Human immunodeficiency virus (HIV) incidence is increasing among youth, particularly young men who have sex with men and racial/ethnic minorities. Earlier presentation to care, a goal of public health initiatives, can limit immune deterioration and HIV transmission. We determined if fewer nonperinatally HIV (nPHIV)–infected youth are presenting for care at lower CD4 counts.
This was a retrospective study of nPHIV-infected 12- to 24-year-olds presenting for care at HIV Research Network (HIVRN) sites between 2002 and 2010.1 The 13 geographically distributed sites that contributed data over the study period all had institutional review board approval for the study (from Alameda County Medical Center, Children's Hospital of Philadelphia, Community Health Network, Drexel University, Johns Hopkins University, Montefiore Medical Group, Montefiore Medical Center, Oregon Health and Science University, Parkland Health and Hospital System, St. Jude's Children's Hospital and University of Tennessee, St. Luke's Roosevelt Hospital Center, Tampa General Health Care, University of California, San Diego, and Wayne State University). Eligible patients, who provided informed consent (oral or written depending on the rules of the approving institutional review board), had at least 1 CD4 value and were antiretroviral therapy naive. To assure exclusion of patients who received care previously, we excluded patients whose first recorded HIV-1 RNA level was less than the limit of detection of the used assay or less than 2.6 log10 HIV-1 RNA copies/mL (n = 174); patients whose first CD4 or HIV-1 RNA measurement preceded clinic enrollment by more than 45 days (n = 200); and those with incomplete data (n = 2; unable to rule out prior antiretroviral therapy). The primary outcome was a presenting CD4 count less than 350 cells/mm3. Multivariate logistic regression assessed demographic and clinical factors associated with the outcome. Given the large proportion of males, we also conducted a male-only subgroup analysis.
One thousand four hundred ninety-seven nPHIV-infected 12- to 24-year-old youth presented to care at HIVRN sites (Table 1). The proportion with a presenting CD4 count less than 350 cells/mm3 remained between 30% and 45% over the study period (P trend >.05). Black race (adjusted odds ratio [AOR], 2.03 [95% CI, 1.31-3.15]), Hispanic ethnicity (AOR, 1.69 [95% CI, 1.21-2.34]), male gender (AOR, 1.63 [95% CI, 1.16-2.30]), heterosexual acquisition risk (AOR, 1.43 [95% CI, 1.08-1.88]), higher HIV-1 RNA level, and increasing age (AOR, 1.14 [95% CI, 1.06-1.23]) were independently associated with a greater likelihood of a presenting CD4 count less than 350 cells/mm3 (Table 2). These findings remained consistent in the male-only subgroup analysis (Table 3).
Between 2002 and 2010, there was no overall improvement in presenting CD4 count among nPHIV-infected youth at HIVRN sites, contrary to data in adults.2,3 The trend in youth may be related to continued risk behaviors in this population related to developmental and cognitive stage, in addition to testing and engagement challenges. As in adults, racial/ethnic minority status is associated with lower presenting CD4 count among youth, particularly young men who have sex with men, a population at the forefront of the youth epidemic. While recent data show improvements in racial/ethnic disparities in adults,3 our data demonstrate no apparent improvement over the past decade for youth. The gender disparity among youth is opposite to that in adults.2,3
Female youth may access health care more frequently than males, in part because of reproductive and gynecologic/obstetric needs,4 which may increase opportunities for HIV testing and linkage to care. More effective methods to recruit at-risk male youth into early testing and linkage to care are needed.
Heterosexual acquisition was also associated with an increased likelihood of presenting with a CD4 count less than 350 cells/mm3, highlighting a potential gap in outreach efforts because they may engage in high risk behaviors and not perceive that they are at risk and thereby test and present for care later.5 Lastly, higher HIV-1 RNA level, which increases risk of progression to AIDS, was associated with a presenting CD4 count less than 350 cells/mm3. Of concern is that significant proportions of youth, who often continue to engage in high-risk behaviors,6 had high HIV-1 RNA levels, increasing HIV transmission risk.
