Transition into Adult Care: Factors Associated with Level of Preparedness among Adolescents Living

with HIV in Cambodia

Siyan Yi, MD, MHSc, PhD

Director, KHANA Center for Population

Health Research, Cambodia

Adjunct Ass. Professor, Touro University California, USA

Email: siyan@doctor.com

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HIV in Adolescents

▪ Adolescents: (WHO, 2012; UNICEF, 2013)

– Number of ALHIV: 2.1 million

– Sub-Saharan Africa: 80% (1,620,000)

– Asia-Pacific: 11% (240,000)

– >90% through maternal to child transmission

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Estimated number of adolescents (ages 10─19) living with HIV, 2015

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Mortality & Access to Treatment

▪ HIV mortality rates: (Idele et al., 2014)

• All other age groups: decreased by 32% between 2005 and 2012

• ALHIV: Increased 50% from 71,000 in 2005 to 110,000 in 2012

▪ Compared to adults: (Hudelson, 2015)

• Less likely to receive ART • Poorer treatment outcomes• Higher treatment failure rates

▪ Issues around disclosure: (UNICEF, 2013)

• Awareness of HIV status: 45% for ALHIV <14 years

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Transition to Adult Services

• Transition preparedness: (WHO, 2014)

o Basic health-care awareness

o Awareness of their HIV status

o Understanding of their disease

o Initial development of health-care management skills

• Transition process:

o Enables adolescents to be autonomous by the time they engage with adult services (Righetti et al., 2015)

o Transition process should take into account –characteristics of adolescents and family, physical and emotional development, complexity of health problems, and access to health care providers (Ojikutu et al., 2014)

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Objective of the Study

To explore potential factors associated with level of preparedness for

transition into adult care among adolescents living with HIV

in Cambodia

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Study Design & Sites

▪ Cross-sectional survey: in 2016 among 312 ALHIV

▪ Number of ALHIV per ART clinic: 1 to 116 ALHIV

▪ ART sites: 90% of ALHIV distributed in 15 clinics

▪ Exclusion: ART clinics with <10 ALHIV

▪ Total ALHIV remained in the sampling frame: 598 ALHIV in 15 ART clinics in the capital city and 12 provinces

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Inclusion Criteria

▪ Aged between 15 to 17 years

▪ Receiving treatment and care services from the selected ART clinics

▪ Able to communicate in Khmer

▪ Allowed by a parent or guardian to participate

▪ Able to present themselves on the day of the interview

▪ Physically and mentally stable to assent and participate in the study

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Sample size

Sample size calculation for the survey:o Population size of 598o Confidence interval of 95%o Estimated prevalence of adolescent

readiness for adult transition of 20%o Design effect of 1.4o Drop-out or refusal rate: 10%

Minimum required sample size: 300

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Sampling Procedures

o Probability proportional to size sampling method

o Eligible ALHIV were randomly selected from a database

o A list of selected ALHIV with an ID was prepared and sent to the project coordinator

o Selected ALHIV were contacted informing about research objective, place, date and time of the interview

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Ethics Procedures

▪ Informed consent:

oGoal and objectives

oRisks and benefits

oConfidentiality

o Study procedures

o Time required

▪ Ethical approval from NECHR

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Personal Identification Number (PIN)

▪ Confidentiality

▪ Link between

biological and

behavioral data Provincial code (01= BMC)

Four digit for 1730 (0001-1730)

010001

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Compensation

▪ 2.5 USD in gift

▪ 5 USD for

transportation

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Questionnaire

o Socio-demographic characteristics

o Integration in the society

o Social and financial support

o Experience of preparation for transition

o Disclosure assessment

o HIV knowledge

o Disease knowledge and practice assessment

o Stigma and discrimination

o Assessment of level of preparedness for the transition into adult care

o Health risk behaviors

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Data Analyses

• Descriptive analyses: - Calculation: Proportion, mean, median, etc.

- Chi-square or Fisher’s Exact test for categorical variables

- Student’s t-test or ANOVA for continuous variables

• Risk factor identification:

• Multivariable logistic regression model

• Covariates: Variables associated with HIV infection in bivariate analyses at p<0.05

• Significance level: Two-sided p< 0.05

• Software: Stata 12

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Figure 1. Assessment of readiness for the transition from pediatric to adult care among male

and female adolescents living with HIV

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Socio-demographiccharacteristics

Total(n= 223)

Level of preparedness for transition

Low (≤7) (n= 104) High (>7) (n= 119) P-value

Currently living with: 0.004

Parents 91 (40.8) 30 (28.8) 61 (51.3)

Grandparents 35 (15.7) 18 (17.3) 17 (14.3)

