HIV Prevention and Management Among Adolescents
In this podcast, Samantha Hill, MD, MPH, FAAP, discusses considerations and challenges for health care practitioners in the prevention and management for HIV in adolescent patient populations, including sexual health education among teens, addressing all of a patient's needs, strategies to increase medication adherence, and more. Dr Hill presented on this topic during her session "IYKYK: HIV care for adolescents" at IDWeek 2023 in Boston, MA.
Additional resource:
- Rana A, Agwu A, Hill S, Fields E. IYKYK: HIV care for adolescents. Talk presented at: IDWeek 2023; October 11-15, 2023; Boston, MA. Accessed November 3, 2023. https://idweek.org/
For more IDWeek 2023 content, visit the Resource Center.
Samantha Hill, MD, MPH, FAAP, is an assistant professor in the Department of Pediatrics in the Section on Adolescent Medicine at Emory University in Atlanta, GA.
TRANSCRIPT:
Leigh Precopio: Hello everyone and welcome to another installment of Podcasts360, your go-to resource for medical education and clinical updates. I'm your moderator, Leigh Precopio, with Consultant360, a multidisciplinary medical information network.
Providing HIV care is complex and multifaceted in and of itself; providing HIV care to adolescent populations comes with additional unique considerations.
As adolescents and young adults make up approximately 20% of all new cases of HIV within the United States, understanding the challenges in prevention and approaches to treatment in this patient population is key to providing successful HIV care.
Samantha Hill, MD, MPH, FAAP, recently discussed HIV care for adolescent patients in her recent session at IDWeek 2023. Dr Hill is a physician-researcher and Assistant Professor in the Division of General Pediatrics and Adolescent Medicine at Emory School of Medicine. Dr Hill joins us today to further discuss specific considerations for HIV among adolescents.
Thank you for taking the time to speak with me today. To begin, could you please give an overview of your session?
Samantha Hill, MD, MPH, FAAP: So for ID week 2023 in the session on HIV and adolescence, our goal, myself and my two colleagues' goal, was to really provide a spectrum of what it is to take care of young people, whether they're living with HIV or they are someone who may have the potential to acquire HIV through certain behaviors. And we really wanted to shed some light on some of the nuances because adolescents do appear to be similar to adults on both the treatment and the prevention side, but there are some small differences that if you're aware of can make a big difference in outcomes and management plans.
LP: Can you discuss some of the challenges associated with testing adolescents for HIV?
SH: Of course. So challenges associated with testing adolescents for HIV, there are a lot. Probably the first and foremost actually boils down to the fact that there's really not equal access to education about sexual health in general in this country. Likely in other places of the world as well, but in this country. And so without that actual information about comprehensive, medically accurate sexual health education, the biggest challenge is do teens realize the importance of HIV testing? Do they know what it is and do they understand why they should get it? In that, what I'm not saying is there are still teens that may be engaging in sexual behaviors that don't actually think they're engaging in sex because they've been informed, educated, or amongst their peers, maybe even discussed what sex is and what it isn't. And because they don't have the actual medically accurate comprehensive sex education access, they've gotten it wrong. And so that's one barrier.
The next barrier is really do teens know where to go to get these tests? And in that, the flip side is do providers recognize that a lot of the touch points we see, so whether we're their medical provider, maybe we even are seeing them for something else; maybe we're a sub-specialist that's not doing primary care and not doing STI care; maybe we're the endocrinologist, the GI doc, the GI provider. Do we know that we should be mentioning it to them? If they've already disclosed that maybe they're sexually active, we should be mentioning to them they should get an HIV test? So that's the other part. Do we know and do our due diligence, to make sure that they're getting tested or recommend that they get tested or mentioned that they get tested.
I think another challenge is really for those teens that do get STI tested in general, they make, and it's an appropriate assumption to make, that when you're testing them for STIs, that includes HIV. And so oftentimes as providers and people in health care settings, we forget to mention, "so we just collected a lot of blood or urine or whatever kind of samples, these samples test for X, Y, or Z." So making sure that we state what they test for. We don't have to go into all the nitty gritty details, but we tested you today for gonorrhea, chlamydia, and HIV. Gonorrhea, chlamydia, and syphilis trichomonas. We forget to do that. And so it's not uncommon for teens to be like, "yeah, I was STI tested 6 months ago." And if you have access, if you're lucky enough to have access to their records, you're like, "oh but they didn't get an HIV test," But the teen isn't likely to do that. That's because there was a disconnect between what the teen thought they were doing and what we as the person in health care mentioned that we were doing.