The study has some limitations. Socioeconomic data are not collected by HIVRN, and mental health and substance abuse data are incomplete and were not evaluated. A limited number of 12- to 16-year-olds, injection drug users, or heterosexual males were in the cohort. Last, some patients may have presented for care previously at other sites.
The proportion of nPHIV-infected youth presenting to HIVRN sites with a CD4 count less than 350 cells/mm3 remained essentially unchanged between 2002 and 2010. Minority, male, and heterosexual youth may warrant innovative strategies to target these populations.
Corresponding Author: Allison L. Agwu, MD, ScM, 200 N Wolfe St, Room 3145, Baltimore, MD 21287 (firstname.lastname@example.org).
Published Online: February 3, 2014. doi:10.1001/jamapediatrics.2013.4531.
Author Contributions: Dr Agwu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Agwu, Yehia, Rutstein.
Acquisition of data: Voss.
Analysis and interpretation of data: Agwu, Neptune, Yehia.
Drafting of the manuscript: Agwu, Neptune, Voss.
Critical revision of the manuscript for important intellectual content: Agwu, Neptune, Yehia, Rutstein.
Statistical analysis: Agwu, Neptune.
Obtained funding: Agwu.
Administrative, technical, or material support: Voss, Yehia.
Study supervision: Agwu.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by Agency for Healthcare Research and Quality grant 290-01-0012 and Health Resources and Services Administration contract HHSH250201200008C . Dr Agwu was supported by National Institutes of Allergy and Infectious Diseases grant 1K23 AI084549 and a Ross Clinician Scientist Award. Ms Neptune was supported by the James A. Ferguson Emerging Infectious Diseases Fellowship (5U50MN000025-02). Dr Yehia was supported by National Institutes of Health grant K23-MH-097647-01A1.
Role of the Sponsor: The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Group Information: HIV Research Network participating sites and principal investigators: Alameda County Medical Center, Oakland, California: Howard Edelstein, MD; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania: Richard Rutstein, MD; Community Health Network, Rochester, New York: Roberto Corales, DO; Drexel University, Philadelphia, Pennsylvania: Jeffrey Jacobson, MD, Sara Allen, CRNP; Johns Hopkins University, Baltimore, Maryland: Kelly Gebo, MD, Richard Moore, MD, Allison Agwu, MD; Montefiore Medical Group, Bronx, New York: Robert Beil, MD; Montefiore Medical Center, Bronx, New York: Lawrence Hanau, MD; Oregon Health and Science University, Portland: P. Todd Korthuis, MD; Parkland Health and Hospital System, Dallas, Texas: Ank Nijhawan, MD, Muhammad Akbar, MD; St. Jude's Children's Hospital and University of Tennessee, Memphis: Aditya Gaur, MD; St. Luke's Roosevelt Hospital Center, New York, New York: Victoria Sharp, MD, Stephen Arpadi, MD; Tampa General Health Care, Tampa, Florida: Charurut Somboonwit, MD; University of California, San Diego: W. Christopher Mathews, MD; Wayne State University, Detroit, Michigan: Jonathan Cohn, MD. Sponsoring agencies: Agency for Healthcare Research and Quality, Rockville, Maryland: Fred Hellinger, PhD, John Fleishman, PhD, Irene Fraser, PhD; Health Resources and Services Administration, Rockville, Maryland: Robert Mills, PhD, Faye Malitz, MS. Data Coordinating Center: Johns Hopkins University: Richard Moore, MD, Jeanne Keruly, CRNP, Kelly Gebo, MD, Cindy Voss, MA.
Disclaimer: The views expressed in this article are those of the authors. No official endorsement by the Department of Health and Human Services, the National Institutes of Health, or the Agency for Healthcare Research and Quality is intended or should be inferred.
Agwu AL, Neptune A, Voss C, Yehia B, Rutstein R, for the HIV Research Network. CD4 Counts of Nonperinatally HIV–Infected Youth and Young Adults Presenting for HIV Care Between 2002 and 2010. JAMA Pediatr. 2014;168(4):381–383. doi:10.1001/jamapediatrics.2013.4531