In the Journals

Q&A: Evaluating adolescents for HIV PrEP

Mary R. Tanner

The authors of a recent MMWR report noted several “unique considerations” that clinicians face when evaluating adolescent patients for HIV pre-exposure prophylaxis, or PrEP, including legal issues of consent and the potential need for more support to promote adherence to the medication.

Healio spoke with Mary R. Tanner, MD, of the CDC’s Division of HIV/AIDS Prevention, about PrEP use among adolescents and how clinicians can counsel their young patients about it. Tanner was the lead author of the new report. – by Ken Downey Jr.

Question: Do data support PrEP use in adolescents?

Answer: PrEP is one possible component in a comprehensive approach to health for adolescents who are at risk for acquiring HIV. National data show that every year, some adolescents in the United States acquire HIV. This indicates that some adolescents in the U.S. may benefit from enhanced HIV prevention strategies like PrEP.

In 2018, the FDA approved PrEP — both tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) and tenofovir alafenamide/emtricitabine (TAF/FTC) — for adolescents who are at risk for HIV and weigh at least 77 pounds. (Editor’s note: The FDA approval for TAF/FTC excludes patients at risk for acquiring HIV through receptive vaginal sex.) Data supporting the safety of PrEP in adolescents include results from two open-label clinical trials of TDF/FTC as PrEP for adolescents: 1) the Adolescent Trials Network 113 (ATN 113) study among persons aged 15 to 17 years in the U.S., and 2) the Choices for Adolescent Methods of Prevention in South Africa (CHAMPS) PlusPills study among persons aged 15 to 19 years in South Africa. Both studies found that TDF/FTC for PrEP was safe and well tolerated among different adolescent populations at risk for HIV acquisition.

Studies in adults aged 18 years or older have shown that PrEP reduces the risk for getting HIV from sex by about 99% when taken daily. Among people who inject drugs, PrEP reduces the risk for getting HIV by at least 74% when taken daily.

Q: Which patients would benefit most from PrEP?

A: PrEP is for people without HIV who are at risk for getting the virus from sex or injection drug use. The U.S. Public Health Service PrEP guideline recommends that PrEP be considered for people who are HIV negative who:

Have had anal or vaginal sex in the past 6 months and:

  • Have a sexual partner with HIV (especially if the partner has an unknown or detectable viral load), or
  • Have not consistently used a condom, or
  • Have been diagnosed with an STD in the past 6 months

PrEP is also recommended for people who inject drugs and:

  • Have an injection partner with HIV, or
  • Share needles, syringes or other equipment to inject drugs (for example, cookers).

PrEP should also be considered for people who have been prescribed nonoccupational postexposure prophylaxis (PEP) and:

  • Report continued risk behavior, or
  • Have used multiple courses of PEP.

Q: How should clinicians approach counseling adolescent patients about PrEP?

A: Health care providers who are considering providing PrEP to an adolescent patient should collaborate with the patient for PrEP decisions, recognizing the adolescent’s autonomy to the extent allowable by law, and include parents in the conversation about PrEP when it is safe and appropriate to do so.

A clinical approach tailored to the adolescent patient can enhance patient-provider communication about PrEP and other important health topics. Obtaining a social, sexual and substance use history is important to identifying adolescents’ health needs and providing individualized recommendations and counseling. Effective communication skills and culturally competent care are important components of counseling patients, and resources are available for providers who wish to grow their skills in these areas. Such resources include the HHS Office of Minority Health’s Think Cultural Health: A physician’s practical guide to culturally competent care, and the AIDS Education and Training Center Program’s cultural competency curriculum.

Q: Should parents be involved in the conversation?

A: Health care providers who are considering providing PrEP to an adolescent patient who is younger than the age of legal adulthood (minor) should recognize the adolescent’s autonomy to the extent allowable by law, and include parents in the conversation about PrEP when it is safe to do so.

Parental/guardian involvement in an adolescent minor’s health care is often desirable but is sometimes contraindicated for the safety of the adolescent. Laws and regulations that may be relevant for PrEP-related services provided to adolescent minors (including HIV testing) differ by jurisdiction. These laws and regulations pertain to consent, confidentiality, parental disclosure and circumstances requiring reporting to local agencies.

Clinicians considering providing PrEP to an adolescent minor should be aware of local laws, regulations and policies that may apply. For more information on local laws, see: https://www.cdc.gov/hiv/policies/law/states/minors.html

Q: Once PrEP is initiated, how can clinicians help adolescent patients adhere to the medication?

A: Strict adherence to daily PrEP medication is required to prevent HIV acquisition. Clinical trials of PrEP use in adolescents (aged 15 to 17 years) and young adults (aged 18 to 24 years) showed that quarterly clinical visits were associated with poorer medication adherence than the initial monthly visits. Adolescents might benefit from more frequent contact with clinical staff to support medication adherence. Other potentially useful clinical approaches might include more flexible clinic schedules (eg, after-hours availability), peer navigators and other youth-friendly strategies. There are ongoing clinical trials evaluating innovative technology-focused interventions and other strategies to improve use of HIV prevention services and PrEP among adolescents and young adults at risk for HIV acquisition. The U.S. Public Health Service PrEP guideline includes recommendations for adherence counseling and support.

