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Trends in ART Prescription and Viral Suppression Among HIV-Positive Young Adults in Care in the United States, 2009-2013 - "sustainably virally suppressed significantly increased (29%-46%)"
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JAIDS Sept 1 2017 - Beer, Linda PhD; Mattson, Christine L. PhD; Bradley, Heather PhD; Shouse, Roy L. MD; for the Medical Monitoring Project
Background: Only 13% of HIV-positive young adults are estimated to be virally suppressed and, even among those receiving medical care, HIV-positive young adults are less likely than older adults to take antiretroviral therapy (ART), be adherent, and be virally suppressed. We sought to examine trends in treatment and health outcomes from 2009 to 2013 among HIV-positive young adults (aged 18-24 years) in care.
Setting: The Medical Monitoring Project is a complex sample survey of HIV-infected adults receiving medical care in the United States.
Methods: We used weighted interview and medical record data collected from June 2009 to May 2014 to estimate trends in the prevalence of ART prescription, adherence, side effects, single-tablet ART regimens, regular care utilization, and viral suppression among young adults.
Results: From 2009 to 2013, there were significant increases in ART prescription (76%-87%) and the proportion of young adults taking ART who reported taking single-tablet regimens (49%-62%). There was no significant change in adherence, side effects, or regular care utilization. Although viral suppression at last test did not change (65% at both time periods), the proportion of young adults who were sustainably virally suppressed significantly increased (29%-46%) [sustained viral suppression (>200 copies/mL at all tests during past 12 months)]. Accounting for ART prescription and single-tablet regimen use attenuated the sustained viral suppression trend.
Conclusions: Although the level of viral suppression among young adults in care remains suboptimal, the observed increases in ART prescription and sustained viral suppression may be a cause for optimism regarding efforts to improve outcomes for this vulnerable population.
INTRODUCTION
HIV viral suppression is key to reducing the risk of HIV transmission, morbidity, and mortality,1,2 and thus it is crucial for prevention and care efforts. Only 13% of HIV-positive young adults are estimated to be virally suppressed3 and, even among those receiving medical care, HIV-positive young adults are less likely than older adults to take antiretroviral therapy (ART), be adherent, and be virally suppressed.4-6Agwu et al found evidence of increasing ART use and decreasing viremia from 2002 to 2010 among a cohort of youth living with HIV who were perinatally infected.7 Recent developments in HIV care and treatment may have improved levels of viral suppression more broadly among young adults. Clinical guidelines now recommend the universal prescription of ART, and simpler, more tolerable ART regimens that may be more forgiving of nonadherence have been developed.8-10 There has also been enhanced focus across medical, public health, and community groups on improving the HIV care continuum among youth.11-13 However, the effect of these developments among HIV-positive youth nationally is unknown.
This analysis was guided by the following questions: have recent developments in HIV care and treatment been accompanied by increased ART prescription, adherence, and care utilization among young adults in care? If so, have these changes contributed to improvements in viral suppression? To answer these questions, we estimated temporal trends in these factors among HIV-positive young adults in care in the United States from 2009 to 2013.
ART prescription among young adults significantly increased from 76% in 2009 to 87% in 2013 (βTREND = 0.04 PTREND = 0.01; Table 2). Among those taking ART, however, ART adherence and reported problems with side effects did not significantly change over the period. The proportion of young adults taking ART who reported taking a single-tablet regimen significantly increased from 49% in 2009 to 62% in 2013 (βTREND = 0.04 PTREND = 0.04). There was no significant change in regular care utilization over the period.
Although viral suppression at last test did not change over the period (65% in 2009 to 65% in 2013, βTREND = 0.02 PTREND = 0.22), the proportion of young adults who were sustainably virally suppressed significantly increased (29% in 2009 to 46% in 2013, βTREND = 0.05 PTREND ≤ 0.01). Figure 1 illustrates these findings. The proportion of young adults who were virally suppressed at their last test and had sustained viral suppression increased from 2009 to 2013, but there was no concomitant increase in those who were virally suppressed only at their last test. Instead, the proportion who were only virally suppressed at their last visit decreased over the period. Adjusting for the increasing proportion of men among young adults over the period did not change the sustained viral suppression trend (adjusted βTREND = 0.05 PTREND ≤ 0.01; data not shown in table). Accounting for ART prescription somewhat attenuated the sustained viral suppression trend (adjusted βTREND = 0.04, PTREND = 0.02), suggesting that some of the increase in sustained viral suppression was mediated by increased ART prescription. Adding to the model a variable measuring whether the person prescribed ART reported taking a single-tablet regimen further attenuated the sustained viral suppression trend (adjusted βTREND = 0.03, PTREND = 0.04).
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