Date Published: July 17, 2017
Publisher: BioMed Central
Author(s): Siyan Yi, Chanrith Ngin, Khuondyla Pal, Vohith Khol, Sovannary Tuot, Sokunmealiny Sau, Pheak Chhoun, Gitau Mburu, Sok Chamreun Choub, Kolab Chhim, Penhsun Ly.
Preparing adolescents for transition into adult care and supporting their acquisition of self-health care management skills is a critical determinant of their post-transition HIV care outcomes. However, there is a scarcity of research on effective transition strategies. This study explores factors associated with adolescent preparedness for transition into adult care in Cambodia.
In August 2016, a cross-sectional study was conducted among 223 adolescents living with HIV aged 15–17, randomly selected from 11 antiretroviral therapy clinics, utilizing a structured questionnaire. The level of preparedness was determined using a pre-existing scale, and adolescents were categorized as having a high- or low level of preparedness for transition. Bivariate and multivariate analyses were conducted.
Of 223 adolescents, 55.2% were male, and their mean age was 15.8 years. Overall, 53.3% had a high level of preparedness for transition. As part of the transition protocol, 2.7% had completed a transfer form, 24.7% had a transition case manager, 29.6% had been counselled about the transition, and 19.7% had visited an adult ART clinic. In multivariate analysis, a higher level of preparedness for transition was independently associated with older age (AOR 2.44, 95% CI 1.34–4.46; p = 0.004), family having received social support for their health (AOR 5.32, 95% CI 1.97–14.36; p = 0.001), knowing the kind of treatment they received (ART) (AOR 12.67, 95% CI 2.91–15.19; p = 0.001), trust in friends or family for HIV treatment (AOR 7.82, 95% CI 1.13–8.89; p = 0.008), receiving counseling on transition (AOR 3.17, 95% CI 1.15–8.76; p = 0.03), having a ‘Case Manager’ identified to support them during the preparation process for transition (AOR 3.89, 95% CI 1.08–13.96; p = 0.04), and satisfaction with preparation process for transition in general (AOR 0.35, 95% CI 0.03–0.87; p = 0.01).
A range of individual, social and health system and services factors may determine successful transition preparedness among adolescents in Cambodia. Strengthening implementation of age-appropriate and individualized case management transition at all sites, while creating supportive family, peer, and healthcare environments for adolescent transition is required.
Globally, adolescents and young people represent a growing share of people living with human immunodeficiency virus (HIV). Latest available data suggests that adolescents account for 12% of new HIV infections globally . Approximately 670,000 young people between the ages of 15–24 were newly infected with HIV in 2015 alone, of whom 250,000 were adolescents between the ages of 15 and 19 . About 1.8 million adolescents between the ages of 10 and 19 were living with HIV worldwide in 2015 , and this number is projected to increase further due to rising access to antiretroviral therapy (ART) and ongoing new horizontal infections [2, 3]. The Pacific and South East Asia regions have the highest number of adolescents living with HIV outside of Sub-Saharan Africa, accounting for 11% of the global population of adolescents living with HIV . As in other contexts [3, 5], majority of these adolescents have been vertically infected .
Preparing adolescents for transition into adult care and supporting their acquisition of self-health care management skills is an essential part of transition protocols [44, 45], which affects outcomes after transition [31, 34, 45, 46]. This is the first study exploring factors associated with preparedness for transition from pediatric to adult care among adolescents living with HIV in Cambodia. A number of findings that merit program and policy attention.
Data reported in this study were collected from a diverse sample of major ART clinics in 13 city and provinces with different socio-demographic and geographical characteristics. However, generalizability of these results may be limited by biases resulting from the use of self-reported measures, recall of events that had taken several months or years before the study. The study focused exclusively on large ART clinics, adolescents who could communicate in Khmer and adolescents who were with a parent or guardian available for consent and ability to transport themselves to the clinic. These criteria may limit the generalizability of the study findings to only adolescents who are more affluent, educated and living in urban areas where there tend to be more resources available. One may speculate that this population is more prepared for the transition into adult care. It is possible that factors influencing preparedness for transition could change over time; however, this cross-sectional study captured a snapshot of these factors. In addition, qualitative data will be useful in contextualizing findings reported in this paper.
This study reports individual, social, and health system and services factors that contribute to successful transition preparedness in the context of a clear and structured transition protocol for adolescents living with HIV in Cambodia, a substantial proportion of whom were prepared for the transition to adult services. Nevertheless, gaps were identified, which will require to be addressed to ensure that age-appropriate and individualized case management for transition is enhanced and uniformly implemented across different sites. Transition process and interventions will also need to concurrently address contextual issues facing adolescents living with HIV, by focusing on disclosure, sexuality, stigma, social protection, and social support, as well as HIV education and ART literacy, while at the same time creating supportive family, peer, and healthcare environments for adolescent transition. To achieve these goals, adolescents, parents, and health providers should be involved.