May 3, 2009
Research led by Johns Hopkins Children's Center has found that many HIV-infected youth who meet criteria for treatment with HAART (highly active anti-retroviral therapy) either get no treatment or do not get it in the recommended time, which puts them at risk for complications and may speed up the progression from HIV infection to full-blown AIDS.
In a study of hundreds of HIV-infected youth seen in high-volume HIV clinics nationwide, researchers found that overall 43 percent of the 656 who qualified for treatment by one of several criteria were not given HAART, the gold standard of HIV therapy to ward off complications, restore immunologic function and reduce the risk of infecting others.
Treatment criteria have evolved since 1997, when HAART became available, but currently most HIV experts agree that anyone with a CD4 cell count below 350 per cubic milliliter of blood should start HAART. CD4 cells, immune cells that are a favorite target of HIV, are slowly destroyed as the disease progresses. Other HIV care providers may rely on different criteria, prescribing HAART only to those with a viral load above 100,000 per cubic milliliter of blood regardless of CD4 count, or HAART treatment only for those who have both high viral load and low CD4 count. Using all three criteria, separately and in combination, the researchers assessed initiation of HAART.
Applying the most stringent definition of who should get treatment -- those who had both high viral loads and low CD4 counts -- researchers found that 26 percent of the 227 youth who qualified by this standard did not get therapy. Among those who qualified for treatment by CD4 count alone, 50 percent of 142 did not get treatment. Among 63 who qualified for HAART by viral load alone, 55 percent did not get treated.
Teenagers and young adults traditionally have been the hardest group to treat because they often miss appointments and find it hard to follow the complicated multidrug regimens that make up HAART. However, frontline HIV care-providers must realize that they too are part of the equation, the researchers say, and find ways to increase both initiation and compliance with HAART.
"We're not blaming anyone, but it takes two to tango: Teens should want to be treated, and providers should persist in treating them," said lead investigator Allison Agwu, M.D., an infectious disease specialist at Hopkins Children's. "We must figure out just why it is that we're not treating so many of these young people and, once we do, design better strategies to get them on timely treatment."
According to the CDC, there are 53,000 new HIV infections diagnosed each year in the United States, and 14 percent of these infections occur in 13- to 25-year-olds.
Other Hopkins investigators in the study include Jonathan Ellen, M.D., and Kelly Gebo, M.D.
Other institutions in the study: Children's Hospital of Philadelphia, St. Jude's Children's Research Hospital, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, University of California-San Diego, St. Luke's-Roosevelt Hospital, New York.