Introduction: what youth need--adapting HIV care models to meet the lifestyles and special needs of adolescents and young adults

The Clarification of Depression and Social Support's Contribution to the Prediction of Antiretroviral Medication Adherence and the Rate of CD4 in People with HIV

With the development of the antiretroviral therapy, the number of the people with HIV is increasing; therefore, identifying the factors affecting HIV is of great importance. This study aimed to investigate the relationship between the antiretroviral medication adherence and the rate of CD4 with depression and social support in the people with HIV. The research method was a descriptive study kind of correlation. The statistical population included all patients with HIV in Shiraz, of whom, 220 people who had referred to the Behavioral Diseases Consultation Center were selected using the available sampling method. Philips et al.'s Social Support Questionnaire, Beck's Depression Questionnaire II, and ACTG Medication Adherence Questionnaire were used as the research tools. Results were analyzed using the stepwise regression and stepwise hierarchical multiple regression. Regression analysis showed that social support and depression variables could predict totally 47% (P<0.001) of changes of medication adherence variable, and depression could predict only 2% (P<0.01) of rate variance of CD4.

Determinants of utilization of a no-cost HIV transition clinic: a cross-sectional study of young adults living with HIV/AIDS

There is minimal research that has been conducted among young adults to understand the determinants of the utilization of human immunodeficiency virus (HIV) health services in this population. The purpose of this study was to explore the levels and determinants of HIV transition clinic (HTC) services utilization by young adults living with HIV/acquired immunodeficiency syndrome (YALHA). The study used a cross-sectional design and quantitative methods to collect data from a sample of 379 YALHA between the ages of 15–24 years who were registered clients of an HTC in Uganda. During data analysis, utilization was categorized into two levels: regular (kept all appointment visits) and irregular (missed one or more appointment visits) utilization. Univariable, bivariable, and multivariable logistic regression analyses were used to examine the determinants associated with HTC utilization. The HTC services that were most utilized by the YALHA were those based at the clinic and provided by professional health care providers and these were: clinical examination (96%); laboratory services (87.1%); and counseling (69.7%). The services that were least utilized were home visiting (5.8%) and peer support services (19.8%). Of the 379 YALHA, only 32.4% regularly utilized the HTC. Multivariable analysis showed that the main determinants of HTC utilization were CD4 count category of ≥251/μL (adjusted odds ratio [AOR] =0.58, 95% confidence interval [CI] =0.36–0.95); not being on antiretroviral therapy (AOR =0.27, 95% CI =0.15–0.47); and not receiving counseling services (AOR =0.47, 95% CI =0.27–0.83). Regular utilization of the HTC by YALHA was low and utilization seems to be influenced by HIV infection stage and HIV counseling services, but not sociodemographic factors or community factors.

Psychosocial support for youth living with HIV

This clinical report provides guidance for the pediatrician in addressing the psychosocial needs of adolescents and young adults living with HIV, which can improve linkage to care and adherence to life-saving antiretroviral (ARV) therapy. Recent national case surveillance data for youth (defined here as adolescents and young adults 13 to 24 years of age) revealed that the burden of HIV/AIDS fell most heavily and disproportionately on African American youth, particularly males having sex with males. To effectively increase linkage to care and sustain adherence to therapy, interventions should address the immediate drivers of ARV compliance and also address factors that provide broader social and structural support for HIV-infected adolescents and young adults. Interventions should address psychosocial development, including lack of future orientation, inadequate educational attainment and limited health literacy, failure to focus on the long-term consequences of near-term risk behaviors, and coping ability. Associated challenges are closely linked to the structural environment. Individual case management is essential to linkage to and retention in care, ARV adherence, and management of associated comorbidities. Integrating these skills into pediatric and adolescent HIV practice in a medical home setting is critical, given the alarming increase in new HIV infections in youth in the United States.

