Only about one third of 2200 HIV-positive youth and young adults in care in the United States have an undetectable viral load, according to results of a 2009-2012 study.1 Consistent HIV care and more education were among the factors that raised chances of having an undetectable viral load.
Teens and young adults 13 to 24 years old made up 26% of new HIV infections in the United States in 2010.2 Detecting HIV infection early and starting antiretroviral therapy can prevent new infections because an HIV-positive person with an undetectable viral load has a much lower chance of passing HIV to a sex partner. Starting antiretroviral therapy and reaching an undetectable viral load are also essential steps in returning to health and ensuring a long and productive life.
Young people with HIV infection face several obstacles to reaching and keeping an undetectable viral load. Some research shows that low proportions of youth in care for HIV infection begin antiretroviral therapy, while other work indicates that younger people are less likely to achieve an undetectable viral load than older people. Recent research by the Centers for Disease Control and Prevention (CDC) found that young African Americans have the lowest undetectable viral load rate of any group studied, 18%.3
Understanding how many teens and young adults enter care, start antiretroviral therapy, and reach an undetectable viral load is essential to planning care for this growing group of HIV-positive people. Understanding which factors favor reaching an undetectable viral load can help more youngsters and young adults achieve that target. With those goals in mind, researchers conducted the study described here.
From December 2009 to June 2012, researchers invited HIV-positive people from 12 to 26 years old to enter the study. All invited participants were in care at one of 20 clinics of the Adolescent Medicine Trials Network for HIV/AIDS Interventions across the United States and Puerto Rico. All participants had to be aware of their HIV infection and receiving care at one of the 20 clinics. The researchers classified each participant as either perinatally infected (infected with HIV in the womb or around the time of birth and called the "birth group" in this article) or behaviorally infected (infected with HIV through sex or drug use and called the "behavior group" in this article) (Table 1).
|Table 1. Researchers Divided Study Participants Into Two Groups|
All participants completed an extensive computer-assisted survey that covered (1) basic personal information (like age, gender, sexual orientation, and race or ethnic origin), (2) substance use, (3) mental health, (4) sexual behavior, and (5) adherence to antiretroviral therapy (taking all antiretroviral drugs as scheduled).
The researchers also determined whether each person was taking antiretroviral therapy and had an undetectable viral load at least 6 months after starting antiretroviral therapy. They classified a person as eligible for antiretroviral therapy if that person had a CD4 count at or below 500, which was the recommended CD4 starting level when this study was done. (Now US guidelines recommend antiretroviral therapy for everyone with HIV infection, whatever their CD4 count.)
The researchers used accepted statistical methods to identify factors linked to (1) taking antiretroviral therapy and (2) having an undetectable viral load. This type of analysis singles out individual factors that affect those two outcomes regardless of other factors (such as race, ethnic origin, and gender) that might affect the two outcomes.
The study involved 649 youth infected at birth (the "birth group") and 1547 infected via sex or drugs (the "behavior group") (Table 1). Age averaged 17.9 in the birth group and 21.2 in the behavior group. Boys and men made up 44% of the birth group, while girls and women made up 55%. Proportions of boys/men and girls/women in the behavior group were 76% and 24%. Two thirds of both the birth group and the behavior group were black, about 12% were white, and the rest were mixed-race or Asian. Hispanics made up 20% of each group. Heterosexuals made up 88% of the birth group, while gays, lesbians, and bisexuals made up 11%. Heterosexuals made up 27% of the behavior group, while gays, lesbians, and bisexuals made up 69%.
A standard substance use survey classified 16% in the birth group and 43% in the behavior group as substance users. Proportions of people who had any sex without condoms were 14% in the birth group and 37% in the behavior group. Proportions who had condom-free sex with an HIV-negative partner or a partner with an unknown HIV status were 12% and 26%.
A large majority of the birth group -- 92%--had been diagnosed with HIV for 25 months or more, compared with 40% of the behavior group. Most people in the birth group -- 82% -- were taking antiretroviral therapy, compared with 49% of the behavior group (Figure 1). More than half of the group not taking antiretrovirals, 56%, had a CD4 count at or below 500. A CD4 count at or below 500 meant they should be taking antiretrovirals, according to treatment guidelines in effect at the time of this study. More than a quarter of this untreated group, 28%, had a CD4 count at or below 350.
Figure 1. A study of 2196 young people infected with HIV around the time of birth (Birth group) or later in life (Behavior group) found that only 59% were taking combination antiretroviral therapy (ART) and only 30% had an undetectable viral load. These rates were higher in the birth group than in the behavior group.
Proportions of study participants with an undetectable viral load were 37% in the birth group and 27% in the behavior group (Figure 1). Most people in both groups (85% or more) had taken their antiretrovirals for the past 7 days. The birth group missed an average 1.5 medical appointments in the past 12 months, while the behavior group missed an average 1.7.
People in the birth group who had been diagnosed with HIV 11 or more years earlier were 62% more likely to be taking antiretroviral therapy than people diagnosed more recently. Among youth in the behavior group, those who tested positive for HIV in the past 12 months were 70% less likely to be taking antiretrovirals than those with a longer time since their positive HIV test. People in the behavior group diagnosed with HIV for 5 or more years were 53% more likely to be taking antiretrovirals than people diagnosed more recently. Statistical analysis that considered several factors at the same time singled out many factors individually linked to higher or lower chances of antiretroviral use in the birth group and the behavior group (Figure 2) and to higher or lower chances of an undetectable viral load in the two groups (Figure 3). Missing medical appointments lowered chances of antiretroviral use in the birth group and lowered chances of an undetectable viral load in both groups. In the behavior group, three factors were linked to higher chances of antiretroviral use: older age, completing high school, and employment.
Figure 2. Seven factors predicted lower or higher chances of taking antiretroviral therapy in young people infected in the womb or around the time of birth (Birth group) or later in life, usually through sex (Behavior group).
Figure 3. In a study of young people in care for HIV infection, four factors predicted lower chances of having an undetectable viral load, while five factors predicted higher chances. Participants were infected with HIV in the womb or around the time of birth (Birth group) or later in life (Behavior group). ART, antiretroviral therapy.
In both the birth group and the behavior group, taking antiretroviral therapy for 6 or more months and taking antiretrovirals on time at least 90% of the time were tied to higher chances of an undetectable viral load. Completing high school was tied to doubled chances of an undetectable viral load in the behavior group.
Finally, the researchers found that almost one third of these young people had sex without condoms in the past 3 months. Three quarters of study participants who had sex without condoms had a detectable viral load, meaning they had a chance of passing HIV to their sex partner. And three quarters of this group had condom-free sex with an HIV-negative partner or did not know if their partner had HIV.
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