Caring for youth living with HIV across the continuum: turning gaps into opportunities

Interventions for Improving HIV Care Continuum Outcomes Among LGBTQ+ Youth in the United States: A Narrative Review

Lesbian, gay, bisexual, transgender, queer, and all sexually and gender diverse (LGBTQ+) youth with HIV face multiple barriers to progression along the HIV care continuum. We searched PubMed, PsycInfo, clinicaltrials.gov, and the Adolescent Medicine Trials Network for HIV/AIDS Interventions for interventions focused on improving linkage to care, retention in care, adherence to antiretroviral therapy, or viral suppression (VS) among LGBTQ+ youth with HIV in the United States. Included studies were published in English between January 1, 2017 and December 31, 2022, took place in the United States, and had samples with a minimum age of 12 years, a median or mean age of 24 years or less, and with ≥50% reporting an LGBTQ+ identity. Our search identified 11 interventions that met our criteria, of which only three were designed and tailored exclusively for LGBTQ+ populations. Interventions used a variety of modalities, including remote electronic delivery, in-person delivery, or both. Interventions most commonly aimed to enhance self-efficacy, HIV health knowledge, and medication self-management to facilitate improvements in HIV care continuum outcomes. Only two interventions showed statistically significant improvements in VS. More interventions tailored for LGBTQ+ youth are needed to end the HIV epidemic in the United States.

Overview of the Epidemiology and Clinical Care Considerations for Adolescents and Young Adults Living with or at Risk of Human Immunodeficiency Virus

This article provides an updated examination of human immunodeficiency virus (HIV) epidemiologic trends among adolescents and young adults (AYAs) in the United States, highlighting the significant public health challenge posed by HIV within this demographic. Despite a notable decline in HIV diagnoses among AYAs, challenges remain, particularly due to 50% of AYAs living with HIV being unaware of their status. The article aims to evaluate current clinical recommendations, identify deficiencies, and propose evidence-based improvements for HIV prevention, diagnosis, and care, with the goal of enhancing health outcomes and reducing HIV prevalence among AYAs.

More than just Reminders: Using text Messaging to Improve HIV care Outcomes Among Youth and Young Adults Living with HIV

This study evaluated engagement, satisfaction, and efficacy of an automated and live two-way text messaging intervention that linked youth and young adults at high risk for poor HIV outcomes to their medical case managers, with the aims of increasing viral load suppression rates and improving medical visit attendance. Participants (N = 100) were an average age of 22-23 years old. Most were Black (93%) and men who have sex with men (82%). A total of 89,681 automated text messages were sent to participants; and 62% of participants engaged in monthly text-message exchanges with medical case managers. McNemar's test results indicated that a significantly greater proportion of intervention participants were virally suppressed at 6 and 12 month follow-up than at enrollment. Adjusted odds ratio results showed a significant association between likelihood of achieving viral suppression at 6 and 12 months, and a greater number of participant responses to automated text messages. Future research should prospectively compare outcomes between usual care case management and usual care plus text-messaging to test for significant differences between groups.

Experiences of Caring for Adolescents Living with HIV (ALHIV): A Qualitative Interview with Caregivers

Purpose

This study aims at exploring experiences of people caring for adolescents living with HIV, also known as caregivers. By 2021, 150,000 adolescents were living with HIV and 32,000 adolescents were dying of AIDS related causes. HIV/AIDS remains one of the most serious public health problems, especially among the adolescents. This has placed a heavy burden on many caregivers, yet they are essential in caring for ALHIV. However, focus of all interventions has excluded caregivers of ALHIV. Thus, this is the reason why this study is being conducted to find out caregivers' experience in caring for ALHIV.

Participants and Methods

A phenomenological study was carried out. Purposive sampling was used to select a total of 15 caregivers to participate in the study. These participants were subjected to in-depth semi-structured interviews. Their responses were recorded, transcribed and translated for thematic analysis.

