IAS 2015: HIV+ Youth Are Less Likely than Adults to Achieve Viral Suppression on ART

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While adolescents and young adults are about as likely as older people to be linked to care after being diagnosed with HIV, less than a third were retained in care or started antiretroviral therapy (ART), and only 7% reached undetectable viral load -- much lower than the rate for older individuals, researchers reported at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention last month in Vancouver. Prompt referral to youth-friendly services, however, increased the likelihood of viral suppression.

Bill Kapogiannis from the National Institute of Child Health and Human Development and fellow investigators with the SMILE Collaborative looked at the HIV continuum of care for young people with HIV. SMILE (Strategic Multisite Initiative for the Identification, Linkage and Engagement in Care of Youth with Undiagnosed HIV Infection) is a collaboration between the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), the Health Resources and Services Administration (HRSA), and the Centers for Disease Control and Prevention(CDC).

The continuum or cascade of care refers to the sequence of steps from HIV testing and diagnosis, to linkage into care, to starting treatment, to achieving viral suppression. Public health researchers track progress in addressing the epidemic by looking at how many people "get lost" or fall out of care at each step.

Approximately one-quarter of all new HIV infections in the U.S. occur among youth age 13-24 years, the researchers noted as background, yet there is little youth-specific data on engagement in care.

The CDC estimates that 86% of the 1.2 million people living with HIV in the U.S. have been tested and know their status, falling to 49% among youth age 18-24, according to 2011 figures reported in the November 28, 2014 Morbidity and Mortality Weekly Report.

The SMILE study started at the next step of the continuum, looking at outcomes among 1548 youth, age 12-24, who were diagnosed with HIV and identified by the collaboration between October 2012 and September 2014. Among the 733 participants with available data, 81% were men, 72% were black, 70% identified as gay or bisexual, the mean age was 20.6 years, and the mean CD4 T-cell count was 463 cells/mm3.

The researchers determined the number of participants who were referred to care, linked to care (within 42 days after referral), engaged in care (defined as at least 1 additional visit within 16 weeks after linkage), retained in care (at least 1 additional visit within 52 weeks of engagement), and achieved viral suppression or undetectable plasma HIV RNA.

Results

The 7% viral suppression rate seen in this analysis is surprisingly low -- substantially lower than the approximately 40% figure for all age groups combined in the CDC's Medical Monitoring Project (according to the July 2015 Supplemental Surveillance Report).

"The SMILE collaborative has demonstrated that HIV-infected youth had high levels of plasma viremia and advanced infection at diagnosis, which have implications for disease progression and transmission potential," the researchers concluded. "While they linked to care at similar rates as adults, youth achieved disproportionately low rates of virologic suppression."

"Prompt referral to youth-friendly linkage-to-care services after HIV testing is an independent predictor of viral load suppression," they continued. "Recent developments affecting the urgency to start antiretroviral treatment for HIV-infected persons have direct implications for youth who would now have even less time for adjustment to their new diagnosis. This argues for more research and services to address such critical issues of treatment readiness and medication adherence among newly infected youth."

8/19/15

Reference

BG Kapogiannis, J Xu, KH Mayer, et al. The HIV continuum of care for adolescents and young adults (12-24 years) attending 13 urban US centers of the NICHD-ATN-CDC-HRSA SMILE collaborative. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract WELBPE16.