Adolescents and
Human Immunodeficiency Virus Infection: The Role
of the
Pediatrician in Prevention and Intervention
Committee
on Pediatric AIDS and Committee on Adolescence
http://pediatrics.aappublications.org/cgi/content/full/107/1/188
PEDIATRICS Vol. 107 No. 1
January 2001, pp. 188-190
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ABSTRACT |
Half of
all new human immunodeficiency virus (HIV) infections in the
United States occur among young people between the ages
of
13 and 24. Sexual
transmission accounts for most cases
of HIV
during adolescence. Pediatricians can play an important
role in educating
adolescents
about HIV prevention,
transmission, and testing, with an
emphasis on risk reduction, and in advocating for the
special needs of
adolescents
for access to information about HIV.
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INTRODUCTION AND BACKGROUND |
Age-appropriate education concerning sexuality, drug use, and
disease
prevention is an important aspect
of preadolescent
and
adolescent health care. The American Academy
of
Pediatrics has previously addressed important issues
of
adolescent
sexuality and sexually transmitted
diseases.1-3
Specific information regarding sex and sexually transmitted
diseases,
including human immunodeficiency virus (HIV) infection and
acquired immunodeficiency syndrome (AIDS), is an
essential component of
anticipatory guidance provided by pediatricians to their
adolescent
patients. Pediatricians play an important role together
with parents in discussing the importance
of postponing
sexual activity, safer sex, and sexually transmitted
diseases
with adolescents.
In addition, pediatricians can be advocates for
school health education on HIV prevention. Educating
adolescents
about sex does not increase sexual activity.4
Half of
all new HIV infections in the United States occur in young
people between the ages
of 13 and 24.5 Thus, pediatricians
and adolescents
should be concerned and
knowledgeable about HIV infection.
The risk of
exposure to HIV varies by prevalence
of HIV infection
in the community, sexual behaviors, and concurrent
substance use. Sexual
transmission accounts for most cases
of
HIV infection during adolescence. Females account for more than
one half of
all new cases in
adolescents, and three quarters
of
new infections in
adolescent females occur via heterosexual
transmission.
Among adolescent
males, at least two thirds
of HIV
transmissions
occur via male-to-male sex.6 African American
and Hispanic adolescents
are at a disproportionately high risk
of becoming
infected with HIV.
Although abstinence from sexual intercourse (including oral
sex) is the safest method
of avoiding
sexual exposure to HIV, it is impossible to predict
which adolescents
will remain abstinent. Therefore, education about
safer sexual practices, including latex condom use,
and other barrier methods should be provided so
adolescents
might opt to stop or alter their sexual behavior.
Alternatives to sexual intercourse, such as
masturbation and petting, should be discussed with
adolescents.
Adolescents
should be educated about the potential consequences
of
sexually transmitted
diseases, including deleterious
effects on ultimate reproductive capacity (eg,
infertility, ectopic pregnancy).
Addressing the consequences
of drug use is
an essential part of
adolescent
health care. Although injection drug use is not
common among adolescents,
any needle sharing, including that done in
administration of
anabolic steroids, carries a risk
of
transmission
of
HIV. In addition, the use
of noninjection
drugs, including alcohol, marijuana, and cocaine, is
associated with an increased risk
of contracting
HIV infection, because impaired judgment associated
with intoxication may increase the likelihood
of unsafe sexual
practices. Fear of
HIV infection may not be sufficient motivation for a
young person to forgo substance use, but pediatricians
nevertheless should include HIV on the list
of risks
inherent to such behavior.
Adolescents
at risk for HIV because
of treatment with blood or blood products should
understand that heat treatment
of factor
VIII concentrates and testing
of blood donors
for HIV antibody since April 1985 has greatly reduced
the risk of
HIV transmission
from transfusion
of blood and blood products.
Adolescents
should be educated about precautions to reduce the
risk of
transmission
of
HIV or other bloodborne pathogens from contact with blood or
open wounds (as in contact sports).7
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COUNSELING |
Counseling of
adolescents
should be directed at behaviors that place
adolescents at
risk. Adolescents
should be informed of
the risk of
continued potential exposure to HIV and other sexually
transmitted
diseases so that they might opt to stop or alter
their sexual behavior, use latex condoms, and engage
in safer sex. Adolescents
with a sexually transmitted
disease, in
particular ulcerative
diseases such as
herpes simplex or syphilis, should be informed about
the association between these conditions and
transmission
of
HIV. In addition to serving as a marker for unprotected sexual
intercourse, these conditions increase the likelihood
of HIV
transmission.
