Characteristics and Care Outcomes Among Persons Living With Perinatally Acquired HIV Infection in the United States, 2015

High mortality in adolescents and young adults with perinatally-acquired HIV in Thailand during the transition to adulthood

Transitioning from pediatric to adult care remains a challenge for adolescents and young adults with perinatally-acquired HIV (AYA-PHIV). We assessed treatment outcomes and mortality among Thai AYA-PHIV. The study included AYA-PHIV who reached age 18-24 years who started antiretroviral treatment during childhood at five pediatric HIV clinics across Thailand. From November 2020-July 2021, data were gathered from a cohort database, medical records, and the Thai National AIDS Program. Of 811 eligible AYA-PHIV, 93% were alive; median age 22.3 years (IQR 20.6-23.7), treatment duration 16.1 years (IQR 13.4-18.0). Current HIV care was provided in adults (71%) and pediatric clinics (29%). Treatment regimens included non-nucleoside reverse transcriptase inhibitors (55%), protease inhibitors (36%), and integrase inhibitors (8%); 78% had HIV RNA <200 copies/ml. Of the 7.0% who died, median age at death was 20.8 years (IQR 20.6-22.1); 88% were AIDS-related death. Mortality after age 18 was 1.76 per 100-person years (95% confidence interval 1.36-2.28). Those with CD4 <200 cell/mm3 at age 15 had higher risk of mortality (adjusted hazard ratio 6.16, 95% CI 2.37-16.02). In conclusion, the high mortality among Thai AYA-PHIV indicated the need for better systems to support AYA-PHIV during the transition to adulthood.

An adapted algorithm for patient engagement in care for young people living with perinatal HIV in England

BACKGROUND

Evidence suggests that engagement in care (EIC) may be worse in young people living with perinatal HIV (YPLPHIV) compared to adults or children living with HIV. We took a published EIC algorithm for adults with HIV, which takes patients' clinical scenarios into account, and adapted it for use in YPLPHIV in England, to measure their EIC.

METHODS

The adult algorithm predicts when in the next 6 months the next clinic visit should be scheduled, based on routinely collected clinical indicators at the current visit. We updated the algorithm based on the latest adult guidelines at the time, and modified it for young people in paediatric care using the latest European paediatric guidelines. Paediatric/adolescent HIV consultants from the UK reviewed and adapted the resulting flowcharts. The adapted algorithm was applied to the Adolescent and Adults Living with Perinatal HIV (AALPHI) cohort in England. Data for 12 months following entry into AALPHI were used to predicted visits which were then compared to appointment attendances, to measure whether young people were in care in each month. Proxy markers (e.g. dates of CD4 counts, viral loads (VL)) were used to indicate appointment attendance.

RESULTS

Three hundred sixteen patients were in AALPHI, of whom 41% were male, 82% of black African ethnicity and 58% born abroad. At baseline (time of AALPHI interview) median [IQR] age was 17 [15-18] years, median CD4 was 597 [427, 791] cells/µL and 69% had VL ≤50c/mL. 10 patients were dropped due to missing data. 306 YPLPHIV contributed 3,585 person months of follow up across the 12 month study in which a clinic visit was recorded for 1,204 months (38/1204 dropped due to missing data). The remaining 1,166 months were classified into 3 groups: Group-A: on ART, VL ≤ 50c/mL-63%(734/1,166) visit months, Group-B: on ART, VL > 50c/mL-27%(320/1,166) Group-C: not on ART-10%(112/1,166). Most patients were engaged in care with 87% (3,126/3,585) of months fulfilling the definition of engaged in care.

CONCLUSIONS

The adapted algorithm allowed the varying clinical scenarios of YPLPHIV to be taken into account when measuring EIC. However availability of good quality surveillance data is crucial to ensure that EIC can be measured well.

Sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression in the Miami-Dade County Ryan White Program, 2017

This exploratory study examined sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression (SVS). The study population included 6,489 Miami-Dade Ryan White Program (RWP) clients receiving services during 2017; administrative data was analyzed. SVS was defined as having all viral load tests during 2017 below 200 copies/ml. Multilevel logistic regression models accounted for clustering by medical case management site. Models were stratified by sex. Overall, a higher proportion of females did not achieve SVS (23.5%) than males (18.1%). For females (n = 1,503), having acquired HIV perinatally and not having a partner oradult household member were associated with not achieving SVS. For males (n = 4,986), lacking access to food, Black or Haitian race/ethnicity, problematic substance use, and unknown physician were associated with not achieving SVS. For both sexes, younger age, lower household income, ever having an AIDS diagnosis, feeling depressed or anxious, and experiencing homelessness were associated with not achieving SVS. Elements of the transition from adolescent to adult HIV care that may differentially impact female clients and factors associated with disclosure should be explored further. Male clients may require additional support for food security. Improving culturally specific care for Haitian and non-Hispanic Black male clients should also be explored.

