Health outcomes for young adults with perinatally acquired HIV infection following transfer to adult services
Charlotte Walker, HIV i-Base
Globally there are an estimated 2.1 million children under 15 infected with HIV. In the UK, the Collaborative HIV Paediatric Study (CHIPS) estimates the number of HIV-positive children to be 1,645 as of March 2010. Of these, 65% are over 10 years. A total of 262 have now been transferred to adult care.
As HAART has only been available since 1996, this is the first generation born with HIV to have survived to adulthood. As a result the long-term outcomes of HIV infection from birth and HIV treatment in childhood is still relatively uncertain.
This study aimed to examine the health outcomes of a cohort of 58 young people with perinatally acquired HIV infection that were originally part of the 900 clinic at St Marys Hospital and are now in adult care. The 900 clinic provides services for young people who were diagnosed with HIV when they were children and have been treated at St Marys Hospital since their diagnosis.
This was a case note review of all HIV-positive young people seen at the 900 clinic between January 2006-2011.
The median age of transfer from paediatric care in this cohort was 17.2 years (range 16.3 18.6) and the current median age was 20.6 (range 16.9 26.1) years. Overall outcomes of the 58 young people includes 5 (9%) who were transferred to local adult services, 51 who were still patients at the 900 clinic and 2 (4%) died (one 20 year old female due to MDR end-stage HIV disease and a 21 year old female due to nephropathy and sepsis who had declined ART). There was no loss to follow up and 7 of the patients included in the study had babies.
Of the 51 patients currently at the 900 clinic, their median current CD4 count was 425 cells/mm3 (IQR: 30-1140). More specifically, 22% had a CD4 count of <200 cells/mm3, 8% had a CD4 count of 200-350 cells/mm3 and 69% had a CD4 count of >350 cells/mm3. Of the 51 patients, 5 (10%) were ART na, 14 (27%) were on NNRTI-based regimens, 18 (35%) were on PI-based regimens, 2(4%) were on triple NRTI-based regimens and 12 (24%) had stopped ART.
Focusing on the 34 patients currently on ART, the median CD4 count was 480 with 6 patients had a CD4 count of <200 cells/mm3 (of which 3 had detectable viral loads), 2 had a CD4 count of 200-350 (of which 1 had a detectable viral load) and 26 had a CD4 count of >350 (of which 1 had a detectable viral load).
As far as complications of disease and treatment were concerned, 2 patients required gastrostromy tubes to help adherence, 6 (12%) had severe lipodystrophy (5 requiring surgery and 1 injectable fillers), 11 patients had a history of mental health problems (this included 4 patients who had intentional overdoses requiring admission to hospital) and 7 (14%) who had been prescribed antidepressants at some point.
Of the 51 patients currently at the 900 clinic, 13 (25%) had been admitted to adult inpatient services for a median duration of 9 days (range 3-133), 2 for OIs (PCP and MAI), 4 following overdoses and 1 for CVA and osteonecrosis.
The investigators concluded that after 2 decades of living with HIV, 20% of the patients at the 900 clinic have severe immunosuppression (CD4 <200), 25% have required hospital admission an 3% died. There were high rates of co-morbidity, lipodystrophy and depression. There are also a small group of young people who remain off ART with low CD4 counts. Overall 85% of those on ART currently have undetectable viral loads.
The high rate of suppression on HAART (>85%) is a significant achievement given complicated treatment histories. Complicated balance for people still of treatment given the focus of long-term uncontrolled viraemia in adult patients, but also balanced with concern for long-term complications including cardiovascular and bone health.
Rate of psychiatric-related morbidity is especially concerning.
Wan T et al. Health outcomes for young adults with perinatally acquired HIV-1 infection following transfer to adult services. 17th Annual BHIVA Conference, 68 April 2011, Bournemouth. Oral abstract O31.