ABSTRACT: Adolescents make up an increasing percentage of the U.S. population with human immunodeficiency virus (HIV). Adolescent-focused care is critical to identify and reduce at-risk behavior, comorbidities, and partner transmission. Optimal medical and reproductive health care, both now and in the future, with an adolescent-focused approach, are important for HIV-infected adolescents. Adolescents who are infected with HIV should receive care that allows them to realize their sexual and reproductive goals while maximizing their personal health and minimizing the risk of unintended pregnancy, acquisition of new sexually transmitted infections, and transmission of infection to partners or offspring. Key strategies for preventing the spread of infection include, early diagnosis, guideline-based treatment, and partner notification of HIV status.
According to surveillance data from the Centers for Disease Control and Prevention (CDC), from 2008 through 2011, the annual estimated number and rate of diagnoses of human immunodeficiency virus (HIV) infection in the United States remained stable (1). Rates among individuals aged 15–19 years were also stable while rates for individuals aged 20–24 years increased over that period (1). In 2011, the estimated rate of diagnoses of HIV infection was 15.8 per 100,000 population (1). Females accounted for 21% of all diagnoses of HIV infection among adults and adolescents (1). Of these, the highest rate, 36.4 per 100,000 population, was for individuals aged 20–24 years (1). The rate for individuals aged 15–19 years was 10.4 per 100,000 population (1). Additionally, with advancements in highly active antiretroviral therapy (HAART), the number of adolescent survivors of perinatal HIV infection continues to grow. In 2008, an estimated 22% of individuals aged 13–24 years living with HIV infections were infected perinatally (2).
It is estimated that HIV infection is undiagnosed in approximately one in five individuals with HIV infection in the United States (3). Early detection of asymptomatic disease is an important aspect of management because it allows for optimal therapy, including early initiation of HAART. Adolescents in the United States can legally consent to the confidential diagnosis and treatment of sexually transmitted infections (STIs); however, in some states, HIV testing and treatment is not included in the package of STI services to which minors may consent (4). For information on screening guidelines refer to the American College of Obstetricians and Gynecologists’ (the College) Committee Opinion Number 411, Routine Human Immunodeficiency Virus Screening (5).
Management of Adolescents With HIV
Along with the recognized barriers found in providing care to the general adolescent population, HIV-infected adolescents present additional management concerns and challenges. Most HIV-infected children and adolescents receive their medical care in a pediatric or adolescent medical setting; however, as they mature, they must transition to adult-centered medical services (6). Ideally, care for an HIV-infected adolescent entails a holistic approach that addresses the young person’s emotional and social needs, in addition to providing medical treatment. Holistic care seeks to understand the larger context of an adolescent’s life that may affect her medical care including, a need to “fit in,” a desire to “be normal,” and individual experiences with the stigma of having HIV and being bullied. This system of care often provides social workers, psychologists, and peer support groups along with medical services to encourage retention of patients in care and adherence to treatment, which is particularly challenging among adolescents. In a retrospective report from a comprehensive adolescent HIV clinic, 72% of teens did not adhere to their retroviral regimens (7). When available, teen-friendly, multidisciplinary specialty clinics that provide a “one-stop-shop” approach to health care are associated with higher retention in the care of HIV-infected adolescents (8, 9). A practitioner who provides obstetric and gynecologic services may need to provide care to HIV-infected female adolescents. They should be knowledgeable about the treatment options available in their communities, educate individuals with HIV about the illness, and know where to refer their patients for support services typically provided by specialists who care for HIV-infected patients. Health care providers are encouraged to refer to the College’s Practice Bulletin Number 117, Gynecologic Care for Women With Human Immunodeficiency Virus, as a resource for gynecologic care of the HIV-infected patient (10). The following recommendations are meant to supplement the previously mentioned bulletin and highlight unique aspects of care for the HIV-infected adolescent.
