Recently, I saw an adolescent female patient with shingles. Within the past year, she had also been evaluated for a persistent fever of unknown origin.
Her infectious disease and immunology workup was normal, but it got me thinking about the prevalence of HIV in young people, and what can be done in the primary care setting to effectively identify those at higher risk.
In fact, I wondered whether routine screening should be considered for all adolescents, and if any other type of in-office intervention would be preventative.
Since the HIV epidemic began in 1981, 37,599 cases of AIDS have been reported in 15-24 year olds in the United States. In fact, the CDC reported 35,606 cases of HIV infection diagnosed in 2014, with 7723 of those cases occurring in 15-24 year olds.
During annual exams of my adolescent patients, I regularly ask about high-risk behaviors and other conditions that increase the risk for HIV infection. It is estimated that between 60% and 75% of adolescents with HIV are not aware of their infection, since it can take up to 10 years to develop into AIDS, and spread it unknowingly. Females of reproductive age who don’t know they’re infected can pass the virus perinatally to their children.
In spite of that reality, it is estimated that only 13% of teenagers get tested each year, and even as low as less than 2%. The CDC recommends that everyone between the ages of 13 and 64 years be tested at least once, and that those at high risk be tested annually. High-risk individuals include people who are sexually active with multiple partners (more than 10% of adolescents report having had intercourse with 4 or more partners, and only slightly more than half of them used a condom}, active gay and bisexual males and people with diagnosed STDs other than HIV. The American Academy of Pediatrics adds to this list people with substance-use disorders.
Other risk factors that may warrant testing include the presence of psychiatric conditions, such as conduct disorder and depression. Marijuana use is common in adolescents — often associated with engagement in unprotected sexual intercourse — which reduces immunity and allows accelerated progression of HIV to AIDS. Methamphetamine is not commonly used among teens (about 5% reported), but meth use also leads to disinhibition and unprotected sexual intercourse — as well as reducing the efficacy of antiretroviral therapies, also accelerating the disease progression.
In the primary-care setting, besides identifying high-risk behaviors by assessing sexual activity, sexual orientation and substance use (the CRAFFT Screening Test is helpful for this), physicians should be alert to the presence of other psychiatric risk factors, such as depression (the PHQ-9 modified for Adolescents is helpful), conduct disorder or incarceration. Screening should be offered regularly to all at-risk adolescents. In those who are identified as at-risk and offered screening, it is also essential to offer appropriate referral to treatment for substance use and mental health issues.
Substance-use treatment plus HIV education and behavioral skills training for risk reduction — usually 12-16 initial sessions — has been shown to be effective. One study, by Thurstone et al., used the Teen Health Survey (THS), which measures teen attitudes, beliefs and behaviors related to HIV/AIDS, to evaluate one session of a 16-session substance-use treatment program. Results indicated that the single session appeared to improve knowledge regarding HIV/AIDS as well as attitudes and intentions regarding condom use. It may prove helpful to use this kind of one-time intervention in practices such as my own, which serves as a medical home. It is possible that nurse care managers or in-office mental-health providers could develop a protocol for administering such an intervention to patients identified as at-risk during routine health visits.
I did hear a wonderful news report recently — there were no HIV-positive newborns born in New York City during 2016! That is excellent progress in prevention. We must strive to continue it!