Poor outcomes in 17 to 24 year olds using adult HIV services

American research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes has highlighted the importance of providing  appropriate support to HIV-positive adolescents and young adults as they begin to use adult HIV clinics.

Investigators from Chicago found that HIV-positive individuals aged 17 to 24 were less likely than older HIV-positive adults to achieve and maintain an undetectable viral load. Moreover, adolescents and young adults were significantly more likely to be lost to follow-up.

Especially poor outcomes were seen in African Americans adolescents and young adults.

“We found inferior virologic outcomes and higher loss to follow-up among HIV-infected AYA [adolescents and young adults] compared to matched HIV-infected adults,” comment the investigators. They also note “African American AYA had the lowest rates of viral suppression and the highest rates of viral rebound.”

Thanks to antiretroviral therapy, many children who were infected with HIV at birth are now reaching adulthood.

HIV care for children is usually provided in specialist paediatric clinics, but in adolescence or early adulthood care is transferred to adult HIV services.

Moreover, there are significant numbers of new HIV infections in teenagers and individuals in their early 20s.

Little is known about the outcomes of adolescents and young adults who are cared for in adults-oriented HIV clinics. Therefore, investigators at Chicago’s Northwestern Memorial Hospital designed a retrospective study including 46 patients aged 17 to 24 who were matched on a one-to-one basis with patients aged between 25 and 40.

The investigators compared the proportion of patients in each age group who had an undetectable viral load six months after starting HIV therapy or if they were already taking antiretroviral drugs, the commencement of their care at the clinic. Rates of rebound in viral load and loss to follow-up were also compared.

The study included individuals who received care between 2003 and 2009.

Adolescents and young adults were less likely than older adults to have an undetectable viral after six months (59% vs. 78%, p = 0.025).

Pregnant younger patients also had poor rates of virological suppression after six-months than adult patients who were pregnant (56% vs. 85%, p 0.04).

In addition, viral load rebound was more frequent in adolescents and young adults than in older adults (56% vs. 13%, p = 0.002).

Almost half (44%) of those aged 17 to 24 were lost to follow-up compared to only 11% of older adults, a highly significant difference (p = 0.001).

Especially poor outcomes were seen in young African American patients.

Only 44% of this patient group had virological suppression after six months, compared to 71% of African American adults, 77% of non-African American adolescents and young adults, and 91% of non-African American adults.

High rates of viral load rebound were also seen in young African American patients (77% vs. 42% non-African American 17 to 24 year olds vs. 18% African American adults vs. 6% non-African American adults).

However, there were no significant differences in rates of six-month virologic control between the seven younger patients infected with HIV at birth and the 17 to 24 year olds infected with HIV through other means (57% vs. 59%).

The investigators suggest that “several factors render adolescents and young adults at higher risk of poor clinical outcomes,” including development issues, socioeconomic stresses, and HIV-related stigma.

Moreover, the investigators note “adolescents often experience feelings of invulnerability which can increase their risk of HIV acquisition, reduce rates of testing, and reinforce negative health care behaviors after diagnosis.”

A number of limitations are acknowledged by the investigators, including the study’s retrospective design and small sample size.

They also emphasise “our AYA clinic population included only a small group with perinatally-acquired HIV infection, a complex patient population whose outcomes may differ from behaviorally-infected AYA though this was not demonstrated in our study.”

Nevertheless, the researchers believe their findings have implications for the care provided to adolescents and young adults who are using adult HIV services.

They conclude, “these patients will benefit from careful study and additional resources directed to improve outcomes. Potential strategies to improve outcomes may include improved social support, provider training, and systems-based quality improvements.”