Management and outcomes for adolescents with perinatally acquired HIV infection in Asia

Adolescents with perinatal HIV infection (PHIVA) are subject to a chronic systemic infection associated with immune dysfunction and long-term exposure to combination antiretroviral therapy (cART). The interplay of these pathophysiologic processes in the complex biopsychosocial context of adolescence makes this cohort susceptible to poor outcomes. Descriptive, survival and regression analyses, using data from a regional Asian observational cohort study (Therapeutics Research, Education, and AIDS Training paediatric Observational Database), were conducted to evaluate the management and outcomes for Asian PHIVA. Asian PHIVA experienced delays in HIV diagnosis and cART initiation, leading to poor virologic, immunologic and clinical disease control by adolescent entry that had a lasting impact on morbidity and mortality throughout adolescence. Early adolescence was dominated by disease-related morbidity that shifted toward treatment-related morbidity in later adolescence. Real-world use of virologic monitoring underappreciated the burden of cART failure; and only a small proportion of those with cART failure had a switch in regimen, which led to better virologic and immunologic outcomes. Alternate strategies of antiretroviral monotherapy and treatment interruption were used sparingly, and their viability limited by immunological vulnerability. Across conventional and novel methods in determining loss to follow-up (LTFU), treatment fatigue and decentralised clinic settings were associated with LTFU. Upon reaching transition to adult HIV services, earlier cART initiation had resulted in better virologic and immunologic outcomes but more complex cART exposure. PHIVA carry with them the legacy of HIV health policies and infrastructures present throughout their infancy and childhood. This has implications for the timeliness of their HIV diagnosis, the timing and nature of cART, and engagement in care. These early determinants have a lasting impact on their life course and adolescence represents a crucial period for developing positive health attitudes and behaviours. Improving chronic disease models of HIV care, through more proactive monitoring and management of treatment failure, regular surveillance and multidisciplinary management of morbidity, and incorporation of adolescent-friendly services into decentralised and diversified HIV health services is key to minimise the HIV burden experienced as an adolescent and optimise their outlook for adulthood