Discussion of
the dangers of
sharing needles and methods for sterilizing needles may be
appropriate for the
adolescent who continues injection
drug use despite efforts to interrupt this behavior.
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TESTING FOR HIV |
Because it is estimated that more than half
of all
HIV-infected adolescents
have not been tested and, thus, are unaware
of
their infection, discussion also should address availability and
importance of
testing for the presence
of HIV. Testing
is important for prevention
of HIV
transmission and
for referral of
HIV-infected
adolescents to care. A negative HIV test result
can allay anxiety resulting from a high-risk event or
high-risk behaviors and is a good opportunity to
counsel on, and to reduce future, high-risk behavior.
Pediatricians should remember that HIV seropositivity
may not appear for several months after infection (window
period), so retesting after 6 months is advisable in
the context of
recent or ongoing high-risk behaviors. The risk
reduction activities discussed previously should be
reinforced. For
adolescents with a positive HIV test
result, it is important to provide support, address
medical and psychosocial needs, and arrange referrals
to appropriate care. Awareness
of a positive
HIV test result helps facilitate reasoned planning
of
future behavior, which can affect not only the
welfare of
HIV-infected adolescents
but also that
of as-yet
uninfected partners or contacts. Results should be reported
in a straightforward way, and
adolescents
should be given time to react before the meaning
of the
test result is discussed.
Adolescents
may be linked with a specialist in
adolescents and
HIV disease
or an infectious
diseases specialist. Pediatricians should
recognize the stress
of being
informed of
the presence of
HIV infection and
offer support
and referral to appropriate counseling as needed. In
addition, pediatricians are encouraged to arrange for follow-up
and ensure that such
adolescents
enter appropriate care programs.
Advances in the treatment
of HIV infection
and AIDS include early use
of combination
regimens of
antiretroviral medications, which can relieve
HIV-related symptoms and prolong survival. An
important benefit of
knowledge
of HIV
seropositivity for
adolescent females who become
pregnant is the ability to reduce the risk
of
mother-to-child HIV
transmission by intervening with antiretroviral
therapy, including zidovudine. Zidovudine, started in the
second trimester and given through delivery and then
to the infant for 6 weeks, reduces the HIV vertical
transmission
rate by two thirds, from 25% to 8%.8
Combination regimens of
antiretroviral medications currently being studied
and in widespread clinical use, may reduce the risk
of HIV
vertical transmission
even further.
Adolescents
who are infected with HIV may exhibit reluctance or refusal to
inform sexual partners
of their serostatus. In such cases,
pediatricians should explore with their patients the
reasons for refusal, which may include fear
of rejection or
even potential violence. Pediatricians should
offer support
and counseling as needed, and if helpful, provide the
assistance of
public health experts in partner notification, who
will maintain the anonymity
of the
HIV-infected individual. Pediatricians also may be able
to offer
assistance in informing the sexual partner(s) through
role playing and/or providing a safe and supportive setting in
which to make the disclosure.
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CONSENT AND CONFIDENTIALITY |
Laws concerning consent and confidentiality for HIV care and
treatment vary from state to state, and pediatricians need to
be familiar with the laws
of the state in
which they practice. In general, individuals 18 years
or older may consent to their own medical care.
Similarly, individuals younger than 18 years who are
self-supporting, married, parents themselves, or members
of
the armed services may consent to their own health care without
the need for parental involvement. In addition, public
health statutes and legal precedents allow for
medical evaluation and treatment
of minors for
certain categorical illnesses, in particular sexually
transmitted diseases,
without parental
knowledge or consent. To date,
however, not every state has explicitly defined HIV infection
as a condition for which evaluation or treatment
of a minor may
proceed without parental consent.
Some adolescents
may not wish to involve a parent in decisions relative to
evaluation or treatment
of HIV infection. Such reluctance may
arise from a desire not to inform family members
about HIV status or a reluctance to reveal behaviors that placed
the adolescent
at risk for infection. Although it is usually best to
involve the family in the health care
of
adolescents,
this is not always the case. Deference to parental
wishes to be informed must not interfere with needed
evaluation or treatment
of
adolescents. For
adolescents who
are able to understand the implications
of
testing and treatment and are capable
of informed
consent, and in the absence
of local laws to
the contrary, it is best to proceed on the basis
of this
consent alone rather than insisting on parental
involvement. Similarly, an
adolescent's
consent should be obtained before release
of any
information concerning HIV status.
