From transmission to transition: lessons learnt from the Thai paediatric antiretroviral programme.

Olivia Tulloch,Sanchai Chasombat,Miriam Taegtmeyer,Pope Kosalaraksa,Thidaporn Jirawattanapisal,Sally Theobald,Pagakrong Lumbiganon,Jintanat Ananworanich,Sudrak Lakonphon,Clive M Gray

doi:10.1371/journal.pone.0099061

Abstract

BackgroundThe Thai HIV programme is a leader in the public health approach to HIV treatment. Starting at transmission of HIV and ending with transition to adult services this paper assesses the paediatric HIV treatment continuum from three perspectives: service-user, provider and policy maker, to understand what works well and why.MethodsA qualitative research design was used to assess and triangulate the stakeholder perspectives. Semi-structured interviews were conducted with ART service-users (n = 35), policy actors (n = 20); telephone interviews with prior caregivers of orphans (n = 10); and three focus group discussions with service-providers (hospital staff and volunteers) from a district, provincial and a university hospital.FindingsChildren accessing HIV care were often orphaned, cared for by elderly relatives and experiencing multiple vulnerabilities. Services were divided into three stages, 1. Diagnosis and linkage: Despite strong policies there were supply and demand-side gaps in the prevention of mother-to-child transmission ‘cascade’ preventing early diagnosis and/or treatment. 2. Maintenance on ART - Children did well on treatment; caregivers took adherence seriously and valued the quality of services. Drug resistance, adherence and psychosocial issues were important concerns from all perspectives. 3. Adolescents and transition: Adolescent service-users faced greater complexity in their physical and emotional lives for which providers lacked skills; transition from the security of paediatric clinic was a daunting prospect. Dedicated healthcare providers felt they struggled to deliver services that met service-users' diverse needs at all stages. Child- and adolescent-specific elements of HIV policy were considered low priority.ConclusionsUsing the notion of the continuum of care a number of strengths and weaknesses were identified. Features of paediatric services need to evolve alongside the changing needs of service users. Peer-support volunteers have potential to add continuity and support at all stages. It is critical that adolescents receive targeted support, particularly during transition to adult services.

Highlights

Thailand has a concentrated HIV epidemic with a seroprevalence of less than one per cent in antenatal sentinel surveillance sites and an estimated 14,000–35,000 infected children in 2011 [1,2]
Features of paediatric services need to evolve alongside the changing needs of service users
It is critical that adolescents receive targeted support, during transition to adult services

Summary

Introduction

Thailand has a concentrated HIV epidemic with a seroprevalence of less than one per cent in antenatal sentinel surveillance sites and an estimated 14,000–35,000 infected children in 2011 [1,2]. Since 2000 antiretroviral therapy (ART) for the prevention of mother-to-child transmission (PMTCT) and routine testing in antenatal care (ANC) has been available [4,5]. In this successful and evolving programme government data showed a sharp drop in MTCT, ranging between 3% and 6% from 2004–2008, depending on protocol compliance [6]. Starting at transmission of HIV and ending with transition to adult services this paper assesses the paediatric HIV treatment continuum from three perspectives: service-user, provider and policy maker, to understand what works well and why

Methods

Results

Discussion

Conclusion