Long-term outcomes of young adults with perinatal HIV infection in the U.S. and Puerto Rico

Background Data on mortality, clinical events, viral load (VL), and immunosuppression among young adults aging with perinatally-acquired HIV (YAPHIV) are limited. Methods Among YAPHIV ≥18 years in the Pediatric HIV/AIDS Cohort Study, we calculated incident mortality, CDC-C/WHO-4 rates, and proportion of person-years (PY) with elevated VL (≥200 copies/mL) and immunosuppression (CD4 <200 cells/mm3) by age strata 18-21, 22-25, 26-29, and ≥30 years. We compared mortality rates to the US population and identified predictors of mortality/CDC-C/WHO-4 events at age ≥25 years. Results 617 participants had median follow-up of 6.5 years; at baseline 63% were 18-21 years, 61% were female, 63% self-reported as Black, median CD4 count was 561 cells/mm3, and 66% had VL <200 copies/mL. Mortality was highest at ≥30 years (8.1 per 1000PY [95% CI: 3.0, 22.0]). Black YAPHIV had mortality rates at least 7.1 (3.0, 17.1) times higher than white non-Hispanic persons in the US population. Proportion of elevated VL person-time decreased while low CD4 person-time increased as participants aged. Among 307 participants followed after age ≥25 years, elevated VL, low CD4, and prior CDC-C/WHO-4 event strongly predicted risk of incident mortality/CDC-C/WHO-4 event (C-index: 0.94); risk at 3 years of follow-up was 19% (0%, 45%) among those with all three characteristics. Other important predictors were poor treatment adherence, current cannabis use, lack of current employment/education, and stressful events (C-index: 0.81). Conclusions There is excess mortality with age for YAPHIV, particularly for Black YAPHIV. Interdisciplinary interventions are needed to improve treatment outcomes for YAPHIV at highest identified risk.