Disclosures: The authors report no relevant financial disclosures.

Mary R. Tanner

The authors of a recent MMWR report noted several “unique considerations” that clinicians face when evaluating adolescent patients for HIV pre-exposure prophylaxis, or PrEP, including legal issues of consent and the potential need for more support to promote adherence to the medication.

Healio spoke with Mary R. Tanner, MD, of the CDC’s Division of HIV/AIDS Prevention, about PrEP use among adolescents and how clinicians can counsel their young patients about it. Tanner was the lead author of the new report. – by Ken Downey Jr.

Question: Do data support PrEP use in adolescents?

Answer: PrEP is one possible component in a comprehensive approach to health for adolescents who are at risk for acquiring HIV. National data show that every year, some adolescents in the United States acquire HIV. This indicates that some adolescents in the U.S. may benefit from enhanced HIV prevention strategies like PrEP.

In 2018, the FDA approved PrEP — both tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) and tenofovir alafenamide/emtricitabine (TAF/FTC) — for adolescents who are at risk for HIV and weigh at least 77 pounds. (Editor’s note: The FDA approval for TAF/FTC excludes patients at risk for acquiring HIV through receptive vaginal sex.) Data supporting the safety of PrEP in adolescents include results from two open-label clinical trials of TDF/FTC as PrEP for adolescents: 1) the Adolescent Trials Network 113 (ATN 113) study among persons aged 15 to 17 years in the U.S., and 2) the Choices for Adolescent Methods of Prevention in South Africa (CHAMPS) PlusPills study among persons aged 15 to 19 years in South Africa. Both studies found that TDF/FTC for PrEP was safe and well tolerated among different adolescent populations at risk for HIV acquisition.

Studies in adults aged 18 years or older have shown that PrEP reduces the risk for getting HIV from sex by about 99% when taken daily. Among people who inject drugs, PrEP reduces the risk for getting HIV by at least 74% when taken daily.

Q: Which patients would benefit most from PrEP?

A: PrEP is for people without HIV who are at risk for getting the virus from sex or injection drug use. The U.S. Public Health Service PrEP guideline recommends that PrEP be considered for people who are HIV negative who:

Have had anal or vaginal sex in the past 6 months and:

  • Have a sexual partner with HIV (especially if the partner has an unknown or detectable viral load), or
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  • Have not consistently used a condom, or
  • Have been diagnosed with an STD in the past 6 months

PrEP is also recommended for people who inject drugs and:

  • Have an injection partner with HIV, or
  • Share needles, syringes or other equipment to inject drugs (for example, cookers).

PrEP should also be considered for people who have been prescribed nonoccupational postexposure prophylaxis (PEP) and:

  • Report continued risk behavior, or
  • Have used multiple courses of PEP.

Q: How should clinicians approach counseling adolescent patients about PrEP?

A: Health care providers who are considering providing PrEP to an adolescent patient should collaborate with the patient for PrEP decisions, recognizing the adolescent’s autonomy to the extent allowable by law, and include parents in the conversation about PrEP when it is safe and appropriate to do so.

A clinical approach tailored to the adolescent patient can enhance patient-provider communication about PrEP and other important health topics. Obtaining a social, sexual and substance use history is important to identifying adolescents’ health needs and providing individualized recommendations and counseling. Effective communication skills and culturally competent care are important components of counseling patients, and resources are available for providers who wish to grow their skills in these areas. Such resources include the HHS Office of Minority Health’s Think Cultural Health: A physician’s practical guide to culturally competent care, and the AIDS Education and Training Center Program’s cultural competency curriculum.

Q: Should parents be involved in the conversation?

A: Health care providers who are considering providing PrEP to an adolescent patient who is younger than the age of legal adulthood (minor) should recognize the adolescent’s autonomy to the extent allowable by law, and include parents in the conversation about PrEP when it is safe to do so.

Parental/guardian involvement in an adolescent minor’s health care is often desirable but is sometimes contraindicated for the safety of the adolescent. Laws and regulations that may be relevant for PrEP-related services provided to adolescent minors (including HIV testing) differ by jurisdiction. These laws and regulations pertain to consent, confidentiality, parental disclosure and circumstances requiring reporting to local agencies.

Clinicians considering providing PrEP to an adolescent minor should be aware of local laws, regulations and policies that may apply. For more information on local laws, see: https://www.cdc.gov/hiv/policies/law/states/minors.html

Q: Once PrEP is initiated, how can clinicians help adolescent patients adhere to the medication?

A: Strict adherence to daily PrEP medication is required to prevent HIV acquisition. Clinical trials of PrEP use in adolescents (aged 15 to 17 years) and young adults (aged 18 to 24 years) showed that quarterly clinical visits were associated with poorer medication adherence than the initial monthly visits. Adolescents might benefit from more frequent contact with clinical staff to support medication adherence. Other potentially useful clinical approaches might include more flexible clinic schedules (eg, after-hours availability), peer navigators and other youth-friendly strategies. There are ongoing clinical trials evaluating innovative technology-focused interventions and other strategies to improve use of HIV prevention services and PrEP among adolescents and young adults at risk for HIV acquisition. The U.S. Public Health Service PrEP guideline includes recommendations for adherence counseling and support.

Disclosures: The authors report no relevant financial disclosures.