Low-transition rates in human immunodeficiency virus-infected adolescents: A cross-sectional mixed study of pediatric to adult care transition in Uganda

Table 1 Socio-demographic characteristics of participants, n (%)

Variables (n = 261)	Category	Frequency/percent
Sex	Male	140 (53.6)
	Female	121 (46.4)
Age (years)	10-12	67 (25.7)
	13-15	93 (35.6)
	16-18	77 (29.5)
	19-20	24 (9.2)
Religion	Catholic	98 (37.5)
	Protestant	105 (40.2)
	Muslim	38 (14.6)
	Pentecostal/Born-again	20 (7.7)
Highest level of education attained	None	57 (21.8)
	P1-P4	55 (21.1)
	P5-P7	86 (33.0)
	Secondary	57 (21.8)
	Tertiary	6 (2.3)
Ever had a sexual partner	Yes	186 (71.3)
	No	75 (28.7)
Duration of work on a typical working day (hours)	8-10	252 (96.6)
	11-12	9 (3.4)

Table 2 Personal factors associated with transition into adulthood human immunodeficiency virus, n (%)

Variables (n = 261)	Category	Frequency/percent
Had a VL test in the last 2 years	No	5 (1.9)
	Yes	256 (98.1)
Recent VL results (copies)	< 1000	178 (68.2)
	≥ 1000	83 (31.8)
Reduction in current VL compared to previous VL results	No	81 (31.0)
	Yes	180 (69.0)
Time initiated on ART (months ago)	< 6	9 (3.4)
	6-12	58 (22.2)
	13-24	58 (22.2)
	Over 24	136 (52.1)
Ever had any treatment holiday	No	140 (53.6)
	Yes	121 (46.4)
Heard about transition care	No	44 (16.9)
	Yes	217 (83.1)
Source of information on transition	Fellow clients	44 (16.9)
	Adolescent clients	30 (11.5)
	Community	12 (4.6)
	Health worker	112 (42.9)
	Treatment supporter	63 (24.1)
Willingness to transition from adolescent ART care to adult care	No	87 (33.3)
	Yes	174 (66.7)
Time required to transition to adult care	Immediately	12 (4.6)
	≤ 1 week	2 (0.8)
	within 1 month	27 (10.3)
	within 6 months	47 (18)
	within 1 year	173 (66.3)
Components of TC	Transitioning team at adolescent clinic	48 (18.4)
	Transitioning plan once adult 18 years	189 (72.4)
	Adolescent’s readiness assessment > 2 years	10 (3.8)
	Appointment counselling sessions on TC	14 (5.4)
Benefits of transitioning to adult care	Retention in HIV care	13 (5.0)
	Continued ART adherence	75 (29.0)
	Successful viral suppression	126 (48.0)
	Partner HIV disclosure	371 (4.2)
	HIV care self-management	10 (3.8)
Stay with parent or relatives	No	53 (20.3)
	Yes	208 (79.7)
Person staying with if not parents or relative	Partner	15 (5.7)
	Friend	73 (28.0)
	Fellow client	1 (0.4)
	Well-wisher/organization	172 (65.9)
Have siblings	No	89 (34.1)
	Yes	172 (65.9)

ART: Antiretroviral therapy; HIV: Human immunodeficiency virus; TC: Transitioning care; VL: Viral load.

Table 3 Psychosocial factors associated with transition into adulthood human immunodeficiency virus care, n (%)

Variable (n = 261)	Category	Frequency/percent
Ever felt disgraced because of your HIV status	No	117 (44.8)
	Yes	144 (55.2)
Ever encountered disgrace to you because of your HIV status	No	154 (59.0)
	Yes	107 (41.0)
Place you face this disgrace/humiliation	Home	13 (5.0)
	Work	5 (1.9)
	School	145 (55.6)
	Among relatives	70 (26.8)
	Community activity	28 (10.7)
Ever been discriminated/denied anything because of your HIV status	No	152 (58.2)
	Yes	109 (41.8)
Place of discrimination against	Home	39 (15.0)
	Work	13 (5.0)
	School	89 (34.1)
	Among relatives	89 (34.1)
	Community activity	16 (6.1)
	Others	15 (5.7)
People you socialize with as peers	Fellow clients	37 (14.2)
	School mates	134 (51.3)
	Workmates	38 (14.6)
	Social clubs	52 (19.9)
Peers affect your decision in transitioning from adolescent to adult antiretroviral therapy care	No	153 (58.6)
	Yes	108 (41.4)
How they affect your decision in transitioning from adolescent to adult care	Encourage it	161 (61.7)
	Discourage it	63 (24.1)
	May prevent it	37 (14.2)
Disclosed your HIV status to anyone	No	50 (19.2)
	Yes	211 (80.8)
Person to whom you disclosed your HIV status	Relatives	85 (32.6)
	Peers	112 (42.9)
	Workmates	15 (5.70)
	Sexual partner(s)	49 (18.8)
Reasons for not disclosing your status	Fear of rejection	109 (41.7)
	Fear of ill treatment	28 (10.7)
	Not necessary	52 (20.0)
	Fear of loss of respect	26 (10.0)
	Fear of loss of social status	46 (17.6)
Difficulty in disclosing status to peer	Very difficult	39 (15.0)
	Difficult	61 (23.4)
	Not difficult	102 (39.0)
	Easy	59 (22.6)
Difficulty in disclosing status to partner	Very difficult	48 (18.4)
	Difficult	92 (35.2)
	Not difficult	78 (29.9)
	Easy	43 (16.5)
Think you need to transition from Adolescent clinic to adult clinic	No	115 (44.1)
	Yes	146 (55.9)
Reasons for needing to transition to the adult clinic	I’m of age	170 (65.1)
	Health workers say I should	39 (14.9)
	Peers say I should	11 (4.0)
	I don’t fit in adolescent clinic	41 (16.0)

