Young HIV patients — less awareness, less medical care

Teens and people in their 20s are significantly less likely to know they have HIV than older adults despite recommendations that physicians screen for the disease in patients as young as 13, a study shows.

Even more concerning, young people fare worse through the entire continuum of care for HIV/AIDS compared with adults 45 and older, said the study, posted online June 17 in JAMA Internal Medicine. The continuum of care consists of being diagnosed with the disease, getting linked to care, staying in treatment, receiving antiretroviral therapy and achieving suppressed viral load.

Having low levels of the virus lessens a person's chance of transmitting HIV to another individual, medical experts say. “Increasing the percentage of young people diagnosed and receiving continuous care is critical to addressing HIV in the United States,” the study authors said.

Among people ages 25 to 34, 56% were linked to care, 28% stayed in treatment and 15% had a suppressed viral load. That is markedly different than the findings for adults 55 to 64: 74% were linked to care, 46% remained in treatment and 36% had low viral load levels.

Contributing to the problem probably are lower rates of HIV testing for young people and a reduced sense of urgency about treating those who test positive, because many are otherwise healthy, the study said. Medication adherence also can be challenging for young people who often don't think about the long-term health consequences of not properly treating HIV, said lead study author H. Irene Hall, PhD.

“Even for young people, regular care and treatment is still needed to ensure they are staying healthy and that there's less chance of the virus being transmitted to others,” said Hall, chief of the HIV incidence and case surveillance branch at the Centers for Disease Control and Prevention.

To ensure that doctors identify young patients with the disease, Hall encourages them to make it routine to screen for HIV among patients ages 13 to 64. The CDC recommends that doctors screen all patients in that age group at least once.

Physicians should not, however, consider such tests a one-time action, said Rockville, Md., internist Michael A. Horberg, MD. He encourages doctors to ask patients regularly if they're sexually active and inquire about risk factors, such as engaging in unprotected sex and using intravenous drugs.

Doctors should screen patients at risk of developing HIV at least once a year, according to the CDC.

“People's sexual behavior and attractions can change over time,” said Dr. Horberg, chair of the HIV Medical Assn. and director of HIV/AIDS for Kaiser Permanente. “It's important to be active in inquiry.”

When patients test positive, physicians should start them on the proper medications or refer them to an HIV/AIDS specialist for treatment, Dr. Horberg said. To help ensure that patients take their medication properly, he recommends that doctors emphasize that the drugs not only will enable them to live longer, healthier lives but also will help prevent them from transmitting the disease during sex.

Light shed on epidemic

To determine HIV prevalence in the U.S., researchers examined data from the National HIV Surveillance System on people 13 and older who had the virus. They calculated the percentage of people linked to care within three months of diagnosis on the basis of individuals' CD4 cell levels and viral load test results.

Data from the Medical Monitoring Project were used to estimate the percentage of people with HIV who were retained in care, prescribed ART and who achieved viral load suppression. Patients who had at least one medical visit between January and April 2009 were considered retained in care, and ART treatment was defined as documentation in the medical record of any ART prescription during the past year. A patient's viral load was considered suppressed if the most recent measure was no greater than 200 copies/ml.

Researchers found that an estimated 1.1 million people were living with HIV in the U.S. in 2009, and 18% did not know they were infected. Among the 82% who were diagnosed with the disease, 66% were linked to care, 37% were retained in care, 33% were prescribed ART and only 25% had a suppressed viral load.

“Even though the percentage of people linked to care is fairly high, there is a big drop-off for retention in care and again for [viral load] suppression,” Hall said.

The percentage of people who were aware they had HIV was lower among blacks (81% knew they were infected) and Hispanics (80%) compared with whites (85%). There was no significant difference in viral load suppression among race or ethnic groups.

Eliminating those age, racial and ethnic disparities requires addressing barriers to HIV care, said an editorial in the same journal issue. Those barriers include stigma related to HIV and a lack of trust in physicians, the editorial said.

At its Annual Meeting in June, the American Medical Association House of Delegates adopted policy that supports programs to raise physician awareness of early treatment and “treatment as prevention,” and the need to link newly diagnosed patients to clinical care and partner services.

The JAMA Internal Medicine study “confirms many of the things that we already knew. … [And] it's adding an extra spotlight on to all of this,” Dr. Horberg said. The study shows “that HIV is still an epidemic in the U.S.”