Youth and HIV Infection

Ana M. Alvarez, M.D., Director of the Youth Program of the Rainbow Center for Women, Adolescents, Children and Families and Assistant Professor of Pediatric Infectious Diseases and Immunology at the University of Florida Health Science Center/Jacksonville.

 

Epidemiology

Adolescents and young people are now infected and affected by HIV more than any other population group. The number of HIV and AIDS cases reported among youth aged 13 to 24 years continues to increase worldwide and in the United States. It is estimated that approximately half of new infections occur in this age group1. They account for at least 12% of reported new infections in Florida and 22% of reported new cases in Duval County. However, the number of reported cases represents only a small proportion of the actual number of HIV-infected individuals. Most young people who are already HIV-infected do not know it. In addition, it is estimated that only 30% of the reported cases in Northeast Florida are currently receiving care. Clearly, main gaps in the current health system include an effective identification of HIV-infected youth and appropriate mechanisms to link them to care.

According to the Bureau of HIV/AIDS of the Florida Department of Health, the reported cumulative number of persons aged 13-24 with HIV/AIDS within Duval County was 407 (165 HIV and 242 AIDS) at the end of 2000. There were 87 cases reported in the 13-19 year old group and 320 cases in the 20-24 year old group. More importantly, the number of HIV and AIDS cases reported per year among youth continues to rise in Duval County. See Figure 1.

The leading mode of transmission in this age group is through heterosexual contact (36%), followed by "no identified risk" or NIR (35%) and "men who have sex with men" or MSM (22%). It is assumed that most cases classified as NIR represent heterosexual transmission. African-Americans and females have been disproportionately diagnosed with HIV infection in Duval County, representing 74% and 45% of total cases, respectively. In the 13-24 age group this disproportion is even more marked with 85% of cumulative cases occurring in African-Americans and 60% occurring in females.

Risk Factors

The risk factors for HIV infection in adolescents and young people can be classified into three categories: behavioral, socioeconomic and biological risks.

High-risk behaviors that adolescents often experiment with include:

Sexual activity

  • Initiated at a young age
  • Includes heterosexual, homosexual, and/or bisexual contacts
  • Multiple partners, many of which are older males, IV drug users, or individuals who have multiple partners themselves
  • Prostitution, particularly common among homeless youth

Alcohol and/or drug use

  • They impaired judgement and increase potential for more high-risk behaviors

Running away and becoming homeless2.

Other socioeconomic factors that increase adolescents risk for HIV infection include: poverty, lack of medical insurance, poor access to medical care, poor education, lack of positive family and/or social support, history of physical or sexual abuse, and involvement with juvenile justice system3 .

Biological risks in adolescent women include the lack of maturation of the cellular lining of the cervix which at the beginning of puberty consists of a single-layer columnar epithelium. This epithelium is much more vulnerable to Sexually Transmitted Diseases (STDs). In addition, the inflammatory process that occurs during STDs facilitates the transmission of HIV. At the same time, male to female transmission of STDs and HIV is much more efficient than female to male transmission because of the larger surface area of the lower female genital tract and the mechanics of sexual intercourse resulting in mucosal trauma to women2.

Challenges in Adolescents HIV Care

Adolescence is a transitional period of human development. A combination of physical, cognitive, emotional, and social changes combined with coping with a life-threatening illness makes young people infected with HIV an extremely challenging group. Some of the challenges include:

  • Getting youth tested and counseled
  • Linking and retaining youth in health care

Getting Youth Tested and Counseled

Information about Sexually Transmitted Diseases (STD), including HIV, should be an important component of the anticipatory guidance provided by pediatricians to their adolescent patients4. When risk factors are identified, HIV testing should be offered and encouraged.

