Current Issues in Adolescents and HIV

2. At the end of 2006, 5,678 adolescents 13 to 19 years of age were living with HIV/AIDS in 33 states with confidential name-based HIV infection reporting. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.At the end of 2006, 5,678 adolescents 13 to 19 years of age were living with HIV/AIDS in 33 states with confidential name-based HIV infection reporting. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.

3. In 2006, there were 1,373 adolescents aged 13 to 19 years diagnosed with HIV/AIDS from 33 states with confidential name-based HIV infection reporting. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.In 2006, there were 1,373 adolescents aged 13 to 19 years diagnosed with HIV/AIDS from 33 states with confidential name-based HIV infection reporting. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.

4. At the end of 2006, 3,116 adolescents 13 to 19 years of age were reported to be living with AIDS in the United States and dependent areas. At the end of 2006, 3,116 adolescents 13 to 19 years of age were reported to be living with AIDS in the United States and dependent areas.

5. In 2006, 581 adolescents 13 to 19 years of age were reported with AIDS in the United States and dependent areas. In 2006, 581 adolescents 13 to 19 years of age were reported with AIDS in the United States and dependent areas.

6. From 1985 through 2006, 6,642 adolescents (persons aged 13-19 years) were reported with AIDS. In earlier years, most reported cases were in adolescent males; over time, the male-to-female ratio has decreased. In 2006, 581 adolescents were reported with AIDS; of these, 354 (61%) were male and 227 (39%) were female.From 1985 through 2006, 6,642 adolescents (persons aged 13-19 years) were reported with AIDS. In earlier years, most reported cases were in adolescent males; over time, the male-to-female ratio has decreased. In 2006, 581 adolescents were reported with AIDS; of these, 354 (61%) were male and 227 (39%) were female.

7. From 1985 through 2006, a total of 36,293 young adults aged 20 to 24 years were reported with AIDS; most were male. In 1985, 89% of cases reported in young adults 20 to 24 years old were in males. However, as high-risk heterosexual contact has accounted for an increasing proportion of HIV infections, particularly in females, the proportion of AIDS cases reported in females has increased. In 2006, 30% of the 1,755 cases reported were in females.From 1985 through 2006, a total of 36,293 young adults aged 20 to 24 years were reported with AIDS; most were male. In 1985, 89% of cases reported in young adults 20 to 24 years old were in males. However, as high-risk heterosexual contact has accounted for an increasing proportion of HIV infections, particularly in females, the proportion of AIDS cases reported in females has increased. In 2006, 30% of the 1,755 cases reported were in females.

8. From 2003 through 2006, the majority of HIV/AIDS cases among adolescent and young adult males were attributed to male-to-male sexual contact. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.From 2003 through 2006, the majority of HIV/AIDS cases among adolescent and young adult males were attributed to male-to-male sexual contact. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.

9. From 2002 through 2006, 1,231 adolescent males age 13 to 19 years and 5,552 young adult males age 20 to 24 years were diagnosed with AIDS. The majority of males age 13 to 19 (60%) and 20 to 24 (72%) with AIDS had a risk factor of male-to-male sexual contact. Twelve percent of AIDS cases among males age 13 to 19 and 13% of cases among males age 20-24 years were attributed to high-risk heterosexual contact.From 2002 through 2006, 1,231 adolescent males age 13 to 19 years and 5,552 young adult males age 20 to 24 years were diagnosed with AIDS. The majority of males age 13 to 19 (60%) and 20 to 24 (72%) with AIDS had a risk factor of male-to-male sexual contact. Twelve percent of AIDS cases among males age 13 to 19 and 13% of cases among males age 20-24 years were attributed to high-risk heterosexual contact.

10. From 2003 through 2006, the majority of AIDS cases diagnosed among adolescent and young adult females were attributed to high-risk heterosexual contact. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.From 2003 through 2006, the majority of AIDS cases diagnosed among adolescent and young adult females were attributed to high-risk heterosexual contact. The following 33 states have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.

11. From 2002 through 2006, the majority of AIDS cases among adolescent and young adult females were attributed to high-risk heterosexual contact. From 2002 through 2006, the majority of AIDS cases among adolescent and young adult females were attributed to high-risk heterosexual contact.

12. Burgess ClinicChildren�s National Medical CenterWashington, D.C.

13. Burgess Clinic Comprehensive primary and specialty care service for HIV infected adolescents Full range of medical, psychosocial, and preventive care Embedded in Adolescent Health Center, offering full range of educational and support services of Center available to Burgess patients and families Site of Adolescent Trial Network (ATN) Grant

14. Burgess Clinic HIV Infected Youth in Care 160 patients with HIV infection 76 (47%) female; 84 (53%) male 91 (57%) perinatally infected 64 (40%) behaviorally infected 3 (2%) sexual assault victims and 2 (1%) �unknown� Perinatally infected teens largest source of new patients 70 (44%) now defined as having AIDS

15. Burgess Clinic Scope of Services for HIV Infected Patients and Families Medical Care Mental Health Services Substance Abuse Counseling Social Support Services Case Management Respite Care Health Education Projects Community Advocacy and Research

16. Unique Psychosocial Situation of Behaviorally Infected Teens: �Marginalized� youth; they have run away or have been �thrown away� by their families, and many have been abused. (Chabon & Futterman, 1999; Lyon, Richmond, D�Angelo, 1996; Lyon, Silber, D�Angelo, 1997) More likely to be school drop-outs and more likely to have a high rate of psychiatric co-morbidity (Murphy et al., 2001; Murphy, Moscicki, Vermund, & Muenz, 2000; Pao, Lyon, et al, 2000; Rotheram-Bones, Murphy et al, 2001).

