SUSTAINABILITY OF AN EVIDENCE BASED INTERVENTION SUPPORTING TRANSITION TO INDEPENDENT CARE FOR ADOLESCENTS LIVING WITH HIV IN KENYA

Abstract

Background: Integrating and sustaining evidence-based interventions in routine care is crucial to improve HIV treatment outcomes among youth living with HIV (YLH). An Adolescent Transition Package (ATP), tested in Kenya in 2021, significantly improved YLH readiness to transition from pediatric to adult care. Post-trial, participating clinics could continue using the ATP after study staff exited. We evaluated ATP use in intervention clinics one-year post-trial. Methods: We conducted thirty in-depth interviews with health care workers (HCWs) from ATP intervention sites to characterize determinants of continued ATP implementation. HCWs were purposively recruited to represent a range of cadres and ATP implementation experiences. Interviews used semi-structured guides, informed by the Consolidated Framework for Implementation Research (CFIR) version 2.0, were audio recorded, translated, and transcribed. Transcripts were analyzed thematically to identify key influences of ATP sustainment and fidelity post-trial. Results: The median age of participating HCW was 34 years, and the majority (73%) were female. The median number of years working with YLH was 7 years, with 2.8 years implementing the ATP. HCWs described overall high acceptability, feasibility, and appropriateness of the ATP, which motivated sustained implementation. Effective training and ongoing support were crucial for continued implementation, especially among newly hired clinic staff. Key determinants of sustainment included observed positive impact of the ATP on patient outcomes (improved literacy, adherence or viral suppression), patient-centered clinic cultures, and supportive clinic and external (Ministry of Health) leadership. Staff shortages and high rates of staff turnover, lack of integration into the existing electronic medical system, and maintaining staff motivation were barriers to ATP sustainment. Implementation fidelity was similarly influenced by workforce resources and HCW beliefs about the importance of individualizing content and delivery to be responsive to individual patient needs. ATP adaptability afforded optimization of delivery to overcome workforce constraints and meet patient needs, increasing HCW perceptions of feasibility and motivating continued use. Conclusion: Post-trial, sustained ATP use was influenced by HCW perceptions of the ATP, workforce resources, and intervention adaptability. Strategies to ensure continued training and integration of tools into existing systems have the potential to further enhance ATP sustainability.