Bridging the Gap: How Structured Transitions Can Keep Adolescents with HIV in Care

The transition from pediatric to adult HIV care has become a critical juncture in the continuum of treatment. Yet for many young people, this handoff is anything but seamless. A new systematic review published in Tropical Medicine and Infectious Disease underscores the vulnerabilities of this population and offers compelling evidence that structured, youth-centered transition programs can dramatically improve retention in care—even though challenges remain in sustaining viral suppression.

Adolescents living with HIV face a complex array of clinical and psychosocial barriers as they shift from child-focused to adult healthcare systems. According to the review, which synthesized findings from 32 studies across diverse settings, retention in care declines precipitously after transition. While roughly 81% of youth are still engaged in care one year post-transfer, that number drops to just 69% by year two. Viral suppression rates also decline, with only about two-thirds maintaining suppressed viral loads—far below the UNAIDS target of 95%.

Adolescents are often unprepared for the expectations of adult clinics, which may lack the nurturing environment and support systems they are accustomed to in pediatric care. Stigma, mental health concerns, and loss of caregiver involvement exacerbate disengagement. 

Key predictors of successful transition include transferring at an older age and avoiding care gaps between pediatric discharge and adult enrollment. For instance, a natural experiment in South Africa found that adolescents forced to transition at age 12 had a one-year retention rate of just 49%, compared to 92% for those who transitioned later.

Programs that incorporate early preparation, formal readiness assessments, coordinated handoffs between pediatric and adult providers, and sustained psychosocial support consistently outperformed standard care. The Stepping Up (STEP) Program at the University of Maryland, for example, achieved a 95% retention rate at 12 months post-transition—nearly double the rate in a pre-intervention cohort. Similarly, Thailand’s Happy Teen Program and Italy’s pilot multidisciplinary clinic both reported retention and viral suppression rates exceeding 85% after one year.

Peer support emerged as another crucial component, though its effectiveness varied by context. Community-based models like Zimbabwe’s Zvandiri program showed substantial reductions in virologic failure and improved retention, while clinic-based teen clubs in Namibia produced no significant difference compared to standard care. This suggests that the structure, intensity, and integration of peer support into broader care models may determine its impact.

However, improved retention does not always translate into better viral suppression. Some high-performing programs saw limited gains in virologic outcomes, highlighting that mere attendance isn’t enough—youth-friendly services must also address adherence challenges, mental health, and substance use. The review calls attention to this “second gap,” emphasizing that retention is a necessary but insufficient condition for sustained health benefits.

Structural barriers—such as fragmented health systems, lack of formal transition protocols, and limited access to sexual and reproductive health services—further complicate the landscape. While high-income countries are increasingly adopting standardized transition practices, many low-resource settings lack national policies or infrastructure to support adolescents during this vulnerable phase.

Ultimately, the transition from pediatric to adult care should be treated as a developmental journey requiring ongoing investment. Done right, it can secure the hard-fought treatment successes of childhood and lay the foundation for lifelong health and engagement.