HIV-infected Young Adults Research Articles

Treatment Outcomes of HIV-Infected Adolescents Attending Public-Sector HIV Clinics Across Gauteng and Mpumalanga, South Africa

There is little evidence comparing treatment outcomes between adolescents and other age groups, particularly in resource-limited settings. A retrospective analysis of data from seven HIV clinics across urban Gauteng (n=5) and rural Mpumalanga (n=2), South Africa was conducted. The analysis compared HIV-positive antiretroviral treatment (ART)-naive young adolescents (10-14 years), older adolescents (15-19), and young adults (20-24 years) to adults (≥25 years) initiated onto standard first-line ART between April 2004 and August 2010. Log-binomial regression was used to estimate relative risk (RR) of failure to suppress viral load (≥400 copies/ml) or failure to achieve an adequate CD4 response at 6 or 12 months. The effect of age group on virological failure, mortality, and loss to follow-up (LTFU; ≥90 days since scheduled visit date) was estimated using Cox proportional hazards models. Of 42,427 patients initiating ART, 310 (0.7%) were young adolescents, 342 (0.8%) were older adolescents, and 1599 (3.8%) were young adults. Adolescents were similar to adults in terms of proportion male, baseline CD4 count, hemoglobin, and TB. Compared to adults, both older adolescents (6 months RR 1.75 95% CI 1.25-2.47) and young adults (6 months RR 1.33 95% CI 1.10-1.60 and 12 months RR 1.64 95% CI 1.23-2.19) were more likely to have an unsuppressed viral load and were more likely to fail virologically (HR 2.90 95% CI 1.74-4.86; HR 2.94 95% CI 1.63-5.31). Among those that died or were LTFU, the median time from ART initiation until death or LTFU was 4.7 months (IQR 1.5-13.2) and 10.9 months (IQR 5.0-22.7), respectively. There was no difference in risk of mortality by age category, compared to adults. Young adolescents were less likely to be LTFU at any time period after ART initiation (HR 0.43 95% CI 0.26-0.69) whereas older adolescents and young adults were more likely to be LTFU after ART initiation (HR 1.78 95% CI 1.34-2.36; HR 1.63 95% CI 1.41-1.89) compared to adults. HIV-infected adolescents and young adults between 15 and 24 years have poorer ART treatment outcomes in terms of virological response, LTFU, and virological failure than adults receiving ART. Interventions are needed to help improve outcomes and retention in care in this unique population.

Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic

To the Editor—We read with great interest the study by Moore et al [1], which showed that among human immunodeficiency virus (HIV)–infected adults followed at Moore Clinic during 1996–2012, there were no significant differences in virologic, immunologic, or HIV clinical outcomes by race/ethnicity. The study was of particular interest because the Moore clinic population is analogous to ours. We report findings from the CORE Center, Chicago, that describe differences in the rate of engagement in care and virologic suppression by demographic characteristics. The CORE Center is the largest HIV care center in the Midwest and provides care to a large number of ethnic minorities, many uninsured. The CORE Center provides comprehensive primary care including extensive psychosocial support. Access to visits and antiretrovirals are available regardless of insurance status or ability to pay. We performed a cross-sectional electronic medical record review of patients ≥13 years of age who had ≥1 clinic visit at the CORE Center in 2010. Engagement in care was defined as having ≥2 HIV RNA measurements in 2010 and viral suppression as having ≥2 undetectable HIV RNA measurements (<75 copies/mL) in 2010. Factors associated with nonengagement and viral nonsuppression (VNS) were assessed by multivariable logistic regression controlling for age, race/ethnicity, and sex. Engagement in Care A total of 4810 HIV-infected patients had ≥1 clinic visit at the CORE center in 2010; 3572 (74%) were male, 65% non-Hispanic black, 20% Hispanic, and 12% non-Hispanic white. The median age was 45 years, the median CD4 count was 401 cells/mm3, and 71% had undetectable HIV RNA; 1286 (27%) were not actively engaged in care. Nonengaged patients were younger and more likely to be black (Table ​(Table1).1). They also had lower rates of virologic suppression (50% vs 78%; P < .0001), and lower CD4 counts (335 vs 412 cells/mm3; P < .0001). Table 1. Multivariable Logistic Regression: Factors Associated With Not Being Actively Engaged in Care Among HIV-Infected Patients at CORE in 2010 (n = 4577) Virologic Suppression Of the 3524 patients engaged in care, 2499 (71%) were suppressed. Patients who had VNS were more likely to be young, female, and black compared to suppressed patients (Table ​(Table2).2). Patients with VNS had lower median CD4 counts (300 vs 456 cells/mm3; P < .0001). Table 2. Multivariable Logistic Regression: Factors Associated With Viral Nonsuppression Among Patients in Care at CORE in 2010 (n = 3342) While overall rates of viral suppression were relatively high at 71%, we found significant differences in rates of engagement in care and viral suppression by demographic characteristics. The lower rate of active engagement among young, non-Hispanic black patients contributes to the documented racial disparities in HIV prevalence in Chicago and other communities across the United States. Among patients engaged in care, non-Hispanic black race, younger age, and being female were independently associated with viral nonsuppression. In both analyses, age 13–24 years was independently associated with poor outcomes, highlighting the need for new and innovative methods for engaging and retaining HIV-infected young adults in care. This initial study allows us to define subgroups within the larger CORE population who require targeted interventions. Our clinic model and diverse population, similar to the Moore clinic, allows us to actively study and address these disparities. Interventions to improve engagement in care and viral suppression are necessary to reduce health-related disparities and achieve the full salutary effect of treatment as prevention in Chicago.

