Pediatric Annals

Healthy Baby/Healthy Child 

Preventing HIV Infection—What Pediatricians Should Know About HIV Pre-Exposure Prophylaxis

Sabrina Fernandez, MD

Abstract

I recently diagnosed my first adolescent patient with new-onset HIV. As a primary care pediatrician, these cases are rare. I cried with the shock of the initial diagnosis, just as the patient did when I told him. One of my first thoughts was how could I have served him better. He had been inconsistent with condom use, and had several partners. I had encouraged safe sex practices, told him to talk to his partners about pregnancy prevention, and screened for sexually transmitted disease nearly every time he came into my office. However, there was one more thing I could have done that may have spared him this diagnosis in the first place. I could have prescribed HIV Pre-Exposure Prophylaxis (PrEP). This article is meant to introduce primary care pediatricians to the idea of HIV PrEP. The article reviews patient eligibility, how to prescribe HIV PrEP, as well as drug monitoring and follow-up. [Pediatr Ann. 2018;47(1):e2–e4.]

Abstract

I recently diagnosed my first adolescent patient with new-onset HIV. As a primary care pediatrician, these cases are rare. I cried with the shock of the initial diagnosis, just as the patient did when I told him. One of my first thoughts was how could I have served him better. He had been inconsistent with condom use, and had several partners. I had encouraged safe sex practices, told him to talk to his partners about pregnancy prevention, and screened for sexually transmitted disease nearly every time he came into my office. However, there was one more thing I could have done that may have spared him this diagnosis in the first place. I could have prescribed HIV Pre-Exposure Prophylaxis (PrEP). This article is meant to introduce primary care pediatricians to the idea of HIV PrEP. The article reviews patient eligibility, how to prescribe HIV PrEP, as well as drug monitoring and follow-up. [Pediatr Ann. 2018;47(1):e2–e4.]

HIV infection is an incurable, chronic disease that, if left untreated, can lead to AIDS and potentially death. Since the discovery in the 1980s that HIV causes AIDS,1 research in the field has come a long way. Screening tests are faster and cheaper, new medications have fewer side effects, and patients are living longer. There is even research about an HIV vaccine that could prevent the infection and disease altogether.2 Despite these advancements, many young adult patients are still acquiring HIV, because infection can be asymptomatic for years. The American Academy of Pediatrics recommends screening all adolescents between ages 16 and 18 years, regardless of whether they report being sexually active.3

Presently, there is no cure, and a diagnosis of HIV can be devastating. In 2015, there were approximately 39,500 cases of new onset HIV in the United States.4 Young people age 13 to 24 years accounted for about 8,800 of these cases (22%).4 HIV in people age 13 to 24 years disproportionally affects African-American patients and men who have sex with men (MSM).5 HIV Pre-Exposure Prophylaxis (PrEP) is a safe and effective way of preventing HIV infection. This article seeks to introduce the idea of HIV PrEP for primary care providers, including how to identify at-risk youth, how to prescribe HIV PrEP, and how to monitor patients who are taking it.

Eligible Patients

The Centers for Disease Control and Prevention (CDC) recommends that HIV PrEP be prescribed for any patient who is at substantial risk for HIV infection, including transmission via sexual intercourse or injection drug use. Patients who are at risk of acquiring HIV through sexual transmission include heterosexual men and women who do not use condoms consistently, and people whose partners are at high risk for acquiring HIV (ie, people who inject drugs or who have bisexual male partners).6 This also includes gay and bisexual men who have had anal sex without a condom, have been diagnosed with a recent bacterial sexually transmitted infection (STI) in the last 6 months, and anyone who has an ongoing sexual relationship with someone who is HIV positive.6

Patients at risk for acquiring HIV through injection drug use include those who are currently injecting drugs and who are sharing injecting equipment or have been in a drug treatment program in the last 6 months.6

