Adolescents who live in areas with high HIV prevalence rates should be
routinely screened by age 18 years, according to a new policy statement from
the American Academy of Pediatrics.
The statement recommends specifically that routine screening be offered
to all adolescents at least once by the time they are aged 16 to 18 years, when
the prevalence of HIV in the patient population is more than 0.1%.
In areas of lower community HIV prevalence, routine HIV testing is
encouraged for all sexually active adolescents and those with other risk
factors for HIV, according to the statement.
The CDC recommends universal and routine
HIV testing for all patients aged 13 to 64 years.
Other conclusions and recommendations offered by the AAPs
Committee on Pediatric AIDS include that high-risk youth should be tested
annually for HIV, and adolescents tested for other sexually transmitted
infections should be tested for HIV during the same visit. The authors of the
statement also said EDs and urgent care facilities in high prevalence areas
should implement routine HIV testing to provide an excellent opportunity
to reach youth who do not seek primary care services often.
Physicians should be aware of symptoms of the acute retroviral syndrome
(mononucleosis-like syndromes), and HIV RNA testing should be considered in the
diagnostic workup when the appropriate risk factors are present.
As an essential part of routine adolescent care, pediatricians should
assess sexual and substance use behaviors, and creating an environment of
tolerance is also important, especially when facilitating discussions about
gender and sexual orientation.
Preventive care screening, according to the AAP, should include
universal coverage and adequate payment for
HIV testing and related counseling. To maintain
confidentiality, physicians should advocate for confidential billing practices
related to HIV and STI testing in adolescent and young adults.
The authors of the AAP statement indicate that opt-out HIV testing is
preferred if allowed by state laws; rapid HIV testing has similar sensitivity
to enzyme-linked immunoassay and can provide immediate notification of
preliminary results. However, physicians must follow the guidelines of their
local jurisdictions for routine HIV opt-out testing in adolescents. The AAP
encouraged pediatricians to advocate for change when such jurisdictions
create barriers for implementation of opt-out testing.
Regarding HIV education and testing, the committee said pediatricians
are encouraged to advocate for the dissemination of accurate, evidence-based
prevention education, access to confidential HIV and STI testing and
counseling, and HIV treatment. For adolescents with a negative HIV test result,
pediatricians are advised to use that opportunity to counsel adolescents on
sexual and drug-use behaviors to reduce future risk. Adolescents who have a
positive HIV test result must be provided with age-appropriate HIV specialty
care, including prenatal care when appropriate.
It is encouraging that the CDC is exerting a proactive stance regarding
recommending HIV testing for adolescents, and the nationwide legalization of an
opt-out mode of testing. Adolescents are at increased risk for sexually
transmitted infections and HIV for many reasons. Many feel that they are
invulnerable, and yet it is a frequent time of sexual exploration (65% report
being sexually active), and most do not seek routine medical care. The
availability of rapid, non-invasive, sensitive and specific diagnostic testing
that is well accepted by youth increases its utility and should increase ease
of implementation of the recommendations. Hopefully, pediatricians will heed
the recommendations of the CDC to protect this young, vulnerable population.
Standardized assessment tools and a confidentiality protocol can assist
pediatricians in discussing sexual risk behaviors with adolescents in their
practice, which should be performed, regardless of perceived risk.
Toni Darville, MD
Infectious Diseases in
Children Editorial Board member
Disclosure: Dr. Darville reports no relevant financial