Cardiac effects in perinatally HIV‐infected and HIV‐exposed but uninfected children and adolescents: a view from the United States of America

IntroductionHuman immunodeficiency virus (HIV) infection is a primary cause of acquired heart disease, particularly of accelerated atherosclerosis, symptomatic heart failure, and pulmonary arterial hypertension. Cardiac complications often occur in late-stage HIV infections as prolonged viral infection is becoming more relevant as longevity improves. Thus, multi-agent HIV therapies that help sustain life may also increase the risk of cardiovascular events and accelerated atherosclerosis.DiscussionBefore highly active antiretroviral therapy (HAART), the two-to-five-year incidence of symptomatic heart failure ranged from 4 to 28% in HIV patients. Patients both before and after HAART also frequently have asymptomatic abnormalities in cardiovascular structure. Echocardiographic measurements indicate left ventricular (LV) systolic dysfunction in 18%, LV hypertrophy in 6.5%, and left atrial dilation in 40% of patients followed on HAART therapy. Diastolic dysfunction is also common in long-term survivors of HIV infection. Accelerated atherosclerosis has been found in HIV-infected young adults and children without traditional coronary risk factors. Infective endocarditis, although rare in children, has high mortality in late-stage AIDS patients with poor nutritional status and severely compromised immune systems. Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare. Rates of congenital cardiovascular malformations range from 5.6 to 8.9% in cohorts of HIV-uninfected and HIV-infected children with HIV-infected mothers. In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.ConclusionsRoutine, systematic, and comprehensive cardiac evaluation, including a thorough history and directed laboratory assays, is essential for the care of HIV-infected adults and children as cardiovascular illness has become a part of care for long-term survivors of HIV infection. The history should include traditional risk factors for atherosclerosis, prior opportunistic infections, environmental exposures, and therapeutic and illicit drug use. Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load. Asymptomatic cardiac disease related to HIV can be fatal, and secondary effects of HIV infection often disguise cardiac symptoms, so systematic echocardiographic monitoring is warranted.

Barriers to medication adherence in behaviorally and perinatally infected youth living with HIV.

The study explored barriers to antiretroviral medication adherence in perinatally and behaviorally HIV infected adolescents and young adults in a cross-sectional, multisite sample. The study included a subset of a convenience sample from a cross-sectional analysis. Participants were youth with HIV ages 12-24 who were prescribed HIV medication and reported missing medication in the past 7 days (n = 484, 28.4 % of protocol sample). The top barriers were similar for perinatally and behaviorally infected youth, but perinatally infected youth reported significantly more barriers. Forgetting, not feeling like taking medication and not wanting to be reminded of HIV infection were the most common barriers reported. Number of barriers was significantly correlated with percent of doses missed, viral load, and psychological distress for perinatally infected youth and with doses missed, psychological distress, and substance use for behaviorally infected youth. Interventions to improve adherence to HIV medications should not only address forgetfulness and choosing not to take medications, but also consider route of infection.

