A Multicenter Study of Initiation of Antiretroviral Therapy and Transmitted Drug Resistance in Antiretroviral-Naive Adolescents and Young Adults With HIV in New York City

CID A Multicenter Study of Initiation of Antiretroviral Therapy and Transmitted Drug Resistance in Antiretroviral-Naive Adolescents and Young Adults With HIV in New York City Christina Gagliardo () 2 3 Ava Brozovich 2 3 Jeffrey Birnbaum 1 2 Anita Radix 0 2 Marc Foca 2 3 John Nelson 2 3 Lisa Saiman 2 3 4 Michael Yin 2 3 Elektra Carras-Terzian 2 3 Emily West 2 3 Natalie Neu 2 3 0 Callen-Lorde Community Health Center , New York 1 SUNY Downstate Medical Center , Brooklyn 2 Received 20 June 2013; accepted 14 November 2013; electronically published 14 January 2014. Hospital , 977 48th St, Brooklyn, NY 11219 3 Columbia University Medical Center , New York 4 Department of Infection Prevention and Control, NewYork-Presbyterian Hospital , New York , New York Background. In December 2009, the Department of Health and Human Services guidelines for initiation of antiretroviral therapy (ART) changed to include patients with CD4 counts between 350 and 500 cells/µL. The aims of this study were to assess uptake of this recommendation in ART-naive youth with human immunodeficiency virus (HIV) and to describe the epidemiology of transmitted genotypic drug resistance mutations (DRMs) in this population. Methods. A multicenter, retrospective cohort study of ART initiation in ART-naive youth was performed. Eligible subjects were 13-25 years of age, were diagnosed with HIV within 1 year of presentation to care at the study sites, and presented to care from January 2007 to June 2011. Results. Of 685 potential subjects identified, 331 (49%) fulfilled inclusion criteria. Mean CD4 count at presentation to care was 452 cells/µL. Overall, 191 (58%) subjects started ART. The mean CD4 count at ART initiation was 261 cells/µL before and 363 cells/µL after the 2009 guideline change (P < .0001). Of 212 (64%) subjects with resistance testing available prior to ART initiation, 38 (18%) subjects had a major DRM and an increased proportion of resistance was seen in later study years. Conclusions. Our study demonstrated an uptake in recently changed guideline recommendations to treat HIVinfected individuals at higher CD4 counts and reinforces the importance of performing resistance testing at entry into care, as 18% of our population had major DRMs prior to initiation of ART. - HIV; adolescents; youth; genotypic resistance; antiretroviral therapy. The optimal time to initiate antiretroviral therapy (ART) in adolescents with human immunodeficiency virus (HIV) has not been studied in randomized trials; therefore, current HIV treatment recommendations for adolescents follow adult guidelines. Adolescents and young adults aged 13–24 years are one of the fastestgrowing demographic groups acquiring new infections, with 25.7% of all new HIV diagnoses occurring in this age group [1]. Trends in viral resistance patterns, initial CD4 count, and plasma RNA in this younger HIVinfected population in the United States have not been studied in depth. The Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents made recommendations for earlier initiation of ART; in December 2009, the DHHS recommended ART initiation at a CD4 count of <500 cells/ µL [2]. Of note, the panel was divided, as 55% of panel members voted for a strong recommendation (A) and 45% for a moderate recommendation (B) [2]. In February 2013, the panel recommended treatment for all HIV-infected individuals regardless of CD4 count [3]. Timely initiation of ART initiation aims to prevent HIV-associated morbidity and mortality, to decrease HIV transmission, and in patients with higher CD4 counts, to prevent non-AIDS-defining diseases including malignancy and kidney, liver, neurologic, and cardiovascular diseases from uncontrolled viremia [3]. Data from the Centers for Disease Control and Prevention show that adolescents generally present to care with higher CD4 counts than adults [4]. The potential benefits or risks of initiating ART earlier in this younger population are unknown and are complicated by developmental and psychosocial factors unique to this age group. Timely initiation of ART in adults has increased in the last decade [5], but ART initiation is less well studied in adolescents. Various reports have found that the rate of drug resistance mutations (DRMs) is 6%–17% among ART-naive HIV-infected adolescents and adults in the United States and 5% in developing countries [6–11]. One study reported specifically on the rate of DRMs in HIV-infected youth in the United States; 18% (10/55) of recently HIV-infected adolescents and young adults had transmitted genotypic DRMs identified [12]. The objectives of this study were to describe the CD4 count, viral load, and prevalence of DRMs in ART-naive, recently diagnosed HIV-infected adolescents and young adults in New York City. We hypothesized that after the DHHS guideline change in 2009, >50% of ART-naive adolescents and young adults had a CD4 count in the range recommended to begin treatm (...truncated)