Less than half of adolescents with HIV since birth in the US have an undetectable viral load

Engagement with the HIV care continuum among individuals with perinatally-acquired HIV in the United States falls well below targets, research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes shows. Only three-quarters received any HIV care, 61% were retained in care and 49% were virally suppressed. Those aged 18 to 25 years had especially low levels of engagement with the care continuum.

The investigators believe their findings show the importance of supporting adolescents with perinatally-acquired HIV (PHIV) to transition from paediatric to adult HIV care.

“The importance of successful transition cannot be overstated, as suboptimal transition has been associated with poor adherence and worse clinical outcomes, lower retention in care and viral suppression rates,” comment the authors. 

Glossary

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

continuum of care

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

antiretroviral resistance

A drug-resistant HIV strain is one which is less susceptible to the effects of one or more anti-HIV drugs because of an accumulation of HIV mutations in its genotype. Resistance can be the result of a poor adherence to treatment or of transmission of an already resistant virus.

Improvements in treatment and care mean that many individuals infected with HIV since birth now have an excellent prognosis. Nevertheless, they can face multiple clinical and psychological challenges that can potentially impact on HIV care outcomes, including stigma, mental health problems, poverty, housing instability and drug abuse.

However, little is known about engagement with the HIV care continuum – diagnosis, linkage to care, retention in care, viral suppression – among individuals with perinatally-acquired HIV (PHIV).

Investigators therefore designed a study to describe the characteristics and engagement in care of individuals with PHIV in the US at the end of 2015. Data were obtained from the National HIV Surveillance System covering 40 separate jurisdictions.

“To the best of our knowledge,” comment the authors, “this study represents the first to use national surveillance data to estimate outcomes along the HIV care continuum for persons living with PHIV in the United States.”

Receipt of HIV care was defined as having at least one CD4 cell count or viral load measurement in 2014; retention in care was two or more CD4/viral load tests at least three months apart during 2014; viral suppression was a viral load measurement below 200 copies/ml at any time during 2014.

By the end of 2015, there were 11,747 individuals with PHIV in the jurisdictions under analysis. Their ages ranged from 0 to 37 years, with a median of 21 years. Almost half (49%) were aged between 18 and 25 years, 21% were older than 26, and 15% aged between 13 and 17 years. Most resided in the South (40%) or Northeast (37%), were female (53%), black (58%) and born in the US and its dependent territories (85%).

A total of 9,562 individuals diagnosed with HIV by the end of 2014 were alive at the end of 2015 and had complete laboratory reporting.

Of these, 75% received some care and 61% were retained in care.

Receipt of care was highest among those aged under 6 years, with those aged 26 years and older having the lowest rate (83% vs. 71%). The proportion retained in care was also higher in those aged under 18 years. Females were a little more likely to be retained in care than males and Hispanic/Latinos had a higher prevalence of retention than whites.

A total of 73% of individuals had at least one viral load test in 2014 and 49% were virally suppressed. Viral load was suppressed in 67% of patients who had at least one viral load test by the end of 2015.

The prevalence of viral suppression was higher among the under-18s and those born outside the US. It was lower in black people.

The authors note that although these rates of retention and viral suppression exceed those observed among adult HIV patients in the US, they are nevertheless well below the 90% targets set by national and international strategies to end AIDS.

“A variety of issues can impede ART adherence and achievement of sustained viral suppression among youth. Viral suppression is impacted by adherence to ART, which tends to decrease as children with HIV age into adolescence and young adulthood, “write the investigators. “Youth living with PHIV can also develop antiretroviral resistance as a result of suboptimal regimens, frequent changes of regimens, and adherence difficulties.” The authors note that half the study sample were born before effective HIV therapy became available in the late 1990s.

“Future studies are needed to explore interventions with efficacy in closing the HIV continuum gap for this population,” conclude the authors. 

References

Gray KM et al. Characteristics and care outcomes among persons living with perinatally acquired HIV infection in the United States. J Acquir Immune Defic Syndr, online edition, doi: 10.1099/QAI.0000000000002091.