From pediatric to adolescent HIV: mortality, viral suppression and transition to adult care

Thesis (Ph.D.)--University of Washington, 2019University of Washington Abstract From pediatric to adolescent HIV: mortality, viral suppression and transition to adult care Irene Nyambura Njuguna Chair of the Supervisory Committee: Professor Grace John-Stewart Departments of Global Health and Epidemiology Introduction: Global scale-up of prevention of mother to child transmission (PMTCT) programs and expansion of pediatric HIV testing and treatment have dramatically changed the course of pediatric HIV. Fewer infants are born with HIV, and early treatment significantly improves survival, growth, neurodevelopment and prevents morbidity. However, challenges with early diagnosis and achieving treatment goals during adolescence exist. A majority of HIV infected children present for care while severely ill, and experience high morbidity and mortality despite initiation of treatment. For children surviving to adolescence, maintaining viral suppression remains challenging, and mortality during adolescence is high. As children grow into adulthood, how to support them transition to adult care and gain independence in their own care remain unanswered questions. Methods: The aims of the dissertation address the following questions: Chapter 1) what are the common diagnoses at death and what are the correlates of viral suppression among severely ill, hospitalized, antiretroviral therapy (ART) naïve HIV-positive children aged 0-12 years in Kenya? Using data from a randomized controlled trial (RCT) on urgent versus post–stabilization antiretroviral treatment (ART) (PUSH trial), we use survival analysis methods examined sociodemographic and clinical correlates of mortality. Chapter 2) What is the prevalence of viral suppression and what clinic and individual level factors are associated with viral suppression among HIV-positive adolescents and young adults (AYA) age 10-24 years, on ART for more than 6 months and enrolled in HIV care programs in Kenya? We used multilevel logistic regression methods to estimate association of viral suppression with hypothesized individual and clinic level factors. Chapter 3) What are the current adolescent transition practices in Kenya, and how can we define transition and its success in programmatic settings in Kenya. We used descriptive statistics to describe adolescent HIV care practice, disclosure and transition services in Kenya and a user-centered design workshop to develop transition definitions and key elements for programmatic use in Kenya. Results: Chapter 1: Overall 39/181 (22%) of hospitalized HIV-positive children enrolled in the PUSH RCT died. Pneumonia or suspected tuberculosis, and gastroenteritis were the most common diagnoses at the time of death. Young age (