Clinical and Behavioral Characteristics of HIV-infected Young Adults in Care in the United States Linda Beer, PhD, Christine L. Mattson, PhD, Joseph Prejean, PhD, and Luke Shouse, MD 10 th International Conference on HIV Treatment and Prevention Adherence June 30, 2015 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
Persons diagnosed with HIV, engaged in medical care, prescribed ART, and virally suppressed among all HIV-infected, by age United States, 2011* 100% 90% 80% 70% Young adults have poorer outcomes at each step of the HIV treatment continuum 60% 50% 49% 40% 30% 20% 22% 18% 13% 10% 0% Diagnosed Engaged in care Prescribed ART Virally suppressed 13-24 25-34 35-44 45-54 55-64 >=65 *Adapted from Vital Signs: HIV diagnosis, care, and treatment among persons living with HIV--United States, 2011. Bradley H et al. MMWR Morb Mortal Wkly Rep. (2014)
Background Lack of suppression leads to increased Morbidity Likelihood of HIV transmission when accompanied by transmission risk behaviors Information on clinical characteristics, risk behaviors, and receipt of prevention services among young adults is needed to Inform interventions to improve health of HIV+ young adults E.g., starting ART early for optimal health and decreased HIV transmission risk Monitor progress towards goals of improving health and increasing healthy behaviors among HIV+ young adults
Medical Monitoring Project (MMP) methods Ongoing HIV surveillance system Collection of interview and medical record data from HIV-infected adults receiving care in 16 U.S. states and Puerto Rico Annual cross-sectional complex sample survey Three-stage probability sampling to produce nationally representative data States; HIV care-providing facilities; HIV-infected adults receiving care Data were weighted to adjust for unequal selection probabilities and non-response Data collected June 2009 - May 2012 Participation rates States 100%; facilities 76-83%, patients 49-51%
Analytic methods Describe characteristics that are useful for guiding prevention interventions and monitoring prevention progress among HIV-infected young adults in care Young adult defined as ages 18-24 N=359, 3% (CI 2-3) of all adults in care Used Rao-Scott chi-square tests to compare 18-24 with 25+ Sociodemographics Depression and substance use Sexual behaviors, risk reduction counseling, and STI screening HIV care and viral status Analyses accounted for clustering, unequal selection probabilities, and non-response
RESULTS
Characteristics of HIV-infected young adults in care Characteristic N Weighted % Gender Male Female Transgender Race/ethnicity Black Hispanic White Other Age at diagnosis <1 1-12 13+ HIV disease stage AIDS or nadir CD4+ 0-199 No AIDS and nadir CD4+ 200-499 No AIDS and nadir CD4+ >500 Total 359 100 Source: MMP cycles 2009-2011; *Coefficient of variation is > 0.30, estimate may be unreliable. 243 108 8 203 78 63 15 34 17 307 149 174 35 68 28 3* 58 19 18 5 9 4 87 42 47 11
100% Sociodemographic factors among HIV-infected adults in care by age group 90% 80% 70% 59% 61% All differences significant at p < 0.05 60% 50% 50% 40% 30% 40% 44% 35% 30% 20% 10% 12% 24% 17% 15% 8% 11% 5% 0% White men Black men Gay or bisexual Household poverty* Un- or underinsured* Homeless* Incarcerated* Age 18-24 Age 25+ Source: MMP cycles 2009-2011; * Past 12 months; No health insurance/coverage or only Ryan White coverage
100% Depression and substance use among HIV-infected adults in care by age group 90% 80% 70% 60% 50% 40% 30% 20% Not significant 28% 29% 24% p < 0.01 15% p < 0.01 44% 27% Not significant 11% 10% 10% 0% Depression* Binge drinking Any drug use Simulant use Age 18-24 Age 25+ Source: MMP cycles 2009-2011; * past 2 weeks, past 30 days, past 12 months
Sexual behavior, risk reduction counseling, and STI screening among HIV-infected adults in care by age 100% 86% 90% 80% 73% All differences significant at p < 0.01 68% 70% 60% 62% 57% 50% 39% 43% 42% 43% 40% 30% 24% 24% 28% 28% 20% 12% 10% 0% Sexually active* Sex without a condom* Sex without a condom with neg/unkwn partner* Risk reduction counseling by provider* Age 18-24 Age 25+ Gonorrhea screening Chlamydia screening Syphilis screening Source: MMP cycles 2009-2011; All variables measured in past 12 months * reported in interview, documented in medical record, among sexually active
HIV care and viral status among HIV-infected adults in care by age group 100% 90% 80% Not significant 74% 76% 74% 91% 91% 70% 73% 86% All other differences significant at p < 0.01 74% 70% 60% 50% 57% 61% 40% 33% 30% 20% 10% 0% >=1 VL test each 6 month period Prescribed ART Current ART use* Adherent to ART* Virally suppressed at most recent test Age 18-24 Age 25+ Durably virally suppressed Source: MMP cycles 2009-2011; all variables measured in past 12 months; * reported in interview; documented in medical record; most recent viral load test undetectable or <=200 copies/ml); all viral loads over the past 12 months undetectable or <=200 copies/ml
DISCUSSION & CONCLUSIONS
Discussion Although young adults more likely to receive providerdelivered risk reduction counseling and STI screening, also more likely to report sexual risk behaviors Providers may be appropriately focusing efforts on young adults, although STI screening levels in particular are suboptimal Community or social media-based interventions may complement clinic-based risk reduction efforts
Discussion Despite similar levels of care utilization, young adults had lower levels of ART prescription and use, adherence, and viral suppression 66% young adults in care were not durably virally suppressed Getting young adults engaged in care may not be enough to ensure they achieve optimal health
Limitations Population limited to those in care A high proportion of HIV-infected young adults are either not diagnosed or diagnosed but not in care However, analyses of the last steps in the care continuum needed to complement efforts to increase diagnosis and engagement Confounders, mediators, and effect modifiers of the relationship between age and health outcomes not assessed More work on the reasons for suboptimal health among young adults is warranted to guide development of programs and interventions Potentially important differences between perinatally and behaviorally infected young adults not assessed
Conclusions While addressing each step of the care continuum is important, HIV-infected young adults may face greater barriers to achieving optimal health, even among those in care Enhanced interventions to support ART use and adherence among young adults may be needed
Acknowledgments MMP participants, facilities, project area staff, provider and community advisory board members Members of the Clinical Outcomes Team and Behavioral and Clinical Surveillance Branch at CDC
Thank you For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention