Healthcare
providers in sub-Saharan Africa are struggling to provide services for
HIV-positive adolescents, investigators report in the Journal of the International AIDS Society. Facilities in 23
countries, which collectively provide care to over 80,000 adolescents (defined
as 10-19 years) participated in the study. Four major service limitations or
challenges were identified by the researchers:

  • Mechanisms to support adherence
    and retention in care.
  • Service gaps, especially
    transitioning from paediatric to adult care.
  • Poor integration of sexual and
    reproductive health services.
  • Insufficient disaggregation of
    health outcome monitoring data by age. 

“This
multi-country situational analysis provides key insights into the status of HIV
treatment and care services for adolescents in sub-Saharan Africa,” comment the
authors. “Overall, the analysis highlighted a wide variety of approaches in the
region. Additionally, it flags critical areas for research and intervention in
adolescent adherence to ART [antiretroviral therapy] and engagement in care from perspectives of
frontline health providers.”

Latest global
estimates suggest 2.1 million adolescents are living with HIV, with 83% located in sub-Saharan Africa.  

Data are limited
on the provision and type of adolescent-specific HIV services, especially in
sub-Saharan Africa. Investigators from the Paediatric-Adolescent Treatment
Africa (PATA) network therefore surveyed 218 clinics in 23 countries enquiring
about their adolescent services and the challenges they experienced providing
treatment and care to this population. The survey took place in 2014.

Twenty-seven
percent of participating clinics were located in West and Central Africa, 38%
in Southern Africa and 35% in East Africa. Half the facilities were in urban
areas, 17% in peri-urban areas and 33% in rural districts.

The most commonly
reported adolescent treatment and care challenges were adherence to therapy
(40%) and non-disclosure (30%). Socio-economic barriers to care were also
widespread (25%), including poverty, transport costs and food insecurity.

Just over a third
of facilities (35%) reported looking after their adolescent patients separately
from their adult and/or paediatric patients. When present, adolescent services
typically consisted of specially allocated clinic times (88%), staff dedicated
to the care of adolescents (10%) or spaces specifically allocated to
adolescents (8%). However, 25% of clinics did not have an official definition
of adolescence, and even when definitions did exist the age range for
adolescence varied widely, from 8 to 21 years.

As regards
monitoring of treatment outcome, only 43% of facilities checked viral load and
80% of facilities did not disaggregate outcomes by age.

The majority of
facilities (87%) reported that they offered adherence counselling. This largely
focused on the negative outcomes of non-adherence. Two-thirds of clinics
reported offering services to improve adherence among adolescents,
most-commonly peer support (49%). However, 39% of respondents reported having
no guidelines or protocols to manage adolescents with adherence challenges and
many clinics also stated they had no mechanism for assessing adherence, or
defined cut-offs for determining non-adherence.

Only 61% of
facilities reported having services targeted at retaining adolescents in
long-term follow-up. Moreover, just 41% said they had guidelines or protocols
for managing adolescents who were struggling to remain in care. When services
were offered, the most common approaches were peer support (34%) or home visits
(31%).

Approximately
two-thirds of facilities provided sexual and reproductive health services for
adolescents. When offered, services most commonly consisted of family planning
and distribution of contraceptives (72%). Only 31% of clinics offered screening
and treatment for sexually transmitted infections, with 14% providing cervical
cancer screening and 10% prevention of mother-to-child transmission services or
antenatal care.

Counselling or
support when transitioning to adult services was provided by 63% of facilities,
with 51% having protocols or guidelines for the management of this process. A
quarter of facilities reported transitioning patients when they reached the age
of 18 years, but 14% of clinics said this took place when patients reached the
age of 10 years.

Pregnancy led to
transition to adult services at 12% of clinics, with only two facilities
reporting that patients went back to adolescent care post-pregnancy. Support
for pregnant adolescents was limited, with only 46% reporting offering services
such as prevention of mother-to-child transmission, antenatal care, case
management or support groups for this sub-set of patients.

“New initiatives
to address the urgent needs of the growing adolescent population must be put in
place to reach global treatment targets,” the authors conclude.