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Nonadherence and unsuppressed viral load across adolescence among US youth with perinatally acquired HIV

Kacanek, Deboraha,b; Huo, Yanlinga,b; Malee, Kathleenc; Mellins, Claude A.d; Smith, Reneee; Garvie, Patricia A.f; Tassiopoulos, Katherineg; Lee, Soniah; Berman, Claire A.g; Paul, Maryi; Puga, Anaf; Allison, Susannahj for the Pediatric HIV/AIDS Cohort Study

doi: 10.1097/QAD.0000000000002301

Objective: To identify factors associated with nonadherence and unsuppressed viral load across adolescence among youth with perinatally acquired HIV.

Design: Longitudinal study at 15 US clinical sites.

Methods: Self-reported antiretroviral medication nonadherence (any missed dose, past week) and unsuppressed viral load (HIV RNA > 400 copies/ml) were assessed annually. Individual, caregiver, social, and structural factors associated with nonadherence and unsuppressed viral load were identified by age (years): 8–11 (preadolescence), 12–14 (early adolescence), 15–17 (middle adolescence), and 18–22 (late adolescence/young adulthood), utilizing multivariable generalized linear mixed effects models.

Results: During a median 3.3-year follow-up, 381 youth with perinatally acquired HIV contributed viral load measurements and 379 completed 1190 adherence evaluations. From preadolescence to late adolescence/young adulthood, prevalence of nonadherence increased from 31 to 50% (P < 0.001); prevalence of unsuppressed viral load increased from 16 to 40% (P < 0.001). In adjusted analyses, in pre, middle, and late adolescence/young adulthood, perceived antiretroviral side effects were associated with nonadherence. Additional factors associated with nonadherence included: in preadolescence, using a buddy system (as an adherence reminder); in early adolescence, identifying as black, using buddy system; in middle adolescence, CD4+% less than 15%, unmarried caregiver, indirect exposure to violence, stigma/fear of inadvertent disclosure, stressful life events. Associations with unsuppressed viral load included: in early adolescence, youth unawareness of HIV status, lower income; in middle adolescence, perceived antiretroviral side effects, lower income; in late adolescence/young adulthood, distressing physical symptoms, and perceived antiretroviral side effects.

Conclusion: Prevalence of nonadherence and unsuppressed viral load increased with age. Associated factors varied across adolescence. Recognition of age-specific factors is important when considering strategies to support adherence.

aDepartment of Biostatistics

bCenter for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

cDepartment of Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, Illinois

dDepartment of Psychiatry, HIV Center for Clinical and Behavioral Studies, Columbia University Irving Medical Center, New York, New York

eDepartment of Pediatrics, University of Illinois at Chicago, Chicago, Illinois

fResearch Department, Children's Diagnostic & Treatment Center, Fort Lauderdale, Florida

gDepartment of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

hMaternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland

iDepartment of Pediatrics, Retrovirology, Baylor College of Medicine, Houston, Texas

jDivision of AIDS Research, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA.

Correspondence to Deborah Kacanek, ScD, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, 665 Huntington Ave. FXB 505, Boston, MA 02115, USA. Tel: +1 617 432 2833; fax: +1 617 432 3163; e-mail:

Received 18 March, 2019

Revised 9 June, 2019

Accepted 17 June, 2019

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