Adolescents newly diagnosed with HIV need to be rapidly incorporated into HIV care networks to have the best chances of remaining in care in the long term, research from the United States published in the June 1st edition of the Journal of Acquired Immune Deficiency Syndromes shows.

Worryingly, only 62% of newly diagnosed adolescents were linked and engaged in care within 22 weeks of referral following their diagnosis. However, adolescents with shorter intervals between diagnosis and referral to HIV services, and then referral and linkage to care were more likely to quickly engage with care and to stay in care.

“This study demonstrates that the time interval between a newly diagnosed adolescent’s HIV test and care referral and the time interval between care referral and first medical visit (linkage to care) have concrete implications for long-term HIV care engagement,” comment the investigators. “These data have quality of care implications for HIV testing programs in that the speed with which HIV-positive youth are referred for linkage has downstream implications for engagement.”

The HIV care continuum has several stages, specifically diagnosis, referral to specialist care, linkage to care, engagement with care, starting HIV therapy and viral suppression. In the US, adolescents – people aged between 12 and 24 years – have much poorer rates of engagement in HIV care compared to adults, and consequently, only 6% of all adolescents living with HIV have an undetectable viral load compared to approximately a third of adults.

Investigators wanted to see if longer time between HIV diagnosis and referral and linkage to care had subsequent implications for later engagement with care for newly diagnosed adolescents


They therefore collected data from 15 Adolescent Medicine Trials Network Clinic sites in 13 cities across the US and Puerto Rico. Each of these sites implemented the SMILE programme in 2010, which was designed to boost adolescent engagement in the HIV care continuum. SMILE used intensive case management to identify newly diagnosed adolescents, assess individual barriers to linkage to care and achieve personalised referral to specialist care services.

For the purposes of the study, linkage to care was defined as an HIV-related medical appointment within six weeks of referral following diagnosis. Engagement in care was a second visit within 16 weeks of the initial visit.

During 32 months, 1799 newly diagnosed adolescents were referred to the SMILE programme. Of these, 70% were linked to care and 89% of these individuals were engaged in care. Therefore, only 62% of adolescents were linked and engaged with care.

The adolescents were predominately male (80%), black (77%) and were in the men-who-have sex with men risk group (74%). The mean age was 21 years and two-thirds reported drug use. Most (80%) were assigned an outreach worker.

Time from HIV testing to initial referral (under one week vs. over one year) was associated with higher chances of subsequent engagement with care (aHR = 2.91; 95% CI, 1.43-5.94) and also shorter time to engagement (aHR = 1.41; 95% CI, 1.11-1.79).

Moreover, those with shorter intervals between referral and linkage to care (under one week vs. 22-42 days) engaged in care faster (aHR = 2.90; 95% CI, 2.34-3.60) and were more likely to remain engaged in care (aHR = 2.01; 95% CI, 1.04-3.89).

“Our research suggests that each newly diagnosed HIV-infected youth needs to be linked to care as quickly as possible to facilitate more rapid engagement in care, access to medications, and better long-term prognosis,” conclude the authors. “These data should be used to build evidence and help construct a seamless continuum of care for HIV-infected youth to help fulfill the goals outlined in the US National HIV/AIDS Strategy.”


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