Results

While analyzing the results, six themes emerged. They include: diagnosis and reaction to diagnosis, experiences on adolescent's HIV serostatus disclosure, stigma and discrimination, care disengagement, and lastly, challenges during care and coping strategies. Caregivers experienced feelings of fear, Guilt, suicidal thoughts after diagnosis. Stigma and discrimination of adolescents living with HIV which was common at school and from the neighbors and the adolescent stage were some of the challenges experienced by the caregivers and it makes it hard to retain ALHIV in care.

Conclusion

Families are the main source of caregiving to the adolescents living with HIV (ALHIV). The study's findings indicate that caregivers in the families experience challenges related to family needs, and psychological challenges resulting from the adolescence stage. So, families should not be left to shoulder the burden of caring for ALHIV. As a way forward, social network and financial support should also be strengthened for most caregivers as a coping strategy.

Antiretroviral therapy experience, satisfaction, and preferences among a diverse sample of young adults living with HIV

Youth and young adults living with HIV (YLWH) have a high HIV infection rate and suboptimal oral medication adherence. Biomedical researchers hope that long-acting antiretroviral therapy (LAART) modalities can help those who struggle with daily oral adherence. While adults living with HIV have expressed interest in LAART, little research has explored perspectives of YLWH. This study explores ART experiences and perspectives on LAART through qualitative interviews with twenty diverse YLWH (18-29) in the United States. Data were analyzed using framework analysis. Most participants were satisfied with their current ART yet had experienced side effects or had struggled with daily adherence. Preferences for improving daily oral ART included making pills smaller and reformulating ART into flavored chewable gummies. Most expressed enthusiasm for LAART, although needle aversion and previous injection drug use were potential barriers for some. Approximately half were interested in an ART patch, though its visibility and fear of stigmatization was concerning. Few expressed interest in implantable ART, calling it unappealing. Although younger people are most likely to benefit from these advancements in HIV treatment, additional research is needed to identify gaps in uptake and to further explore perspectives of YLWH to improve the success of new treatment modalities.

Advancing data to care strategies for persons with HIV using an innovative reconciliation process

Background

UN AIDS has set ambitious 95-95-95 HIV care continuum targets for global HIV elimination by 2030. The U.S. HIV Care Continuum in 2018 showed that 65% of persons with HIV(PWH) are virally suppressed and 58% retained in care. Incomplete care-engagement not only affects individual health but drives ongoing HIV transmission. Data to Care (D2C) is a strategy using public health surveillance data to identify and re-engage out-of-care (OOC) PWH. Optimization of this strategy is needed.

Setting

Statewide partnership with Connecticut Department of Public Health (CT DPH), 23 HIV clinics and Yale University School of Medicine (YSM). Our site was one of 3 participants in the CDC-sponsored RCT evaluating the efficacy of DPH-employed Disease Intervention Specialists (DIS) for re-engagement in care.

Methods

From 11/2016-7/2018, a data reconciliation process using public health surveillance and clinic visit data was used to identify patients eligible for randomization (defined as in-Care for 12 months and OOC for subsequent 6-months) to receive DIS intervention. Clinic staff further reviewed this list and designated those who would not be randomized based on established criteria.

Results

2958 patients were eligible for randomization; 655 (22.1%) were randomized. Reasons for non-randomizing included: well patient [499 (16.9%)]; recent visit [946 (32.0%)]; upcoming visit [398 (13.5%)]. Compared to non-randomized patients, those who were randomized were likely to be younger (mean age 46.1 vs. 51.6, p < .001), Black (40% vs 35%)/Hispanic (37% vs 32.8%) [(p < .001)], have CD4<200 cells/ul (15.9% vs 8.5%, p < .001) and viral load >20 copies/ml (43.8% vs. 24.1%, 0<0.001). Extrapolating these estimates to a statewide HIV care continuum suggests that only 8.3% of prevalent PWH are truly OOC.

Conclusions

A D2C process that integrated DPH surveillance and clinic data successfully refined the selection of newly OOC PWH eligible for DIS intervention. This approach more accurately reflects real world care engagement and can help prioritize DPH resources.