Relatives 75 (33.6) 47 (45.2) 28 (23.5)

In an orphanage 18 (8.1) 7 (6.7) 11 (9.2)

Other 4 (1.8) 2 (1.9) 2 (1.7)

Mother is still alive 106 (47.5) 42 (40.4) 64 (53.8) 0.04

Main daily caregiver: 0.003

Parent 124 (55.6) 48 (46.2) 76 (63.9)

Grand parent 5 (2.2) 2 (1.9) 3 (2.5)

Sibling 15 (6.7) 4 (3.8) 11 (9.2)

Relatives 72 (32.3) 47 (45.2) 25 (21.0)

Orphanage/NGO staff 7 (3.1) 3 (2.9) 4 (3.4)

Family received social support 108 (48.4) 42 (40.4) 66 (55.5) 0.03

Table 1. Socio-demographic characteristics of adolescents living with HIV

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HIV status disclosure Total(n= 223)

Level of preparedness for transition

Low (≤7)

(n= 104)

High (>7)

(n= 119)

P-value

Know their disease (HIV/AIDS)

209 (93.7) 95 (91.3) 114 (95.8) 0.17

Know how you have been infected

178 (85.1) 82 (86.4) 96 (84.2) 0.78

Know how their HIV was transmitted

216 (96.7) 97 (92.6) 119 (100.0) 0.004

Know what kind of medicines received

186 (83.4) 77 (74.1) 109 (91.6) 0.002

Ever disclosed your HIV status

110 (49.3) 44 (42.3) 66 (55.5) 0.04

Table 2. Assessment of HIV-related knowledge among adolescents living with HIV with a low and high level of preparedness for transition to adult care

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Experiences in preparation process for transition

Total(n= 223)

Level of preparedness for transition

Low (≤7) (n= 104) High (>7) (n= 119) P-value

Person who you trust the most for your HIV treatment, care and support 0.001

Health care providers 176 (78.9) 92 (88.5) 84 (70.6)

Counselors/peer educators 10 (4.5) 5 (4.8) 5 (4.2)

Friends/family 27 (12.1) 3 (2.9) 24 (20.2)

Other 10 (4.5) 4 (3.8) 6 (5.0)

Received counseling on transition 66 (29.6) 22 (21.2) 44 (37.0) 0.01

Ever visited an adult clinic 44 (19.7) 14 (13.5) 30 (25.2) 0.03

Case Manager has been identified 55 (24.7) 13 (12.5) 42 (35.3) <0.001

Preparedness to manage your treatment going forward 0.01

Very prepared 29 (13.0) 8 (7.7) 21 (17.6)

Somewhat prepared 168 (75.3) 81 (77.9) 87 (73.1)

Somewhat unprepared 12 (5.4) 4 (3.8) 8 (6.7)

Very unprepared 14 (6.3) 11 (10.6) 3 (2.5)

Satisfied with transition process 67 (30.1) 17 (16.3) 50 (42.1) <0.001

Table 3. Experience of preparation for transition among adolescents living with HIV with a low and high level of preparedness for transition to adult care

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Variables in the final model Higher level of preparedness for transition into adult care

AOR (95% CI) P-value

Older age 2.44 (1.34-4.46) 0.004

Received social support for your health

No Reference

Yes 5.32 (1.97-14.36) 0.001

Knew what kind of medicines you have received

No Reference

Yes 12.67 (2.91-15.19) 0.001

Received counseling on transition to adult services

No Reference

Yes 3.17 (1.15-8.76) 0.03

Had a ‘Case Manager’ identified to support for the transition process

No Reference

Yes 3.89 (1.08-13.96) 0.04

Satisfaction with the preparation process for the transition in general

Satisfied Reference

Dissatisfied 0.35 (0.03-0.87) 0.01

Table 4. Factors associated with level of preparedness for transition to adult care in multivariate logistic regression model

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Limitations of the Study

▪ Cross-sectional design

▪ Self-reported measures

▪ Recall bias

▪ Generalizability to ALHIV in smaller clinics (<10 ALHIV/clinic)

▪ Unknown validity of the scale to measure level of preparedness for transition

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Conclusions

▪ A range of individual, social and health system factors may determine successful transition into adult care among ALHIV in Cambodia

▪ The national transition protocol was rarely adhered to

▪ Further actions:

o Strengthening implementation of age-appropriate and individualized case management transition at all ART sites

o Creating supportive family, peer and healthcare environments for successful adolescent transition

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Collaborators & Supporters

• UNICEF Cambodia

• KHANA Center for Population Health Research

• NCHADS

• PHDs, ODs, RHs, HCs

• Implementing partners

• Community support volunteers

• Local authorities

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Thank you!Q & A

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