All patients must also fulfill certain criteria, including a negative HIV test prior to starting HIV PrEP, no signs/symptoms of active HIV infection, no contraindicated medications, normal renal function, documented hepatitis B vaccination status, and no laboratory evidence of hepatitis B infection.6 Lastly, medication adherence is extremely important; therefore, patients must make a reasonable commitment to take HIV PrEP daily, as well as follow up with their physician for routine visits and blood tests every 3 months.6

HIV Pre-Exposure Prophylaxis in Adolescents

It is worth saying that many studies on safety and efficacy of HIV PrEP have been done in adult populations.7 The CDC HIV PrEP 2014 guidelines state that there is insufficient evidence for the safety and efficacy of HIV PrEP in adolescents.7 Additionally, when considering prescribing HIV PrEP, one must consider the minor consent laws in the state as well as the likelihood of medication adherence. No state explicitly prohibits the use of HIV PrEP in minors; however, jurisdictions differ on the language of the law. Some states allow consent for preventive or prophylactic services, whereas others specify consent for STI testing and treatment but do not have specific provisions for HIV.8 Therefore, minors' access to HIV PrEP without parental consent is currently unclear.

In my general pediatrics practice, I see patients until age 21 years, and would feel comfortable prescribing HIV PrEP to certain minors and young adults who meet the criteria above and who I believe would be compliant with medications. In general, involvement of the parent or guardian is recommended, although in some cases this may pose a safety risk to the minor and each case must be considered individually. One recent study assessed HIV PrEP medication adherence in healthy MSM, age 15 to 17 years, who were at risk for HIV infection. The study found that approximately one-half of the participants had laboratory evidence of adequate drug levels to protect against acquiring HIV infection. Additionally, medication adherence decreased with subsequent visits every 3 months.9 This study suggests that minors who take HIV PrEP may need more frequent contact with their prescribing physician to maintain adherence.9

Prescribing HIV Pre-Exposure Prophylaxis and Follow-Up Care

The HIV PrEP medication is a pill taken every day, and it is the only medication approved by the US Food and Drug Administration for HIV PrEP. The medication contains 300 mg of tenofovir and 200 mg of emtricitabine. When used daily, the medication reduces the risk of HIV infection in people who are at high risk by approximately 92%.10 HIV PrEP is much more effective when taken consistently every day.10

Patients must be monitored every 3 months while taking HIV PrEP. For minors taking HIV PrEP, more frequent contact may be advisable to ensure compliance. The primary physician should assess medication adherence, side effects, and conduct various blood tests. An HIV test must also be done every 3 months. This is to ensure that the patient did not incidentally acquire HIV while taking HIV PrEP; it is an insufficient medication to treat HIV infection, and its ongoing use in patients with HIV could breed resistance.7 Additionally, patients should be screened for other STIs every 6 months, and female patients should have a pregnancy test every 3 months. Lastly, patients should be referred to drug treatment programs if needed and counseled regularly about risk reduction and safe sex practices.7

Renal function must also be assessed to ensure that patients are not developing renal disease while taking HIV PrEP. A recent study of MSM age 15 to 22 years supported short-term renal safety of HIV PrEP but did document a decline in bone mineral density related to endocrine disruption.11 It seems that more studies are needed to determine the effect of HIV PrEP on growing bones.

Conclusion

In adults with substantial risk for HIV infection, the use of HIV PrEP is becoming more common, and significantly reducing the risk for acquiring HIV. Because HIV is an incurable, chronic disease that can lead to AIDS and death, preventive efforts are profoundly important for patients at risk. Given that more than one-fifth of new onset HIV cases occur in adolescents, pediatricians should be aware of HIV PrEP and the implications for minors and young adults. Each adolescent case must be considered individually, with careful thought regarding the patient's likelihood of adhering to his or her medication regimen, the involvement of a parent or guardian, and the minor consent laws in the state. See Table 1 for a few take-home points.