Predictors of highly active antiretroviral therapy utilization for behaviorally HIV-1-infected youth: impact of adult versus pediatric clinical care site

OBJECTIVES

We evaluated highly active antiretroviral therapy (HAART) utilization in youth infected with HIV through risk behaviors who met treatment criteria for HAART. We assessed the impact of receiving care at an adult or pediatric HIV clinical site on initiation and discontinuation of the first HAART regimen in behaviorally infected youth (BIY).

METHODS

This was a retrospective analysis of treatment-naive BIY, aged 12-24 years, who enrolled in the HIV Research Network between 2002 and 2008 and who met criteria for HAART. The outcomes were time from meeting criteria to initiation of HAART and time to discontinuation of the first HAART regimen. Analyses were conducted using Cox proportional hazards regression.

RESULTS

Of 287 treatment-eligible youth, 198 (69%) received HAART; of these 198 youth, 58 (29.3%) subsequently discontinued HAART. In multivariable analyses, there was no significant difference in the time between meeting treatment criteria and initiating HAART for BIY followed at adult or pediatric HIV clinical sites. However, BIY followed at adult sites discontinued HAART sooner than BIY followed at pediatric HIV clinical sites (adjusted hazard ratio [AHR]: 3.19 [1.26-8.06]).

CONCLUSIONS

Two-thirds of treatment-eligible BIY in the HIV Research Network cohort initiated HAART; however, one-third who initiated HAART discontinued it during the study period. Identifying factors associated with earlier HAART initiation and sustainability can inform interventions to enhance HAART utilization among treatment-eligible youth. The finding of earlier HAART discontinuation for youth at adult care sites deserves further study.

Disparities in antiretroviral treatment: a comparison of behaviorally HIV-infected youth and adults in the HIV Research Network

OBJECTIVES

Increasing numbers of youth are becoming HIV-infected and need highly active antiretroviral therapy (HAART). We hypothesized that behaviorally HIV-infected youth (BIY) ages 18 to 24 years are less likely than adults (25 years or older) to receive HAART and, once initiated, more likely to discontinue their first HAART regimen.

METHODS

Longitudinal analysis of treatment-naïve patients (age 18 years or older) meeting criteria for HAART and followed at HIV Research Network sites (2002-2008). Time from meeting criteria to HAART initiation and duration on first regimen were assessed using Cox proportional hazards regression.

RESULTS

A total of 3127 (268 youth, 2859 adult) treatment-naïve, HIV-infected patients met criteria. BIY were more likely to be black (66.8% vs 51.1%; P < 0.01) and less likely to identify injection drug use HIV risk (1.1% vs 8.8%; P < 0.01) than adults 25 years of age or older. Nearly 69% of BIY started HAART versus 79% of adults (P < 0.001). Adults 25 to 29 years of age (adjusted hazards ratio [AHR], 1.39; 95% confidence interval [CI], 1.12-1.73) and 50 years of age or older (AHR, 1.24; 95% CI, 1.00-1.54), but not 30 to 49 years (AHR, 1.19; 95% CI, 0.99-1.44) were more likely to initiate HAART than BIY. Attending four or more HIV provider visits within 1 year of meeting criteria was associated with HAART initiation (AHR, 1.91; 1.70-2.14). CD4 200 to 350 versus less than 200 cells/mm (AHR, 0.57; 95% CI, 0.52-0.63), and injection drug use (AHR, 0.80; 95% CI, 0.69-0.92) were associated with a lower likelihood of HAART initiation. There were no age-related differences in duration of the first regimen.

CONCLUSION

BIY are less likely to start HAART when meeting treatment criteria. Addressing factors associated with this disparity is critical to improving care for youth.

Predictors of suboptimal virologic response to highly active antiretroviral therapy among human immunodeficiency virus-infected adolescents: analyses of the reaching for excellence in adolescent care and health (REACH) project

OBJECTIVE

To examine the prevalence and biopsychosocial predictors of suboptimal virologic response to highly active antiretroviral therapy (HAART) among human immunodeficiency virus-infected adolescents.

DESIGN

Population-based cohort study.

SETTING

Sixteen academic medical centers across 13 cities in the United States.

PARTICIPANTS

One hundred fifty-four human immunodeficiency virus-infected adolescents who presented for at least 2 consecutive visits after initiation of HAART.