HIV: Human immunodeficiency virus.

Table 4 Health system factors associated with transition into adulthood human immunodeficiency virus care, n (%)

Variable (n = 261)	Category	Frequency/percent
Have a transition team at health facility	No	29 (11.1)
	Yes	232 (88.9)
Adolescent prepared for transition to adult care	No	69 (26.4)
	Yes	192 (73.6)
Ways prepared for transition to adult care	ART adherence counseling	60 (33.0)
	Readiness assessment	60 (33.0)
	Timely exposure to adult caregivers	89 (34.0)
	Early transitioning education	52 (20.0)
Duration since transitioning as an adolescent to adult care (months ago)	< 6	127 (48.6)
	6-12	62 (23.8)
	13-24	40 (15.3)
	Over 24	32 (12.3)
Ways you as a youth facilitated connection to adult clinic	Physical escorting	64 (24.5)
	Referral note	111 (42.5)
	Through peer clients	62 (23.8)
	Others/specify	24 (9.2)
Thoughts of adult ART service providers	Friendly	154 (59.0)
	Receptive	68 (26.1)
	Patient	16 (6.1)
	Unfriendly	12 (4.6)
	Tough	6 (2.3)
	Impatient	5 (1.9)
Thoughts of pediatric ART service providers	Friendly	201 (77.0)
	Receptive	33 (13.0)
	Patient	13 (5.0)
	Unfriendly	4 (1.5)
	Tough	6 (2)
	Impatient	4 (1.5)
Pediatric caregivers skillful	No	49 (18.8)
	Yes	212 (81.2)
Adult caregivers are skillful	No	60 (23.0)
	Yes	201 (77.0)

ART: Antiretroviral therapy.

Table 5 Unadjusted and adjusted factors associated with transition into adulthood human immunodeficiency virus care

Variable	Category	Crude PR (95%CI)	P value	Adjusted PR (95%CI)	P value
Age (years)	10-12	1.553 (1.220-1.592)	0.009	2.525 (2.121-2.944)	0.002
	13-15	1.419 (1.304-1.780)	0.049	1.900 (1.196-3.416)	0.001
	16-18	1.324 (.611-1.339)	0.240	0.991 (0.536-1.242)	0.184
	19-20	1		1
Successful viral suppression	No	1.645 (1.355-1.714)	0.012	1.534 (1.173-1.648)	0.016
	Yes	1		1
Recent viral load results (copies)	< 1000	1.437 (1.078-2.645)	0.002	3.285 (2.155-4.267)	0.007
	≥ 1000	1		1
Disclosure to relatives	No	2.786 (1.356-3.734)	0.001	5.001 (3.411-3.411)	0.001
	Yes	1		1.0
Prepared for transition	No	6.361 (2.221-8.320)	0.030	5.417 (3.468-7.135)	0.041
	Yes	1		1
Thought caregivers are skillful in providing care	No	2.611 (1.146-2.859)	0.001	3.724 (2.084-4.105)	0.005
	Yes	1		1

PR: Prevalence ratio.

Table 6 Themes and subthemes of factors in the transition to adult care

	Themes	Subthemes
Personal factors	Time of initiation of ART	ART adherence
		Understanding purpose of life medication
	Preparation for transition	Lack of positive attitude towards adult HIV care services
		Awareness of the HIV disease
Psychosocial factors	Knowledge of HIV disease management	Lack of adolescent care management expertise
		Weak behavioral change communication interventions
	HIV stigmatization and discrimination	Vulnerability to psychological distress
		Lack of friendly adolescent care
		Lack of community engagement and social support structures
Health system factors	Availability of transition teams	Inadequate staff in HIV adolescent care
		Encourage a multidisciplinary team
		Identify challenges that affect process of transition
	Availability of transition plan	Limited funding to foster the transition process
		Develop personalized plans

ART: Antiretroviral therapy; HIV: Human immunodeficiency virus.