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The HIV Continuum of Care for Adolescents and Young Adults Attending 13 Urban US HIV Care Centers of the NICHD-ATN-CDC-HRSA SMILE Collaborative.....
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"Antiretroviral therapy (ART) was initiated among 474 (34%) and 166 (12%) achieved VS. Promptly referring youth for linkage to care (within the 3 month interval between HIV diagnosis and linkage services), was a significant predictor of achieving viral suppression and is consistent with findings from work with adults.19 This relationship was the strongest when linkage occurred in the shortest window (7 to 42 days) within that interval"
mean age was 20.6 ± 2.3 years, most were males (80%) and non-Hispanic black (72%) and 173 (24%) had previously been in care but had been lost to follow-up and were re-linked
"the low level of viral suppression [12%] among these recently-diagnosed youth (Figure 1b), despite the advent of simpler one pill, once daily regimens, is a source of concern.......It compares unfavorably with the 41.7% overall viral suppression rate among all persons living with diagnosed HIV from contemporaneous national MMP surveillance data22, or the 59.8% rate from the most recent NHSS report,13 or the agedisaggregated
rates in adults older than 24 that ranged 32.4 - 56.6% and 54.2 - 62.8%, respectively.......Low rates of ART initiation and viral suppression for this sample may also reflect a higher burden of psychosocial and socioeconomic comorbidities for HIV-positive youth in the urban centers where the SMILE clinics were located......compared to those for whom referral to care took more than 3 months from time of testing, those referred to care in shorter periods of time had twice the odds of achieving viral suppression (2.52: 1.50-4.23; 0.0005 for 1-6 weeks; 2.08: 1.08-4.04; 0.0294 for 6 weeks to 3 months)......Promptly referring youth for linkage to care (within the 3 month interval between HIV diagnosis and linkage services), was a significant predictor of achieving viral suppression and is consistent with findings from work with adults.19 This relationship was the strongest when linkage occurred in the shortest window (7 to 42 days) within that interval"
This multiagency SMILE collaborative demonstrated that a large national sample of HIVinfected youth who were not in care, most with new HIV diagnoses, had high levels of plasma viremia and advanced infection at presentation. These are consistent with earlier findings17 and highlight the urgency of addressing the high proportion of undiagnosed HIV-infected youth. While youth linked to HIV care at similar rates as adults once they were diagnosed,18,19 they achieved disproportionately lower rates of viral suppression, a major contributor to morbidity and secondary transmission events.20,21 Prompt referral to youth-friendly LTC services after HIV testing independently predicted VL suppression. These findings have implications for disease progression and transmission potential among this vulnerable group
JAIDS Jan 2020 - Kapogiannis, Bill G MDa; Koenig, Linda J PhDb; Xu, Jiahong PhDc; Mayer, Kenneth H MDd; Loeb, Jacqueline MBAc; Greenberg, Lauren PhDc; Monte, Dina RN, BSN, CCRCc; Banks-Shields, Marinna PhDe; Fortenberry, J Dennis MS, MDf the Adolescent Medicine Trials Network for HIV/AIDS Interventions
Abstract
Background:
Almost one-quarter of all new HIV diagnoses in the US occur among persons ages 13-24 years. These youths have the poorest HIV Care Continuum (HCC) outcomes, yet few empirical youth-specific data are available.
Methods:
The Strategic Multisite Initiative for the Identification, Linkage and Engagement in Care of HIV-infected youth (SMILE) helped HIV-infected (mostly newly-diagnosed) youth, ages 12-24 years, link to youth-friendly care, and evaluated each milestone of the HCC (10/2012-09/2014). Numbers of HIV-infected youth referred, linked, engaged and retained in care were recorded, along with socio-demographics. Viral suppression (VS) was defined as ≥ 1 HIV viral load (VL) below the level of detection (BLD) on study. Correlates of VS were examined using Cox Proportional Hazards models.
