The vast majority of deaths in adolescents (ages 13 to 19 years) are caused by accidents, homicides, and suicides. However, acquired immunodeficiency syndrome (AIDS) is now the sixth leading cause of death in 15 to 24 year olds.1,2 As many as one in four adolescents are at risk for school failure, delinquency, early unprotected intercourse, or substance abuse.3 To have an impact on human immunodeficiency virus (HIV) and AIDS, as well as the other major causes of morbidity and mortality in adolescents, pediatricians must extend their anticipatory guidance beyond questions during infancy about safety, feeding, and toilet training to questions during adolescence about drug use, depression, and sexual activity.
The goal of this article is to assist pediatricians in integrating HIV risk assessment and risk reduction education into the routine care of adolescents, to provide an overview of HIV testing, and to discuss the initial medical management of adolescents infected with HIV.
Although the prevalence of HIV in adolescents is unknown, the following information gives us ample evidence that HIV has entered the adolescent population. As of December, 1992, less than 1% (946) of AIDS cases were in 13 to 19 year olds; however, 20% (48 295) of cases occurred in 20 to 29 year olds.4 With a 10-year median incubation period, many 20 to 29 year olds who developed AIDS must have been infected as adolescents. Older adolescents, males, and ethnic and racial minorities are disproportionately represented among those infected with the HIV virus. Among 13 to 19 year olds with AIDS, the following exposure categories were found: 24% were males who had sex with men; 13% were injecting drug users; 4% were males who had sex with men and were injecting drug users; 30% were hemophiliacs or received coagulation products; 16% were infected through heterosexual contact; 6% were infected through blood transfusions; and 7% were undetermined. Therefore, 57% became infected through sexual contact or injecting drug use. This percentage increased to 92% for 22 to 24 year olds.
Seroprevalence data for adolescents are limited. Data from the following groups are the best available.
* In the Job Corps, a federally funded job training program for economically and educationally disadvantaged youth, the prevalence among 16 to 20 year olds was 3.9 per thousand.5
* Among military recruits less than 20 years old, seropervalence was 0.34 per thousand.6
* Anonymous unlinked testing of sexually active college students having blood drawn for reasons other than HIV-related care at 13 student health centers showed that one out of 500 students were HIV positive.7
* Two hospitals chosen as sentinel hospitals to screen for HIV in communities with a high prevalence of AIDS found 1.1% to 3.8% of adolescents from 15 to 19 years old to be seropositive for HIV.8
* D'Angelo et al in a 5 -year study of the seroprevalence of HIV among urban adolescents in Washington, DC, found the prevalence to have increased from 4.03 to 19.94/1000 during the years 1987 to 1992.9
Pediatricians who feel that it is unnecessary to discuss HIV and AIDS with their patients or to ask intimate questions about sexuality or drug use should consider the following.
Less than 10% of pediatricians surveyed by Marks said they provided comprehensive care to teenage patients on the issues of sexuality, substance abuse, body image, or mental health, and half were worried that parents did not want these issues addressed.10 Fisher found, howeveT, that 81% of parents in a middle class suburban area of New York felt that their pediatrician should routinely discuss sexuality with their adolescents, and 64% said that such discussions should begin before age 14- Similarly, 81% of parents wanted physicians to discuss drug use, with 80% stating that this should begin before age 14.11
Seventy percent of teenagers wanted to discuss sexually transmitted disease (STD), 66% contraception, and 50% drugs and alcohol.11 Several teenage females wished to discuss the appropriate age to become sexually active, and both males and females wanted the physician to raise the issues of STDs or contraception rather than having to initiate the request for information themselves.12
A study by the Centers for Disease Control and Prevention (CLXD) reported that 74% of mothers and 49% of fathers discussed AIDS with their 10- to 17-year-old children. While 76% of patients who said they knew a lot about AIDS discussed it with their children, only 19% who knew little about AIDS discussed this important subject with their children.13
Patients and their parents do wish their pediatrician to discuss the issue of HIV and AIDS and although many parents do discuss this important subject, those who are less informed do not. Pediatricians have an important role in offering early AIDS education to patients, supporting parents in their role as educators at home, and as sources of information about HIV and AIDS for parents, teachers, and community groups.