Determinants of health-related quality of life in young adults living with perinatally acquired HIV infection in Botswana

Background

Due to the successful antiretroviral therapy (ART) programme in Botswana, large numbers of perinatally HIV-infected adolescents are emerging into young adulthood. Young adulthood is a critical period of human development. However, there is lack of information on the factors affecting the health-related quality of life (HRQOL) of young adults living with perinatally acquired HIV (YALPH) in Botswana.

Objectives

The objective of this study was to assess the HRQOL and its determinants among YALPH who were enrolled on ART at Botswana-Baylor Children’s Clinical Centre of Excellence in Gaborone, Botswana.

Method

A cross-sectional study assessed the HRQOL of 509 YALPH aged 18–30 years using the WHOQOL-HIV BREF. Data about other variables of interest were abstracted from medical records. Bivariate analyses were performed using t and Chi-square tests to determine the associations between demographic and clinical variables and general HRQOL. The variables that were associated with the general HRQOL at P-value < 0.1 were included in the multivariable analysis using the logistic regression approach.

Results

The majority of participants had good general HRQOL (78.4%). The highest mean HRQOL score was in the Physical domain (5.4 [± 2.9]) and the lowest in the Environment domain (13.8 [± 2.7]). The factors that were significantly associated with the general HRQOL included: level of education attained (P = 0.012), employment status (P = 0.069), viral load suppression (P = 0.073) and self-reported illness (P = 0.001).

Conclusion

Interventions that effectively increase educational attainment, employment opportunities, ART adherence, and prevention or management of illness are needed to promote good HRQOL among YALPH in Botswana.

Point-of-care viral load testing among adolescents and young adults living with HIV in Haiti: a randomized control trial

HIV viral load (VL) monitoring can reinforce antiretroviral therapy (ART) adherence. Standard VL testing requires high laboratory capacity and coordination between clinic and laboratory which can delay results. A randomized trial comparing point-of-care (POC) VL testing to standard VL testing among 150 adolescents and young adults, ages 10-24 years, living with HIV in Haiti determined if POC VL testing could return faster results and improve ART adherence and viral suppression. Participants received a POC VL test with same-day result (POC arm) or a standard VL test with result given 1 month later (SOC arm). POC arm participants were more likely to receive a test result within 6 weeks than SOC arm participants (94.7% vs. 80.1%; p1000 copies/ml and low self-reported ART adherence was stronger in the POC arm (OR: 6.57; 95%CI: 2.12-25.21) than the SOC arm (OR: 2.62; 95%CI: 0.97-7.44) suggesting more accurate self-report in the POC arm. POC VL testing was effectively implemented in this low-resource setting with faster results and is a pragmatic intervention that may enable clinicians to identify those with high VL to provide enhanced counseling or regimen changes sooner.Trial registration: ClinicalTrials.gov identifier: NCT03288246.

Ethics of HIV cure research: an unfinished agenda

Background

The pursuit of a cure for HIV is a high priority for researchers, funding agencies, governments and people living with HIV (PLWH). To date, over 250 biomedical studies worldwide are or have been related to discovering a safe, effective, and scalable HIV cure, most of which are early translational research and experimental medicine. As HIV cure research increases, it is critical to identify and address the ethical challenges posed by this research.

Methods

We conducted a scoping review of the growing HIV cure research ethics literature, focusing on articles published in English peer-reviewed journals from 2013 to 2021. We extracted and summarized key developments in the ethics of HIV cure research. Twelve community advocates actively engaged in HIV cure research provided input on this summary and suggested areas warranting further ethical inquiry and foresight via email exchange and video conferencing.

Discussion

Despite substantial scholarship related to the ethics of HIV cure research, additional attention should focus on emerging issues in six categories of ethical issues: (1) social value (ongoing and emerging biomedical research and scalability considerations); (2) scientific validity (study design issues, such as the use of analytical treatment interruptions and placebos); (3) fair selection of participants (equity and justice considerations); (4) favorable benefit/risk balance (early phase research, benefit-risk balance, risk perception, psychological risks, and pediatric research); (5) informed consent (attention to language, decision-making, informed consent processes and scientific uncertainty); and (6) respect for enrolled participants and community (perspectives of people living with HIV and affected communities and representation).

