Tracking the transition of adolescents into adult HIV care: a global assessment

Emergence of the issue of adolescent-to-adult HIV care transition as a priority in the HIV response has been like an iceberg rising out of the water. In the early years of the AIDS epidemic, it did not even merit a footnote, as the world was too busy watching children die without treatment. After we had a few antiretrovirals – crushed adultsized pills used off-label – things got better, but there were complications of delayed treatment and drug side effects that diverted our attention. We are now in an era where more of the world’s HIV-infected children and adolescents can be diagnosed and access potent combination antiretroviral therapy (ART) regimens, but our focus has more frequently been on considering how to help them maintain adherence to life-long ART to avoid treatment failure and drug resistance. In the midst of these clinical considerations, they began aging out of the traditional paediatric clinic structure. Whether or not they or their current or future providers were ready for them to move on to adult HIV care, the simple passage of time means that all of us now have to face this change. Paediatric providers of health services for children with chronic diseases are regularly, if quietly, criticized for “holding on” to our patients for too long. With the scaleup of ART, HIV has been added to the list of conditions like congenital heart disease and cystic fibrosis where children eventually move on to adult clinics. In some high-income countries, adolescent HIV care may be extended into early adulthood [1]. In lowand middle-income countries, this is less likely to happen because of health system policies around aging out of specialist paediatric care or the use of all-ages or family-centred HIV clinics; however, adolescent development and changes in responsibility for selfcare do still occur. Whatever the setting, the collective goal is for all of those diagnosed with HIV as children and adolescents to continuously remain in care, and thrive as adults. In order to know if this is happening, we need data on who transfers or transitions, and what their outcomes are over time. To know how well this is happening, we need data on the quality of transition processes and services. For this special issue of the Journal of the International AIDS Society, we conducted a global appraisal of adolescent transition to collect these data, taking a deep dive into the issues that they face today. The articles represent a snapshot of what we think we know, and represent expert opinion on where research, implementation, and policy efforts need to be focused to document and improve the quality of adolescent and young adult HIV care in the future. The articles taken together provide a comprehensive review of the transition situation globally, and our authors have tackled many different aspects of transition, from estimates of the size of the adolescent epidemic to mental health issues, and from HIV treatment and care services to the policy response, often bringing disparate data together for the first time. The main focus is on young people who acquired HIV in childhood, but not to the exclusion of those who were behaviourally infected, for whom common as well as contrasting themes are highlighted.