HIV RISK ASSESSMENT
Adolescents see physicians infrequently14 and over 75% of visits last less than 15 minutes.15 For HIV education and risk assessment to be practical, pediatricians must be able to integrate it into the routine evaluation of adolescents in their busy office practices. The psychosocial assessment tool, HEADSS (Home, Education, Activities, Drugs, Sexuality, Suicide/ depression), can be used to structure a brief psychosocial assessment. It is also useful for identifying risk factors for HIV, providing a forum for discussing risk reduction, and evaluating the social support system and psychologic state of a teen requesting HIV testing.16-18
Table 1 contains examples of questions to be asked on a HEADSS assessment of all patients. The following section will elaborate on the use of the HEADSS assessment as it relates to HIV and AIDS.
The status of the teen's relation with his or her family and access to supportive adults in the home is useful information when performing pre- and postHIV counseling.
If a teen has run away from home or spends long periods of time home alone, more attention needs to be spent on drug abuse and sexuality. Over one million adolescents are homeless or have run away from home.19 Ninety percent of homeless/runaway youth in Cohen's study were sexually active, 82% used alcohol or other drugs, and 8% were injecting drug users.17 Twenty-five percent practiced survival sex (sex for money, food, clothes, or a place to stay), and 11% identified themselves as homosexual or bisexual. A history of survival sex is associated with higher rates of injecting drug use and STDs.20 Two studies of homeless/runaway youth have found a 6% to 12% prevalence of HIV infection.21,22
A sudden, unexplained drop in grades or frequent unauthorized school absences (cutting class) should lead to questions about other areas of psychological functioning such as sexuality, drug use, and suicide/ depression.
Questions about activities and peers assist the interviewer in understanding the adolescents social support network. Questions about friends, daily, weekend, or evening activities, and attendance at parties provide indirect information about sexual activity and drug use. Patients involved in body building should be questioned about steroid use, since needle-sharing has transmitted HIV.23 Tattooing and body piercing also have the potential to transmit HIV. The pediatrician may use this opportunity to provide education about the risks of needle sharing.
Discussion of alcohol and other drug use is essential when evaluating risk of exposure to HIV. A nationwide survey of high school students found that 1% of females and 2% of males used injected drugs.24 Despite infrequent injection drug use in teens, 13% of AIDS cases in 13 to 19 year olds are the result of injection drug use. The use of alcohol and other drugs may place the adolescent at higher risk for STD or HIV through decreased use of safer sexual practices.24,25 Sex may be exchanged for drugs.
The confidentiality of conversations about sexuality must be clearly stated. Teenagers should be informed that questions about sexuality are asked of all patients. Acknowledge that questions might be embarrassing but need to be asked in order to provide them with good health care. Questions regarding sexual activities should not be glossed over. Take the time to ask the questions outlined in Table 1 . A frank discussion of condom use, including a demonstration of the proper technique for putting them on and taking them off, is an integral part of discussing safe sex. Adolescents surveyed in Massachusetts who carried condoms and who discussed AIDS with a physician were 2.7 and 1.7 times more likely to use them, respectively.25 DiClemente also found that discussing AIDS with a physician predicted increased condom use by adolescents.26 By discussing condom use, pediatricians can reduce their patients' risk of infection with an STD or HIV Making condoms available in the office will decrease barriers to their use and emphasize the importance of protected sexual activity. Make no assumptions about sexual orientation or sexual practices.
Fifty-one percent of females and 57% of male high school students were sexually active according to a 1991 CDC study. Only 38% of females and 54% of males had used a condom at last intercourse.24 In 1990, the average age of first sexual experience for 9th to 12th grade students was 16.1 for males and 16.9 for females. Thirty-three percent of males and 20% of females initiated sexual activity before the age of 1 5.27 Twenty-six percent of women in an adolescent clinic in New \fork28 and 21% in San Francisco29 reported receptive anal intercourse. Sexual practices vary widely, so explicit questions regarding oral, vaginal, anal, and other variations should be asked. Patients seldom feel comfortable volunteering this information.