Conclusion

HIV cure research ethics has an unfinished agenda. Scientific research and bioethics should work in tandem to advance ethical HIV cure research. Because the science of HIV cure research will continue to rapidly advance, ethical considerations of the major themes we identified will need to be revisited and refined over time.

Adolescents and young adults with early acquired HIV infection in the united states: unique challenges in treatment and secondary prevention

INTRODUCTION

Worldwide, children who acquired human immunodeficiency virus (HIV) at an early age, either perinatally or through blood transfusion, are reaching adolescence and adulthood due to successful antiretroviral treatment (ART). While many are thriving, a significant proportion face unprecedented multilevel challenges that can affect their long-term outcomes. Specifically, longstanding and poorly controlled HIV resulting from inadequate early regimens and nonadherence, along with the toxicities of some ART agents, can predispose them to sequelae including HIV-associated complications and other comorbidities.

AREAS COVERED

This paper reviews and summarizes the unique issues facing adolescents and young adults with early acquired HIV (AYA-EAHIV), including ART challenges, emerging comorbidities, and complications, including mental health comorbidities, secondary prevention, and transition from pediatric/adolescent to adult care.

EXPERT OPINION

AYA-EAHIV are a special population that have lived their entire lives with the physical and psychological toll of HIV mandating targeted and purposeful approaches to optimize their management and outcomes. Multifaceted inclusive and context-specific approaches focusing on heightened research, risk reduction interventions, and 'outside the box' thinking will be required to optimize treatment and reduce morbidity and mortality.

Reasons People Living with HIV Might Prefer Oral Daily Antiretroviral Therapy, Long-Acting Formulations, or Future HIV Remission Options

A growing body of research is beginning to elucidate reasons people living with HIV (PLWHIV) might prefer oral daily antiretroviral treatment (ART) compared with emerging long-acting ART (LA-ART) or HIV remission strategies under investigation. Our objective is to provide qualitative insights into the reasons why PLWHIV might prefer one of these HIV control therapies over others. From May to August 2018, we implemented a semistructured cross-sectional survey of PLWHIV in the United States to better understand patient preferences around various HIV treatment and remission options. Using free text, respondents were asked to explain why they preferred one HIV control option over the other two. We analyzed responses to the open-ended survey questions on reasons for preferring oral daily ART versus LA-ART versus HIV remission strategies using conventional content analysis. The results showed that PLWHIV preferred oral daily ART because of its familiarity and known safety and efficacy profile, whereas those who preferred LA-ART would value the convenience it offers. Finally, HIV remission strategies would be preferred to avoid taking ART altogether. The qualitative results provide insights into reasons why PLWHIV in the United States might prefer oral daily ART versus novel therapies. More importantly, they provide information to better align HIV virological control strategies with end-user perspectives. To make informed choices around evolving HIV therapeutics, PLWHIV and HIV care providers would benefit from decision tools to better assess options and trade-offs. More research is needed on how best to effectively support PLWHIV and HIV care providers in shared decision-making.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

Adherence Self-Management and the Influence of Contextual Factors Among Emerging Adults With Human Immunodeficiency Virus

BACKGROUND

Maintaining adherence to antiretroviral therapy (ART) is a significant challenge for human immunodeficiency virus (HIV)-infected racial and ethnic minority adolescents and young adults (youth). Given the consequences of suboptimal ART adherence, there is a pressing need for an expanded understanding of adherence behavior in this cohort.

OBJECTIVES

As part of an exploratory sequential, mixed-methods study, we used qualitative inquiry to explore adherence information, motivation, and behavioral skills among HIV-infected racial and ethnic minority youth. Our secondary aim was to gain an understanding of the contextual factors surrounding adherence behavior.

