title: From transmission to transition: lessons learnt from the Thai paediatric antiretroviral programme.
abstract: BACKGROUND
  The 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.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  Children 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.
  
  
  CONCLUSIONS
  Using 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.
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Olivia
authors.initials: O
authors.lastname: Tulloch
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Sally
authors.initials: S
authors.lastname: Theobald
authors.affiliation: SEARCH and HIV-NAT, The Thai Red Cross AIDS Research Center, Bangkok, Thailand; Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
authors.forename: Jintanat
authors.initials: J
authors.lastname: Ananworanich
authors.affiliation: Bureau of AIDS, Tuberculosis and Sexually Transmitted Infections, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand.
authors.forename: Sanchai
authors.initials: S
authors.lastname: Chasombat
authors.affiliation: Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Pope
authors.initials: P
authors.lastname: Kosalaraksa
authors.affiliation: Bureau of AIDS, Tuberculosis and Sexually Transmitted Infections, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand.
authors.forename: Thidaporn
authors.initials: T
authors.lastname: Jirawattanapisal
authors.affiliation: SEARCH and HIV-NAT, The Thai Red Cross AIDS Research Center, Bangkok, Thailand.
authors.forename: Sudrak
authors.initials: S
authors.lastname: Lakonphon
authors.affiliation: Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Pagakrong
authors.initials: P
authors.lastname: Lumbiganon
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Miriam
authors.initials: M
authors.lastname: Taegtmeyer
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D017028:Caregivers / Q000523:psychology; D002648:Child; D054540:Child, Orphaned / Q000523:psychology; D003695:Delivery of Health Care; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000523:psychology*; D006801:Humans; D007407:Interviews as Topic; D015397:Program Evaluation; D000297:Psychology, Adolescent; D013785:Thailand
chemical_list: D044966:Anti-Retroviral Agents