Adolescents With Whom to Discuss Human Immunodeficiency Virus Testing
Four surveys of young American men have described a 17% to 32% incidence of homosexual activity to orgasm on at least one occasion.30 The sexual partners of adolescent male homosexuals are on the average 7 years older than they are and therefore are in an age group with a higher prevalence of HIV/AIDS.30
One quarter of adolescents acquire STDs in high school and one million become pregnant.31,32 Having an STD places an adolescent at higher risk for having HIV. Two studies of STD clinics found a 1% and 2% seroprevalence rate in adolescents.33,34
Assessing past and current feelings of depression and risk for suicide are an essential part of the psychosocial assessment of adolescents, as well as necessary during pre- and post-test counseling for an HIV test.
WHICH ADOLESCENTS TO TEST
Stiffman in a multi-clinic study of 13 to 1 8 year olds found that 3% of youth were at high risk for HIV using the exposure categories of prostitution, injection drug use, men having sex with men, or having an ulcerative STD. Sixteen percent were at risk secondary to having more than six sexual partners or having an STD.35
Review of Body Systems*
Relying on specific narrowly defined risk criteria may miss a considerable number of HIV-positive adolescents as shown by D'Angelo et al,36 who found that when using the stringent criteria of commonly acknowledged risk factors, they only detected 38% of adolescents who tested positive for HIV. Table 2 reviews some of the factors that should prompt a discussion of HIV testing with an adolescent.
ISSUES RELATED TO HIV TESTING OF ADOLESCENTS
An HIV test is not just another laboratory test. Before a physician orders the test for the first time, the following questions should be considered.
* What lab will 1 use? What are the lab's criteria for a positive test? What confirmatory test does the lab use? For which patients should the test be repeated before the diagnosis of HIV infection is made?
* Is confidentiality assured by the lab as well as by my own office? When would testing at an anonymous test site be better for a patient? What do I need to discuss in the pre- and post-test counseling of adolescents? Can my teenaged patient consent to HIV testing?
* Am I ready and equipped to handle the emotional and medical aspects of a positive HIV test? Am I prepared to openly and frankly discuss issues related to sexual orientation and sexuality? How will I handle issues related to confidentiality that could compete with my own desire for parental and partner notification?
By preparing in advance, the physician can avoid making decisions in a crisis atmosphere. The following section briefly elaborates on some of the issues raised above.
The HlV Test
The usual test for HIV antibodies is an enzymelinked immunosorbent assay (ELISA) test, which, if positive, is confirmed by a Western blot. A positive ELISA is not a positive test for HIV and should never be reported as such to a patient.37 An indeterminate Western blot in low-risk individuals often means the individual has a disease other than HIV such as liver disease or systemic lupus erythematosus.38 The laboratory conducting HIV tests should repeat the test before reporting a positive result, and for low-risk patients, a second, separate blood sample should be tested before the diagnosis is made.39 Adherence to diese rules will prevent false positive tests from being reported to patients with possible serious negative effects. Since it takes from 6 weeks to 6 months to seroconvert after exposure to HIV, a negative test is not absolute assurance that the person is uninfected, especially if there has been unsafe behavior within the last 6 months.
Confidentiality regarding HIV serostatus is paramount. The physician should be aware that even if he or she attempts to protect confidentiality, there are many other areas of potential leaks including the staff of the laboratory, the hospital, and the physician's own office. Selected patients would be better protected by being tested at an anonymous test site. States vary in the protections they mandate to prevent unauthorized disclosure of a person's HIV status. In California, unauthorized disclosure is a crime except under special circumstances.
Human Immunodeficiency Virus-Related Findings on Physical Examination
Specific Elements of Laboratory Assessment in Adolescents Infected With Human Immunodeficiency Virus
Physicians with an HIV-positive adolescent may find themselves in an uncomfortable position if the patient does not wish to discuss their HIV-positive status with their parents. Patience in these cases will usually lead to a rewarding outcome. An initial refusal to include parents often, with time, gives way to a desire to inform them. Parents may be perceived as punitive or prejudiced. Try to determine the reality of the teen's concerns. Review with the adolescent his or her parents' past reactions to emotionally charged issues or events. If the family is not well known to you, a useful strategy is to offer to schedule a meeting with the teen and his or her parents to discuss a neutral issue such as growth and development or anouSer health issue. This allows you to evaluate family interactions and identify possible supportive people within the family.