MAIN OUTCOME MEASURES

Viral load (plasma concentration of human immunodeficiency virus RNA) and CD4(+) lymphocyte count.

RESULTS

Of the 154 adolescents enrolled in the study, 50 (32.5%) demonstrated early and sustained virologic suppression while receiving HAART. The remaining 104 adolescents (67.5%) had a poor virologic response. Adequate adherence (>50%)-reported by 70.8% of respondents-was associated with 60% reduced odds of suboptimal virologic suppression in a multivariable logistic regression model (adjusted odds ratio = 0.4; 95% confidence interval, 0.2-1.0). Exposure to suboptimal antiretroviral therapy prior to HAART, on the other hand, was associated with more than 2-fold increased odds of suboptimal virologic response (adjusted odds ratio = 2.6; 95% confidence interval, 1.1-5.7).

CONCLUSIONS

Fully two-thirds of human immunodeficiency virus-infected adolescents in the current study demonstrated a suboptimal virologic response to HAART. Nonadherence and prior single or dual antiretroviral therapy were associated with subsequent poor virologic responses to HAART. These predictors of HAART failure echo findings in pediatric and adult populations. Given the unique developmental stage of adolescence, age-specific interventions are indicated to address high rates of nonadherence and therapeutic failure.

To say or not to say: a qualitative study on the disclosure of their condition by human immunodeficiency virus-positive adolescents

PURPOSE

Human immunodeficiency virus (HIV)-positive adolescents face a number of challenges in dealing with their disease, treatment, and developmental tasks. This qualitative study describes some of the reasons why, and the extent to which, adolescents may or may not disclose their condition to others.

METHODS

A semistructured interview lasting 40-110 minutes was conducted with each of 29 adolescents 12-20 years old, 22 female and seven male) living in Switzerland. Interviews were tape recorded and transcribed verbatim. The analysis of the content of interviews allowed us to identify salient topics (e.g., disclosure), which were then explored in detail.

RESULTS

Of 29 participants, eight had not disclosed their condition to anyone outside the family, 19 had disclosed it to good friends, and 16 had disclosed it to some teachers. Four participants had engaged in public disclosure, and six of 10 sexually active teenagers disclosed their status to their partners. The attitudes toward disclosure among younger adolescents were mostly related to those of the parents, particularly the mother. Older adolescents, engaged in their search for autonomy, tended to decide independently what to say and to whom. Although foster/adoptive parents would often encourage disclosure, biological parents, especially HIV-positive mothers, insisted on not disclosing the adolescent's status for fear of stigma.

CONCLUSION

The health care team should systematically address the issue of disclosure with the adolescent and his family (or foster parents), the aim being to balance the right of the adolescent and that adolescent's family to maintain privacy against the concerns of sexual partners, as well as the adolescent's interest in divulging HIV status to relatives, school staff, and friends.

The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: a systematic review

This article presents the results of a systematic review of the effectiveness and economic efficiency of individual-, group-, and community-level behavioral interventions intended to reduce the risk of acquiring sexually transmitted HIV in adult men who have sex with men (MSM). These results form the basis for recommendations by the Task Force on Community Preventive Services on the use of these interventions. Sexual risk behavior and condom use were the outcomes used to assess effectiveness. Intervention effectiveness on biological outcomes could not be assessed because too few studies of adequate quality have been published. The evidence found in our review shows that individual-level, group-level, and community-level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse (range 27% to 43% decrease) and increasing the odds of condom use for the group-level approach (by 81%). The Task Force concluded that the findings are applicable to MSM aged 20 years or older, across a range of settings and populations, assuming that interventions are appropriately adapted to the needs and characteristics of the MSM population of interest. Based on findings from economic evaluation studies, the Task Force also concluded that group- and community-level HIV behavioral interventions for adult MSM are not only cost effective but also result in actual cost savings. Additional information about other effects, barriers to implementation, and research gaps is provided in this paper. The recommendations based on these systematic reviews are expected to serve the needs of researchers, planners, and other public health decision makers.