Background
More data are needed to understand the rates and associated risk factors of mortality, serious clinical events, elevated viral load, and immunosuppression in the aging population of young adults with perinatally acquired HIV (YAPHIV) in the US.
Methods
Among YAPHIV ≥18 years in the Pediatric HIV/AIDS Cohort Study AMP and AMP Up protocols, we calculated incident mortality and CDC-C/WHO-4 rates and the proportion of person-time with elevated viral loads (≥200 copies/mL) and low CD4 counts (<200 cells/mm3) by age strata 18-21, 22-25, 26-29, and ≥30 years. We used Cox models to identify risk factors at age 18-24 years which best predicted mortality/CDC-C events for YAPHIV at ≥25 years.
Results
617 participants were followed for incident events (median follow-up 6.5 years; 63% were 18-21 years, 61% female, and 63% Black non-Hispanic; median CD4 count 561 cells/mm3 and 66% viral load <200 copies/mL at baseline). Mortality (per 1000 PY) was highest at ≥30 years at 8.1 (95% CI: 3.0,22.0) and lowest at 3.1 participants (95% CI: 1.0,9.9) at ages 22-25. Black non-Hispanic female and male YAPHIV had mortality rates 11.5 (95% CI: 5.8,23.1) and 4.7 (95 CI: 2.0,11.3) times higher than Black non-Hispanic females and males in the US population, and 14.9 (95% CI: 7.4,29.7) and 7.1 (95% CI: 3.0,17.1) times higher than white non-Hispanic females and males in the US population. 44 CDC-C/WHO-4 events were reported over 4034 PY; incidence was highest at 18-21 years at 20.0 (95% CI: 11.5,34.7) events per 1000 PY. The proportion of person-time with viral suppression <200 copies/mL increased as participants aged, but CD4 count <200 cells/mm3 also increased. Among 307 participants in follow-up at age 25 years, those with high viral load, low CD4 count, a prior CDC-C/WHO-4 event, poor medication adherence, current marijuana use, or who were unemployed were more likely to have an incident CDC-C/WHO-4 event or death after age 25 years. In multivariable analyses, the most important independent predictors of incident CDC-C/WHO-4 event or death were high viral load, low CD4 count, and a prior CDC-C/WHO-4 event (C-index: 0.92), conferring a 54.6% risk of CDC-C/WHO-4 event or death by year 3 of follow-up compared to 0.3% risk for participants without these risk factors.
Conclusions
There is increased mortality with age for YAPHIV, particularly for Black non-Hispanic young adults. Providers should identify interventions that lower the risk for high viral load, low CD4 count, and incident CDC-C/WHO-4 events for YAPHIV.
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