METHODS

The information-motivation-behavioral skills model (IMB model) was applied to identify the conceptual determinants of adherence behavior in our target population, along with attention to emergent themes. In-depth, individual, semistructured interviews, including open-ended questions with probes, were conducted with a convenience sample of HIV-infected racial and ethnic minority youth (ages 16-29 years), receiving ART and with evidence of virologic failure (i.e., detectable HIV viral load). New participants were interviewed until information redundancy was reached. Qualitative interviews were digitally recorded, transcribed verbatim, and analyzed using Atlas.ti (v8). Directed content analysis was performed to generate categories and broad themes. Coding was initially conceptually driven (IMB model) and shifted to a data-driven approach, allowing for the discovery of key contextual factors that influence adherence behavior in this population. Methodological rigor was ensured by member checks, an audit trail, thick descriptive data, and triangulation of data sources.

RESULTS

Twenty racial and ethnic minority participants (mean age = 24.3 years, 55.0% male) completed interviews. We found adherence information was understood in relation to HIV biomarkers; adherence motivation and behavioral skills were influenced by stigma and social context. We identified five primary themes regarding ART self-management: (a) emerging adulthood with a chronic illness, (b) stigma and disclosure concerns, (c) support systems and support deficits, (d) mental and behavioral health risks and challenges, and (e) mode of HIV transmission and perceptions of power and control.

DISCUSSION

Key constructs of the IMB model were applicable to participating HIV-infected youth yet did not fully explain the essence of adherence behavior. As such, we recommend expansion of current adherence models and frameworks to include known contextual factors associated with ART self-management among HIV-infected racial and ethnic minority youth.

Improving Timely Linkage to Care among Newly Diagnosed HIV-Infected Youth: Results of SMILE

Delayed linkage to care deprives youth living with HIV of the benefits of HIV treatment and risks increased HIV transmission. Developing and testing linkage-to-care models that are capable of simultaneously addressing structural and individual obstacles are necessary to attain national goals for timely linkage of newly diagnosed youth to care. We assessed an integrated, multi-pronged strategy for improving youth's timely linkage to care carried out in eight adolescent medicine clinical trials units (AMTUs) in the USA. In phase I, the intervention strategy paired intensive medical case management with formalized relationships to local health departments, including granting of public health authority (PHA) to four of the AMTUs. In phase II, local coalitions run by the AMTUs to address structural changes to meet youth's HIV prevention and HIV testing needs began to advocate for local structural changes to improve timely access to care. Results of an ARIMA model demonstrated sustained decline in the average number of days to link to care over a 6-year period (ARIMA (1,2,1) AIC = 245.74, BIC = 248.70, p < .01)). By the end of the study, approximately 90% of youth linked to care had an initial medical visit in 42 or fewer days post-diagnosis. PHA improved the timeliness of linkage to care (b = - 69.56, p < .05). A piecewise regression suggested the addition of structural change initiatives during phase II made a statistically significant contribution to reducing time to linkage over and above achievements attained via case management alone (F (3,19) = 5.48, p < .01; Adj. R² = .3794). Multi-level linkage-to-care interventions show promise for improving youth's timely access to HIV medical care.

Interest of Youth Living With HIV in Long-Acting Antiretrovirals

OBJECTIVES

This study's primary objective was to characterize attitudes to long-acting antiretrovirals (LAARV), among youth aged 13-24 years living with perinatally acquired HIV and nonperinatally acquired HIV. Secondary objectives included: assessing whether those with detectable HIV RNA PCR viral load had higher enthusiasm for LAARV compared to those with suppressed viral load, and examining characteristics associated with LAARV enthusiasm.

METHODS

A cross-sectional survey of 303 youth living with HIV (YHIV) followed at 4 pediatric/adolescent HIV clinics in the United States was performed to determine interest in LAARV, using a modified survey instrument previously used in adults. Interest in LAARV across groups was compared. Poisson regression with robust variance was used to determine the impact of various characteristics on interest in LAARV.

FINDINGS

Overall, 88% of YHIV reported probable or definite willingness to use LAARV. The enthusiasm level was similar between youth with perinatally acquired HIV and nonperinatally acquired HIV (P = 0.93). Youth with HIV viral load >1000 copies per milliliter had significantly higher interest than youth with suppressed viral load [prevalence ratio 1.12 (95% confidence interval: 1.03 to 1.20); P = 0.005]. Female youth participants who had had past experience with implantable contraceptive methods had a significantly higher interest in LAARV (100% vs. 85.5%; P = 0.002). Proportion of respondents endorsing definite willingness to use was significantly higher with decreased injection frequency compared with increased injection frequency.

