Addressing the Needs of Youth With HIV Infection in the Era of Combination Antiretroviral Therapy Free

To the Editor—Mirani and coauthors [1], as well as the study teams of International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1074 and P219C, are to be commended for their foresight and perseverance in meticulously collecting and astutely analyzing long-term outcome data, which continue to provide valuable epidemiological and clinical insights on US youth battling human immunodeficiency virus (HIV) infection. As the authors point out, the skillful deployment of combination antiretroviral therapy (cART) has markedly reduced mortality among children and adolescents infected with HIV [2]. Improved therapeutic outcomes with cART have changed the face of the HIV epidemic and, with it, the needs of young patients and families [3]. Nevertheless, even in this latest report, the mortality among youth was 31.5 times that of the US population [1].

Strikingly, 86% of deaths in this cohort of youth, who were, by definition, connected with care and on study were due to HIV-related medical conditions; those who died were less likely to be receiving cART [1]. These data underscore the impact of recent evidence of exaggerated health disparities demonstrated in the US adolescent and young adult HIV cascade of care. Data from that cascade of care indicate that only 41% of HIV-infected youth in the United States are aware of their diagnosis, and of those who initiate cART, only 54% achieve viral suppression. It is further estimated that <6% of all HIV-infected youth in the United States remain virally suppressed [4].

A large majority (87%) of youth studied in P1074 had acquired HIV infection perinatally, with most (74%) of the remaining young people infected via sexual activity [1]. Mean ages of participants at the beginning and end of the study period were 17.4 and 20.9 years, respectively, indicating that, regardless of the route of infection, issues related to transition from pediatric to adult care were likely critical in retaining these youths in care and maintaining adherence to effective cART. Attention to transitional care challenges is also of utmost importance from an epidemiological perspective and in keeping with the Centers for Disease Control and Prevention's “Prevention Is Care” initiative, to further reduce HIV transmission by infected youth.

While there have been >40 000 adolescents diagnosed with HIV since the start of the epidemic, it is now estimated that 13% of all new infections are occurring in young persons aged 13–24 years. In that age group, male-to-male sexual contact is the leading risk factor for transmission [5]. It is estimated that >25 000 HIV-infected US youths aged 13–24 years will require transition to adult care within the next decade. Transition planning must address issues of cognitive development and mental health, medication adherence, sexuality, reproductive health, and gender identity, socioeconomic and health insurance status, stigma and disclosure, disrupted relationships with pediatric care providers, and communication [6].

Clinical experience with HIV and other chronic illnesses would indicate the critical need for support of programs offering a multidisciplinary, developmentally sensitive approach to meeting the challenges inherent in care transition that begins early and is monitored with regular evaluation and revision to more effectively address the needs of youth battling HIV and to stem the tide of the continuing epidemic.

Note

Potential conflict of interest. Author certifies no potential conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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