Many young people do not routinely seek medical care, but only seek care when they are sick. Proactive outreach efforts to promote HIV testing are required. These are some suggestions to enhance HIV testing among youth:

Convenient place and time5,6

  • Easy access: community - based clinic is preferred to institution-based
  • Not perceived as "HIV Labeled"
  • Youth friendly environment (office décor, magazines and other reading materials, videos, music, etc.).
  • Drop-In
  • After school hours, weekends if possible

Convenient and confidential testing5,6

  • Young people prefer saliva test rather than blood test.
  • Use of quick test avoids the inconvenience of a return visit for test results, but requires careful planning for notifying the results
  • Pre- and post-test counseling sessions provide an opportunity to promote preventive behaviors
  • Low fee or free testing should be offered whenever possible
  • Special precautions should be taken to ensure confidentiality, especially in institutional settings (foster care, residential treatment or detention).

Good Staff Attitudes

In general, youth prefer providers to initiate the discussion about HIV and STD prevention and risk assessment. However, the staff attitudes in doing so will affect how much they listen to and how likely they are to come back. The staff should be respectful, nonjudgmental, patient and willing to listen, and friendly.

Legal issues on HIV testing7

  • Legally, adolescents can consent for HIV and other STD diagnosis and treatment for themselves.
  • Florida's laws do not require parental consent in those circumstances, but forbids telling parents about the adolescent's HIV test and results without the adolescent's permission.
  • All adolescents should be encouraged to involve a supportive adult in their care.
  • When requesting consent for HIV testing, the provider must make an individual judgement of the cognitive and emotional capacity of the adolescent to understand the risks and benefits of the test.

Linking and Retaining Youth in Health Care

The needs of HIV-infected youth for adequate medical and psychosocial care, including risk reduction education, can only be met if there are effective mechanisms of linking youth that test positive to care. Here are some suggestions:

  • Meet youth where the test results will be given (e.g. community-based organization).
  • Address immediate needs (e.g. stable housing, food and adequate sanitation, safety, etc.).
  • Offer educational and support services (mental health, drug addiction treatment, legal services, nutritional support, etc.) 6.
  • Utilize peer educators because young people are more likely to listen to their peers than to any adult.
  • Promote attendance to follow up visits (cautious phone calls, home visits, use of incentives)
  • Offer a therapeutic alliance. Involve youth in their own care8
  • Use youth-appropriate adherence programs.

HIV Care

The guidelines for evaluation and monitoring the course of HIV infection in youth follow those of adults. However, there is some evidence suggesting that youth may have a greater potential for immune reconstitution than adults as a result of residual thymic function9. This information highlights the importance of early detection and early initiation of effective treatment in this population. Additionally, because this age group has a higher incidence of STDs than adults, routine screening for chlamydia, gonorrhea and syphilis is recommended for sexually active youth. There is also a high prevalence of Human Papillomavirus (HPV) infections in adolescent girls and data suggest that HIV may enhance HPV proliferation10. Therefore, cervical cytology should also be performed routinely in this population.

In general, adolescents require more immunizations than adults11. Vaccinations may briefly boost the viral load. Therefore, they should be given on the same day or after viral load measurements.

Pneumococcal vaccine

Patients with HIV are considered at high risk and should be vaccinated.

  • Conjugate 7-valent pneumococcal vaccine has not been studied sufficiently among older children or adults to make recommendations for its use among persons aged = 5 years12. Use of 23-valent polysaccharide vaccine should continue in those individuals.
  • Hepatitis B vaccine -  Three doses should be completed
  • Influenza vaccine - Should be administered yearly in September
  • Hepatitis A vaccine - Not recommended routinely, but for HIV patients that may be at high risk (drug use, homosexual behavior, chronic liver disease/Hepatitis C).
  • Varicella vaccine
  • HIV-infected patients are at increased risk of morbidity from varicella and herpes zoster.
  • Varicella vaccine is a live virus vaccine. It should be considered for HIV-infected adolescents in CDC class I (CD4 percentage = 25%) with mild or no signs or symptoms who have not been vaccinated or who do not have a reliable history of chickenpox13.
  • Measles, mumps and rubella (MMR) vaccine - ˇ A live virus vaccine that should be administered to HIV infected adolescents who have not received 2 doses and who are not severely immunocompromised14.
  • Tetanus and diphtheria toxoid (Td) - Recommended for adolescents (at 11-12 years) if not given within the last 5 years. Booster doses every 10 years thereafter.