Screening for At-Risk Behavior and Comorbidities
Comorbidities are often present in the HIV-infected adolescent. Diligent screening is key to maintaining optimal health in this group. Gathering accurate information, screening for noncoital sexual activity, and providing effective counseling are crucial in caring for the HIV-infected adolescent (11). Ensuring confidentiality, being sensitive, and using nonjudgmental interview techniques maximizes the comfort level of the adolescent, facilitates obtaining a thorough medical history, and allows for risk assessment. Young individuals who become infected with HIV are often disenfranchised and have additional barriers that include lack of access to medical services, poor socioeconomic support, and higher rates of drug use and mental health disorders. Adolescents and young adults living with HIV, who were either behaviorally or perinatally infected, also have higher rates of cognitive impairment and mental health problems such as anxiety, depression, attention-deficit/hyperactivity disorder, and posttraumatic stress disorder when compared with their HIV-negative counterparts (9). Adolescents with HIV in whom substance abuse and mental health problems are concomitantly diagnosed may need to be treated for these conditions before their HIV infection can be managed (12). Annual screening for substance abuse and mental health problems is recommended (13). If screening results are positive, the clinician should be prepared to make referrals for treatment.
Appropriate STI screening is especially critical for adolescents with HIV because STIs increase the risk of HIV transmission to seronegative partners (14, 15). The CDC and the College recommend annual screening of all sexually active HIV-infected women aged 25 years and younger for chlamydia, gonorrhea, and syphilis (16, 17). More frequent STI screening may be appropriate depending on individual risk behavior, the local epidemiology of STIs, and the presence of symptoms (18). Individual risk behavior warranting more frequent STI screening at 3-month to 6-month intervals includes, multiple partners; unprotected intercourse; and sex in conjunction with illicit drug use, methamphetamine use, or partners who participate in such activities (19). Screening for gonorrhea and chlamydia at oropharyngeal and anal sites in addition to urogenital screening is recommended among HIV-infected individuals who engage in oral or anal sex (19). This practice should not be limited to high-risk STI clinics, but expanded to the primary care setting as well (20).
Genital ulcers in HIV-infected individuals are primarily due to herpes simplex virus (HSV) or syphillis or both. Individuals with genital ulcers should have a serologic test for syphillis and a diagnostic test for HSV. Typing of HSV is recommended because of the prognostic significance—HSV type 1 recurs less frequently than HSV type 2 (HSV-2) in the genital area (19). Because of the poor sensitivity and specificity of clinical diagnosis, extensive interactions between HIV and HSV-2, and the availability of effective therapy for HSV-2, routine type-specific serologic testing for HSV-2 should be considered in individuals who seek HIV care (19). Diagnosis of HSV should be accompanied by counseling that includes discussion of the risk of transmission of HIV and HSV infection to sex partners (19).
Individuals infected with HIV also should be tested for hepatitis B virus (HBV) infection (19). Patients infected with HIV who do not have evidence of previous exposure to HBV should be vaccinated with the hepatitis B vaccine (19). Pregnant HIV-infected women should be screened for hepatitis B surface antigen. Those who are hepatitis B surface antigen-negative and without antibodies to hepatitis B should be offered vaccination against HBV. This vaccination can be administered during pregnancy (21). All HIV-infected individuals should be screened for chronic infection with hepatitis C virus (19).
Cervical cytology screening recommendations differ for immunocompromised patients (19). In contrast to recommendations for nonimmunocompromised adolescents, screening of HIV-infected adolescents should start within the first year after the onset of sexual activity. This screening should include Pap tests at a 6-month interval during the first year of screening and, if the results are normal, annually thereafter (19). Human papillomavirus (HPV) testing currently has no role in the triage of HIV-infected adolescents with abnormal cytology results or for follow-up after treatment for cervical intraepithelial neoplasia. A diagnosis of atypical squamous cells of undetermined significance should result in repeat cytology in 6–12-months (19). If abnormal cytology persists, referral for colposcopy is recommended (19). For any lesion greater than atypical squamous cells of undetermined significance, referral for colposcopy is recommended (19). In addition, adolescents with HIV are encouraged to receive HPV vaccination to prevent HPV infection (19).
The CDC does not currently have recommendations regarding anal cytologic screening initiation in adolescents or adults (22). Although HIV infection is a risk factor for anal HPV infection and abnormal anal cytology results in sexually active adolescents, there currently is no evidence to suggest benefit from anal cytology screening in adolescent females (23). Refer to the CDC’s Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents for management of abnormal cytology of HIV-infected adoelscents (19).
