Objectives: To determine clinic-level and individual-level correlates of viral suppression among HIV-positive adolescents and young adult (AYA) aged 10–24 years receiving antiretroviral treatment (ART). Design: Multilevel cross-sectional analysis using viral load data and facility surveys from HIV treatment programs throughout Kenya. Methods: We abstracted medical records of AYA in HIV care, analyzed the subset on ART for more than 6 months between January 2016 and December 2017, and collected information on services at each clinic. Multilevel logistic regression models were used to determine correlates of viral suppression at most recent assessment. Results: In 99 HIV clinics, among 10 096 AYA on ART more than 6 months, 2683 (27%) had unsuppressed viral load at last test. Among 16% of clinics, more than 80% of AYA were virally suppressed. Clinic-level correlates of individual viral suppression included designated adolescent spaces [aOR: 1.32, 95% CI (1.07–1.63)] and faster viral load turnaround time [aOR: 1.06 (95% CI 1.03–1.09)]. Adjusting for clinic-level factors, AYA aged 10–14 and 15–19 years had lower odds of viral suppression compared with AYA aged 20–24 years [aOR: 0.61 (0.54–0.69) and 0.59 (0.52–0.67], respectively. Compared with female patients, male patients had lower odds of viral suppression [aOR: 0.69 (0.62–0.77)]. Compared with ART duration of 6–12 months, ART for 2–5, above 5–10 or more than 10 years was associated with poor viral suppression (P < 0.001). Conclusion: Dedicated adolescent space, rapid viral load turnaround time, and tailored approaches for male individuals and perinatally infected AYA may improve viral suppression. Routine summarization of viral load suppression in clinics could provide benchmarking to motivate innovations in clinic-AYA and individual-AYA care strategies.

Expansion of access to diagnosis and treatment for human immunodeficiency virus (HIV) and a high incidence of HIV infection in adolescence has resulted in a growing population of adolescents and young adults living with HIV. The prevalence of poor retention in care, insufficient viral suppression and loss to follow-up are higher among adolescents and young adults compared with other age groups. Poor outcomes could be attributed to psychosocial changes during adolescence, but also to poor transitional care from paediatric to adult HIV services. In many countries, transition processes remain poorly defined and unstructured, which may jeopardize treatment adherence and retention. We describe existing definitions of transition and transition frameworks, and key elements of transition as proposed by key national stakeholders in Kenya. Our consensus definition of transition is “a planned process by which adolescents and young adults living with HIV, and their caregivers, are empowered with knowledge and skills to enable them to independently manage their health.” Transition should begin soon after disclosure of HIV status until an adolescent gains the necessary knowledge and skills and is willing to move to adult services, or by 25 years of age. Proposed key elements of transition are: target ages for milestone achievement; readiness assessment; caregiver involvement and communication with adult clinics; flexibility to return to adolescent or paediatric clinics; group transition; and considerations for adolescents with special needs. Retention in care, linkage to care and viral suppression are important markers of transition success. Proposed definitions and key elements could provide a framework for structuring transition programmes in other countries.

ObjectiveTailored services for adolescents and young adults (AYA) living with HIV may improve treatment outcomes. We surveyed HIV clinics throughout Kenya to determine AYA clinic practices, disclosure and transition services.MethodsWe deployed a mobile team to conduct surveys in a random sample of 102 public HIV clinics with> 300 total clients. Data were collected from healthcare workers offering AYA services who had >6 months of experience delivering AYA care.ResultsOf 102 surveyed HIV clinics, almost all (101/102) had the same staff to provide services to all age groups. AYA‐specific services included dedicated clinic days (91%), the majority being on weekends (57%) and designated clinic spaces (20%). Activities to support AYA retention and adherence were common (support groups [97%] and HIV literacy meetings [93%]). Fewer clinics offered more holistic care, including psychosocial support (16%) and career education (2%), posted additional staff during the AYA day (17%), provided food (17%) or had sporting activities (10%) as incentives. Tracking of disclosure of HIV status to AYA was common (87%). In 40% of clinics, disclosure discussions with caregivers or AYA occurred a median of 2 years later in practice than stated in clinic policy. Transition was not routinely tracked, and definitions were heterogeneous. Median age at transition was reported as 20 years (range: 14–30 years).ConclusionHIV programmes have implemented varied approaches to enhance AYA services that could be leveraged to support transition to adult services. Research on the impact of these services on health outcomes is needed.

IntroductionSuccessfully transitioning adolescents to adult HIV care is critical for optimising outcomes. Disclosure of HIV status, a prerequisite to transition, remains suboptimal in sub-Saharan Africa. Few interventions have addressed both disclosure and transition. An adolescent transition package (ATP) that combines disclosure and transition tools could support transition and improve outcomes.Methods and analysisIn this hybrid type 1 effectiveness-implementation cluster randomised controlled trial, 10 HIV clinics with an estimated ≥100 adolescents and young adults age 10–24 living with HIV (ALWHIV) in Kenya will be randomised to implement the ATP and compared with 10 clinics receiving standard of care. The ATP includes provider tools to assist disclosure and transition. Healthcare providers at intervention clinics will receive training on ATP use and support to adapt it through continuous quality improvement cycles over the initial 6 months of the study, with continued implementation for 1 year. The primary outcome is transition readiness among ALWHIV ages 15–24 years, assessed 6 monthly using a 22-item readiness score. Secondary outcomes including retention and viral suppression among ALWHIV at the end of the intervention period (month 18), implementation outcomes (acceptability, feasibility, fidelity, coverage and penetration) and programme costs complement effectiveness outcomes. The primary analysis will be intent to treat, using mixed-effects linear regression models to compare transition readiness scores (overall and by domain (HIV literacy, self-management, communication, support)) over time in control and intervention sites with adjustment for multiple testing, accounting for clustering by clinic and repeated assessments. We will estimate the coefficients and 95% CIs with a two- sided α=0.05.Ethics and disseminationThe study was approved by the University of Washington Institutional Review Board and the Kenyatta National Hospital Ethics and Research Committee. Study results will be shared with participating facilities, county and national policy-makers.Trials registration numberNCT03574129.

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