In this sample of urban, predominately African American YPLH, we found that most patients engaged in the measured health protective behaviors more than half the time. They were particularly diligent about attending medical appointments (75% of the time) while 57% reported adherence to ARV medication regimens, well within the reported range of HIV medication adherence for youth [7
]. The least frequent HPB was participation in regular exercise, reported by 55% of participants.
The finding that YPLH who adhere to ARV treatment, which in this sample was at least half the respondents, are also more likely to engage in other HPB suggesting that adherence is likely to be part of a wider constellation of HPB. As the community of YPLH is very insular, these patients may be able to serve as role models to their peers in promoting a healthy lifestyle.
This study also found that the frequency with which YPLH engaged in HPB varied by demographic and disease characteristics. Females in our sample exercised less often than males, which correspond to findings among healthy adolescents. According to surveillance summaries of physical activity conducted by the CDC, girls in every grade of high school exercise far less than boys [39
With regards to the measured disease characteristics, viral load was significantly associated with taking ARV medications and exercise. It seems likely that neglecting to engage in certain HPB such as taking ARV medications precedes viral load increases; however this could not be deduced from our cross-sectional analysis. It may also be the case that those with higher viral loads are more symptomatic and thus do not feel well enough to exercise or were abiding by their doctor’s recommendations not to participate in strenuous physical activities [26
]. Although there was a trend toward lower HPB among behaviorally-infected patients in unadjusted models, the differences may not have reached statistical significance due to the small proportion of behaviorally-compared to perinatally-infected youth.
The most consistent correlate of HPB in our sample was patient age. In particular, patients who were no longer minors (i.e., 18 and over) engaged in all behaviors less frequently than their younger counterparts. This pattern was significant for taking other medicines/vitamins/supplements, keeping medical appointments and eating a well-balanced diet, even when controlling for transmission mode, which is closely associated with age (i.e., perinatally-infected youth are younger than behaviorally-infected).
We purport that the lower engagement in HPB among older YPLH may be due to a number of changing environmental factors that accompany their transition into adulthood and independence. For instance, patients living apart from their caregivers may receive less assistance from family members preparing meals, reminding them to take other medicines, or helping coordinate/schedule healthcare appointments [35
]. Youth in this age group are also more likely to be unstably housed [40
] and have limited employment opportunities, stressors that consume their energy and divert attention away from participation in HPB. They are also likely to be behaviorally infected youth who have been shown to have higher depression rates, more exposure to violence and substance abusers [41
The age difference in HPB may also reflect the focus of care providers in the infectious disease clinic from which participants were recruited. In this clinic, for example, providers are typically most concerned with adherence to ARV regimens. They use vitamins as a mechanism for establishing a habit of daily pill taking before starting ARV medication regimens, but as they get older YPLH may discontinue taking the vitamins/supplements because they do not understand that these remain a beneficial component of their healthcare alongside ARV medications. As patients become older adolescents, the clinical focus often shifts to include more of an emphasis on reducing risk factors (e.g., substance abuse, unsafe sex) than on promoting behaviors that can sustain positive health outcomes. While both issues are clinically relevant for YPLH, longer clinical appointments may be necessary to address these issues equally.
Interestingly, data from this study revealed no significant differences by transmission mode, once age was controlled. This finding is contrary to other research that found significant differences in adherence related behavior when distinguishing a cohort of YPLH by mode of transmission [44
]. With few existing studies that compare health behaviors between those with perinatally and behaviorally acquired HIV infection; this is an area of research that deserves more attention.
On the whole, findings regarding age differences in HPB may highlight a need for broader scaffolding in the transition to independent living and adult health care [20
]. Providers and caregivers could encourage HPB in older adolescents and young adults by emphasizing their value, particularly with regard to exercise reducing viral load, and facilitating routines for and helping to address environmental barriers to taking other medicines/vitamins/supplements, keeping medical appointments and eating well-balanced meals. When working with younger HIV-positive patients, providers should view their time as an opportunity to promote healthy living above and beyond taking ARV medicines as a lifetime goal. Our clinical experiences working with YPLH suggest that in spite of their diagnosis, they want to be treated like their non-infected peers. Perhaps by encouraging HPB in general, providers can reduce stigma concerns raised by secondary prevention initiatives targeting people living with HIV [45
]. The establishment and maintenance of healthy lifestyle practices early in adolescence should translate into positive long-term health outcomes, especially given the relationship between general HPB and adherence to ARV treatment. Thus, it is important to help YPLH think in a future-oriented manner, possibly by highlighted how HPB will promote achievement of life goals/milestones.
Limitations and future directions
Several limitations should be considered when interpreting these results. First, behavioral data were self-reported and therefore subject to self-enhancement bias [46
], although the use of ACASI may minimize this effect [47
]. Future research would benefit by broadening the HPB variables examined to include behaviors such as stress management, dental check-ups, and exercise to include aerobic and muscle and bone strengthening activities as well as asking about HPB (e.g., exercise, diet) in relation to professional recommendations/guidelines to facilitate comparisons across studies. Additional demographic variables might include SES, education, poverty, sexual orientation and substance use supplemented by information on self-efficacy (i.e., behavior specific cognitions and affect) and social support and living arrangements (i.e., situational/interpersonal influences). Secondly, while this investigation reports only cross-sectional data, this is only a constraint on the conclusions that can be drawn about the direction of associations between HPB and viral load. The other independent variables are static or, in the case of age, only change in one direction. This study represents a first step in a new line of research on HPB among YPLH, thus it was prudent to examine cross-sectional correlations to develop hypotheses for future longitudinal investigations. Longitudinal data looking at individual change over time will be useful for determining whether age is associated with a reduction in HPB as opposed to our findings being explained by other differences between age cohorts. Finally, our findings are not generalizable to other inner-city, minority populations as this sample was predominantly African American and perinatally infected.