Ending the Epidemic Among Youth IAS 2016 | Durban | July 20, 2016 Donna Futterman, MD Director, Adolescent AIDS Program Professor of Clinical Pediatrics, Einstein College of Medicine Bronx, New York

Key Questions What is the global picture of HIV among youth? What are the challenges to decrease the burden of HIV among youth? How do we turn Activism into Action to end the epidemic?

Globally, AIDS Deaths: Only Rising Among Adolescents I’d like to start by talking about this picture that we’ve seen and heard about several times this week. [PAUSE] The only group in whom AIDS deaths are increasing is adolescents as shown by the red line above. Every day, 300 adolescents are dying due to AIDS. At UNICEF, we’ve analysed the best data available and what we’ve found is that ten years ago, in 2005, 69,000 adolescents died of AIDS. By the end of 2012, that number had increased by 50% [REPEAT] 50% --- yet AIDS deaths had fallen by 30% across all age groups. [PAUSE]   This is a humbling reminder that we have not done our best for adolescents and we must turn our attention to addressing this gap. We have got to end the AIDS epidemic among adolescents and to address this inequity, we must act with urgency. Source: UNAIDS 2012 HIV and AIDS estimates AdolescentAIDS.org

Global:5M Youth Living with HIV Majority perinatally infected | 250,000 new infections annually | 2/3 female Generalized Epidemics Sexual transmission (Africa) Perinatal (Africa) Non-Generalized: High-Risk Populations IDUs (Asia & E. Europe) YMSM (developed & developing countries) Commercial & Transactional Sex Youth in juvenile detention More children will survive into adolescence Majority of HIV+ mothers are also youth AdolescentAIDS.org

Global HIV Care Cascade: How do we improve to 90-90-90 for youth? Diagnosed HIV+ Prescribed ART Suppressed Virally In 23 PEPFAR countries, the number of 15-24 y.o. on ART will need to quadruple between 2014 and 2020 to meet 90-90-90 goals. ISSUES: Most youth have not been tested. Most youth have inadequate access to ART & youth-friendly adherence support. Poor data & wide variance (27% -89%) in reported global viral suppression in youth. AdolescentAIDS.org

Optimizing the Care Cascade: HIV Testing Most HIV+ youth don’t know Majority not symptomatic Need routine, targeted and ongoing testing Routine testing needed in clinical sites Outreach-based (schools, communities, venues) Address consent and confidentiality with minors Test all youth: undisclosed sexual activity/abuse and perinatally infected

Optimizing the Care Cascade: Youth-friendly Care More intensive engagement & retention required Providers: knowledgeable & nonjudgmental Peer support: engage peers and cohort youth to single day Address Coping, Stigma, Disclosure Adherence to ARVs & Prevention Respect minors’ confidentiality and consent Transitioning to adult care

Optimizing the Care Cascade: Viral Suppression Immediate treatment is game changer Check pubertal development for dosing Developmental issues key Concrete and present-oriented thinking Adverse events may seem intolerable Meds rebellion as a form of independence Mistrust providers YET trust misinformation from peers – learn barriers and motivators Perinatally infected have unique needs Monitor program & follow-up defaulters PrEP VAGINAL MICROBICIDES 30% reduction in male to female HIV transmission Female-controlled prevention method Acceptability and empowerment? Sex less consistent, hard to include in research Rectal microbicides key for MSM and some women Biological issues in young women Lack of progesterone in anovulatory menstrual cycle Enhanced susceptibility to STIs with cervical ectopy VMMC Timing: babies, children, adolescents, adults Surgical vs. ritual circumcision (rite of passage) Disinhibition Will lower condom use increase risk for women? Increased risk post-op needs behavior intervention Wide variation based on culture, religion, SES 60% reduction in female to male HIV transmission

Preventing New Youth Infections Must understand barriers and motivators PMTCT PrEP Male Circumcision Vaginal Microbicides Vaccines Prevention with Positives Youth Engagement/Mobilization PrEP VAGINAL MICROBICIDES 30% reduction in male to female HIV transmission Female-controlled prevention method Acceptability and empowerment? Sex less consistent, hard to include in research Rectal microbicides key for MSM and some women Biological issues in young women Lack of progesterone in anovulatory menstrual cycle Enhanced susceptibility to STIs with cervical ectopy VMMC Timing: babies, children, adolescents, adults Surgical vs. ritual circumcision (rite of passage) Disinhibition Will lower condom use increase risk for women? Increased risk post-op needs behavior intervention Wide variation based on culture, religion, SES 60% reduction in female to male HIV transmission PWP Key element of HIV care and public health Protect yourself/others from STIs and new HIV Prevention messages PrEP for HIV- partners Condomize every time you have sex Engage partners: testing/disclosure if safe Fewer partners = less risk Drugs and alcohol = greater risk (SEP) Consider not having sex (other ways to express love) Discuss safe pregnancy options (PMTCT)

Key lessons to end the epidemic! New generation every 5 years Multiple realities: some youth feel invincible, others fear HIV is inevitable Sex is complicated Vulnerable youth not well served Gender, economic, racial, & sexual orientation disparities Youth-friendly services must be scaled up Ongoing commitment of leadership & funding Mobilize youth leadership through activism

Acknowledgements Stephen Stafford Terri Jackson, MA, MPhil Providers & Youth Donna Futterman, MD dfutterman@adolescentaids.org

Ending the Epidemic Among Youth IAS 2016 | Durban | July 20, 2016 Donna Futterman, MD Director, Adolescent AIDS Program Professor of Clinical Pediatrics, Einstein College of Medicine Bronx, New York

Ending the Epidemic Among Youth IAS 2016 | Durban | July 20, 2016 Donna Futterman, MD Director, Adolescent AIDS Program Professor of Clinical Pediatrics, Einstein College of Medicine Bronx, New York