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HIV treatment programmes need to prepare for the 'youth bulge', South African experience shows
Carole Leach-Lemens, 2016-07-19 18:30:00
Treatment programmes in
sub-Saharan Africa must prepare for a growing population of adolescents over
the next few years as perinatally-infected children grow up and begin a
transition from child health services to adult clinics, Dr Mhairi Maskew of University
of Witwatersrand told participants at the 21st International AIDS
Conference (AIDS 2016) in Durban on Tuesday.
South Africa in particular is
beginning to experience a 'youth bulge' as the number of infants infected with
HIV declines due to the success of efforts to eliminate mother-to-child
transmission, and children infected during the 2000s begin to reach
HIV infections among
adolescents, especially girls and young women, also remain high. Data presented
by UNICEF at AIDS 2016 suggest that 29 adolescents aged 15-19 are infected every
hour, the vast majority in sub-Saharan Africa.
Unprecedented survival rates among this
population highlight the need for adult services to become more adolescent-friendly.
Evidence suggests adolescents are especially vulnerable to loss to follow up
and adherence difficulties as they transition to adult care with consequent
rebound of viral load. Although the South African cohort is likely to be the largest, all countries in Sub-Saharan Africa with successful PMTCT programmes are beginning to experience this shift in the balance of needs away from infants and towards adolescents.
As a group with a lower rate of viral suppression, adolescents are a particular priority for country programmes as they seek to increase the proportions of people living with HIV on treatment and virally suppressed.
Without large well-defined
cohorts, the monitoring of adolescent treatment programmes in this context is very
difficult. Adolescents are a key group for health-systems planning. However,
until now in South Africa a nationally representative cohort has not been
available. So treatment outcome data are rare.
Dr. Maskew and colleagues
suggest that laboratory datasets from South Africa’s National Health Laboratory
Service (NHLS) database may provide an important tool for national and local
resource allocation and planning.
The NHLS is the sole provider
of laboratory testing services to public sector clinics, including CD4 cell
counts and viral load testing. As such it represents a powerful database to
capture a patient’s HIV care progress. Entry into care is defined as one CD4
cell count or viral load recorded for an individual in the database. Treatment
initiation is measured by viral load results. Viral load is only tested in the
over five-year olds if they have been on treatment for six months, not before
Using a national patient
cohort developed from the NHLS database Dr. Maskew and colleagues determined
the size of the adolescent ART population and the proportion virologically
Analysis of data on all
public sector viral load tests and CD4 tests since 2004 of those under 20 years
of age at test date was performed. The total number getting ART care in any
given year was derived from the number of individual patients with viral load
To determine shifts in age
distribution of those on ART over time, data were stratified by age and year
from 2004 to 2014. The proportions of those virally suppressed were assessed by
age in 2014.
929,274 person-years of
follow up were analysed. Among the under five-year age group the increase in
the number of children on ART was steady until 2011 after which the numbers
stabilised. Children under five represented 50% of the total during the period
2004 to 2007 but probably due to the success of PMTCT programmes declined
steadily, and by the time period 2012 to 2014 the proportion of under-fives had
more than halved (23%).
Conversely adolescents, aged
10 to14 and 15 to 19 years, for the period 2004 to 2007 represented 11% (8,854)
and 8% (5,904) of the total, respectively, with dramatically increasing numbers
representing 28% (141,945) and 19% (96,042), respectively for the period 2012
It is anticipated that the 15
to 19-year age group will increase further over the next five years into the15
to 20-year age group and the increase in the numbers on treatment will be very
In 2014 the proportion of those
virally suppressed declined as the children grew into adolescence from 74%
among 5-9 year olds, 69% among 10-14 year olds and 62% among 15 to 19 year
olds. While retention, as measured by the proportion virally suppressed,
declines with age, there is no gender disparity.
After adjusting for site,
characteristics of perinatally infected adolescents more likely to transfer
included: being on ART for a longer period of time at 10 years of age, aHR:
1.29, (95% CI: 1.22-1.35), not being severely immunodeficient at ART start,
aHR: 1.25 (95% CI: 1.03-1.52), having a CD4 cell count greater than 500
cells/mm3 at age 10, aHR: 1.30 (95% CI: 1.01-1.6) and having a viral
load under 400 copies/mL at age10, aHR: 1.38 (95% CI: 1.05-1.82).
This group is now transitioning into
adult care and it is critical to plan for this now. The age of transition into
adult care is facility-dependent.
Adherence issues among this population
are multi-faceted with different needs from other groups. Transition into
economic activity or a caregiving role in the household can also affect the
ability to attend clinic and so affect retention in care.