Adolescents with HIV:
Engagement and Treatment
Challenges
Jaime Martinez, MD
Division Of Adolescent and
Young Adult Medicine
Stroger Hospital/ CORE Center
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
Epidemiology: Slide #2
2003 -2006,
Increase in estimated number of HIV/AIDS cases (13-24 yo)
~14% of all new HIV/AIDS diagnoses are under 25 yo,
primarily through sexual activity.
•Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2007; 19: 1-63.
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Centers for Disease Control and Prevention. (2008). Trends in HIV/AIDS
diagnoses among men who have sex with men – 33 states, 2001-2006. MMWR Weekly, 57(25):681-686.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a2.htm.
Transmission categories 20-24 yo 13-19 yo
(2004-2007):
Males: Male to Male Sexual Contact 87% 83%
Females: Heterosexual Contact 88% 87
Centers for Disease Control and Prevention. HIV/AIDS surveillance in adolescents and young adults (through 2007).
ttp://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/.
Youth from Communities of Color (AA 66%, L21%) comprise
over 85% of all cases of AIDS
National Center for HIV, STD and TB Prevention Divisions of HIV/AIDS Prevention. HIV/AIDS among Youth May 2005.
http://www.cdc.gov/hiv/pubs/facts/youth.htm
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
Slide #3
15%
increase
per year
Largest
Proportion
al increase
is in the
13-24 yos
MSM(15-22yo): Seven Urban Areas; (N= 3492 )
HIV+ Sero Prevalence: 14.3% TG;14% AA ; 7% L; 3% W.
Among HIV+: 82% unaware of infection; 61% hx sex with
(CDC.MMWR. 2001)
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
THE IMPORTANCE OF BEING AWARE OF HIV: Slide #4
RISKS OF AWARE V. UNAWARE
HIV POSITIVE AWARE HIV POSITIVE UNAWARE
More likely to practice safer sex Less likely to practice safer sex
•Lower cases of sexually transmitted infections
(73% lower)
•Lower self report of unprotected anal and or
vaginal intercourse (53% lower)
Less likely to transmit the virus More likely to transmit the virus;
Transmission rate of new infections was 3.5 X
higher in unaware.
More likely to be younger
(48% youth unaware v. 21% adults)
Marks G. JAIDS. 2005; Mansergh G. AIDS. 1998; Crepaz N, AIDS Educ Prev. 2000
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
BEHAVIORAL RISKS: Sexual Activity & Sexual Behaviors #5
Slide
Youth in Youth in Homeless
School (%) Alternative Youth (%)**
School (%)*
Ever had sex 47.8 87.8 92.3
(64.6% by
12th grade)
Early Coitarche 7.1 22
(sex 4)
Substance use at 22.5 40.1
last sex
Condom Use at 61.5 45.9
last sex
Tested for HIV 12.9 (M=11.1;
F=14.8)
CDC. MMWR. 2008
*National Alternative High School Youth Risk Behavior Survey, 1998;
**http://www.nationalhomeless.org/factsheets/education.html
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
BIOLOGIC Slide #6
© 2004. A.D.A.M., Inc.
RISKs
Immature Cervix
Ectropion;
Columnar Vulva
Epithelium
Mature Cervix
Squamous Epithelium
Freidman SB. Comprehensive Adoelscent Health Care.
Quality Medical Publishing, Inc. 1992.
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
Slide #7
Biologic Risk: Brain Development
• Brain volume remains constant after mid adolescence
• Brain gray matter decreases:
Reduction in gray matter & increase white matter to age
20.
• White matter changes: increase myelination, improves
impulse conduction time, speeding up transmission of
signals to and from destination sites in the brain
• Changes result in improved frontal lobe behaviors):
response inhibition, emotional regulation, planning,
organization, and moral reasoning.
Early Adolescence Middle Adolescence Late Adolescence
Period of heighten: Period of heighten Period of maturation of
emotional arousability, invulnerability: frontal lobes facilitates
sensation-seeking, risk-taking, regulatory competence
reward orientation problems in regulation
of affect and behavior
Giedd JN.. J. Adol Health. 2008; ; O’Donnel .Neuroimage. 2005 ;
Cassey B. Trends in Cognitive Sciences. 2005 .
