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US Youngsters Start Antiretrovirals Late and
Stop Early in HIV Research Network
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18th Conference on Retroviruses and Opportunistic Infections, February 27-March 2, 2011, Boston
Mark Mascolini
US teens and young adults with HIV start antiretroviral therapy late, and most stop or switch their regimen within a year [1]. Those findings emerged from a longitudinal study of 287 behaviorally infected young people by the HIV Research Network, a consortium of 18 pediatric and adults clinics that provide primary HIV care.
Although much research attention has turned to an aging HIV population, in the United States people from 15 to 24 make up the fastest-growing HIV-positive age cluster [2,3]. Adolescents and young adults have low HIV testing rates and are often slow to enter care or start antiretroviral therapy [4].
This HIV Research Network study involved HIV-positive 12- to 24-year-olds who enrolled in care and had at least two CD4 counts below 350, the threshold for starting antiretroviral therapy during the study period. No one had started antiretrovirals when follow-up began, and follow-up included only years in which a person had at least one CD4 count and one HIV primary care visit. All study participants were infected sexually or by injecting drugs. The study period ran from 2002 through 2008.
Median age stood at 21 (interquartile range 20 to 23), and 207 study participants (72%) were men or boys. Two thirds of the study group (67.6%) were black, 17.4% Hispanic, and 12.5% white. A small majority (58.2%) acquired HIV during gay sex, while 39% were infected heterosexually, and only 1.4% by injecting drugs.
While 209 of these young people (73%) had a CD4 count between 200 and 350 when they met study entry requirements, 78 (27%) had a CD4 count below 200. Most study participants, 62%, had at least four clinic visits during the year after having a CD4 count under 350. While 225 people (78%) attended an adult clinic, 62 (22%) went to a pediatric/adolescent clinic. One third of the group had public insurance, 8% had private insurance, and 58% had no insurance or only Ryan White Act support.
During the study period, 198 people (69%) started antiretroviral therapy, even though all of them qualified for treatment according to the then-current threshold of 350 CD4 cells. CD4 count and number of office visits were critical determinants of when antiretroviral therapy began: Median time to starting treatment was 56 days for people with a CD4 count below 200 and 336 days for those with a count between 200 and 350. For people who made four or more primary HIV care visits during the year after having a CD4 count under 350, median time to starting antiretrovirals stood at 156 days, compared with 712 days for those who made fewer visits.
Median duration of the first antiretroviral regimen was 356 days (IQR 125 to 937). Median duration was longer for youth treated in a pediatric/adolescent clinic than for those treated in an adult clinic (594 days versus 297 days). Among 117 people who stopped (57%) or switched (43%) antiretrovirals, 21 received care at pediatric clinics and 96 at adult clinics. Among 64 people in care during the year after they stopped therapy, 15 of 15 at pediatric clinics versus 38 of 49 (77.5%) at adult clinics resumed treatment (P = 0.04).
Multivariate analysis identified only two independent predictors of starting antiretroviral therapy. A CD4 count below 200 versus a count of 200 to 350 doubled chances of starting treatment (adjusted hazard ratio [AHR] 2.02, 95% confidence interval [CI] 1.40 to 2.90). And making at least four primary HIV clinic visits during the year after having a CD4 count under 350 more than doubled chances of starting therapy (AHR 2.23, 95% CI 1.50 to 3.31). Gender, race, HIV transmission risk, type of insurance, pediatric versus adult clinic, and year meeting treatment criteria did not affect chances of starting therapy in this analysis.
Only one variable independently predicted stopping or switching a first regimen: Treatment in an adult clinic versus a pediatric clinic doubled chances of stopping or switching (AHR 2.06, 95% CI 1.20 to 3.55). Factors that did not independently affect stopping or switching therapy were gender, race, CD4 count, and number of primary HIV care visits.
The correlation between number of primary HIV care visits in a year and starting antiretroviral therapy could reflect clinician concern that people who miss clinic appointments may adhere poorly to their antiretroviral regimen. The link between adult clinic attendance and a doubled risk of stopping or switching a first antiretroviral combination suggested to the researchers that "there may be an intrinsic difference in the interactions between behaviorally infected youth and the site of care" that could affect treatment outcomes. In this trials network, physicians at pediatric/adolescent clinics may be better prepared to coach youngsters through the first year of treatment. Or young adults in adult clinics may have had a rocky transition from pediatric care.
References
1. Agwu A, Rutstein R, Gaur A, et al. Starting late and stopping early: disparities in HAART utilization for behaviorally HIV-infected youth. 18th Conference on Retroviruses and Opportunistic Infections. February 27-March 2, 2011. Boston. Abstract 692.
2. Centers for Disease Control and Prevention. Diagnoses of HIV infection and AIDS in the United States and dependent areas, 2008. HIV Surveillance Report, Volume 20. http://www.cdc.gov/hiv/surveillance/resources/reports/2008report/index.htm.
3. Centers for Disease Control and Prevention. HIV/AIDS surveillance report: cases of HIV Infection and AIDS in the United States and dependent areas, 2007. February 18, 2009. http://www.cdc.gov/hiv/surveillance/resources/reports/2007report/.
4. Mascolini M. Finding solutions for HIV's lost generation: adolescents and young adults. RITA! 2010;15(2). http://www.centerforaids.org/pdfs/dec2010rita.pdf.
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