Download Care and Management of the HIV+ Youth

Care and Management of the
HIV+ Youth
Ronald Wilcox MD FAAP
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
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
42%
32%
11%
5%
5%
0%
1
2
3
5%
0%
4
5
6
7
8
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
80%
15%
0%
1
5%
2
3
4
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
What is your level of experience of
dealing with HIV+ adolescents?
1.
2.
3.
4.
5.
6.
Non-existent
Minimal
Moderate
High
Expert
Don’t believe there is
any HIV in teens
42%
32%
11%
5%
5%
0%
1
2
3
5%
0%
4
5
6
7
8
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.
• He’s living on the streets and makes money
panhandling.
• He also sometimes sells sex to other men but tells
you he’s not sexually attracted to men and just needs
money.
• You do an HIV antibody test and it’s negative.
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Which of the following groups is the largest in
terms of adolescents 13-24 years of age
diagnosed with HIV infection:
1.
2.
3.
4.
5.
6.
White males
White females
African-American males
African-American females
Hispanic males
Hispanic females
17%
17%
17%
17%
17%
1
2
17%
3
4
5
6
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
The age group with the highest rate of new HIV
infections this year in the US is estimated to be:
1.
2.
3.
4.
5.
1-13 years old
13-24 years old
25-40 years old
40-55 years old
Over 55 years of age
20%
1
20%
20%
2
3
20%
4
20%
5
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
LA Statistics (09/30/12)
HIV/ AIDS Diagnosis in 2011 by Age
380
400
350
325
323
300
243
250
0-12
13-24
25-34
200
35-44
150
45+
100
50
4
0
<1 %
25%
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.
2.
3.
4.
5.
6.
Feelings of invulnerability
Size of the ectropion
Peer pressure
Consistency of condom use
Rate of other STDs
All of the above
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
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RISK FACTORS
• High Rates of STDs
• Biologically More Susceptible
– Columnar tissue thin and friable
– Earlier menarche
• History of Sexual Abuse
• Types of sexual activity
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
14%
0%
81%
5%
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
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Cervical Epithelium
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Sexual Activity
• J Peds & Adol GYN, Volume 20, Issue 5, Oct 2007, Pp
299-304
• Reproductive health histories from 350 sexuallyexperienced adolescent females aged 12-18
participating in a 5-year STI acquisition study at an
urban health center
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
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
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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
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Patients are at highest risk of potential
exposure to HIV at which developmental
stage:
0%
9%
55%
36%
0%
1.
2.
3.
4.
5.
Prepubertal
Early adolescence
Middle adolescence
Late adolescence
Middle age
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
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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
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
RISK FACTORS CONTINUED
• Minority Youth
• Serial Monogamy
• Gay and bisexual males
• Homeless or runaway youth
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Minority MSM
• African-American male youth
– Frequently don’t identify as “gay” or “bisexual”
– Prevalence up to 33%
– 4% - 8% chance of acquisition per year  40-60%
chance infected by age 40
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CDC Recommendations for
HIV Screening and Testing
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
The CDC recommends routine HIV screening for
what age range
20%
20%
20%
20%
20%
1.
2.
3.
4.
5.
1 year to 13 years
13 years to 23 years
13 years to 50 years
13 years to 64 years
24 years to 99 years
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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
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 patient’s 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 patient’s express consent
Nass MT, Pasternak RH. HIV Clinician Spring 2012; 24(2): 3-6
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
• Don’t 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
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Testing and Treatment
Considerations in Youth
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.
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HIV Testing
• Consent legal age depends on state law
• “Opt-in” versus “Opt-out”
• When possible, use rapid testing for youth
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
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.
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
ACTS in terms of HIV counseling and
testing refers to:
1. Advise, confer, teach, simulate
0%
2. Assessment, counseling, testing, support
92%
3. Advertise, coerce, train, supervise
8%
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
ACTS
• Assessment:
– Education
– Identification of risk factors
– Provide recommendations for testing,
prevention, and referral
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
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
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.
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.
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)
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 D’Angelo L.
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Diagnosis Reactions
•
•
•
•
•
Denial
Anger
Unwillingness to disclose
Depression
Stoicism
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
821-4611
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
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
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Therapy Readiness
•
•
•
•
•
Adequate support
Stability in the teen’s life
Change in health status/lab results
Access to HIV care
Decision made jointly by the patient and
provider
• Supportive and nonjudgmental about the
adolescent’s decision
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
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)
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
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
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
haven’t 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.
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
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
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
Contact Info
• Ronald D. Wilcox MD FAAP
• E-Mail:
[email protected]
[email protected]
• Delta AETC:
www.deltaaetc.org
• Cell Phone:
504-491-1219
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org