Adolescents and HIV: Rates, Risk and Intervention Opportunities 1 Katrina Kubicek, MA, PhDc Presentation to the Black AIDS Institute and UCLA HIV Science Academy August 20, 2015

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What is Adolescence? This is a developmental stage of development Age range varies, but generally thought to begin with the pubescent years around the age of ten and continues up until physical maturation is reached around the end of the teenage years. For the duration of this time, significant developments happen with regard to sexual and physical development as well as cognitive changes 3 The World Health Organization (WHO) defines ‘‘adolescents’’ as individuals 10–19 years of age, and ‘‘youth’’ as 15–24 years of age

Emerging Adulthood Developmental period distinct from adolescence – typically defined as years Important distinction from adolescence in that this is often the first time youth live on their own and form more lasting intimate relationships Research indicates that this period may have increased risk for substance use and sexual risk behaviors 4

HIV among Adolescents CDC estimates that youth aged account for 39% of all new HIV infections in the United States; – year olds comprise 21% of the US population Although overall rates of HIV diagnoses remained stable from 2006 to 2009, HIV diagnosis rates increased for youth aged 15–19 and 20– 24 years over the same period Approximately 68,600 young people aged 13–24 years were living with HIV infection at the end of 2008; of those, nearly 60% did not know they were infected. Some youth are more affected than others – Young men who have sex with men – especially young men of color – Adolescent minorities 5

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Diagnoses of HIV Infection and Population Among Adolescents Aged 13 – 19 Years, by Race/Ethnicity

Diagnoses of HIV Infection Among Adolescent and Young Adult Males, by Age Group and Transmission Category 2013—United States and 6 Dependent Areas

Diagnoses of HIV Infection Among Adolescent and Young Adult Females, by Age Group and Transmission Category 2013—United States and 6 Dependent Areas

HIV Risk among Adolescents 47% have had sexual intercourse at least once. 40% of currently sexually active students did not use a condom the last time they had sex. 15% have had four or more sex partners. 6% had sexual intercourse for the first time before age 13. 2% have injected illegal drugs at least once. Sexually transmitted infection rates are highest among adolescents 10

Risk Factors for Adolescents Substance use – club drugs (e.g., methamphetamines, cocaine, ecstasy) other drugs and alcohol linked to unprotected sex Dating violence – link to HIV risk behaviors among adults and adolescents involved in partner violence Impulsivity - sensation seeking, rises dramatically during adolescence and increases risks to healthy development Peer influences – perceptions of what peers do often more important than actual behaviors of peers Education and awareness - Research has shown that a large proportion of young people are not concerned about becoming infected with HIV 11

The Cascade of HIV Prevention: Linkage to Care 12 Current way of looking at the HIV epidemic in the US: Testing/diagnosis Linking to care Adherence Retained in care Suppressed What issues have you seen related to these?

HIV Testing in Adolescence The 2013 Youth Risk Behavior Survey found that 13% of 9th–12th grade students had ever tested for HIV; 35% of adults 18-24; HIV testing varies by factors such as: – Sexual experience – Race/ethnicity – Among sexually active students who did not use a condom the last time they had sex, 22% had ever been tested for HIV HIV testing is recommended by CDC as a routine part of health care for adolescents and adults aged 13–64 years for reducing the spread of HIV 13

The Cascade of HIV Prevention: Linkage to Care 14

The Cascade of HIV Prevention: Linkage to Care Adolescents may experience unique challenges in this arena: – Insurance and confidentiality – Sense of “invincibility” – Maintaining relationships with providers – Medication adherence What interventions have you seen that address these barriers? 15

Biomedical Prevention Methods Field of HIV prevention shifting from behavioral to biomedical model After fighting the HIV/AIDS epidemic for 30 years, it is clear that additional prevention methods are needed Use of these models requires the individual to change behavior in some way – thus a hybrid model is likely necessary Identifying the facilitators and challenges to uptake and adherence of these innovations is important

New(ish) Prevention Methods Pre-exposure prophylaxis or PrEP – aka Truvada – Prescription of a daily pill – Effective in prevention (up to 92% lower risk of becoming HIV infected) IF taken on a daily basis – Post-exposure prophylaxis (PEP) – Antiretroviral drugs after a single high-risk event to stop HIV from making copies of itself – Must be started as soon as possible—and always within 3 days of possible exposure. – Taken for 28 days 17

Attitudes toward Biomedical Interventions In general: – Overall low levels of awareness; but high intent to use – Barriers relate to potential side effects, effectiveness, daily use – Feasibility and acceptability in a trial with YMSM: everything acceptable EXCEPT daily use; same study reported low adherence and poor concordance between self-report and objective measures

