title: Structural Determinants of Antiretroviral Therapy Use, HIV Care Attendance, and Viral Suppression among Adolescents and Young Adults Living with HIV.
abstract: BACKGROUND
  The authors examined associations between structural characteristics and HIV disease management among a geographically diverse sample of behaviorally and perinatally HIV-infected adolescents and young adults in the United States.
  
  
  METHODS
  The sample included 1891 adolescents and young adults living with HIV (27.8% perinatally infected; 72.2% behaviorally infected) who were linked to care through 20 Adolescent Medicine Trials Network for HIV/AIDS Interventions Units. All completed audio computer-assisted self-interview surveys. Chart abstraction or blood draw provided viral load data. Geographic-level variables were extracted from the United States Census Bureau (e.g., socioeconomic disadvantage, percent of Black and Latino households, percent rural) and Esri Crime (e.g., global crime index) databases as Zip Code Tabulation Areas. AIDSVu data (e.g., prevalence of HIV among youth) were extracted at the county-level. Using HLM v.7, the authors conducted means-as-outcomes random effects multi-level models to examine the association between structural-level and individual-level factors and (1) being on antiretroviral therapy (ART) currently; (2) being on ART for at least 6 months; (3) missed HIV care appointments (not having missed any vs. having missed one or more appointments) over the past 12 months; and (4) viral suppression (defined by the corresponding assay cutoff for the lower limit of viral load at each participating site which denoted nondetectability vs. detectability).
  
  
  RESULTS
  Frequencies for the 4 primary outcomes were as follows: current ART use (n = 1120, 59.23%); ART use for ≥6 months (n = 861, 45.53%); at least one missed HIV care appointment (n = 936, 49.50); and viral suppression (n = 577, 30.51%). After adjusting for individual-level factors, youth living in more disadvantaged areas (defined by a composite score derived from 2010 Census indicators including percent poverty, percent receiving public assistance, percent of female, single-headed households, percent unemployment, and percent of people with less than a high school degree) were less likely to report current ART use (OR: 0.85, 95% CI: 0.72-1.00, p = .05). Among current ART users, living in more disadvantaged areas was associated with greater likelihood of having used ART for ≥6 months. Participants living in counties with greater HIV prevalence among 13-24 year olds were more likely to report current ART use (OR: 1.32, 95% CI: 1.05-1.65, p = .02), ≥6 months ART use (OR: 1.32, 95% CI: 1.05-1.65, p = .02), and to be virally suppressed (OR: 1.50, 95% CI: 1.20-1.87, p = .001); however, youth in these areas were also more likely to report missed medical appointments (OR: 1.32, 95% CI: 1.07-1.63, p = .008).
  
  
  CONCLUSIONS
  The findings underscore the multi-level and structural factors associated with ART use, missed HIV care appointments, and viral suppression for adolescents and young adults in the United States. Consideration of these factors is strongly recommended in future intervention, clinical practice, and policy research that seek to understand the contextual influences on individuals' health behaviors.
authors.affiliation: Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse/National Institutes of Health, Bethesda, MD, United States of America.
authors.forename: Shoshana Y
authors.initials: SY
authors.lastname: Kahana
authors.affiliation: Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse/National Institutes of Health, Bethesda, MD, United States of America.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Jenkins
authors.affiliation: Department of Health Sciences, DePaul University, Chicago, IL, United States of America.
authors.forename: Douglas
authors.initials: D
authors.lastname: Bruce
authors.affiliation: Department of Preventive Medicine and Department of Public Health Program, College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, United States of America.
authors.forename: Maria I
authors.initials: MI
authors.lastname: Fernandez
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.
authors.forename: Lisa B
authors.initials: LB
authors.lastname: Hightow-Weidman
authors.affiliation: Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America.
authors.forename: Jose A
authors.initials: JA
authors.lastname: Bauermeister
mesh_terms: D000293:Adolescent; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D044383:Black People; D005260:Female; D006678:HIV / Q000187:drug effects*; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology*; D015438:Health Behavior; D006630:Hispanic or Latino; D006801:Humans; D008297:Male; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult; D001741:Black or African American
chemical_list: D044966:Anti-Retroviral Agents