Experiences of young adults growing up with innate or early acquired HIV infection – a qualitative study

To explore the experience of young adults growing up and living with HIV in urban Sweden. HIV has become a widespread pandemic. Effective antiretroviral treatment has dramatically increased the survival rate of infected individuals, such that HIV infection is currently considered a chronic disease where treatment is available. Data concerning the experience of living with HIV since early childhood is scarce and more empirical knowledge is needed to direct the development of adequate care and interventions for this growing demographic. Exploratory qualitative study. Semi-structured interviews were conducted with ten HIV-infected young adults over the period from January-August 2008. Transcripts of the interviews were analysed using qualitative content analysis. The analysis revealed five categories illustrating the experiences of growing up and living with HIV in Sweden: (1) to protect oneself from the risk of being stigmatized; (2) to be in control; (3) losses in life, but HIV is not a big deal; (4) health care/healthcare providers; and (5) belief in the future. It is essential to offer a safe, trustworthy, and professional healthcare environment during the upbringing of HIV-infected children. Evidence-based interventions are needed to improve care and support, particularly about the handling of stigma and discrimination.

Immunogenicity of a meningococcal serogroup C conjugate vaccine in HIV-infected children, adolescents, and young adults

Children and adolescents infected with HIV typically have a lower response to immunization than do those in the general population. In most developed countries, meningococcal serogroup C conjugate vaccine is one of the recommended vaccines for such individuals. However, there have been no studies evaluating the antibody response to this vaccine in HIV-infected children, adolescents or young adults. In this study, we evaluated that response using serum bactericidal antibody (SBA) and enzyme-linked immunosorbent assay, comparing HIV-infected with non-HIV-infected patients, as well as analysing the occurrence of side effects. In non-responders, we assessed the antibody response to revaccination. This clinical trial involved 92 patients between 10 and 20years of age: 43 HIV-infected patients (HIV+ group) and 49 non-HIV-infected patients (HIV− group). After one dose of the vaccine, 72.1% of the HIV+ group patients and 100% of the HIV− group patients were considered protected. Of the HIV+ group patients who received a second dose of the vaccine, only 40% acquired protection. Overall, 81.4% of the HIV+ group patients acquired protection (after one or two doses of the vaccine). Side effects occurred in 16.3% and 44% of the HIV+ group and HIV− group patients, respectively. Therefore, the meningococcal serogroup C conjugate vaccine proved to be safe and effective for use in HIV-infected children, adolescents, and young adults, although their antibody response was weaker than that shown by non-HIV-infected patients. This indicates the need to discuss changes to the immunization schedule for children, adolescents, and young adults infected with HIV, in order to ensure more effective protection against meningococcal disease.

Human Papillomavirus Vaccines: Where Do They Fit in HIV-Infected Individuals?

Human papillomavirus (HPV) is the etiological agent for cervical cancer and a large majority of anal cancers worldwide. In 2006 two preventive vaccines against the HPV were approved by the US Food and Drug Administration and have since been approved in over 100 countries. HIV-infected populations are at an increased risk for HPV-related cancers. None of the efficacy trials for these vaccines included HIV-infected populations. However, studies in HIV-infected children and adult men show that the vaccine is safe and highly immunogenic. Studies evaluating the vaccine in HIV-infected women are in progress. Based on these studies, the American Council on Immunization Practices recommends HPV vaccination for all HIV-infected children and young adults up to age 26 years. HPV vaccine policies in resource-limited countries, many of which have a high prevalence of HIV infection, are still being developed. Future studies should examine the role of HPV vaccination for older HIV-infected adults who likely have ongoing HPV infection.

