What does transfer mean in SSA What does transfer mean in SSA? Patterns of transfer in Southern African perinatally HIV-infected adolescents Mary-Ann Davies, Shobna Sawry, Sam Phiri, Helena Rabie, Brian Eley, Geoff Fatti, Karl Technau, Frank Tanser, Robin Wood, Janet Giddy, Carolyn Bolton-Moore, Cleophas Chimbetete, Rohan Hazra, Olivia Keiser and Kathryn Stinson for the IeDEA Southern Africa Collaboration 19 July, Durban

The wave of perinatally HIV-infected adolescents (PHA)

Growing population of PHA On ART Eligible, not on Rx Not eligible Johnson et al. PIDJ 2012

Changing age-structure of PHA in IeDEA-SA Age at last FU in those starting ART at <10 years 2008 N=15,144; 14%>10 years old 2014 N=28,520; 22%>10 years old

Outcomes of PHA by 13 years of age competing risks estimation Transfer out 18.2% (17.0-19.5) LTFU 9.3% (8.4-10.3) Death 1.2% (0.9-1.6)

Is transfer the same as transition? Specialist pediatric → adult care Completely integrated care Irrespective of model – transition is STILL happening Children stop coming with caregivers HCW talk to them about different things eg SRH needs Stop measuring height Use different form Illustrated by the cartoon – where it’s heading in HIV care – autonomy Transition ≈ Transfer ?Transfer

Objective To describe transfer patterns in PHA during first 3 years of adolescence – ages 10-13 years.

Methods Routinely collected data from 12 IeDEA-SA cohorts in 4 countries Inclusion criteria ART initiation at <9.5 years Remaining in care beyond 10 years of age Outcome = Transfer out (TFO) Characteristics of patients transferring K-M probability of transfer by cohort Predictors of transfer out Malawi Zambia Zimbabwe South Africa

Results: Characteristics at ART start for those remaining in care (RIC) or TFO n=3657 (excludes children died and LTFU within 6 months)

Results: Characteristics at transfer (TFO) or last visit (remaining in care)

Probability of transfer for different cohorts 25.6% (24.0 to 27.4) 14.0% (12.1-16.2) (pre-2009); 34.4% (31.8 – 37.1)(≥2009) Primary care cohorts Probability of transfer 6.5 (3.1-13.4) 5.1 (2.4-10.8) 10.1 (6.5-15.4) 14.8 (11.8-18.3) 17.3 (9.9-29.3) Hospital cohorts 36.3 (26.6-48.1) 7.6 (5.5-10.4) 45.3 (42.0-49.9) 45.0 (38.8-51.7) 54.3 (40.4-69.5) Months from 10 years of age

Characteristics associated with transfer

Limitations Documented transfers – not “silent transfers” Outcomes in patients who transfer out?

Outcomes after transfer using linkage Patients transferring out of a hospital site. Western Cape Province of South Africa – unique identifiers since 2007 – link to laboratory data. “Successful transfer” – having a laboratory test at the transfer site after transfer. 75% had a lab test result after transfer Lab testing only about 90% complete >80% of children successfully transferred Arowosegbe et al. P_66 HIV Pediatrics Workshop 2016

Conclusions About 1 in 4 patients transfer during early adolescence at a relatively constant rate, but wide variation between cohorts. “Healthier” patients were more likely to be transferred. on ART for longer, ↑CD4 values, ↓HIV-RNA Understanding patterns of transfer and outcomes after transfer is critical to evaluating adolescent and adolescent transition outcomes.

With many thanks to… Patients, caregivers, staff and site investigators from all IeDEA-SA sites IeDEA Data Centres NIAID, NICHD, NCI, NIDA, NIMH