Finally, I think payment for HIV testing is challenging. So there are definitely community events and community organizations that offer free HIV testing. And if you know about those and are okay with going to those because there's stigma oftentimes associated with them, then that works. But if you don't know about those, then you likely are dependent on a HIV testing system that needs your insurance. And what happens if you're uninsured? And so those are some brief, I guess challenges. There are a lot of challenges, but those are the first ones that come to my mind.
LP: What are some common pitfalls when it comes to diagnosing and managing HIV in adolescents that may not be present in other patient populations with HIV?
SH: The two things I think, there are a lot of things, but the two things that I really think are important to mention for pediatric populations, one is again, we have been trained to think about HIV in terms of risk and we forget that "having sex" is risk. So whether you have sex with the same partner every day or not every day, whether that's your partner for a certain period of time or not, there's a potential for HIV there. And I say that because most teens are not asking the hard questions. They're not asking, "Hey partner, when was the last time you were STI tested? Hey partner, are we the only people that are together? Hey partner, can we go get tested together? Hey partner..." Some teens are good at condom negotiation, other teens are not. But most teens aren't necessarily doing those things. And so they may be doing everything as the teen. They have one partner, they get tested regularly, all these fun things, but if they're not asking those questions about their partner, they have no idea what their partner's doing. So that's one area.
I think the other area, and we brought this up in one of the cases we talked about in the session is, there's perinatal HIV and there's still so much stigma whether it's on the mom's end or maybe we're in a health care system or born into a health care system where perinatal HIV transmission is not on the radar or maybe people are not familiar about what to do with it. Are people getting that HIV test when they're born? Are we even recognizing and HIV testing moms to make sure that we know their status if we don't already know it? And so the case that we presented during the session was of, I think they were a middle teenager in Job Corps, so they were probably 18 or 19 and basically they were getting diagnosed for the first time on just a random screening and they had actually been perinatally infected and no one had ever done an HIV test. And so I think that's the other thing to talk about is that we have this idea of what it looks like to have HIV; we have this idea of who should be tested, but the reality is the largest percent of people as far as age group that don't know their status are in the 13 to 24 year old age range. And so all of us that have the opportunity to work with them, whether that's in the school setting, that's in health care settings, that's in some kind of community setting, these are things we have to figure out how to talk to our young people about in an appropriate way, in a medically accurate way, in a culturally sensitive way.
LP: Could you discuss some strategies health care practitioners can utilize to increase medication adherence among adolescents with HIV?
SH: I think first and foremost, it's always having a positive attitude and finding at least one thing positive that the young person has been doing to praise them on. That goes a long way with the normal things that we're all trained to do as far as building rapport. So even if you have a young person that tells you that they never take their medicine or they take their medicine once every 3 months or so, the fact that they showed up to your visit is a positive, that's a win. And so really praising them for that because there's room for growth in every situation, but there's always something that our patients are doing that is right, that is good, that is positive, that is praiseworthy.
I think the next thing is really, it takes time, but really understanding what the challenges are that the young person faces and they're all individualized to the young person. Is it a situation where they have a pill aversion or they don't like to swallow pills? Is that the issue and what can we do? Are there other regimens that we can use that maybe have either smaller pill sizes or don't require pills at all? Are there other social determinants of health that you need to think about? Are they in a household or maybe in a dormitory where there is such a great risk of someone coming across their medicines that it's just not worth the trouble? Their life is much more valuable than taking the meds, and so they're opting to not take their meds, not pick up their meds because of the social environment they're in. Are they in their head and really still working through either their diagnosis or adjusting to their new diagnosis if it's new and do we need to be thinking about mental health resources? Is their life just in fluxx or chaotic to where this is the least of their worries right now? Can I feed myself? Do I have a safe place to stay? If I have dependents, am I able to get the money and the resources I need to take care of them? All of those things probably trump taking your medicines for our young people. And so really as individuals interacting with them, we have to take the time, take the space, breathe. It's going to take an extra five minutes, which we don't have but that's okay, and really kind of figure out what those things are. I think once we know what those things are, then obviously addressing them is helpful. If you have access to things like key chain pill bottles and things like that, that could help some of our young people that maybe don't have a consistent schedule and so they need to always have extra pills on them in case it's now 10:00 AM somewhere and they're not in their usual place.