Durable Viral Suppression Among Young Adults Living with HIV Receiving Ryan White Services in New York City

Identifying factors associated with durable viral suppression (DVS) can inform interventions to support young adults living with HIV (YALWH) in sustaining optimal health. We examined associations between client characteristics and DVS among YALWH aged 18-29 who completed an intake assessment and received ≥ 1 Ryan White Part A service in New York City from 1/2017 to 12/2019. Individuals were classified as achieving DVS at least once if they had ≥ 2 suppressed viral load test results ≥ 90 days apart with: (a) no intervening unsuppressed viral load test results in a 12-month period; and (b) no unsuppressed viral load test results after achieving DVS in that 12-month period. Of 2208 YALWH, 92.1% (n = 2034) had sufficient data in the New York City HIV Surveillance Registry to ascertain DVS status. Of these, 68% achieved DVS at least once. Controlling for ART prescription status at intake, YALWH with higher incomes were significantly more likely to achieve DVS at least once. YALWH with lifetime and recent histories of incarceration and/or drug use were significantly less likely to achieve DVS. Our findings underscore the potential role of tailored harm reduction and post-incarceration programs in reducing health inequities among YALWH.

Navigating Stigma Trajectory and Mental Health Among Young Adults Living with Perinatal HIV in New York City

Perceived HIV stigma and mental health are fluid across the lifespan for people living with perinatally-acquired HIV (PHIV). The process of navigating discredited identities over time in the context of other life demands potentially exerts a toll on the mental health of adolescents and young adults living with PHIV (AYAPHIV). Based on data from a longitudinal study in New York City examining mental health and health risk behaviors among 182 AYAPHIV, we examined if increased perceived HIV stigma predicted mental health, future orientation, HIV-disclosure, and healthcare transition over time (2003-2018). Findings from linear mixed-effects modeling indicated that older age predicted poorer mental health, less future orientation, more HIV-serostatus disclosure, and adult medical services utilization. Perceived stigma was the only significant predictor of mental health and mediated the association between age and mental health-highlighting the importance of addressing stigma across development for AYAPHIV while addressing systems that perpetuate them.

Differential Role of Psychosocial, Health Care System and Neighborhood Factors on the Retention in HIV Care of Women and Men in the Ryan White Program

We investigated potential differential impact of barriers to HIV care retention among women relative to men. Client intake, health assessment, service, and laboratory information among clients receiving medical case management during 2017 in the Miami-Dade County Ryan White Program (RWP) were obtained and linked to American Community Survey data by ZIP code. Cross-classified multilevel logistic regression analysis was conducted. Among 1609 women and 5330 men, 84.6% and 83.7% were retained in care. While simultaneously controlling for all demographic characteristics, vulnerable/enabling factors, and neighborhood indices in the model, younger age, being US born, not working, and having a medical provider with low volume (<10) of clients remained associated with non-retention in care among women and men; while having ≥3 minors in the household and being perinatally infected were additionally associated with retention only for women. Both gender-specific and gender-non-specific barriers should be considered in efforts to achieve higher retention rates.

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.

Transition of children with life-limiting conditions to adult care and healthcare use: a systematic review

BACKGROUND

Improved survival has led to increasing numbers of children with life-limiting conditions transitioning to adult healthcare services. There are concerns that transition may lead to a reduction in care quality and increases in emergency care. This review explores evidence for differences in health or social care use post- versus pre-transition to adult services.

METHODS

MEDLINE, EMBASE, CINAHL, PsychINFO and Social Science Citation Index were searched. Studies published in English since 1990 including individuals with any life-limiting condition post- and pre-transition and reporting a health or social care use outcome were included. Data were extracted and quality assessed by one reviewer with 30% checked by an independent reviewer.

RESULTS

Nineteen papers (18 studies) met the inclusion criteria. There was evidence for both increases and decreases (post- versus pre-transition) in outpatient attendance, inpatient admissions, inpatient bed days and health service costs; for increases in Emergency Department visits and for decreases in individuals receiving physiotherapy.

CONCLUSIONS

Evidence for changes in healthcare use post- versus pre-transition is mixed and conflicting, although there is evidence for an increase in Emergency Department visits and a reduction in access to physiotherapy. More high-quality research is needed to better link changes in care to the transition.

IMPACT

Evidence for changes in healthcare use associated with transition to adult services is conflicting. Emergency Department visits increase and access to physiotherapy decreases at transition. There are marked differences between care patterns in the United States and Canada.