These Standards for early to middle adult life refer to those aged between 25 and 65 years, and will include people diagnosed in childhood, adolescence or early adult life, and who have acquired HIV both perinatally and behaviourally. Young people are defined by the WHO as ‘adolescents’ when aged 10–19 years, and ‘young adults’ when aged 20–24 years. Adults are defined as those aged from 25 years, a chronological age at which the complex neuronal pruning of adolescence nears completion, of peak bone mass accrual and typically a move from education to employment. While definitions of adulthood vary it is generally accepted that early adulthood includes those aged 25–44 and middle adulthood, those aged 45–65 years and spans the period of reproductive health and maximal employment.
People who received care within paediatric and adolescent services may have to negotiate a second transition of care from specialist youth to general adult HIV services. Transfer of care is associated with a higher risk of loss to follow-up and young adults have poorer outcomes at all stages of the HIV care cascade when compared to older adults, with Public Health England (PHE) data suggesting that those who acquired HIV perinatally have the lowest rates of viral suppression. Data in young adult life raises concerns of increased risk of malignancy, suboptimal bone mass accrual, and mental health concerns. In addition, a proportion of those who acquired HIV perinatally will live with the long-term consequences of infantile HIV encephalopathy.
Most people of these ages, however, are diagnosed as adults. Owing to the trend of earlier diagnosis and earlier ART initiation, increasing proportions of people living with HIV have experienced no or minimal HIV-related health problems. Most will be in education, training or employment and will often need services that are streamlined and allow minimum disruption to their lives. However, significant numbers of people will have heightened vulnerabilities due to one or more of a number of different factors including late diagnosis, long duration of HIV, toxicity of early ART, anxiety and depression, drug and alcohol dependency, poor housing, stigma, poverty and immigration status. It is important that services are configured to meet the needs of people in these disparate categories and be sensitive to the fact that people move between non-complex and complex categories. In such cases, they will have enhanced care needs (see Standard 4).
Current evidence suggests that people living with HIV experience higher levels of depression, anxiety and other mental health issues so it is important that mental health is routinely assessed and services are in place to support all people living with HIV (see Standard 6).
Most people in these age groups are sexually active and supporting people to have healthy and fulfilling sex lives is a major part of service provision. Emphasising and reinforcing the role of treatment as prevention (TasP) in negating transmission risk is critical (see Rationale, Standard 1b). Additionally, supporting people to plan and achieve their wishes to have children is paramount (see Standard 5). Key elements of sexual and reproductive health services to be provided, or facilitate access to, include providing information, partner management (including testing, PrEP), contraception, sexually transmitted infection screening and treatment, pre-conception planning, assisted conception, antenatal services, and psychosexual services.
Employment and housing are critical factors that strongly impact aspects of health including HIV. Supporting the achievement and maintenance of these is an important role of HIV services through links into strong community support services.
The regular contact with health services that forms the mainstay of routine HIV follow-up offers opportunities to positively impact longer-term health. Interventions range from supporting healthy lifestyles, through to providing vaccinations to regular risk factor assessment and management. Screening for possible alcohol and substance misuse should be undertaken at least annually and appropriate interventions initiated.