Pivoting Youth HIV Service During the COVID-19 Pandemic: Evaluation of Phone Delivery of an Adolescent Transition Package in Kenya

The global burden of HIV attributable to young people aged 10 – 24 years living with HIV is significant and approximates 2 million youth. The reality of HIV along with the vulnerability associated with being a teenager makes this population one worth paying close attention to given poor HIV outcomes associated with youth living with HIV (YLH). Maintaining engagement in care is critical, especially for older youth aged 15 – 24 years who experience worse HIV-related outcomes than adults or younger adolescents. The risk of loss-to-follow-up is high among YLH transitioning from pediatric to adult HIV clinics. Among youth, mHealth technology has demonstrated the ability to bridge gaps in utilizing health services that are common in this age group, including improving engagement and retaining in care. During the COVID-19 pandemic mHealth was invaluable for HIV clinics as it supported remote access to health services. The Adolescent Transition to Adult Care for HIV-infected Adolescents in Kenya (ATTACH) study which tested an Adolescent Transition Package (ATP) to support YLH transition pivoted from in-person delivery to phone delivery of the intervention. We sought to assess implementation of the ATP using phones to identify best practices for use beyond the pandemic. The first study used qualitative data from providers who work with YLH at public HIV clinics in Kenya to identify barriers and facilitators associated with phone delivery of the ATP intervention. We gathered data enumerating the number of phone calls and the success of each call as far as reaching youth and discussing a chapter of the ATP was concerned. The use of mobile phones was high in the early stages of the pandemic but quickly declined once movement restrictions were lifted. Initially, the providers were less successful at reaching youth until after restrictions were lifted. Using the Consolidated Framework for Implementation Research we found that salient factors influencing acceptability, feasibility and reach were related to the technical simplicity of phone calls, relative convenience, and efficiency of using phones (intervention characteristics), and to inner setting characteristics such as the presence of collaborative teams, individual and collective efficacy to complete tasks, availability of information and resources, and compatibility with the providers’ existing responsibilities. Determinants related to patient needs and resources and community, specifically low phone ownership among youth, and the youths’ relationships, were important. The second study applied the Framework for Reporting Adaptations - Implementation Strategies (FRAME-IS) to characterize provider-led adaptations to mobile phone delivery of the identified from qualitative data collected during Continuous Quality Improvement meetings. Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Most adaptations were derived from changes to the strategy’s context and majority were introduced to increase the feasibility of phone delivery. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%). Adaptations were primarily context adaptions. We found that FRAME-IS was apt for describing adaptations. We propose other uses of FRAME-IS for providers engaged in quality improvement work. The third study used a convergent mixed methods approach to compare youth satisfaction with phone delivery versus in-person delivery of the ATP. We identified higher satisfaction with both options; however, the preference was for receiving in-person delivery compared to phone call delivery of the ATP. Privacy and confidentiality, patient-provider relationship and connection, convenience, and averted time and financial costs were notable drivers of YLH’s perspectives that may be important to consider when designing service delivery strategies for YLH. This dissertation contributes to much needed implementation science research on mHealth in relation to the care of youth living with HIV and underscores factors for consideration when implementing mHealth for this target population. As new efforts emerge to address poor HIV outcomes among YLH, providers and policymakers will require a nuanced understanding of implementation barriers and facilitators, and adaptations. This work highlighted the importance of evaluating YLH experiences with health services to better match delivery strategies to their preferences and needs.

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