Fisher or Chi square Tests were used.

Materials and methods

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Characteristics of 230 HIV infected adolescents Age, median yrs (range) 18 (16-22)Sex N (%) female 117 (51)  male 113 (49)Transmission category N (%) perinatal 222 (96)  transfusion 5 (3)

Others 3 (1) Clinical stage N (%) A 29 (12.6)

B 54 (23.5)C 133 (57.8)

Immunological Stage N (%) 1 33 (14.3)2 57 (23.9)3 126 (65.9)

Post-transition follow-up, median mos (range) 38 (3 - 67)Laboratory tests done post-transition (median, IQR) 3 (1 – 4)Last Viral Load < 50 copies/ml  N, % 145 (62.9)Last CD4 count/ml Median (IQR)  550 (372-788)

Results

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Results

Transition of the patients

8

28

22

77

94

Successful transition

Non successful transition

Not evaluable Transition

To be transfered in the next 3months

Still in The Transition Program tobe prepared

Transitioned N=130

72.3%

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ResultsVariables associated with transition outcome

Variable RR CI 95% p

Sex 0.47 0.40 – 1.50 0.44

Age 0.42

Loss of one or both parents

1.09 0.33 – 2.43 0.83

Caring for his/her own health

0.34 0.19 – 0.63 <0.001

Substance use 2 1.03- 3.89 0.05

Not attending formal education

1.07 0.97 – 3.59 0.06

Missed clinical appointmentsat pediatric hospital

9.11 4.0 – 20.5 <0.00001

Transition delay 0.58 0.26 – 1.32 0.17

Adult-care Hospital 0.70

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Conclusions

1. A program with clear goals and specific strategies to support and prepare adolescents for the transition process has been associated with high rates of successful transitioning of HIV infected adolescents

2. The rate of successful transitioning was 72.3% and most of the patients were virologically suppressed (63%) with a median CD4 count >500 céls/mm3

3. Adequately caring for his/her own health has been associated with successful transition

4. Lack of adherence to clinic appointments has been associated with transition failure

5. Substance use and not attending formal education could be risk factors for transition

6. Special focus on autonomy, prior adherence, and psychosocial support need to be ensured

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Pediatric Team (ID, Mental health, ginecologist, social worker )

Adult Health care Team (ID, Mental health, social worker )

Acknowledgements

We would like to thank the patients who participated in this program and their families, all health care personnel and volunteers Fogarty AITRP #5D43 TW001037

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Results

Variable N %Parents alive 81 35.2

Loss of one parent 59 25.7

Loss of both parents 90 39.1

Attendance to school Yes 147 64.3

No 83 35.7

Smoking (N: 187) No 147 78.6

Yes 40 21.4

Alcohol use (N: 187) No 68 36.6

Ocassional (1/week) 101 54.4

Frequent (>1/week) 18 9

Substance use (N:187) No 153 83.2

Yes 34 16.8

Habits and social characteristics of patients in transition