Reproductive Health Decision-Making in Perinatally HIV-Infected Adolescents and Young Adults

With widespread access to antiretroviral therapy in the United States, many perinatally HIV-infected (PHIV+) children are surviving into adolescence and adulthood, becoming sexually active and making decisions about their reproductive health. The literature focusing on the reproductive decisions of individuals behaviorally infected with HIV can serve as a springboard for understanding the decision-making process of PHIV+ youth. Yet, there are many differences that critically distinguish reproductive health and related decision-making of PHIV+ youth. Given the potential public health implications of their reproductive decisions, better understanding of factors influencing the decision-making process is needed to help inform the development of salient treatment and prevention interventions. To begin addressing this understudied area, a "think tank" session, comprised of clinicians, medical providers, and researchers with expertise in the area of adolescent HIV, was held in Bethesda, MD, on September 21, 2011. The focus was to explore what is known about factors that influence the reproductive decision-making of PHIV+ adolescents and young adults, determine what important data are needed in order to develop appropriate intervention for PHIV+ youth having children, and to recommend future directions for the field in terms of designing and carrying out collaborative studies. In this report, we summarize the findings from this meeting. The paper is organized around the key themes that emerged, including utilizing a developmental perspective to create an operational definition of reproductive decision-making, integration of psychosocial services with medical management, and how to design future research studies. Case examples are presented and model program components proposed.

A Meta-Analysis of Adherence to Antiretroviral Therapy and Virologic Responses in HIV-Infected Children, Adolescents, and Young Adults

The relationship between adherence to antiretroviral therapy (ART) and virologic outcomes in HIV+ children, adolescents, and young adults has been notably understudied, with much of the extant research focused on specific sub-literatures, such as resource-limited regions, specific clinical outcomes and time frames. The authors sought to better characterize the relationship between adherence to ART and virologic functioning along various sample and methodological factors. The authors conducted a meta-analysis of thirty-seven studies and utilized a random effects model to generate weighted mean effect sizes. In addition, the authors conducted meta-ANOVAs to examine potential factors influencing the relationship between adherence and three categories of clinical outcomes, specifically Viral Load (VL) <100, VL < 400, and continuously measured VL. The analyses included 5,344 HIV+ children, adolescents, and young adults. The relationship between adherence behaviors and virologic outcomes varied across different methods of measurement and analysis. The relationship between adherence and continuously measured VL was significantly larger than for dichotomously-coded VL < 400 at Qb (20.69(1), p < .0005). Caregiver self-report indices elicited very small to small magnitude effects across both VL < 100 and VL < 400 outcomes and combined informant reporting (youth/adolescent and parent) produced significantly larger effects than caregiver report alone with adherence and VL < 400 outcomes at Qb (9.28(1), p < .005). More recently published trials reported smaller relationships between adherence and categorical clinical outcomes, such that year of publication significantly negatively correlated with VL < 100 (r = -.71(14), p < .005) and VL < 400 (r = -.43(26), p < .02). The data suggest that the magnitude of the relationship between ART adherence and virologic outcomes among heterogeneous samples of HIV+ children, adolescents and young adults varies across virologic outcomes and may be affected by moderating sample and methodological factors. Methodological and research recommendations for the interpretation of the current findings as well as for future HIV adherence related research are presented.

Using Cluster Heat Maps to Investigate Relationships Between Body Composition and Laboratory Measurements in HIV-Infected and HIV-Uninfected Children and Young Adults

Cluster heat maps were used to investigate relationships between body composition, lipid levels, and glucose metabolism in HIV-infected and HIV-uninfected children and young adults using data from a cross-sectional study. Three distinct clusters of participants were identified. One group had lower body fat and higher lipid measures and was mostly HIV infected. The other 2 groups were a mix of HIV-infected and HIV-uninfected participants. Of these, 1 cluster had more participants with higher body fat and insulin resistance, which are risk factors for future cardiovascular disease, and the other had relatively normal measurements on all outcomes.