 Not clear there is a need for a daily pill for most young men  Adherence can be a real challenge – especially with adolescents and young adults  Very low awareness - education and outreach is needed  Small proportion identified a stigma in PrEP use – “living every day” to have sex; suggests some guilt about sexual behavior that may impede adherence  Concerns about side effects  Concerns about use of condoms with PrEP Formative Research: YMSM Attitudes

Special Populations Homeless Youth Young men who have sex with men (YMSM) African American YMSM Ballroom community African American female adolescents African American male adolescents 20

Homeless Youth 21 Rates vary between 5% - 17%; even lowest of this range is about twice that of the prevalence rates of non-homeless youth High levels of “substance use disorders” among homeless youth Homeless youth may be involved in higher risk activities such as injection drug use and sex exchange Many homeless youth have experienced abuse – particularly sexual abuse Strategies that may decrease risk include the elimination of need to rely on illicit activities for income, provision of basic needs, increased outreach efforts, and early identification of and protection from childhood sexual abuse

Specific Risks for YMSM 22 Strong relationship between drug use and HIV transmission Experiences of harassment, violence and victimization can lead to poorer mental health and HIV risk-related behaviors Societal and familial homophobia contribute to mental health and well-being of YMSM Limited resources such as sexual education and outreach for HIV prevention efforts Additional stressors can increase risk for involvement in risky behaviors Social media and mobile phone apps may present additional risk

23 HIV Among YMSM by Race/Ethnicity

African American Young Men Who Have Sex with Men 24 Higher HIV rates among African American YMSM but sexual risk and substance use rates are similar or lower than their White counterparts Racism and homophobia affect HIV risk Less “safe spaces” African American YMSM tend to have sexual partners of same racial/ethnic group – affects the HIV reservoir

 Derived from Harlem Balls of the 1920s, underground celebrations and competitions  House and Ball communities work in tandem to develop and support a community involving primarily African American and Latino individuals of diverse sexual and gender identities  Houses are different groups of individuals that compete against each other during Balls House and Ball Communities  Balls are underground events involving competitions focused around dance, athletics, and gender expression.  Houses are identified as having a sense of family, friendship, and support and have a Mother and/or Father  The limited research with these communities suggests HIV is a major public health concern

African American Female Adolescents One in four girls (14-19) has an STI; and nearly half (48%) of the African-American girls had at least one STI Despite reporting greater frequency of condom use than their White and Hispanic counterparts, African American female adolescents experience disproportionately high rates of HIV/STIs Younger female adolescents are more susceptible to STIs due to biological factors (e.g., cervical ectopy, maturing immune system) Issues related to higher rates include: – Limited partner communication – Sex refusal self-efficacy – Condom use self-efficacy – STI knowledge Research has found that parent–adolescent communication about sex is protective for young African-American females 26

African American Male Adolescents Of the approximate 19,000 adolescent and young adult males living with a diagnosis of HIV infection, 64% are African American – Chlamydia rate among African American males was 12 times higher than that among White males; syphilis rate is 22 times higher 14% of adolescents have had sexual intercourse with four + persons, yet 39% of African American males reported more than 4 partners Among adolescent males, a traditional conception of manhood is associated with engagement in sexual risk behaviors While some cultural or psychosocial factors may affect risk, again, we see that African Americans are exposed to STIs and HIV at higher rates than other groups 27

The Cascade of HIV Prevention: Linkage to Care Adolescents may experience unique challenges in this arena: – Insurance and confidentiality – Sense of “invincibility” – Maintaining relationships with providers – Medication adherence 28

Promising or Best Practices : Behavioral Interventions Multifaceted approach to HIV prevention, (e.g. individual, peer, familial, school, church, and community programs) is necessary to reduce the incidence of HIV in young people Biomedical Prevention Efforts Examples of Effective Behavioral Interventions – Focus on Youth – Mpowerment – Project AIM – SIHLE – Street Smart 29

Summary Adolescents remain a high risk population – Young MSM, minority youth and homeless populations represents unique challenges for prevention work Challenge in engaging them in the cascade of HIV prevention Affordable Care Act provides new opportunities to engage youth and young adults Working with parents or other social support systems is important Schools should be integrated into public health efforts Churches and other community centers may also offer important prevention opportunities. 30

Resources National Resource Center for HIV/AIDS Prevention among Adolescents - The Center For Strengthening Youth Prevention Paradigms _Strengthening_Youth_Prevention_Paradigms__SYPP__HIV_Prevention __AtRisk_Youth__Webinars.htm#.Uhtno-2K6fQ Society for Adolescent Medicine

Contact Information Katrina Kubicek Program Manager – Community, Health Outcomes and Intervention Research Program Children’s Hospital Los Angeles