17. Unique Psychosocial Situation of Perinatally Infected Teens: Death of a parent Transition to one or more homes Missed a great deal of school due to their illness

18. What Are Adolescents� Risk Factors for HIV Infection? Traditional risk factors �Multiple� sexual partners Non-injection drug use Co-existent sexually transmitted disease Resident in community with high incidence of HIV

19. HIV Risk Profile Studies in Adolescents Infection Rates: Higher in men who have sex with other men Higher in either gender if they are infected with syphilis Higher in men who have receptive anal intercourse Higher in women who have older sexual partners Higher in women who have partners that use drugs

20. What Does this Mean for Adolescents in terms of HIV Risk? �Geography is Destiny� While prevalence rates in the general population may be low, certain groups are at �extremely� high risk Prevention efforts need to focus and refocus on these groups General education can�t be considered �finished�

21. Therapeutic Challenges in Treating the HIV Infected Adolescent Determining the right time to initiate therapy Optimizing Adherence to treatment regimens Dealing with the increasing amount of medication resistance Ensuring appropriate transition to other care systems

22. Challenges of HIV-Infected Teens Demands of complex drug regimens and side effects Disclosure of HIV status (and its accompanying societal, family, and/or peer stigma) Management of a chronic and sexually transmitted illness within the context of the already demanding developmental tasks and changes associated with adolescence.

23. Differences Between Behaviorally-Related and Perinatally HIV Infected Youth CD4 counts are lower (perinatal) Viral loads are higher (perinatal) Resistance more likely (perinatal) Adherence more problematic (behavioral) Associated risk behaviors more likely (behavioral, BUT��) Social disruption more prominent (equal)

24. Developmentally appropriate, adolescent-specific strategies Younger and middle adolescents approach problem solving very concretely cue on the physical attributes of problems are preoccupied by pubertal change are sensitive to body image and developing sexuality are highly egocentric have a strong need for peer acceptance Middle and older adolescents strive to establish a sense of autonomy have feelings of invincibility

25. HIV Prevention-Intervention Studies in Adolescents Studies show success is greatest when: Your Target is African-American Youth Your Target is Older Adolescents You have male facilitators to deal with male patients All assessments are anonymous Condoms are distributed Study groups are smaller

26. Adolescents and Adherence: What are the key factors and what makes them different?

27. Adherence to medications is critical: To maintain the health of the teens To decrease the risk of transmission during unprotected sex Approximately 1/3 of recently HIV-infected teens continue to engage in a high rate of risky behavior following diagnosis Must learn to assume responsibility for their own medication regimens, a task that has proven to be difficult even for adult patients.

28. What does the literature provide on adherence � Sparse studies � Most are descriptive very few examine interventions � Consistency regarding adherence as crucially important � Adherence as development issue � Multi-complex issue � Needs to be addressed from numerous perspectives � Further research need to be conducted

29. Correlates of Adherence Three Broad Categories: Issues Related to medication Indefinite duration of treatment Multiple medications High pill burden Complex dietary considerations Multiple and precise dosing times Storage requirements Low palatability Large pills Adverse effects

30. Correlates continued Issues Related to Patient Age Awareness of status Belief about impact of medications on quality of life Substance use Depression Stress Amount of responsibility for medication taking Improved health status

31. Correlates continued Issues Related to Caregiver/Family Foster vs biological parent Higher self efficacy Belief in efficacy of medications Less concern about hiding child illness Better parent-child communication Less caregiver stress Higher quality of life Better caregiver cognitive functioning Better caregiver knowledge of medications Fewer barriers

32. Intervention Group meetings Individual meetings

33. Public Policy Approach toHIV Infection in Adolescents 1. Create standing task force to combat HIV infection in adolescents 2. Continue primary as well as secondary and tertiary prevention for adolescents through in depth curricula 3. Develop national standards for HIV counseling and testing in adolescents utilizing new technology; consider positive and negative aspects of such testing

34. Public Policy Approach to HIV Infection in Adolescents 4. Create �adolescent-sensitive� services surrounding HIV/AIDS 5. Remove financial and social barriers for adolescents to receive care 6. Co-ordinate research efforts surrounding HIV/AIDS in adolescents

35. The Future of HIV Infection in Adolescents: What Will be Important? Adolescents will continue to be important in the epidemiology of HIV/AIDS, particularly �high risk� teens There will be a growing number of teenagers who were infected in early life Prevention Intervention will target youth �most at risk� �Vaccine Preparedness� will become goal �Adolescent specific� trials will increase Much of this will be coordinated through established research networks

36. Questions? Comments?!?