The National HIV/AIDS Strategy (NHAS) was developed to focus efforts and resources to End the HIV Epidemic in the United States and ensure that people with HIV (PWH) live long and healthy lives.¹ As a part of those efforts, NHAS recognizes the role that social determinants of health (SDOH)² and mental health^3,4 play in driving health inequities and decreasing quality of life (QoL) among PWH, particularly among certain populations disproportionately affected by HIV, including youth aged 13–24 years.^5–7 In CDC National HIV Surveillance System (NHSS) data, persons aged 13–24 years accounted for 19% or 7099 of the 37,981 new HIV diagnoses in 2022.⁸ Recent data from the CDC’s Medical Monitoring Project (MMP), an HIV surveillance system that provides nationally representative estimates, show that compared with persons aged ≥30 years with HIV, persons aged 18–29 years may have lower levels of antiretroviral therapy (ART) prescription and sustained viral suppression.⁹ NHAS prioritizes monitoring HIV stigma and indicators of QoL—including related to physical health, mental or emotional health, and subsistence factors—to ensure that PWH have good health and well-being. These indicators are monitored using data from the CDC’s MMP, which provides estimates of demographic characteristics, SDOH, clinical outcomes, mental health, and barriers to care and viral suppression among PWH.^6,9

Ancillary services for PWH are defined as those that comprehensively support their HIV care engagement, viral suppression, and overall health and well-being, and can address certain barriers to care, including related to SDOH.^9–12 Ancillary services can include HIV support services (eg, HIV case management), non-HIV medical services (eg, dental care, mental health care), and subsistence services (eg, food or shelter assistance).

Sufficient access to ancillary services is essential for ensuring that persons with HIV can maintain good health and well-being. Many PWH have unmet needs for ancillary services and these unmet needs are associated with adverse outcomes.¹² Examining needs for ancillary services—including unmet needs—could help in prioritizing resources and improve QoL for PWH aged 18–24 years. Furthermore, because of their substantial role in driving inequities in health outcomes among PWH, understanding disparities in SDOH and mental health outcomes experienced by persons aged 18–24 years could help direct public health action to improve health and well-being in this important population. Addressing barriers to HIV care engagement and viral suppression, including related to SDOH, could be instrumental in directing national and local efforts to improve outcomes among young adults with HIV. Recent nationally representative estimates of these disparities are needed but are lacking. In this analysis, we assessed differences in demographic characteristics, SDOH, and mental health outcomes between PWH younger (aged 18–24 years) versus older (aged ≥25 years) and examined the prevalence of unmet needs for ancillary services among PWH aged 18–24 years.

MMP is a population-based surveillance system that produces annual, cross-sectional, nationally representative estimates of demographic characteristics, SDOH, barriers to care, viral suppression, and clinical outcomes among persons with diagnosed HIV in the United States. Detailed MMP methods have been previously published.¹³ In brief, during the 2018–2021 data cycles, MMP used a 2-stage complex sample survey design. During the first stage, 16 states and 1 territory were sampled from all US states, the District of Columbia, and Puerto Rico with probabilities proportional to size based on AIDS prevalence at the end of 2002. The selected jurisdictions included California (including the separately funded jurisdictions of Los Angeles County and San Francisco), Delaware, Florida, Georgia, Illinois (including Chicago), Indiana, Michigan, Mississippi, New Jersey, New York (including New York City), North Carolina, Oregon, Pennsylvania (including Philadelphia), Puerto Rico, Texas (including Houston), Virginia, and Washington. During the second stage, simple random samples of persons aged ≥18 years with diagnosed HIV were selected from each jurisdiction from NHSS, a census of persons with diagnosed HIV in the United States. The response rate for jurisdictions was 100% and ranged from 40% to 45% by cycle year at the respondent level.

Data were collected during June of each cycle year through May of the following year through phone or face-to-face interviews, and clinical data from medical records were abstracted at the most frequent source of HIV care reported by respondents during the previous 2 years.⁹ This analysis only included data from the interview. MMP is conducted as part of routine HIV surveillance and is, therefore, considered non-research. Participating jurisdictions obtained IRB approval as needed. All respondents provided informed consent.