Risk Reduction Education
Misconceptions regarding the risk of transmission among HIV-infected adolescents may contribute to greater spread of disease and worsened sequelae of comorbid diseases. Although the risk of male-to-female HIV transmission is higher, the risk of female-to-male HIV transmission remains well documented, whereas female-to-female HIV transmission appears to be a rare occurrence (24, 25). Transmission to seronegative partners is significantly reduced with early initiation of antiretroviral therapy (26). Timing of initiation of antiretroviral therapy should follow current treatment guidelines and be individually based (27).
When obtaining a thorough medical history, health care providers need to address the range of activities in which the young person is engaging and concretely explain the risk associated with these activities. For additional information, refer to the College’s Committee Opinion Number 417, Addressing Health Risks of Noncoital Sexual Activity (11). Health care providers are encouraged to assist the HIV-infected teen in developing strategies for safe sex and barrier contraception if she is sexually active or before initiation of sexual activity. In addition, health care providers can encourage methods of intimacy that avoid penetration of mucosal orifices (vaginal, anal, and oral) and contact with body fluids. Safe sexual expression may include masturbation, kissing, and massage. Health care providers should strongly recommend latex condom use with vaginal, oral, and anal intercourse to decrease the risk of acquiring other STIs or a different serotype of HIV, to decrease the risk of HIV transmission to partners, as well as to reduce the risk of unintended pregnancy. Nonlubricated male latex condoms or use of water-based lubricated latex condoms should be encouraged for use during oral intercourse (28). The use of condoms with nonoxynol-9 should be discouraged because it is associated with an increased risk of HIV transmission through the disruption of genital epithelium.
Physicians should be familiar with the federal and state laws that affect confidentiality in the provision of health care to HIV-infected adolescents, including the Health Insurance Portability and Accountability Act privacy rule. Health care providers should contact their local health departments for information on reporting infectious diseases and partner notification. During interviews with adolescents, it is important to share the limitations of confidentiality. Adolescents should understand state requirements for infectious disease reporting. They also must be aware that explanation of benefits forms issued by insurance companies are often sent to parent policy-holders, which can compromise the confidentiality of information and, therefore, a minor’s access to health care services. However, it is the health care provider’s responsibility to ensure that their billing and health information technology systems are compatible with the requirements of the Health Insurance Portability and Accountability Act and flexible enough to accommodate federal and state privacy laws (29). It also is important to explain to adolescents that behavior that is acutely harmful to themselves or others may require parental or professional notification to maintain their safety.
Partner notification of HIV status is a key strategy in preventing the spread of infection. If penetrative intercourse is occurring, health care providers should encourage patient disclosure to past and current partners. Disclosure is a leading cause of stress among HIV-infected adolescents (30). It is important to identify if partner notification will put the patient at risk of retaliation. For additional information, refer to the College’s Committee Opinion Number 518, Intimate Partner Violence (31). There are no data that have assessed the effectiveness of partner notification by community health care providers. The CDC does provide guidelines for health care provider referral of the HIV-infected individual to local health departments for partner notification. Trained health department specialists are 1.5–6.5 times more effective in notifying partners compared with reliance on the HIV-infected individuals to notify partners (32). Health care providers are not generally expected to engage in third-party notification, but may aid in the process of gathering contact information to assist the health department specialist.
Sexual and Reproductive Health Considerations
Adolescence is a natural time for the exploration of sexuality. This process may be particularly complex and confusing for a young person who is infected with HIV. Adolescents who are infected with HIV should receive counseling and care that allows them to realize their sexual and reproductive goals while maximizing their personal health and minimizing the risk of unintended pregnancy, acquisition of new STIs, and transmission of infection to partners or offspring.