If a parent asks you a direct question about their teen's HIV status or any other confidential information, you can respond by inquiring as to why the parent is concerned and ascertain if they have discussed these concerns with their teen. Ask what they would do if their teen was HIV positive, had an STD, or was pregnant. The information gained from a neutral meeting with the parents and teen together and discussing the parents concerns will allow both you and the teen to determine if it is the appropriate time to discuss sensitive issues with their parents. When talking to teens alone, offer to assist them in discussing these issues with their parents. Help them weigh the risks and benefits of revealing this information, realizing that revealing a teen's HIV status might lead to discussions of sexuality or drug use that they are not ready to discuss. Under no circumstances should the physician tell the parents without the teen's consent. While teens may choose not to discuss their HIV status that day, these discussions may open the door to revealing this information at a later date.
Similarly, the physician may worry about an HIV-positive patient continuing unsafe sexual practices. Although many patients will initially resist disclosure of their status, with time, most will elect to inform important persons in their lives. Several state or local departments of public health have mechanisms in place to allow anonymous notification of previous sexual contacts of HIV-positive persons. When confronted with the concern of continued unsafe sex, it is useful to remember that safe sex is the responsibility of both partners. Except for forced sexual activity, no one becomes HIV infected without consenting to unsafe sexual practices. The cornerstone of successful voluntary testing is confidentiality and respect for patients' rights. Coercion will drive potential patients away and contribute to the alienation of those affected by the epidemic.
As of 1990, 12 states explicitly allow adolescents over the age of 12 to consent to HIV testing: Arizona, California, Colorado, Delaware, Iowa, Michigan, Montana, New Mexico, New York, Ohio, Washington, and Wisconsin.40,41 In 1990, North discussed consent and concluded that sufficient legal authority exists for physicians in any state to test mature competent adolescents who give permission to be tested.41 Informed consent must be obtained from the adolescent before testing. Adolescents have the right to refuse testing and test results may not be released to others without the adolescents written permission.
1993 Revised Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults
Green and McCreaner extensively discuss pre- and posttest counseling.42 If the pediatrician feels that they are unable to discuss these issues, then the patient should be referred to a provider or a test-site that can provide adolescent-sensitive pre- and posttest counseling. Pretest counseling involves discussing the following:
* developmentally appropriate education about HIV and AIDS,
* establishing why the patient wishes to be tested and evaluating potential risk factors,
* risk reduction education,
* the meaning of the test and its limits (for example, the length of time required to convert to positive [window period], and the possible need to repeat the test),
* the therapeutic implications of a positive or negative result,
* discussion of legal and financial repercussions,
* determining who the patient would tell if the result is positive and the likely response of those persons,
* identification of available support systems, and
* the patient's probable response to a positive or negative test, including suicide risk.
Posttest counseling places a negative test result in the context of the need for safe sexual and drug use practices.
The reporting of a positive result will cause emotional distress for both the physician and the patient. It is helpful at this moment to remember that early identification of HIV-positive patients allows timely intervention and prolongs life. The patient can take control of his or her life and make plans to enhance living while beginning therapy to control the infection. After disclosing the positive result, allow the patient time to react to the results. Answer any initial questions raised by the patient. Ask the patient to explain the meaning of the results to verify their understanding of a positive result. Briefly describe the biology of the disease, and stress the difference between HIV infection and AIDS. Keep the explanations short and simple- Assist them in deciding who else to share their results with and how best to inform them. Anangements can be made for conferences with parents and current sexual partners. Discuss the importance of informing the support person identified during pretest counseling. The risk of the patient revealing his or her HIV status indiscriminately to many persons should be emphasized. The confidentiality of the results should be reiterated. However, it is advisable to instruct the patient to inform health care professionals, such as dentists and physicians, of their positive result.