Generally, pediatricians should respect an
adolescent's
request for privacy. Nevertheless, questions about whether
pediatricians may disclose or receive information
about a patient's HIV status without the consent
of the
patient can arise in several contexts, including
disclosure by obstetricians to pediatricians, mandated
reporting to health departments, reporting to
institutional authorities and employers, the care
of
accused or convicted sex
offenders,
instances of
accidental needle sticks involving known HIV-infected
patients, and issues of
charting HIV status in the medical record. Although
each of
these contexts may at times involve an
adolescent
patient, they are not specific to young people.
Accordingly, disclosure
of the HIV
status of
an adolescent
should be held to the same legal and ethical
standards as disclosure
of the HIV status
of an
adult. A concern most relevant to the care
of HIV-infected
adolescents
is the limits of
confidentiality as they would apply to sexual
partners. A difficult question is whether to disclose
HIV status to the sexual partner(s)
of a patient
known to be HIV positive and who persistently refuses
to agree to such disclosure. There should be little
debate about the desirability
of using
all reasonable means to persuade an infected person to
inform his or her partner(s) on a voluntary basis.
Physicians who intend to disclose information about HIV
infection status to sexual partners should consider their duty
to inform
adolescent patients before testing that results
will be disclosed to partners and under what
circumstances. Partner notification (without
revealing the source of
exposure) is available in many areas through local
health departments. Maintaining confidentiality is
important. Disclosure of
HIV infection status is regulated by state laws.
Disclosure of
HIV infection status to school authorities without an
adolescent's
consent generally is not indicated.9 When desired by
an adolescent,
pediatricians can play an important role in
disclosure and education
of school
authorities.
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CONCLUSIONS AND RECOMMENDATIONS |
- Information about HIV infection and
AIDS and the availability
of HIV
testing should be regarded as an essential component
of
the anticipatory guidance provided by pediatricians to all
adolescent
patients. This guidance should include information
about HIV prevention and
transmission
and implications of
infection.
- Prevention guidance should include
helping adolescents
understand the responsibilities
of becoming
sexually active. Information should be provided
on abstinence from sexual activity and use
of
safer sexual practices to reduce the risk
of unplanned
pregnancy and sexually transmitted
diseases,
including HIV. All
adolescents should be counseled
about the correct and consistent use
of latex
condoms to reduce risk
of
infection.
- Availability
of HIV
testing should be discussed with all
adolescents
and should be encouraged with consent for those who are
sexually active or substance users.
- Although parental involvement in
adolescent
health care is a desirable goal, consent
of an
adolescent
alone should be sufficient to provide evaluation
and treatment for suspected or confirmed HIV
infection.
- A negative HIV test result can allay
anxiety resulting from a high-risk event or high-risk
behaviors and is a good opportunity to counsel on
reducing high-risk behaviors to reduce future risk.
- For
adolescents
with a positive HIV test result, it is important to provide
support, address medical and psychosocial needs,
and arrange linkages to appropriate care.
- Pediatricians should help
adolescents
with HIV infection to understand the importance
of informing
their sexual partners
of
their potential exposure to HIV. Pediatricians can
provide this help directly or via referral to a
state or local health department's partner
referral program.
- Pediatricians should advocate for the
special needs of
adolescents
for information about HIV, access to HIV testing and
counseling, and HIV treatment.
Committee on Pediatric AIDS, 2000-2001
Mark W. Kline, MD, Chairperson
Robert J. Boyle, MD
Donna Futterman, MD
Peter L. Havens, MD
Susan King, MD
Lynne M. Mofenson,
MD
Gwendolyn B. Scott, MD
Diane W. Wara, MD
Patricia N. Whitley-Williams, MD
Liaison
Mary Lou Lindegren, MD
Centers for Disease
Control and Prevention
Staff
Eileen Casey, MS
Committee on Adolescence, 2000-2001
David W. Kaplan, MD, MPH, Chairperson
Ronald A. Feinstein, MD
Martin M. Fisher, MD
Jonathan D. Klein, MD, MPH
Luis F. Olmedo, MD
Ellen S. Rome, MD, MPH
W. Samuel Yancy, MD
Liaisons
Paula J. Adams Hillard, MD
American College of
Obstetricians and Gynecologists
Glen Pearson, MD
American Academy of
Child and Adolescent
Psychiatry
Diane Sacks, MD
Canadian Paediatric Society
Section Liaison
Barbara L. Frankowski, MD, MPH
Section on School Health
Staff
Tammy Piazza Hurley
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FOOTNOTES |
The recommendations in this statement do not indicate an
exclusive course of
treatment or serve as a standard
of medical care.
Variations, taking into account individual circumstances,
may be appropriate.
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ABBREVIATIONS |
HIV, human immunodeficiency virus; AIDS, acquired
immunodeficiency syndrome.
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REFERENCES |
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School-based programs to reduce sexual risk behaviors: a
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