1. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Care and Management of the HIV+ Youth Ronald Wilcox MD FAAP

2. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Care and Management of the HIV+ Youth Ronald Wilcox MD FAAP AKA Man with Many Hats

3. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org What is your profession? 1.Student / Resident / Fellow 2.Primary Care Provider in Practice 3.Specialty Provider in Practice 4.Nursing 5.Public Health 6.Pharmacist 7.Other

4. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org HIV in Youth 1.Is very rare 2.Occurs only in MSM 3.Is found proportionately to racial make-up of US 4.Is a growing epidemic

5. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org What is your level of experience of dealing with HIV+ adolescents? 1.Non-existent 2.Minimal 3.Moderate 4.High 5.Expert 6.Dont believe there is any HIV in teens

6. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Case 1 An 18 year old boy recently aged out of foster care. He received transitional services and had a job in a fast food restaurant when he left his foster home. He quickly lost that job and is now homeless. Hes living on the streets and makes money panhandling. He also sometimes sells sex to other men but tells you hes not sexually attracted to men and just needs money. You do an HIV antibody test and its negative.

7. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org

9. Which of the following groups is the largest in terms of adolescents 13-24 years of age diagnosed with HIV infection: 1.White males 2.White females 3.African-American males 4.African-American females 5.Hispanic males 6.Hispanic females

10. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org

14. The age group with the highest rate of new HIV infections this year in the US is estimated to be: 1.1-13 years old 2.13-24 years old 3.25-40 years old 4.40-55 years old 5.Over 55 years of age

15. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org LA Statistics (09/30/12) HIV/ AIDS Diagnosis in 2011 by Age <1 %25%

16. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org All of the following are examples of factors of increased risk for HIV for adolescents EXCEPT: 1.Feelings of invulnerability 2.Size of the ectropion 3.Peer pressure 4.Consistency of condom use 5.Rate of other STDs 6.All of the above

17. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org HIV Risk in Youth Exploration of sexuality Lack of sense of risk and feeling of invincibility Lack of condom use Incidence of other STDs Social situations – ie homelessness Transformation zone Access to care Domestic or sexual abuse Mental health issues Substance abuse issues Commercial sexual behavior Social networking and sexting

18. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org RISK FACTORS High Rates of STDs Biologically More Susceptible – Columnar tissue thin and friable – Earlier menarche History of Sexual Abuse Types of sexual activity

19. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org The transformation zone 1.Is a clinic which caters to transgendered youth 2.Is larger in older women than younger women 3.Is area of the cervix which changes from squamous to columnar epithelium 4. Is the area where the vaginal tissue has the highest density of lymphocytes

20. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Cervical Epithelium

21. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Sexual Activity J Peds & Adol GYN, Volume 20, Issue 5, Oct 2007, Pp 299-304 Reproductive health histories from 350 sexually- experienced adolescent females aged 12-18 participating in a 5-year STI acquisition study at an urban health center

22. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Sexual Activity 41% teens had sexual relations with casual partners, 86% with main partners Anal intercourse – 16% with main partners and 12% of those with casual partners Condom use more with casual than main – Vaginal – 61% versus 32.4% – Anal – 47.1% vs 21.3% Casual relationship – more likely to use anal intercourse for contraception

23. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Anal Intercourse in Young Adults Gorbach PM et al. Anal intercourse among young heterosexuals in three sexually transmitted disease clinics in the United States. Sex Transm Dis 2009 Mar 4; e-pub ahead of press. 2001-2004: Interviewed 1084 heterosexual 18-26 y/o patients in Seattle, New Orleans, and St. Louis presenting to an STD clinic 37% had anal intercourse at some point 28.9% had anal intercourse with at least 1 of last 3 partners 19% had anal intercourse with their last partner Women reported less condom use with last AI than men (26% versus 45%, p<0.001) Risk for AI for women: meeting partner same day, having over 3 partners in lifetime, and having sex for money

24. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Risky behavior 2009 – 46% of high school students had had intercourse 34% in past three months 39% did not use a condom the last time 77% did not use other contraception 14% had 4 or more partners in lifetime – 8300 cases of HIV in 13-24 year olds – Nearly half of all new STDs in 15-24 year olds – > 400,000 teen girls gave birth www.cdc.gov fact sheets on Sexual Behaviors of Adolescents

25. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Patients are at highest risk of potential exposure to HIV at which developmental stage: 1.Prepubertal 2.Early adolescence 3.Middle adolescence 4.Late adolescence 5.Middle age

26. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Middle Adolescence ages 14-16 Often the greatest experimental, risk-taking time Drinking, drugs, smoking, and sexual experimentation highest interest between 12 and 16 years This is when first intercourse, first drink, or first pregnancy frequently occur

27. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Middle Adolescence Little concept of cause and effect Omnipotence and invulnerability are the rule Unpredictable surges in sexual drive Sexuality is often the MAJOR preoccupation of the middle adolescent

28. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org RISK FACTORS CONTINUED Minority Youth Serial Monogamy Gay and bisexual males Homeless or runaway youth

29. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Minority MSM African-American male youth – Frequently dont identify as gay or bisexual – Prevalence up to 33% – 4% - 8% chance of acquisition per year 40-60% chance infected by age 40

30. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org CDC Recommendations for HIV Screening and Testing

31. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org The CDC recommends routine HIV screening for what age range 1.1 year to 13 years 2.13 years to 23 years 3.13 years to 50 years 4.13 years to 64 years 5.24 years to 99 years

32. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Risk assessment HIV Testing should be offered routinely from 13-64 years of age Consider yearly testing in 13-24 year old and others at high risk Testing based ONLY on reported risk discouraged 25 years of age and older – yearly risk assessment and consider testing

33. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Assessment in Youth Assure confidentiality Refrain from speaking with parents privately without expressed permission from youth Assure parents do not stand outside room Place siblings in different rooms Obtain patients cell phone at each visit and assure patient that results will be given directly to him/her Ask nursing staff to knock before entering and refrain from talking with parents without patients express consent Nass MT, Pasternak RH. HIV Clinician Spring 2012; 24(2): 3-6

34. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Assessment in youth Repeat the same questions to each patient Perform risk assessments at preventive and acute care visits Dont assume patient understands the ? – Consider rephrasing it Ask patient what they mean by sex and ask about specific behaviors Lead with questions that minimize vulnerability Use gender neutral language Avoid using personal norms as standards Nass MT, Pasternak RH. HIV Clinician Spring 2012; 24(2): 3-6

35. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Testing and Treatment Considerations in Youth

36. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Case 2 A 15 year old young woman decides to become sexually active with her 24 year old boyfriend. They do not use condoms because he wants her to prove her love and tells her she is his only girlfriend. She later finds out that he also has a boyfriend so she goes to her school based clinic and asks for a test for STDs. Her rapid HIV test is positive.

37. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org HIV Testing Consent legal age depends on state law Opt-in versus Opt-out When possible, use rapid testing for youth

38. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Repeat testing Patients at high risk for HIV based on risk assessment, offered yearly – Adolescents are classified as high risk – MSM – IVDU – Known HIV+ partners

39. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Requested Testing Usually within first 24 hours of a high risk behavior Often requested when they had a previous positive test to confirm.

40. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org ACTS in terms of HIV counseling and testing refers to: 1.Advise, confer, teach, simulate 2.Assessment, counseling, testing, support 3.Advertise, coerce, train, supervise

41. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org ACTS Assessment: – Education – Identification of risk factors – Provide recommendations for testing, prevention, and referral

42. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org ACTS Assessment Counseling – Clarifies meaning of positive and negative test – Patient readiness and social support network are assessed – Consent is obtained

43. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org ACTS Assessment Counseling Testing – Rapid testing preferred except when hospitalized – Must confirm positive results with Western Blot

44. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org ACTS Assessment Counseling Testing Support – Negative result – stress importance of retest in 3 months and ways to decrease risk – Positive result – offer support and referral for treatment and prevention. Discuss partner notification.

45. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Factors for Testing: Connect 2 Protect (ATN) Individual factors – Less likely if < 18 y/o Still in school – More likely if African-American (2 x) G/L/B activity (3x) Had 3 or more sex partners in 3 months Ever had an STI Used condoms half the time or less Using substances during the sexual encounter Had a known HIV+ partner Straub DM, Arrington-Sanders R, Harris DR et al. Correlates of HIV Testing History Among Urban Youth Recruited Through Venue-Based Testing in 15 US Cities. Sexually Transmitted Diseases 2011 Aug; 38(8): 691-6.

46. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Factors for Testing Connect 2 Protect (ATN) (Straub) Partner Factors – Less likely if > or = 1 episode when a partner made them have sex without a condom Had a partner with unknown status compared to those with HIV negative partners (p<0.001) – More likely if Partner who used hard drugs Partner who had relationships outside the primary (p<0.001)

47. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org HIV Testing in Adolescents 16,410 students who participated in 2009 national Youth Risk Behavior Survey – 7,591 reported ever having intercourse 22.6% had ever been HIV tested Used IV drugs at least once (280) - 41% ever HIV tested Forced to have sex (1055) - 36% ever tested for HIV Did not use condom at last intercourse (4797) – 28.7% tested Had 4 or more partners (2292) – 34.7% tested Balaji AB, Eaton DK, Voetsch AC et al. Arch Pediatr Adolesc Med 2012 Jan (epub) with editorial by DAngelo L.

48. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Diagnosis Reactions Denial Anger Unwillingness to disclose Depression Stoicism

49. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 821-4611

50. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Health Promotion After Diagnosis Sexual health education Disclosure education Importance of adherence to medical care and medications Treatment as prevention Harm reduction counseling regarding illicit drug use Support of youth as they continue to mature Transition of care when ages to adulthood

51. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Disclosure To the perinatally infected youth To friends or family – Possible ostracism or loss of shelter – Trust to not disclose to others – Infection control issues To sexual partners – < 25% disclose to casual partners – The longer the person is with a partner, the more likely they are to disclose – Worry about rejection, disclosure to others, violence

52. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Therapy Readiness Adequate support Stability in the teens life Change in health status/lab results Access to HIV care Decision made jointly by the patient and provider Supportive and nonjudgmental about the adolescents decision

53. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Medication Tanner stage I or II – pediatric guidelines for dosing Tanner Stage III or IV who have began growth spurt and Stage V – adult dosing REACH Study – 40% of adolescents reported full adherence

54. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Adherence to ART by Youth Chandwani S et al. J Adol Health 2012; 51: 242-51 104 participants – 65.4% reported full adherence – Indicators of likely failure Behaviorally acquired disease (OR 4.378) AIDS diagnosis (OR 4.78) Discussed HIV disease with providers (OR 4.57) Reported difficulty with medication regimen (OR 1.84) Experienced internalizing behavior problems Used drugs Missing doses because of forgetfulness (OR 2.53)

55. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Immunizations Human Papilloma Virus Meningococcus Tetanus / diphtheria / pertussis Influenza Pneumococcus Hepatitis A & B Varicella zoster Measles – mumps – rubella Begue R. HIV Clinician Spring 2012; 24(2): 15-9

56. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org PAP Smears in Perinatally Infected Youth Guidelines in general – Begin at 21 years of age – HIV positive women – 2 in first year then yearly after that; refer to colposcopy if anything beyond ASCUS – Perinatally infected PACTG 219 – 48 of 101 girls with a PAP had abnormal findings – ASCUS in 18 – LGSIL in 27 – HGSIL in 3

57. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Case 3 A 13 year old perinatally HIV infected girl is living with her adoptive parents. Her biological mother died of AIDS shortly after she was born. The parents tell you that their daughter is doing well on antiretroviral treatment but they havent told her she has AIDS or that she is adopted. When you meet with the daughter she tells you that she has a boyfriend and right now all they do is kiss.

58. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Pregnancy in Perinatally Infected Youth Badell ML, Lindsay M. AIDS Res Treat 2012 70% of these youth want children Premature Delivery – Of 10 perinatally infected women with pregnancies, 31% had premature ROM and delivery (compared to 13-18% in usual adolescents) {Williams 2008, A J Ob Gyn} – In 9 patients in Europe, 44% incidence of premature delivery {Thorne 2007, AIDS} – 34 perinatally infected women versus 54 sexually infected women mean gestational age at delivery 33.7 versus 38.8 {Beckerman 2011, Proceedings of the IDSA Annual Meeting} – Prospective study in India of 30 pregnancies no increase in prematurity

59. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Challenges Poor access to care Lack of experience with and negative perceptions of health care system Unorthodox self-perceptions of sexual orientation HIV stigma Sexual minority stigma

60. DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Contact Info Ronald D. Wilcox MD FAAP E-Mail:rwilco@lsuhsc.edu ronw@noaidstf.org Delta AETC:www.deltaaetc.org Cell Phone:504-491-1219