Take-Home Points

Table 1:

Take-Home Points

References

  1. Office of NIH History. Discovery of HIV. https://history.nih.gov/nihinownwords/docs/page_04.html. Accessed December 14, 2017.
  2. U.S. Department of Health and Human Services. What is a preventive HIV vaccine? https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/19/96/what-is-a-preventive-hiv-vaccine-. Accessed December 14, 2017.
  3. Emmanuel PJ, Martinez JCommittee on Pediatric AIDS. Adolescents and HIV infection: the pediatrician's role in promoting routing testing. Pediatrics. 2011;(129)5:1023–1029. doi:10.1542/peds.2011-1761 [CrossRef].
  4. Centers for Disease Control and Prevention. HIV surveillance report. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed December 14, 2017.
  5. Centers for Disease Control and Prevention. HIV surveillance report—adolescents and young adults. https://www.cdc.gov/hiv/pdf/statistics_surveillance_Adolescents.pdf. Accessed December 14, 2017.
  6. Centers for Disease Control and Prevention. Pre-exposure prophylaxis (PrEP) for HIV prevention. https://www.cdc.gov/hiv/pdf/PrEP_fact_sheet_final.pdf. Accessed December 14, 2017.
  7. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States – 2014. A clinical practice guideline. https://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf. Accessed December 14, 2017.
  8. Culp L, Caucci L. State adolescent consent laws and implications for HIV pre-exposure prophylaxis. Am J Prev Med. 2013;44(suppl 2):S119–S124. doi:. doi:10.1016/j.amepre.2012.09.044 [CrossRef]
  9. Hosek SG, Landovitz RJ, Kapogiannis B, et al. Safety and feasibility of antiretroviral preexposure prophylaxis for adolescent men who have sex with men aged 15 to 17 years in the United States. JAMA Pediatr. 2017;171(11):1063–1071. doi:. doi:10.1001/jamapediatrics.2017.2007 [CrossRef]
  10. Centers for Disease Control and Prevention. Pre-exposure prophylaxis (PrEP). https://www.cdc.gov/hiv/risk/prep/index.html. Accessed December 14, 2017.
  11. Havens PL, Stephensen CB, Van Loan MD. Decline in bone mass with Tenofovir disoprixil fumerate/emtricitabine is associated with hormonal changes in the absence of renal impairment when used by HIV-uninfected adolescent boys and young men for HIV preexposure prophylaxis. Clin Infect Dis. 2016;64(3):317–325. doi:. doi:10.1093/cid/ciw765 [CrossRef]

Take-Home Points

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The American Academy of Pediatrics recommends HIV screening for all patients age 16 to 18 years, regardless of whether the patient reports being sexually active3

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People age 13 to 24 years account for approximately 22% of new HIV cases in the United States,4 with a disproportionate number being African American and/or MSM5

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Patients at high risk for acquiring HIV may include heterosexual men and women as well as MSM and patients who use intravenous drugs6

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Patients must have baseline laboratory tests, including a negative HIV test, prior to starting HIV PrEP.6

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Patients must be monitored every 3 months with an office visit and blood tests 6

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Adolescent patients may need more frequent contact with their prescribing physician9

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HIV PrEP has been shown to be effective in reducing the risk for HIV infection by up to 92%. Efficacy is correlated with consistent daily use10

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If HIV PrEP is prescribed, it should be used in conjunction with counseling on safer sex practices and referral to drug treatment programs if needed

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Pediatricians should weigh risk and benefits in adolescents and young adult patients, with careful consideration of the risk for HIV disease, the likelihood of medication adherence, the potential medication side effects, including renal toxicity and lower bone mineral density, the involvement of the parent or guardian, and the minor consent laws in the state

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Authors
Sabrina Fernandez, MD

Sabrina Fernandez, MD, is a Primary Care Pediatrician, University of California San Francisco, Benioff Children's Hospital; and an Assistant Professor of Pediatrics, Department of Pediatrics, University of California San Francisco.

Address correspondence to Sabrina Fernandez, MD, via email: sabrina.fernandez@ucsf.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20171214-03

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