We demonstrated that young adults with diagnosed HIV experience numerous challenges related to socioeconomic disadvantage and showed that, compared with persons ≥25 years, persons aged 18–24 years were more likely to experience challenges related to both socioeconomic disadvantage and social community context, including unstable housing or homelessness, hunger/food insecurity, poverty, lack of insurance, and HIV stigma. In addition, PWH aged 18–24 years were more likely to report symptoms of anxiety than those aged ≥25 years. PWH aged 18–24 years also had high needs for ancillary services, many of which were unmet—particularly related to subsistence, dental care, and mental health. More than three-quarters of PWH aged 18–24 years had ≥3 unmet needs; more unmet needs can be associated with HIV clinical outcomes demonstrating the compound impact of these factors on health outcomes.¹⁸ Evidence shows that cumulative exposure to socioeconomic disadvantage can also affect HIV care outcomes in a dose–response fashion, exemplifying the importance of comprehensive screening of subsistence factors within the medical system.⁵ In addition, poor subsistence may be detrimental to physical health,¹⁹ demonstrating the importance of addressing these needs. Cholli et al¹⁹ found that lower “good or better” self-rated health was associated with poor subsistence, including unstable housing or homelessness and hunger or food insecurity, than persons with HIV who self-rated their health higher. Adequate access to ancillary services may help ensure people are able to address their needs related to subsistence. However, barriers to accessing these services are important to ascertain and should be assessed wherever possible. Although we did not assess reasons for unmet needs among PWH aged 18–24 years in this analysis, previously published MMP data among persons who inject drugs¹² and persons experiencing homelessness²⁰ have found lack of knowledge of services was a substantial barrier to subsistence services. For instance, screening for housing, food, and transportation needs could be incorporated into comprehensive physical and mental health examinations. Recognizing the needs for subsistence services can address barriers to care, improve overall QoL, and well-being for the priority population of PWH aged 18–24 years.

In this analysis, 17% of young adults with HIV had no insurance coverage or were receiving RWHAP assistance. More than half reported needing medicine through ADAP. RWHAP provides comprehensive services for low-income persons with HIV for medical care, medications, and ancillary or support services.²¹ Although more young adults have health insurance coverage after the Affordable Care Act was established in 2010,²² some persons aged 18–24 with HIV remain uninsured or underinsured.²³

Food insecurity, another consequence of low income, is associated with poor ART adherence and poor HIV outcomes among persons with HIV.^24,25 Reeder and colleagues²⁵ found more than half of young adults with HIV surveyed experienced unmet subsistence needs, including food insecurity, housing instability, and difficulty finding places to wash and use the bathroom. Moreover, these authors found food insecurity was associated with lower ART adherence among these youth. In our survey, approximately one-third of persons with HIV aged 18–24 years reported hunger or food insecurity and 43% of those with a need for meal or food services reported an unmet need for these services. Although entitlement programs such as SNAP and WIC provide subsidies for some food items, approximately 2 in 5 adults with HIV aged 18–24 years who reported a need for SNAP or WIC had an unmet need for these services. Better understanding of barriers, such as lack of awareness, bureaucratic logistics, transportation, or other deterrents to eligibility and access to SNAP and WIC, particularly among PWH aged 18–24 years, is needed to alleviate this unmet need. Lack of adequate food and nourishment can adversely affect HIV outcomes, QoL, and overall mental and physical health for persons with HIV.

Persons aged 18–24 comprise 7.3% of the population of people experiencing homelessness.²⁶ Young adults are often undercounted in estimates of persons experiencing homelessness because they may stay in locations that do not meet US Department of Housing and Urban Development definitions of homelessness or because they are staying with friends or family (“couch surfing”) or are otherwise unstably housed.²⁶ Unstable housing, independent of homelessness, can lead to poor HIV outcomes.²⁷ Previous MMP analysis found that people with diagnosed HIV who experienced homelessness or unstable housing were less likely to be retained in care, less likely to be ART dose adherent, and less likely to be virally suppressed than people who were stably housed.²⁷ We found more than one-third of persons with HIV aged 18–24 years had experienced unstable housing or homelessness in the past year. Furthermore, of those who reported a need for shelter or housing services, more than half had an unmet need. Unmet needs for housing among young adults could be ameliorated with increased supportive housing services.²⁸ Young adults are often in the position of needing housing services but lacking the resources to achieve stable housing primarily because of financial considerations. Moreover, young adults in need of housing services may be unaccompanied for the first time, without financial or social support, and unaware of policies, procedures, or requirements to attain stable housing. Programs such as Housing Opportunities for Persons with AIDS, a federal program to provide housing services to low-income PWH, could be accessed.²⁹ Although Housing Opportunities for Persons with AIDS funds are often limited in certain geographic locations, combined with RWHAP funding³⁰ and other sources of housing support, such as Medicaid programs that address health-related social needs,³¹ they can provide housing assistance, when available in local areas.²⁰ Braiding these funding sources among various federal and community partners ensures a holistic approach to addressing the needs of young adults with HIV related to subsistence and overall health and well-being.

