Pilot Study of a Transition Intervention for ALWH
Condition: Treatment Adherence
Study type: Interventional

Summary: 
      The investigators will conduct a pilot study of a community-based intervention designed to
      improve outcomes among adolescents living with HIV (ALWH) transitioning to adult HIV care in
      Lima, Peru. The investigators will enroll adolescents transitioning to adult HIV care, either
      due to a recent diagnosis or having aged out of their pediatric clinic. ALWH previously lost
      from care during the transition process will also be invited to participate. The nine-month
      intervention will consist of (1) logistical, adherence and social support delivered by
      entry-level health workers who will accompany adolescents during their transition to adult
      HIV care and (2) group sessions to improve health-related knowledge, skills, and social
      support. The investigators will assess intervention feasibility and effectiveness in
      improving medication adherence, psycho-social outcomes, and transition readiness after 6, 9,
      and 12 months.
    

Detailed description: 
      Adolescents living with HIV (ALWH) face an elevated risk of poor health outcomes when
      transitioning into adult-oriented care. Evidence-based interventions to support ALWH during
      this high-risk period are lacking, especially in Latin America.

      The investigators will prospectively enroll adolescents living with HIV into a
      community-based accompaniment (CBA) intervention to assess the feasibility of the
      intervention to improve retention with viral load suppression. The intervention will include
      (a) combined antiretroviral therapy (cART) directly observed therapy (DOT) for participants
      at risk of or with a history of non-adherence, (b) monthly home visits by trained health
      promoters to assess adherence and barriers to care and provide social support, (c) ongoing
      support in navigating the health system, such as accompaniment to appointments and assistance
      enrolling in public health insurance, and (d) monthly peer support groups. The intervention
      activities will be delivered more frequently in an intensive phase for 6 months followed by a
      taper phase for 3 months. The investigators also aim to pilot study procedures relevant to a
      future trial, including an evaluation of new data collection tools, intervention fidelity
      assessments, and consent procedures.

      Data collection will consist of the use of self-administered questionnaires using RedCap,
      focus groups with participants, and in-depth interviews with a subset of participants. To
      examine changes in outcomes throughout the intervention, the investigators will calculate
      within-person changes from baseline to 6, 9, and 12 months and will use paired t-tests or
      Wilcoxon signed-rank tests to test whether these quantities differ from zero. The
      investigators will stratify analyses by early childhood versus recent diagnosis of HIV to
      understand any differences in effectiveness among subgroups. Data will be analyzed using SAS
      version 9.4.
    

Intervention name(s): Community-based accompaniment and home visits; Directly Observed Therapy; Monthly Peer Support Groups
Intervention type(s): Other; Behavioral; Behavioral
Intervention description(s): Trained health promoters will accompany adolescents to their first appointments; facilitate enrollment in public health insurance and completion of other administrative requisites (e.g. obtaining a foreign identification card for migrants; transferring to a different health facility); help troubleshoot new logistical and/or social challenges; and will foster communication between the adult care providers and the patient.
Health promoters will visit the participant's home or another mutually-agreed upon location at least monthly, to review ART adherence, identify barriers to care and adherence, remind patients of upcoming medical encounters, screen and follow-up for clinical and social problems, and offer social support.; Among adolescents who have already initiated combination antiretroviral therapy (cART), directly observed therapy (DOT) will be provided to the subset of adolescents identified as being at high risk of non-adherence, defined by meeting at least one of the following criteria: 1) identified by the pediatric health provider as having unstable adherence; or 2) having a detectable viral load at one of their two previous measurements. In adolescents newly initiating cART, there will not be an adherence precedent. This group will choose whether they wish to receive DOT. As part of this research, trained community health workers (CHWs) will deliver DOT in participant's homes or in a mutually agreed upon location. CHWs will observe ingestion of cART daily, ensure it is taken as prescribed and record each dose as DOT, self-administered, not taken or not prescribed.; The investigators will assign ALWH to a social support group with 9 to 11 other adolescents also participating in the research. The goal of the social support groups is to provide a venue for participants to share experiences and resources and provide encouragement and support to one another. Each group will last approximately 3 to 4 hours. Support groups will be led by adult peers or trained community health workers. The final group session will incorporate a discussion about the group experience, how it may change behavior, recommendations for improvement, and unmet needs that should be considered for a future intervention.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: adolescents; social support; differentiated care; HIV care continuum; key and vulnerable populations