Antiretroviral Nonadherence, Unsuppressed Viral Load Prevalent Across Adolescence

The prevalence of nonadherence and unsuppressed viral load increased through adolescence and into young adulthood.

Investigators looking to identify factors associated with nonadherence and unsuppressed viral load across adolescence and young adulthood among individuals with perinatally acquired HIV found that the prevalence of both increased with age. The results, published in AIDS, also showed that the factors associated with these varied across adolescence.

In this longitudinal study at 15 US clinical sites, self-reported antiretroviral nonadherence (any missed dose in the past week) and unsuppressed viral load (HIV RNA >400 copies/mL) were assessed annually. The individual, caregiver, social and structural factors associated with each were also identified by age. Investigators identified 4 age strata: (1) pre-adolescence (aged 8-11 years), (2) early adolescence (aged 12-14 years), (3) middle adolescence (aged 15-17 years), and (4) late adolescence/young adulthood (aged 18-22 years).

The study had a median 3.4-year follow-up and included 381 participants who contributed viral load measurements; 379 participants completed 1190 adherence evaluations. During the period of pre-adolescence to late adolescence/young adulthood, the prevalence of nonadherence increased from 31% to 50% (P <.001). In the same period, the prevalence of unsuppressed viral load also increased, rising from 16% to 40% (P <.001).

In the periods of pre-, middle- and late adolescence perceived antiretroviral side effects were associated with nonadherence. Factors associated with nonadherence in pre-adolescence were using a buddy system; in addition, identifying as black was also associated with nonadherence in participants in early adolescence. For those in middle adolescence, nonadherence factors were a nadir CD4% <15%, having an unmarried caregiver, indirect exposure to violence, stigma/fear of inadvertent disclosure, and stressful life events.

Unsuppressed viral load was associated with youth unawareness of HIV status and lower income during early adolescence, with perceived side effects and low income during middle adolescence, and with distressing physical symptoms and perceived side effects during late adolescence.

Statistical power to evaluate the associations was limited in this study as a result of a small sample size in some age strata. Being a clinic-based sample also limited the generalizability of the results to all youth with perinatally acquired HIV. It was also noted that adherence was assessed infrequently, meaning there was limited ability to capture short-term fluctuations.

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According to investigators, the results do have implications, “for programs and policies to mitigate risk of nonadherence and unsuppressed viral load among youth with perinatally acquired HIV as they transition through adolescence into adulthood.” Further, researchers recommended that services aimed at helping this group navigate typical developmental challenges should recognize age-specific risks and build on sources of resilience at the individual, family, and structural level.


Kacanek D, Huo Y, Malee K, et al. Nonadherence and unsuppressed viral load across adolescence among US youth with perinatally acquired HIV. AIDS. 2019;33:1923-1934.