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PEDIATRICS Vol. 107 No. 1 January 2001, pp. 188-190
AMERICAN ACADEMY OF PEDIATRICS:
Adolescents and Human Immunodeficiency Virus Infection: The
Role of the Pediatrician in Prevention and Intervention
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ABSTRACT |
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Abstract
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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.
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
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.
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.
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.
INTRODUCTION AND BACKGROUND
COUNSELING
TESTING FOR HIV
CONSENT AND CONFIDENTIALITY
CONCLUSIONS AND RECOMMENDATIONS
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 |
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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 |
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HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome.
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REFERENCES |
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Abstract
References
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American Academy of Pediatrics, Committee on Adolescence
Condom
availability for youth.
Pediatrics.
1995;
95:281-285
[Abstract/Free Full Text] -
American Academy of Pediatrics, Committee on Adolescence
Contraception
and adolescents
. Pediatrics.
1999;
104:1161-1166
[Abstract/Free Full Text] -
American Academy of Pediatrics, Committee on Adolescence
Sexually
transmitted diseases.
Pediatrics.
1994;
94:568-572
[Abstract/Free Full Text] - Kirby D, Short L, Collins J, School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Rep 1994; 109:339-360 [Medline]
- Futterman D, Chabon B, Hoffman ND HIV and AIDS in adolescents. Pediatr Clin North Am 2000; 47:171-188 [CrossRef][Medline]
- US Department of Health and Human Services, Public Health Service. HIV/AIDS Surveillance Report. Atlanta, GA: Centers for Disease Control and Prevention; 1999;11:1-42
-
American Academy of Pediatrics, Committee on Sports Medicine and
Fitness
Human immunodeficiency virus and other blood-borne viral
pathogens in the athletic setting.
Pediatrics.
1999;
104:1400-1403
[Abstract/Free Full Text] - Centers for Disease Control and Prevention. Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and reducing perinatal HIV-1 transmission in the United States. MMWR Morb Mortal Wkly Rep. 1998;47(RR-2):1-30. Updates available at: http://www.hivatis.org
-
American Academy of Pediatrics, Committee on Pediatric AIDS
Education
of children with human immunodeficiency virus infection.
Pediatrics
2000;
105:1358-1360
[Abstract/Free Full Text]
Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics
Statement of reaffirmation:
- AAP Publications Retired and Reaffirmed
- American Academy of Pediatrics
Pediatrics 2005 115: 1438.[Extract] [Full Text] [PDF]
The following policy statement has been revised:
- Adolescents and Human Immunodeficiency Virus Infection: The Role of the Pediatrician in Prevention and Intervention
- TASK FORCE ON PEDIATRIC AIDS
Pediatrics 1993 92: 626-630.[Abstract] [PDF]
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