The basics of HIV transmission should be discussed along with the need for safe sexual practices. The actual methods of engaging in safer sex must be addressed in the context of the adolescent's understanding and ability. Remember that for safer sex to work, it must be satisfying. In order to work, the solutions for safer sex must be the adolescent's not the physician's. Discuss with your patient their current sexual practices. Define together which practices are safe and which entail risk.
A list of the relative risk of various sexual practices follows. Safe practices include dry kissing, massage, petting, mutual masturbation, and oral-genital sex with condom (male) or rubber dam (female) in place. Possibly safe is French kissing and getting semen on intact skin. Somewhat more risky behaviors include fellatio, although not to the point of ejaculation without barrier protection, and ejaculation in partner with condom in place (because of risk of breakage). Risky behaviors include getting semen, blood, or vaginal secretions in the mouth. Very risky behaviors include vaginal intercourse to ejaculation without a condom, and most risky is rectal intercourse to ejaculation without a condom and placing fingers into the anus (because of trauma/bleeding).
The HIV-positive person should avoid further exposure to HIV because repeated reinfection with HIV can accelerate the progress of the disease toward AIDS. The patient and physician can identify what acts to stop and what acts to continue. Substitutes for risky behaviors that are satisfying to the patient can be found with some ingenuity on the part of the patient. Be realistic about the risks of various behaviors, and discuss change over time. A patient may initially resist abandoning a favorite activity. Suggest a temporary moratorium on the behavior with further discussion later about how to permanently abandon a favorite behavior. Patients should refrain from donating blood, semen, or pledging their organs to a transfer program upon death. Emphasize that household and normal casual contact does not transmit the virus.
The last subject is keeping well. The benefits of healthy practices such as getting enough sleep and eating a balanced diet can be discussed. Persons who are HIV positive should avoid raw meats, raw eggs, and raw fish (sushi), which carry a risk of contamination with infectious agents. The physician should offer to assist the patient in stopping smoking and reducing excessive alcohol intake.
Counseling the HIV*Positive Patient
Whenever possible, HIV-infected youth should be connected to psychosocial support services to assist the physician in supplying support and risk reduction and encouraging compliance. A series of predictable negative emotional reactions follows the disclosure that a patient is HIV positive. If these feelings are discussed before they happen, the patient is forewarned and thus better able to cope with them. Feelings of shock, anger, guilt, decreased self-esteem, loss of identity, loss of security, loss of control, fear, and sadness will arise from time to time. Advance plans for coping can help the patients maintain control of their lives. The elements discussed above will need constant reinforcement during future visits. In some cases these subjects can be spread out over several visits, especially if the patient has difficulty understanding or dealing with factual information discussed during the initial appointment at which their HIV infection is revealed. The patient's risk of suicide needs to be reassessed.
INITIAL EVALUATION OF AN HIV-POSITIVE ADOLESCENT
A complete history and physical examination may be conducted over several sessions to allow an unhurried approach to the problem. The physician can assess the adolescent's coping while providing support during this crucial time. Much of the psychosocial history is discussed above. Additional medical history should inquire about previous serious illnesses including those that are associated with immune compromise such as herpes zoster, bacterial pneumonia and sinusitis, recurrent herpes simplex, persistent vaginal candidiasis, presence of cervical, vaginal, penile or perianal condyloma, and a history of abnormal Pap smears. A complete and detailed STD history, including a history of hepatitis, should be obtained. Particularly important is a history of syphilis and the adequacy of prior treatment. A complete menstrual and pregnancy history should be obtained from female patients. Previous places of residence may be important in the future when concerned about unusual infections (consider the relationship between the Southwest United States and coccidioidomycosis). Exposure to tuberculosis could lead to rapidly progressive illness, which in some cases may be complicated by multiple drug -resistant organisms. Special areas of concern to address during the review of systems are listed in Table 3. Human immunodeficiency related findings on physical examination are presented in Table 4.43 Initial laboratory tests for the newly diagnosed HIV-positive patient are listed in Table 5.43
Immunizations should be up-to-date. This includes a diphtheria tetanus immunization at age 1 5 and two lifetime measles-mumps-rubella vaccines. Additional immunizations recommended once an individual is diagnosed with HIV include pneumococcal vaccine and HemopfuÍMS influenzae^ vaccine plus yearly influenza immunization. Hepatitis B vaccine should be given unless the patient is immune or is hepatitis B surface antigen positive. Oral polio vaccine is contraindicated in the patient and in other members of his or her family, but inactivated polio vaccine may be given.