From J Martinez, MD,MD,12th 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
From J Martinez, at at Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
Slide #8
Forgoing or postponing care:
Newly Diagnosed HIV + individuals:
•17 - 29% fail to receive care within 6 mos of diagnosis
(Turner BJ, Cunningham WE, Duan N, Andersen RM, Shapiro MF, Bozzette SA et al. Delayed medical care after diagnosis in a US national
probability sample of persons infected with human immunodeficiency virus. Archives of Internal Medicine. 2000;160, 2614-2622.)
Youth in particular, delay or forgo care due to
multiple reasons including:
•Sense of invulnerability
•Stigma & disclosure
•Rejection or disbelief of their HIV+ tests,
•Mental health issues and substance abuse,
•Health care system: Access ; “Youth insensitive” staff
Grant AM Pediatrics, 2006.
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA. Martinez J. J Natl Med Assoc. 2000
I just found out I am HIV+…. Slide #9
DO YOU KNOW WHAT I AM GOING THROUGH?
ATN 055: Results :
(N=30; AA=50%; Latinos=43%; W=6%; F=47%, M=53%)
Critical period -the first year after receiving an HIV diagnosis is
very challenging for youth .
HIV + Adolescents confronted with a myriad of stressors:
1. Developmental issues ; HIV stigma; life-threatening illness
2. Struggle with learning to accept the diagnosis.
(Testing >3-5 times)
3. Acceptance was tumultuous -intense feelings of
depression, isolation, and at times, suicidal ideation.
4. Issues with disclosure (conflicted about when and who)
Hosek SG. Journal of HIV/AIDS Prevention in Children and Youth. 2008.
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
PRIMARY CARE NEEDS OF YOUTH: Slide #10
(Importance of Case Managers)
ISSUE: BARRIERS AND UNMET NEEDS:
What youth say they need!!!!!!
YOUTH AT TIME OF INITIAL PRESENTATION TO CARE.
N= 107 (AA=73.8%; L=14%;W=4.7%; O=7.4%) (5 SPNS
YOUTH SITES)
•PERCEIVED BARRIERS TO HEALTH CARE 10%
•PERCEIVED NEEDS FOR MENTAL HEALTH 45%
•PERCEIVED NEED FOR ALCOHOL AND DRUG 14%
TREATMENT
•PERCEIVED NEED FOR TRANSPORTATION 40%
•PERCEIVED NEED FOR HOUSING 47%
•PERCEIVED HOUSING AS UNSTABLE 38%
Martinez J. J.Adol Health 2003 .
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
MENTAL HEALTH ISSUES OF HIV + YOUTH Slide #11
Martinez J. AIDS Patient Care and STDs. 2009.
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
HIV Resistance in ARV-Naïve Slide #12
Adolescents
• Study of resistance: pts age 12-24 from 15 US cities
(n=55)
• HIV-infected with 180 days using “detuned” assay
• Major mutations: IAS-USA Drug Resistance Group
Genotype Phenotype
Overall 18% 22%
NRTI 4% 4%
NNRTI 15% 18%
PI 3.6% 5.5%
Viani RM. J. Infect Dis. 2006.
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
HIV+ Youth Medical Issues to consider in TX: Slide #13
• Adherence Issues with ARVs
• Irregular Menses (amenorrhea; skipped periods; heavy
bleeding; short and frequent periods)
• Abnormal PAP Smears (HPV + CD4 counts)
• Unprotected Sex and Continued risk for:
– *STDs/STIs (13-17%)
– *subspecies of HIV
• Contraception:
– Barrier Methods, Issue of IUD, Hormonal Methods
• Caution: A.R.T. (NNRTIs & PIs) induces cyto P450
System:- may cause conc of steroid hormones
• Pregnancy (7-14%/yr)
• Death from refusal to take meds (1-2 youth per year)
Cejtin HE. Obstet & Gynecol Clin N Am. 2003;.
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.
Slide #14
Conclusions:
• Youth are biologically and developmentally different from
adultscontribute to the acquisition of HIV infection.
• Youth specific services are important for provision of care
and retention in care.
– (Adult programs are not transportable to youth.)
• Addressing psychological, social, and medical issues is
defined as primary care for HIV+ youth.
• A trusting relationship between the youth and medical
provider is also important in retaining the youth in care and
on treatment despite overwhelming social and
psychological issues.
• Youth may already harbor HIV resistant strains
From J Martinez, MD, at 12th Annual Ryan White HIV/AIDS Program Clinical Conference, IAS–USA.