Antiretroviral Therapy for Youth15

The goals of therapy are:

  • Maximal and durable suppression of HIV replication (viral load)
  • Restoration and/or preservation of immunologic function
  • Prevention of opportunistic infections
  • Treatment of opportunistic infections
  • Improvement of quality of life
  • Maintenance of nutrition
  • Maintenance of psychosocial well-being
  • Reduction of HIV-related morbidity and mortality

Special considerations for therapy in HIV-infected adolescent

  • HIV-infected adolescents infected sexually or via injection drug use appear to follow a clinical course that is more similar to HIV disease in adults than in children.
  • HIV-infected adolescents infected perinatally or via blood products as young children have a unique clinical course that may differ from other adolescents and long-term surviving adults.
  • Medications dosage used to treat HIV and opportunistic infections in adolescents should be based on Tanner staging of puberty and not specific age7:
    • Early puberty (Tanner I-II): dosed under pediatric guidelines
    • Mid-puberty (Tanner III females and Tanner IV males): close monitoring for medication efficacy and toxicity when choosing adult or pediatric dosing guidelines
    • Late puberty (Tanner V): dosed by adult guidelines.

Adherence

Barriers to Adolescent Adherence to HIV/AIDS Medication8, 16

  • Medication compliance may not be a priority for adolescents, as they may not understand the long-term effects of non-compliance.
  • The adolescent may not have mastered abstract thinking. If they do not feel or look sick, they believe that they do not need the medication. This is particularly true if they experience side effects from the medication.
  • They may value their peer group more then parents or authority figures. There are many myths and misconceptions about HIV/AIDS in the community. Therefore, the adolescent may not believe the information given by the physician.
  • The adolescent may not be able to access the health care system. They may not have insurance or transportation.
  • Adolescents may fear that they will be labeled or stigmatized if they are seen entering the clinic.
  • The medication regime may conflict with their life style. Many adolescents will not take medication in front of a friend for fear that they will be labeled.
  • The adolescent may not have adequate family and/or social support. Therefore, they are dealing with issues that are beyond their level of maturity.
  • The adolescent may have cognitive or learning delays, which interfere with his/her ability to understand the medication regime.
  • The number of pills and the frequency of the dosage may prevent an adolescent from taking the medication as prescribed.

Therapeutic Regimens Enhancing Adherence
in Teens: The TREAT Program17

  • Adherence Program developed for adolescents
  • Based on the Stages of Change Transtheoretical Model by Prochaska and DiClemente, in which an individual moves cyclically through a series of changes (precontemplation, contemplation, preparation, action, maintenance, and relapse) as he/she adopts a new behavior.
  • Acknowledges the adolescent's stage of readiness for treatment
  • Utilizes video and audio tapes demonstrating teenagers in a group
  • Offers positive role models and effective coping strategies
  • Trial series of placebos help the adolescent determine if he/she is ready to begin taking medication
  • Suggests the use of a treatment buddy to increase compliance

Psychosocial Support

Coping with their HIV status18

  • Adolescents need to receive a sense of hope and encouragement when they are notified of the HIV diagnosis
  • They need guidance and support in the disclosure process: determining when it is appropriate and safe to disclose the diagnosis, deciding who they are going to tell and overcoming fear of rejection and losing the love and support of family and friends.
  • They need education and guidance regarding HIV disease progression, significance of the viral load and CD4 counts, and benefits of medications
  • It may be difficult for them to understand the concept of disease latency when they are asymptomatic
  • Becoming symptomatic may overwhelm some adolescents, while it may encourage others to fight the infection
  • Individual counseling and peer support groups can help them in adjusting and coping with their illness10.

Mental illnesses and substance abuse

  • Frequent co-morbidities for HIV-infected adolescents
  • Include depression, bipolar disorder, anxiety, post traumatic stress disorder (could be due to childhood sexual abuse), alcohol and drug abuse19.
  • Screening and appropriate referrals are very important in managing these patients.
  • Treatment of mental illnesses and substance abuse should precede treatment of HIV infection.

Summary

Young people under age 25 have been called a "generation at risk" because of the alarming rates of HIV infection observed in this population. This is as true in Jacksonville as it is in the rest of the world. Given the socio-demographic characteristics of HIV-infected youth, it is clear that intensive, culturally sensitive and youth-friendly approaches must be implemented in order to reach them effectively.

References

  1. UNAIDS Briefing Paper: Young People and HIV/AIDS. Joint United Nations Programme on HIV/AIDS.Geneva 1999.
  2. Chabon B, Futterman D. Adolescents and HIV. AIDS Clin Care 1999; 11: 9-16.
  3. Boyd-Franklin N, Steiner G, Boland MG, editors. Children, families, and HIV/AIDS: Psychosocial and therapeutic issues. New York: Guilford Press; 1995.
  4. American Academy of Pediatrics, Task Force on Pediatric AIDS. Adolescents and Human Immunodeficiency Virus Infection: the role of the pediatrician in prevention and intervention (RE9331). Pediatrics 1993; 92: 626-630.
  5. Rotheram-Borus MJ, Futterman D. Promoting early detection of Human Immunodeficiency Virus infection among adolescents. Arch Pediatr Adolesc Med 2000; 154: 435-439.
  6. Tenner A, Feudo R Woods ER. Shared experiences: three programs serving HIV-positive youths. Child Welfare 1998; 77: 222-250.
  7. Hartog JP. Florida's Omnibus AIDS Act: A Brief Legal Guide for Health Care Profesionals. Tallahassee: Florida Department of Health; 1999.
  8. Hoffman ND, Futterman D, Myerson A. Treatment issues for HIV positive adolescents. AIDS Clin Care 1999; 11: 17-24.
  9. Rogers AS, Futterman DC, et al. The REACH project of the Adolescent Medicine HIV/AIDS Research Network: Design, methods, and selected characteristics of participants. J Adole Health 1998; 22: 300-311.
  10. Moscicki AB, Ellenberg JG, Vermud SH, et al. Prevalence of and risks for cervical Human Papillomavirus infection and squamous intraepithelial lesions in adolescent girls. Arch Pediatr Adolesc Med 2000; 154: 127-133.
  11. CDC. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49(RR-9):1-10.
  12. American Academy of Pediatrics, Committee on Infectious Diseases. Immunization of Adolescents: Recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association (RE9711). Pediatrics 1997;99:479-488.
  13. American Academy of Pediatrics: Committee on Infectious Diseases. Varicella Vaccine Update. Pediatrics 2000;105:136-141.
  14. American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Pediatric AIDS. Measles immunization in HIV-infected children (RE9837). Pediatrics 1999;103:1057-1060.
  15. Panel on Clinical Practices for Treatment of HIV Infection. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Department of Health and Human Services and the Henry J. Kaiser Family Foundation 2001. Available from URL: http://wwwhivatis.org/.
  16. La Greca A M, Schuman W B. Adherence to prescribed medical regimens. In: Handbook of Pediatric Psychology. New York: Guilford Press; 1995.P.55-83.
  17. Schietinger H, Sawyer M, Futterman D, et al. Helping adolescents with HIV adhere to HAART. TREAT Monograph. Rockville, MD: HRSA/HAB 1999.
  18. O'Connor M F, editor. Treating the psychological consequences of HIV. San Francisco: Jossey-Bass Inc; 1997.
  19. Pao M, Lyon M, D'Angelo LJ, et al. Psychiatric diagnosis in adolescents seropositive for the Human Immunodeficiency Virus. Arch Pediatr Adolesc Med 2000; 154: 240-244.

June-July 2001 / Jacksonville Medicine

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