The CDC revised its classification system for diagnosis of AIDS in 1993 (Table 6).46 The recent changes reflect the importance of CD4 + T-lymphocyte counts in the categorization of HIVrelated clinical conditions. The new definition of AIDS includes all persons with CD4 + T-lymphocyte counts less than 200/mL or a CD4+ T-lymphocyte percentage of total lymphocytes less than 14. Three clinical conditions also were added to the previous 23 conditions that defined AIDS, including pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer.
Therapy of HIV and AIDS in children and adolescents is discussed elsewhere in this issue of Pediatric Annals and will not be covered in this article except to mention that, in general, patients at Tanner 1 puberty stage should be given pediatric doses, and those at Tanner 5 stage should be given adult doses. The doses for stages 2 through 4 are as yet undetermined.47
At some point in the course of their illness adolescents positive for HIV will require medical therapy that will need to continue for the rest of their lives. Although adolescents are often accused of being noncompliant, recent reviews on the subject suggest that age alone is not an adequate predictor of compliance.48'52 Physicians fare little better than chance in predicting compliance behavior in their patients. There have been no systematic studies of compliance with anti-retrovirals or Pneumocystis carinii pneumonia (PCP) prophylaxis in HIV-infected adolescents. Our experience and that reported in two recent abstracts53,54 is that over half of adolescent patients diagnosed with HIV have CD4 counts less than 500/mm3, thus qualifying for anti-retroviral therapy. One out of five have CD4 counts of less than 200 or CD4 percentiles of less than 20%, which puts them at risk for PCP and mandates PCP prophylaxis. Of those who agree to take anti-retroviral therapy, approximately one third are compliant. The acknowledgment that they are "sick" and need medication may impede compliance among adolescents. Many adolescents state that being told that they need to start zidovudine treatment had a similar psychological impact to being told that they were HIV positive. Taking the medication is a daily reminder that they are infected; and if they are asymptomatic and feeling well, they often see little value in taking a medication whose side effects may actually make them feel worse.
While the multitude of factors that influence compliance are beyond the scope of this article, suggestions to increase compliance are found in Table 7.
Human immunodeficiency vims has entered the adolescent population, and pediatricians will be caring for youngsters who are HIV positive or at risk of being infected. We should remember that it is risky sexual behavior and injection drug use that places a teen at risk for HlV infection, not their sexual orientation, ethnicity, or gender. Parents and their teenagers desire and expect their pediatricians to provide care and guidance for the diseases and problems that adolescents face. A screening psychosocial assessment of teenagers can identify those who need more in-depth counseling. Although the subjects of sex and drug use initially may be uncomfortable for a physician, practice using the HEADSS assessment will rapidly lead to comfort in discussing these important subjects. An understanding of HIV testing and pre- and post-test counseling will prepare the physician for the inevitable patient who wishes testing or who is HIV positive. Much of the treatment of HIV-positive adolescents involves patience and support while the adolescent grapples with the serious implications of being HIV positive. The initial history and physical exam establishes baselines regarding previous infections and illnesses that may bear on HIV infection, as well as determining which symptoms and signs of HIV infection are present. The initial laboratory tests further define the patient's current clinical state and will determine what therapies are immediately needed. Human immunodeficiency virus continues to evolve toward a manageable chronic illness that responds most favorably to early intervention.
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Adolescents With Whom to Discuss Human Immunodeficiency Virus Testing
Review of Body Systems*
Human Immunodeficiency Virus-Related Findings on Physical Examination
Specific Elements of Laboratory Assessment in Adolescents Infected With Human Immunodeficiency Virus
1993 Revised Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults