by Jeffrey T. Kirchner, DO, AAHIVS, AAHIVM Chief Medical Officer

July 16, 2019

Featured Literature:

Kacanek, D. et al for the Pediatric HIV/AIDS Cohort Study. Nonadherence and unsuppressed viral load across adolescence among US youth with perinatally acquired HIV.
AIDS: July 3, 2019 – Volume Publish Ahead of Printdoi: 10.1097/QAD.0000000000002301

Perinatally HIV-infected adolescents and young adults are a challenging patient population to care for. In recent years, these individuals have been transitioned from pediatric to adult HIV clinical settings. The authors’ intent in this study was to identify factors associated with nonadherence to ART and thus having an unsuppressed viral load (VL). The study group included 379 patients from 15 U.S. clinical sites who were followed for a median time of 3.3 years. They accounted for 1190 clinical visits that included adherence evaluations and VL measurements. Self-reported ART “non-adherence” was defined as any missed dose in the week prior to the visit. An unsuppressed VL was any HIV-RNA level >400 copies/mL. Individual, caregiver, structural, and social factors associated with nonadherence and detectable VL were identified based on age. These age groups were 8–11 years (“pre-adolescence”), 12–14 years (“early adolescence”), 15–17 years (“middle adolescence”), and 18–22 (“late adolescence/young adulthood”).

From pre-adolescence to young adulthood, the prevalence of nonadherence increased from 31% to 50% and the prevalence of detectable viremia increased from 16% to 40%. In all age groups, perceived ART side-effects were associated with nonadherence. For the pre-adolescents, a key factor associated with nonadherence was lack of an adherence reminder or a “buddy system”. For the early adolescent group lack of adherence was associated with not having a buddy system or identifying as black. For the middle adolescents having an unmarried caregiver, indirect exposure to violence, fear of inadvertent HIV disclosure, and stressful life events were associated with poor ART adherence. Associated with lack of VL suppression in early adolescence included unawareness of HIV status and having a lower income. For the middle adolescents, perceived ART side-effects and lower income were associated with lack of VL suppression. With the older adolescents / young adults, distressing physical symptoms and perceived ART side effects were most associated with not having an undetectable VL. Collectively, the prevalence of medication nonadherence and having a detectable viral load increased with age. However, as noted from these data, associated factors varied by different age groups.

Author’s Commentary: Depending on where you practice, you may or may not have perinatally-infected patients under your care. Those who do will concur that they represent a challenging clinical cohort. Many have neurocognitive, developmental, and mental health issues. In addition, many have grown up in unstable psychosocial situations. Providing age-appropriate supports and interventions are key to therapeutic success and retention in care. On a positive note, with the significant drop in HIV MTCT this is a population that should diminish over time and hopefully to zero at some point in the future.

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