Adolescents who are sexually active should be encouraged to use dual protection and couple a highly effective contraceptive method with latex condom use to prevent transmission of HIV and STIs. There are a wide variety of safe and effective contraceptives available to HIV-infected adolescents. Adolescents experience greater difficulty in using contraception consistently and are at higher risk of discontinuation of birth control because of issues associated with cognitive skills, access, and confidentiality (33). In addition to medical contraindications, health care providers need to consider a range of psychosocial factors that affect an adolescents’ ability to use contraception effectively. Detailed guidelines about use of various methods in women with medical conditions are found in the U.S. Medical Eligibility Criteria for Contraceptive Use (34, 35). Although HIV status alone does not preclude the use of any hormonal contraception, medical conditions and therapies in HIV-infected adolescents may influence contraceptive choices. A review of potential drug interactions for women using HAART is provided in the College’s Practice Bulletin Number 117, Gynecologic Care for Women With Human Immunodeficiency Virus (10). Being aware of these interactions is critical because some drugs cause decreased efficacy of oral contraceptives, and some hormonal contraceptives can alter particular HAART drug levels.
Some studies suggest that seronegative women using progestogen-only injectable contraception may be at an increased risk of HIV acquisition while other studies do not. A World Health Organization expert group recommended that there should continue to be no restrictions (U.S. Medical Eligibility Criteria for Contraceptive Use Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV infection (35, 36). The CDC also supports this guidance and, consistent with the World Health Organization, added a clarification for women at high risk of HIV infection using progestin-only injectable contraception, which strongly encourages condom use and other measures to prevent HIV infection (35). Health care providers should consider the use of long-acting reversible contraceptives, namely implants and intrauterine devices, because these methods offer long-term top-tier protection against unintended pregnancy. Benefits of using these methods generally outweigh risks in HIV-infected adolescents. The use of an intrauterine device is not recommended for patients with advanced immunosuppression (CD4 lymphocyte count less than 200) who are not being treated with antiretroviral therapy (34). (For additional information on the eligibility criteria for contraceptive use in HIV-infected women, refer to the College’s Practice Bulletin Number 117, Gynecologic Care for Women With Human Immunodeficiency Virus .)
More than 80% of pregnancies that occur in women 19 years and younger are reported as unintended (37). Nearly one in three pregnant adolescents have delayed or no prenatal care, and almost one half reported delays because they did not know they were pregnant (38). Adolescents with HIV should be counseled to seek pregnancy testing for any change in menstrual pattern or symptoms of pregnancy. This will prevent delays in pregnancy detection and enable early initiation of antiretroviral therapy. Upon detection of pregnancy, providing pregnancy option counseling or referral for counseling is important. Individuals with HIV desiring pregnancy termination should be evaluated promptly; abortion is safe for those with and without HIV infection, but first-trimester procedures are associated with fewer complications than those performed later in pregnancy (39).
Early recognition of pregnancy among HIV-infected individuals is crucial to initiate effective and timely antiretroviral therapy to reduce vertical transmission of the virus to the newborn. In addition, all HIV-infected pregnant women should be counseled regarding the need for cesarean delivery if viral suppression to a viral load of less than 1,000 cells per cubic millimeter cannot be achieved (10, 21, 40). Counseling regarding avoidance of breastfeeding, and providing newborns with prophylactic antiretroviral medications for several weeks also is important (10, 21, 40). More complete recommendations of medical care for the pregnant HIV-infected patient may be found at http://www.aidsinfo.nih.gov.
Health care providers who treat HIV-infected adolescents face unique challenges. Ideally, a teen-friendly, multidisciplinary specialty clinic will provide optimal care to this population. However, all practitioners should be familiar with management recommendations if HIV-infected adolescents seek care from their practices. It is recommended that health care providers incorporate the following practices into their medical care for HIV-infected adolescents:
- Use interviewing and counseling techniques appropriate for the cognitive level of adolescents.
- Screen diligently according to College and CDC guidelines to detect comorbidities.
- Educate and support patient efforts to reduce high-risk behavior and notify past, current, and potential partners of their HIV status when it is safe to do so.
- Consider the most effective forms of reversible contraception based on the patient’s goals and clinical status.
- Counsel patients about pregnancy options or refer for such counseling in the event of an unintended pregnancy.
- Appropriately counsel and care for HIV-infected pregnant adolescents to optimize pregnancy outcomes.
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