Transition to independent care for youth living with HIV: a cluster randomised clinical trial

Njuguna, Irene; Beima‐Sofie, Kristin; Mburu, Caren; Mugo, Cyrus; Itindi, Janet; Onyango, Alvin; Richardson, Barbra A.; Oyiengo, Laura; Wamalwa, Dalton; John‐Stewart, Grace

doi:10.1016/s2352-3018(22)00244-2

Cited by 9 publications

(9 citation statements)

References 24 publications

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“…While YLH and caregivers acknowledged the benefit of boarding school, some were hesitant to attend boarding school for fear of stigma. Boarding schools are common in SSA; in Kenya, over 60% of secondary schools have boarding facilities [18]. As HIV transitions from a life‐threatening condition to a chronic illness, it is critical to ensure optimisation of educational opportunities for YLH, to enable them to reach their full potential.…”

Section: Discussionmentioning

confidence: 99%

“…Perceived or manifested stigma may result in school drop‐out, minimising academic potential and further perpetuating social disparities among YLH [11, 12, 14]. A guide to support YLH in Kenyan schools was published in 2019 but has not been widely implemented [17, 18]. To optimise both health and social outcomes for YLH, there is a critical need to address stigma in the school environment.…”

Section: Introductionmentioning

confidence: 99%

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‘They should show them love even if their status of beingHIVpositive is known’: Youth and caregiver stigma experience and strategies to endHIVstigma in schools

Njuguna,

Moraa,

Mugo

et al. 2023

Tropical Med Int Health

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Objective HIV stigma and discrimination is widespread in sub‐Saharan Africa and is associated with poor clinical outcomes. Schools play a critical role in the life of youth and have been identified as a potentially stigmatising environment. We sought to explore school HIV stigma drivers, facilitators, manifestations and outcomes among youth living with HIV (YLH) as well as potential stigma reduction interventions in Kenya. Methods Semi‐structured in‐depth qualitative interviews with 28 school‐attending YLH aged 14–19 years and 24 caregivers of YLH were analysed using directed content analysis. Results were summarised using the Health and Stigma Framework. Results Drivers and facilitators of HIV stigma in the school environment included misconceptions about HIV transmission, HIV treatment outcomes and long‐term overall health of people living with HIV. HIV stigma manifested largely as gossip, isolation and loss of friendships. Fear of HIV stigma or experienced stigma resulted in poor adherence to antiretroviral treatment—particularly among YLH in boarding schools—and poor mental health. Stigma also impacted school choice (boarding vs. day school) and prevented HIV disclosure to schools which was necessary for optimal support for care. Proposed interventions to address HIV stigma in schools included HIV education, psychosocial support for YLH, support for HIV disclosure to schools while ensuring confidentiality and building YLH resilience. Conclusion There is an urgent need to develop interventions to address HIV stigma in schools to ensure optimised health and social outcomes for YLH. Future studies to understand the most effective and efficient interventions are needed.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

‘They should show them love even if their status of beingHIVpositive is known’: Youth and caregiver stigma experience and strategies to endHIVstigma in schools

Njuguna,

Moraa,

Mugo

et al. 2023

Tropical Med Int Health

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“…The trial tested the effectiveness of the ATP and found that those receiving the intervention had signi cantly higher overall transition readiness scores and higher scores in HIV literacy domain compared to those in the control arm. 37 When COVID-19 social distancing and movement restrictions were put in place, the study pivoted from in-person to phone delivery of the ATP. HCWs made phone calls to YLH once a month for up to one hour to deliver the contents of the ATP.…”

Section: Setting and Study Designmentioning

confidence: 99%

“…36 The ATP aimed to prepare youth with HIV as they transition to independent care by increasing HIV knowledge and self-management skills required for independent care. 37 In this trial, frontline HCWs applied continuous quality improvement (CQI) meetings and plan-do-study-act (PDSA) cycles to develop dynamic, provider-led adaptations to phone delivery of the ATP following the onset of the COVID-19 pandemic. In this paper we characterize the adaptations using the expanded Framework for Reporting Adaptations and Modi cations for Implementation Strategies (FRAME-IS).…”

Section: Introductionmentioning

confidence: 99%

Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya Using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach

Mangale

Onyango

Mugo

et al. 2023

Preprint

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Background: The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected Adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker-delivered disclosure and transition intervention – the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP. Methods: We conducted continuous quality improvement (CQI) meetings with healthcare workers (HCWs) involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience and outcomes. Results: We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n=38), content (49%, n=35), and evaluation processes (13%, n=9). Context adaptations primarily featured changes to personnel, format and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n=69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n=60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%). Conclusion: Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility. Incorporating for a strategy for tracking outcomes within FRAME-IS may further our understanding of how adaptations influence implementation. Trial Registration: Trial registered on clinicaltrial.gov as NCT03574129.

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“…ATP effectiveness was evaluated in a cluster randomized clinical trial (RCT; Trial Registration Number NCT03574129) across 20 clinics in four Kenyan counties, assigned 1:1 to either the ATP intervention or standard of care for one year. Results showed the scores of participants in ATP clinics were significantly higher for overall readiness (adjusted mean difference 1.7, 95%CI 0.3, 3.1) and HIV literacy (adjusted mean difference 1, 95%CI 0.2, 1.7) than those in the standard of care clinics [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

Estimating the costs of adolescent HIV care visits and an intervention to facilitate transition to adult care in Kenya

Saldarriaga,

Beima-Sofie,

Wamalwa

et al. 2024

PLoS ONE

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Introduction Adolescents with HIV in sub-Saharan Africa face challenges transitioning to adult HIV care, which can affect long-term HIV care adherence and retention. An adolescent transition package (ATP) focused on transition tools can improve post-transition clinical outcomes, but its implementation costs are unknown. Methods We estimated the average cost per patient of an HIV care visit and ATP provision to adolescents. Data was collected from 13 HIV clinics involved in a randomized clinical trial evaluating ATP in western Kenya. We conducted a micro-costing and activity-driven time estimation to assess costs from the provider perspective. We developed a flow-map, conducted staff interviews, and completed time and motion observation. ATP costs were estimated as the difference in average cost for an HIV care transition visit in the intervention compared to control facilities. We assessed uncertainty in costing estimates via Monte Carlo simulations. Results The average cost of an adolescent HIV care visit was 29.8USD (95%CI 27.5, 33.4) in the standard of care arm and 32.9USD (95%CI 30.5, 36.8) in the ATP intervention arm, yielding an incremental cost of 3.1USD (95%CI 3.0, 3.4) for the ATP intervention. The majority of the intervention cost (2.8USD) was due ATP booklet discussion with the adolescent. Conclusion The ATP can be feasibly implemented in HIV care clinics at a modest increase in overall clinic visit cost. Our cost estimates can be used to inform economic evaluations or budgetary planning of adolescent HIV care interventions in Kenya.

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Transition to independent care for youth living with HIV: a cluster randomised clinical trial

Cited by 9 publications

References 24 publications

‘They should show them love even if their status of beingHIVpositive is known’: Youth and caregiver stigma experience and strategies to endHIVstigma in schools

‘They should show them love even if their status of beingHIVpositive is known’: Youth and caregiver stigma experience and strategies to endHIVstigma in schools

Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya Using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach

Estimating the costs of adolescent HIV care visits and an intervention to facilitate transition to adult care in Kenya

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