Safety and immunogenicity of a monovalent MF59®-adjuvanted A/H1N1 vaccine in HIV-infected children and young adults

BackgroundThis Phase IV study evaluated the safety and immunogenicity of a two-dose, MF59®-adjuvanted (Novartis Vaccines, Marburg, Germany), monovalent, A/H1N1 pandemic influenza vaccination schedule in Human Immunodeficiency Virus (HIV) positive children and young adults. MethodsA total of 83 children infected with HIV-1, and 37 non-immunocompromised, age-matched controls were enrolled. All participants received two vaccine doses administered three weeks apart. Antibody responses were assessed by haemagglutination assay at baseline, three weeks after each vaccine dose, and six months after immunization. Vaccines were evaluated according to European influenza vaccine licensure criteria. ResultsThe investigational vaccine was well tolerated. After the first vaccine dose, seroconversion rates were significantly lower in HIV-positive patients (60%) than controls (82%), with GMTs of 419 and 600, respectively. No significant differences in seroconversion rates were observed between the two study groups in response to the second vaccine dose. Persisting antibody titers were similar for both HIV-positive and non-infected controls, six months after immunization. ConclusionOne dose of MF59-adjuvanted vaccine was sufficient to provide adequate levels of seroprotection against A/H1N1 influenza disease in HIV-positive children. However, a two-dose vaccination schedule may be optimal for this population.

Updated AAP Policy Statement Promotes Routine HIV Testing in Adolescents

Almost half of HIV-infected adolescents and young adults are unaware of their infection. Failure to identify these youth contributes to the ongoing

Clinical Outcomes of Adolescents and Young Adults in Adult HIV Care

We sought to describe virologic and clinical retention outcomes among a group of HIV-infected adolescents and young adults (AYA) newly established in an adult HIV clinic compared with matched HIV-infected adults. AYA demonstrated lower rates of HIV-1 virologic suppression and higher rates of HIV-1 viral rebound and loss to follow-up compared with adults. African American AYA had the lowest rates of virologic suppression and the highest rates of viral rebound. Adult providers should consider HIV-infected AYA, particularly African American HIV-infected AYA, to potentially be at high risk for poor clinical outcomes in adult care.

Development of Evidence-Based Exercise Recommendations for Older HIV-Infected Patients

Advances in antiretroviral therapy (ART) have decreased HIV-related morbidity and mortality and contributed to rapidly increasing numbers of older people living with HIV. Successful management of ART-related side effects (metabolic syndrome) and age-related comorbidities (frailty) are major challenges for patients and providers. Exercise has proven beneficial for younger HIV-infected patients, but we know little about which exercise regimens to recommend to the elderly. Our goal was to develop age-appropriate, evidence-based exercise recommendations for older HIV-infected adults (age > 50). We reviewed randomized controlled trials on the effects of physical exercise for: (a) HIV-infected young adults, (b) frail older adults, and (c) elderly individuals with metabolic syndrome. We recommend a combination of endurance and resistance exercises 3 times per week for at least 6 weeks to improve cardiovascular, metabolic, and muscle function. Further research is warranted to study the benefits and risks of physical exercise in older HIV-infected patients.

Long-Term Immunogenicity after One and Two Doses of a Monovalent MF59-Adjuvanted A/H1N1 Influenza Virus Vaccine Coadministered with the Seasonal 2009-2010 Nonadjuvanted Influenza Virus Vaccine in HIV-Infected Children, Adolescents, and Young Adults in a Randomized Controlled Trial

Few data are available on the safety and long-term immunogenicity of A/H1N1 pandemic influenza vaccines for HIV-infected pediatric patients. We performed a randomized controlled trial to evaluate the safety and long-term immunogenicity of 1 versus 2 doses of the 2009 monovalent pandemic influenza A/H1N1 MF59-adjuvanted vaccine (PV) coadministered with the seasonal 2009-2010 trivalent nonadjuvanted influenza vaccine (SV) to HIV-infected children, adolescents, and young adults. A total of 66 HIV-infected patients aged 9 to 26 years were randomized to receive one (group 1) or two (group 2) doses of PV coadministered with 1 dose of SV. The main outcome was the seroconversion rate for PV at 1 month. Secondary outcomes were the geometric mean titer ratios and the seroprotection rates at 1 month for all vaccines, seroconversion rates at 1 month for SV, and longitudinal changes of antibody titers (ABTs) at 1, 2, 6, and 12 months for all vaccines. Groups 1 and 2 had similar CD4 counts and HIV RNA levels during the study. The seroconversion rate for PV was 100% at 1 month in both groups. ABTs for PV were high during the first 6 months and declined below seroprotection levels thereafter. Longitudinal changes in ABTs were similar in groups 1 and 2 for both PV and SV. The side effects of vaccination were mild and mostly local. In HIV-infected children, adolescents, and young adults, the immune response triggered by a single dose of PV was similar to that obtained with a double dose and was associated with long-term antibody response.