Results:
Among 1411 HIV-infected youth, 1053 (75%) were linked, 839 (59%) engaged and 473 (34%) retained in care at adolescent healthcare sites.
Antiretroviral therapy (ART) was initiated among 474 (34%) and 166 (12%) achieved VS.
Predictors of VS included lower VL at baseline [aHR 1.56 (95%CI:1.32-1.89), p<0.0001], recent ART receipt [aHR 3.10 (95%CI:1.86-5.18), p<0.0001], and shorter time from HIV testing until referral to linkage coordinator [aHR 2.52 (95%CI:1.50-4.23), p=0.0005 for 7 days to 6 weeks and aHR 2.08 (95%CI:1.08-4.04), p=0.0294 for 6 weeks to 3 months compared to >3 months].
Conclusions:
Whereas this large national sample of predominately newly-diagnosed youths linked to care at similar rates as adults, they achieved disproportionately lower rates of VS. Prompt referral to youth-friendly linkage services was an independent predictor of VS. Youth-focused interventions are urgently needed to improve their HCC outcomes.
Of the 1411 HIV-infected youth referred to the ATN LTC coordinator, 1053 (75%) were linked to care. Of those linked to care, 839 (80%) engaged in care and 473 (45%) were retained in care at an ATN site. ART was initiated among 474 of the 1053 adolescents who linked to care (45%); of those, 166 (35%) achieved viral suppression at least once during the study period and 152 (32%) had a suppressed VL at the last available measurement on study. Among these 166 youth, 114 (69%) achieved viral suppression during only one visit, an additional 52 (31%) achieved suppression for 2 or more visits. The HCC is shown in Figure 1b using the total sample of HIV-infected youth referred for care as the denominator. Among this group of predominantly newly diagnosed youth, 75% were linked to care, 59% were engaged in care, 34% each were retained in care and started on ART, and 12% achieved viral suppression after a median follow-up of 4.8 months.
The unadjusted relationship of socio-demographics, risk behavior, ART, healthcare utilization,
and data sharing agreements (between ATN sites and local public health authorities) to viral
suppression outcomes are shown in Table 2. There was a positive relationship (HR: 95% CI; p
value) between viral suppression and recent receipt of ART (2.54: 1.59-4.05; <0.001), lower VL
at LTC (1.33: 1.15-1.56; 0.0002), and access to case management services provided by non-ATN
staff (1.67: 1.02-2.73; 0.04) and a negative relationship with recent substance use (0.68: 0.48-
0.95; 0.024). In addition, relative to having a formal data sharing plan, having a limited plan with
sharing of de-identified information only [3.21: 1.80-5.71; <0.001] or having informal or no data
sharing plans [2.88: 1.67-4.99; 0.002]) were associated with viral suppression; as was having a
longer time between the EIC visit and the RIC visit (specifically, when the RIC visit was
between 6 months to 1 year from the EIC visit), compared to a shorter time period (1 to 3 months
[3.37: 1.23-9.19; 0.018]).
Independent predictors (aHR: 95% CI; p value) of viral suppression from the final multivariable
model are also shown in Table 2. For each log10 unit decrease in VL at LTC, there was an
approximately 1.6-fold increase in the likelihood of viral suppression (1.56: 1.32-1.89; <0.0001).
Additional independent predictors were recent receipt of ART (3.10: 1.86-5.18; <0.0001) and
either limited data sharing plans between testing centers and care providers (2.33: 1.22-4.47;
0.0106) or no formal/other sharing (2.78: 1.51-5.11; 0.001). Finally, compared to those for whom
referral to care took more than 3 months from time of testing, those referred to care in shorter
periods of time had twice the odds of achieving viral suppression (2.52: 1.50-4.23; 0.0005 for 1-
6 weeks; 2.08: 1.08-4.04; 0.0294 for 6 weeks to 3 months). Repeating this analysis among the
subset of newly diagnosed youth yielded similar results (data not shown).
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