Sarah Wood1,2,3, Sarah Ratcliffe4,5, Charitha Gowda6,7, Susan Lee1,2, Nadia L Dowshen1,2,3, Robert Gross4,5,7. 1. Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia. 2. Department of Pediatrics, University of Pennsylvania Perelman School of Medicine. 3. PolicyLab, Children's Hospital of Philadelphia. 4. Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. 5. Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. 6. Department of Pediatrics, The Ohio State University College of Medicine, Ohio. 7. Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Abstract
OBJECTIVE: To identify the prevalence of high HIV transmission potential in a cohort of youth living with HIV (YLWH), and determine the impact of insurance coverage on potential for HIV transmission. DESIGN: Retrospective cohort study of antiretroviral therapy (ART)-treated YLWH at a US adolescent HIV clinic, 2002-2015. METHODS: The primary exposure was presence or absence of insurance, defined as private, public or pharmacy-only coverage. The primary outcome was high HIV transmission potential, defined as time-concurrent incident bacterial sexually transmitted infections (STI) (gonorrhea, chlamydia or syphilis) and HIV RNA greater than 1500 copies/ml. Marginal structural models adjusting for baseline demographic covariates, prior history of STI and time-varying retention in care assessed the relationship between insurance status and HIV transmission potential. RESULTS: Participants (n = 240) were followed for a median of 22 (IQR 8.1-49) months after ART initiation, and were predominately African-American men and transgender women who have sex with men, with a median age at HIV diagnosis of 19 years (IQR 17-21). We identified 37 (15%) participants with at least one episode of high HIV transmission potential. Insurance coverage was associated with a greater than 50% lower odds of high HIV transmission potential (aOR 0.46, 95% CI 0.26-0.84), and history of STI at or before entry to HIV care conferred more than three-fold higher odds of high transmission potential (aOR 3.21, 95% CI 1.55-6.63). CONCLUSION: We found 15% of YLWH to have episodic high HIV transmission potential despite receiving ART. Insurance coverage, including pharmacy-only benefits, was protective against transmission risk, suggesting a pivotal role for universal ART coverage in treatment as prevention.
OBJECTIVE: To identify the prevalence of high HIV transmission potential in a cohort of youth living with HIV (YLWH), and determine the impact of insurance coverage on potential for HIV transmission. DESIGN: Retrospective cohort study of antiretroviral therapy (ART)-treated YLWH at a US adolescent HIV clinic, 2002-2015. METHODS: The primary exposure was presence or absence of insurance, defined as private, public or pharmacy-only coverage. The primary outcome was high HIV transmission potential, defined as time-concurrent incident bacterial sexually transmitted infections (STI) (gonorrhea, chlamydia or syphilis) and HIV RNA greater than 1500 copies/ml. Marginal structural models adjusting for baseline demographic covariates, prior history of STI and time-varying retention in care assessed the relationship between insurance status and HIV transmission potential. RESULTS:Participants (n = 240) were followed for a median of 22 (IQR 8.1-49) months after ART initiation, and were predominately African-American men and transgender women who have sex with men, with a median age at HIV diagnosis of 19 years (IQR 17-21). We identified 37 (15%) participants with at least one episode of high HIV transmission potential. Insurance coverage was associated with a greater than 50% lower odds of high HIV transmission potential (aOR 0.46, 95% CI 0.26-0.84), and history of STI at or before entry to HIV care conferred more than three-fold higher odds of high transmission potential (aOR 3.21, 95% CI 1.55-6.63). CONCLUSION: We found 15% of YLWH to have episodic high HIV transmission potential despite receiving ART. Insurance coverage, including pharmacy-only benefits, was protective against transmission risk, suggesting a pivotal role for universal ART coverage in treatment as prevention.
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