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HIV control rate not improving in young US adults receiving care.

In 2009 two thirds of HIV-positive 18- to 24-year-olds receiving medical care in the United States had a viral load * below 200 copies on their last viral load test, according to results of a large study. (1) By 2013 that proportion had not improved. But from 2009 to 2013 the proportion of young adults with a viral load below 200 copies on all tests in the past 12 months rose from 29% to 46%.

In recent years researchers have begun tracking rates at which people with HIV receive care for their infection, start antiretroviral therapy, take their antiretroviral pills on time, keep medical appointments, and reach an undetectable viral load. Analysis of these findings helps HIV providers understand the weak points in HIV care, compare changes over time, and compare trends in different groups of people with HIV The ultimate goal is to provide steady, successful care for everyone with HIV.

A few years ago, researchers from the US Centers for Disease Control and Prevention (CDC) estimated that only 13% of young US adults with HIV have an undetectable viral load.2 Even among US adults in care for HIV, younger people are less likely than older adults to receive antiretroviral therapy, take their antiretroviral pills as directed, and reach an undetectable viral load. But some research found recent rising rates of antiretroviral therapy in young people, along with improving undetectable viral load rates. (3)

To get a better understanding of changes in antiretroviral use and success in young adults with HIV, CDC investigators conducted a new study.

How the study worked. The study involved young adults in the Medical Monitoring Project in the years 2009 through 2013. Every year, the Medical Monitoring Project creates a nationally representative sample of adults in care for HIV infection in the United States and Puerto Rico. Participants complete interviews to give personal and health-related data, and researchers collect relevant health findings from their medical records.

For this analysis, CDC investigators selected HIV-positive people from 18 to 24 years old. For each person, the researchers determined how many had the following indicators of HIV care in each study year from 2009 through 2013:

1. Had an antiretroviral therapy prescription during the past 12 months

2. Received regular HIV care (a viral load measure in each 6 months of the last year)

3. Took 100% of antiretroviral doses in the past 3 days

4. Were bothered by antiretroviral side effects in the past 30 days

5. Were taking a once-daily single-tablet antiretroviral combination

6. Had HIV control (viral load below 200 copies on last test)

7. Had steady HIV control (viral load below 200 copies on all tests in last 12 months)

The researchers used a standard statistical method to determine how much the year-to-year change in HIV control was affected by significant changes in one of the other six factors.

What the study found. The study group included 636 young adults, about three quarters of them men, about 60% of them gay or bisexual, and about 60% of them black. While 62% of these young adults lived below the poverty level, about 35% had no health insurance or only Ryan White (government) coverage for HIV care.

The proportion of people with an antiretroviral prescription rose significantly from 76% in 2009 to 87% in 2013. Here and below "significantly" means chance is unlikely to explain the change. But among people with an antiretroviral prescription, the proportion reporting 100% pill taking in the past 3 days did not change over the study years (79% in 2009 and 78% in 2013). The proportion reporting antiretroviral side effects also stayed flat throughout the study period (22% in 2009 and 20% in 2013).

The proportion of young adults using a single-tablet antiretroviral combination jumped significantly from 49% in 2009 to 62% in 2013, while the proportion receiving regular HIV care did not change much throughout the study (74% in 2009 and 69% in 2013).

The proportion of people with a viral load below 200 copies on their last test stood at 65% in 2009. That proportion dipped to 51% in 2010 and 56% in 2011 then rose again but remained at only 65% in 2013 (Figure 1). In contrast, the proportion of young adults with a viral load below 200 copies on all tests in the last 12 months rose steadily across the study period, from 29% in 2009, to 31% in 2010, 38% in 2011, 45% in 2012, and 46% in 2013 (Figure 2). This change was significant across the study years, meaning that chance is unlikely to explain the improvement. Further statistical analysis found evidence that two factors contributed to this improvement in steady HIV control over the study years--being prescribed antiretroviral therapy and taking a single-tablet antiretroviral combination.

What the findings mean for you. The main goals of HIV care are starting antiretroviral therapy then reaching and maintaining an undetectable viral load. This well-planned study of a group representing all 18- to 24-year-olds in care in the United States made several important findings in these areas and on related issues. Some of these findings are good news, while others underline areas that need improvement.

Three findings can be seen as good news:

* The proportion of people having an antiretroviral prescription is on the rise.

* The proportion getting a convenient single-tablet combination is also increasing.

* The proportion with an undetectable viral load throughout the past 12 months improved significantly.

Two findings highlight areas for concern:

* The proportion of young adults receiving regular HIV care did not improve over time.

* The proportion with an undetectable viral load on their last test did not increase.

Two other findings can be viewed as positive or not:

* Only 1 in 5 people reported antiretroviral side effects in the first study year, but this proportion did not improve over the years.

* A high proportion of people, about 80%, reported taking 100% of their antiretrovirals in the past 3 days, but this proportion did not improve over time.

Everyone with HIV--young, middle-aged, or old--should try hard to get good marks in all these areas. US HIV experts recommend that everyone with HIV should take antiretroviral therapy. (4) Reaching an undetectable viral load with antiretroviral therapy depends on keeping all HIV clinic appointments and taking all antiretrovirals on time. If you have trouble keeping appointments, your HIV provider can guide you to a case worker who can work with you to identify and remedy reasons for this problem. Most of today's antiretroviral combinations require only one or two pills daily. But if you have trouble taking your antiretrovirals regularly, work with your HIV provider to address this problem. And if you are not taking only one or two antiretroviral pills daily, you can talk to your provider about whether such a combination may be right for you.

The rising proportion of young people in care with an undetectable viral load on all tests in the past 12 months is a good sign. But fewer than half of these young adults had a steadily undetectable viral load in 2013, the last study year. There's a lot of room for improvement in that finding.

REFERENCES

(1.) Beer L, Mattson CL, Bradley H, Shouse RL; Medical Monitoring Project. Trends in ART prescription and viral suppression among HIV-positive young adults in care in the United States, 2009- 2013. J Acquir Immune Defic Syndr. 2017;76:e1-e6.

(2.) Bradley H, Hall HI, Wolitski R, et al. Vital signs: HIV diagnosis, care, and treatment among persons living with HIV--United States, 2011. MMWR Morb Mortal Wkly Rep. 2014;63:1113-1117.

(3.) Agwu AL, Fleishman JA, Rutstein R, et al. Changes in advanced immunosuppression and detectable HIV viremia among perinatally HIV-infected youth in the multisite United States HIV research network. J Pediatr Infect Dis Soc. 2013;2:215-223.

(4.) US Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. October 2017. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescenttreatment-guidelines/0/

* Words in boldface are explained in the Technical Word List at the end of this issue.
Figure 1. In a study of HIV-positive 18- to 24-year-olds
receiving medical care, the proportion with a viral load
below 200 copies on their last test did not improve over
the 2009-2013 study period.

Percent of young adults with viral load below
200 copies on last test

2009     65%
2010     51%
2011     56%
2012     64%
2013     65%

Note: Table made from bar graph.

Figure 2. In young US adults in medical care (the same
group that provided findings shown in Figure 1), the
proportion with a viral load below 200 copies on all tests
in the last 12 months increased significantly from 2009
through 2013.

Percent of young adults with viral load below
200 copies on all tests in last 12 months

2009      29%
2010      31%
2011      38%
2012      45%
2013      46%

Note: Table made from bar graph.
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Title Annotation:ARTICLE 8
Publication:HIV Treatment: ALERTS!
Date:May 1, 2018
Words:1481
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