That's important. I think being open to including peers in our health care system, like their peers, in our health care system is important. So those are like peer navigators. Maybe the peer navigator is also an adherence counselor. Maybe the peer navigator is not just a peer because they're young, but they're a peer because they're living with HIV or they were diagnosed with HIV at a younger age. So having those individuals help us out is useful and they can actually, that five minutes that you could have spent asking those questions, maybe they can do that, right? If your schedule's really tight, building those individuals, I think that's important.
It's really a team approach. HIV care in young people, in all people, but particularly in young people, a team approach. If you are fortunate to have a parent or guardian that is helping the young person and that's not the case for everybody, even for some of our younger people, then that's great. Use them. Social workers, case management, pharmacists. I would have the pharmacist number on standby because if I had someone that has a lot of pill challenges, I'm always working with the pharmacist to figure out what else can we do? What other strategies can we try? Mental health is key. And then knowing resources in your community, where can I send my young person to get food, to get clothing, to have a safe place to sleep? I think that's key.
And then this is something that's stylistic and every provider's not going to do this and maybe you're lucky enough and you have a social worker or case manager that will do this, but do you have a way to communicate with them? I had a work cell and so I was able to communicate and I set up my boundaries. So for those that are listening to this, I had boundaries. I'm not answering my work cell at all times of the day, and I provided education on when you need to go ahead and contact the emergency room or the police or something. But can they get in contact with me or are they playing phone tag with our phone trees that often are so complicated in our offices. And so how do you work around that? Because sometimes our young persons are trying to reach out and they get dial nine, now dial three, now dial two. And they leave a message. And we know there's no one necessarily always available to answer the phone or to return a message right away, right? Because that's just not how life works. But things fall through the cracks. And then young people, because they live in this immediate gratification world, get discouraged or dismayed and they did make an attempt to call you or contact you and things happen and then now they've kind of fallen off the wayside or they're not able to refill their medicines, things like that. And so there are a lot of things that we can do, but I think from a provider standpoint, it's really about being creative and being open and really having empathy and understanding that life happens and that HIV is super important to us, maybe because of us being in health care, but that may not be the most important thing in an individual's life right now. And we need to just help make sure that taking their medicine is one of their easiest things that they can do every day.
LP: Is there anything else that you would like to add today?
SH: Other things that really stick out to me are just, it's really important when we're working with younger populations that as best as we can, we're addressing as many of their needs as we can. We do know there's always that teen that comes in and they've got a full review of systems that's positive. That's a whole different story. But for teens where it's like they have a few medical complaints, they have some psychological complaints, they have some social determinants of health issues, we really need to do our best to address those because that's what's going to make our individuals successful, not only on the treatment side, but on the prevention side as well. And that doesn't always mean that you as the provider have to do it all. Use your team around you. Maybe your social worker is not in clinic or you don't have one at all, but maybe you have a list of resources that are common resources in the community that you can give this young person and have someone on your team follow up with them to make sure the young person can access them. It's really about holistically addressing our youths' needs because they are going to put and prioritize their needs differently than we do, and we can't help that. There's nothing we can do about that, but we can help make things easier by helping them address things that they may prioritize above and beyond their HIV treatment or their HIV prevention.
I think the other thing is really just, I didn't touch on that really, but just being inclusive and open with our youth. Give them the chance to define themselves, to define different terms, to define things. So I always start with, "Hey, I'm Dr Hill. My pronouns are she/her. What's your name? What do you like to be called? What are your pronouns?" And then if someone's with them, "who is this person with you today?" I give them as much opportunity to share and individualize their preferred needs, wants, and everything that I can, because I really want them to know that when they step into my clinical space, this is their space too, and this is their opportunity to get everything that they want out of their health care and to really get those tools that they need to be awesome young adults and adults in the future.
Outside of that, what I would say, whether you're in prevention or you're in treatment, it's not about sub-specialization. It's not about that. It's really about making use of the resources that you have. Figuring out how you best can operationalize your space that you're seeing these young people in is really key. So what worked for me in my clinic may not work for you as far as how exactly I did it, but the themes are relevant to all of us. And I think if we remember that, we can all work towards better operationalizing the areas in which we work.
LP: Thank you again Dr Hill for taking the time to speak with me.
SH: Thank you. I appreciate the opportunity and particularly for prevention, I hope more of us take up this particular task because we can all do HIV prevention and then for treatment, whether you're actually providing the HIV care or you happen to be their primary care or their sub-specialists, and know that they have HIV, we can all work together to make sure that our young people with HIV are successful and thriving. Thank you.