INTERPRETATION

YHIV at 4 urban US pediatric/adolescent HIV clinics had high levels of enthusiasm for LAARV. LAARV should be given high priority as a potentially viable treatment option to improve clinical outcomes in YHIV.

Impact of a Youth-Focused Care Model on Retention and Virologic Suppression Among Young Adults With HIV Cared for in an Adult HIV Clinic

BACKGROUND

Young adults with HIV (YAHIV) are less likely to be retained in care or achieve viral suppression (VS) when seen in adult clinics. We assessed the outcomes of a youth-focused care model versus standard of care (SOC) within a large adult HIV clinic.

SETTING

The Accessing Care Early (ACE) program for YAHIV is embedded within an adult clinic. Eligibility for ACE includes age 18-30 years with ≥1 criteria: transfer from pediatric care, mental health diagnosis, substance use, or identified adherence barriers. Ineligible patients receive SOC.

METHODS

Retrospective analysis of patients entering ACE versus SOC from 2012 to 2014. Multivariable logistic regression assessed variables associated with retention and VS <200 copies per milliliter, and in separate analysis, clinical services utilization.

RESULTS

One hundred thirty-seven YAHIV entered care (2012-2014), 61 ACE and 76 SOC. Despite higher risk factors, ACE YAHIV were less likely to be lost to follow-up compared with SOC (16% versus 37%, P < 0.01). At 24 months, 49% in ACE versus 26% in SOC met the retention measure (P < 0.01). In adjusted analysis, ACE was associated with retention in care [AOR 3.26 (1.23-8.63)]. Of those meeting the retention measure, 60% of ACE versus 89% of SOC had VS [AOR 0.63 (0.35-1.14)]. Retention was associated with more frequent social work visits, nurse phone calls, and peer navigator interactions.

CONCLUSIONS

Higher risk ACE YAHIV had better retention than SOC YAHIV in an adult clinic. Improved retention did not lead to improved VS, underscoring the need for additional interventions to optimize VS for YAHIV.

Implementing a Comprehensive HCV Clinic within an HIV Clinic: A Model of Care for HCV Micro-elimination

BACKGROUND

Among the 1.2 M persons living with HIV in the United States, 25% are co- infected with HCV. The availability of effective direct antiviral agents (DAAs) makes the goal of HCV elimination feasible, but implementation requires improvements to the HCV treatment cascade, especially linkage to and initiation of treatment in underserved populations.

METHODS

In this retrospective review, a cohort of patients receiving care at a hospital-based HIV clinic in New Haven, CT (1/1/2014-3/31/2017) with chronic HCV infection not previously treated with DAAs were followed longitudinally. Patients were referred to a co-located multi-disciplinary team. Standardized referral and treatment algorithms, electronic medical record templates were developed; monthly meetings were held; a registry was created to review progress.

RESULTS

Of 173 patients, 140 (80.9%) were 50-70 years old; 115 (66.5%) male; 99 (57.2%) African-American, 43 (24.9%) White, 23 (13.3%) Hispanic. Comorbidities included: cirrhosis (25.4%); kidney disease (17.3%) mental health issues (60.7%); alcohol abuse (30.6%); active drug use (54.3%). Overall, 161 (93.1%) were referred, 147 (85%) linked, 122 (70.5%) prescribed DAAs, 97 (56.1%) had SVR12. Comparison between those with SVR12 and those unsuccessfully referred, linked or treated, showed that among those not-engaged in HCV care, there was a higher proportion of younger (mean age 54.2 vs 57 years old, p=0.022), female patients (p= 0.001) and a higher frequency of missed appointments.

CONCLUSIONS

Establishing a co-located HCV clinic within an HIV clinic resulted in treatment initiation in 70.5% and SVR12 in 56.1%. This success in a hard-to-treat population is a model for achieving WHO micro-elimination goals.