In our study, median stigma score was greater among persons aged 18–24 years with HIV than among persons aged ≥25 years with HIV. Other authors have examined multiple, complex levels of stigma among young adults with HIV that affect their personal, interpersonal, clinic, and community interactions.³² These authors found that stigma affected barriers to engagement in care such as delays in seeking care, isolation, fear of disclosure of HIV status, discrimination from family and friends, as well as negative experiences with clinic staff. Programs that provide antidiscrimination training for health care and other service providers can raise awareness and decrease HIV stigma.^33,34 Furthermore, directing interventions toward the various types of stigma (eg, enacted, anticipated, and internalized) experienced by persons aged 18–24 years with HIV will facilitate ending stigma among this population.³⁵ NHAS goals include eliminating stigma and discrimination to reduce inequalities and improve QoL for PWH.¹ Stigma can affect access to services resulting in greater needs.³⁶ Programs such as RWHAP can provide integrated services for young adults to help alleviate barriers to care, improve QoL and clinical outcomes, and decrease HIV transmission.³⁷

PWH aged 18–24 years were more likely to experience symptoms of generalized anxiety disorder than those aged ≥25 years. Experiences of poor mental health have also been associated with poor ART adherence and low viral suppression.^3,4,38 Bucek et al’s³⁸ prospective cohort study among perinatally HIV-infected adolescents and young adults found psychiatric disorders to be associated with missed ART doses and viral loads >1000 copies/mL at least 12 months after baseline interview. In our analysis, >40% of young adults needed mental health services and one-quarter expressed an unmet need for mental health services among those with a need, emphasizing the need for understanding of barriers to care and provision of comprehensive care services through programs, such as RWHAP, that use a whole person approach.³⁹ Annual mental health screenings are recommended for PWH⁴⁰ and these can be integrated with HIV and other medical care to improve engagement in care and support overall health and QoL.

These findings support recommendations such as those identified in the Society for Adolescent Health and Medicine position paper that includes 3 recommendations for improving HIV care outcomes among adolescents and young adults: provision of differentiated and integrated HIV services (eg, mental health or reproductive health services), structural changes (eg, early disclosure to young adolescents with perinatally acquired HIV, economic support, transition to adult care preparedness, elimination of legal barriers to HIV testing and treatment for minors, and elimination of discriminatory laws against individuals living with HIV and individuals who are sexually or gender diverse), and inclusion of young adults “in the conceptualization, design, implementation, monitoring, and evaluation of HIV services designed for them”.⁴¹ Interventions designed for young adults have been shown to improve HIV engagement in care and HIV outcomes. For example, mobile health (mHealth) interventions such as E-VOLUTION⁴² can provide reminders through text messages and engagement with case managers to facilitate linkage to care. In addition, our results emphasize the need for collaboration between HIV providers and community-based organizations who provide subsistence services, such as housing, food, and transportation services to address the unmet needs of persons aged 18–24 years with HIV and to improve HIV outcomes.

Compared with PWH aged ≥25 years, persons aged 18–24 years were more likely to experience challenges with SDOH related to socioeconomic disadvantage, health insurance, and social and community context, and symptoms of generalized anxiety disorder. Persons with HIV aged 18–24 years had high levels of unmet needs related to subsistence, dental care, and mental health services, which—if addressed—could help alleviate disparities related to SDOH and mental health conditions that may be barriers to care and viral suppression, QoL, and overall health and well-being. Persons with HIV aged 18–24 years face challenges unique to their age group and unmet needs for many services including non-HIV medical services and subsistence services that exacerbate these challenges. Addressing unmet needs of young adults with HIV could improve their QoL and overall physical and mental health and is essential for achieving NHAS goals for this priority population.