Life Expectancy in Africa: Back to the Future?

In this issue, Mills and colleagues, using models based on patient-level data, conclude that life expectancy for young HIV-infected adults in Uganda who initiate combination antiretroviral therapy ...

Long-Term Renal Safety of Tenofovir Disoproxil Fumarate in Vertically HIV-Infected Children, Adolescents and Young Adults

Background and Objective: Sporadic cases of renal toxicity have been reported in HIV-infected children treated with tenofovir disoproxil fumarate (TDF). We assessed the long-term renal safety of TDF in a cohort of vertically HIV-infected children, adolescents and young adults. Methods: We evaluated 26 HIV-infected children, adolescents and young adults, aged 4.9–17.4 years at baseline, every 6 months for 60 consecutive months. At the baseline visit, they had an undetectable viral load and a good immune reconstitution and were being treated with lamivudine, stavudine and a protease inhibitor (PI). At the same visit, stavudine was replaced with TDF and the PI with efavirenz. Serum creatinine, estimated glomerular filtration rate (GFR), urine protein to creatinine ratio, serum phosphate, ratio of the maximum rate of tubular phosphate reabsorption to the GFR (TmPO4/GFR), urine glucose, and urine α1-microglobulin to creatinine ratio were used as markers of renal function. The outcome-time relationships were studied using generalized estimating equations (GEEs). In addition to time (continuous, ten equally spaced intervals), sex, age at baseline and CD4+ T-cell count were used as covariates. Results: A moderate reduction in GFR was observed only once in an underweight female patient. There was no occurrence of proteinuria, hypophosphataemia or glycosuria. Moreover, TmPO4/GFR was stable and the urine α1-microglobulin to creatinine ratio was always within normal limits. Conclusion: TDF had an excellent renal safety profile in HIV-infected children, adolescents and young adults regularly followed up for 60 months.

Both HIV-Infection and Long-Term Antiretroviral Therapy are Associated with Increased Common Carotid Intima-Media Thickness in HIV-Infected Adolescents and Young Adults

To evaluate common carotid artery intima-media thickness (CCIMT) and cardiovascular risk factors in HIV-infected adolescents on combination antiretroviral therapy (cART). 23 HIV-infected adolescents were matched with 19 healthy subjects by gender, age and body mass index (BMI). CCIMT was measured by Echo-Doppler ultrasound. Bootstrapped multiple linear regression was used to identify potential predictors of CCIMT including HIV status, gender, age, BMI, waist circumference, HDL-cholesterol, LDL- cholesterol, triglycerides, folate, homocysteine, insulin resistance as detected by the homeostasis model assessment, mean blood pressure, and CD36 expression. In the pooled sample, age ranged from 17 to 23 years and BMI between 16.0 and 25.6 kg/m(2). Mean (SD) CCIMT was higher in HIV-infected than in healthy subjects [0.5 (0.1) vs. 0.1 (0.4) mm, p < 0.001]. Higher values of CCIMT were associated with HIV infection (p < 0.001) and male gender (p < 0.001). CCIMT was also associated with the duration of treatment in subjects with the longest cART exposure, i.e. those exposed to a PI-based and/or NNRTI-based regimen plus a single or double NRTI (p = 0.019). HIV infection and longer duration of cART are associated with higher CCIMT in adolescents and young adults.

Comparison of Adherence to Medications and to Clinic Visits between HIV Infected Adolescents and Young Adults: Perinatally versus Behaviorally Infected

Comparison of Adherence to Medications and to Clinic Visits between HIV Infected Adolescents and Young Adults: Perinatally versus Behaviorally Infected

HIV Testing of High Risk Youth: What Do We Know About Those Who Don't Get Tested?

Purpose: Despite recommendations for routine, universal HIV testing, recent CDC estimates show that 48% of HIV-infected adolescents and young adults are unaware of their status. Research within the ATN presents a unique opportunity to learn how young people at high risk of HIV, that report no history of testing, differ from those who were tested.