Did the 2011 AAP recommendations on youth HIV testing change practice? Trends from a large urban adolescent program.

PURPOSE: The purpose of this study was to determine whether there is adherence to the October 2011 American Academy of Pediatrics (AAP) recommendations for HIV screening in a large urban adolescent program with availability of a publicly funded program providing free, confidential, sexually transmitted infection (STI) and HIV counseling and testing (then rapid or third generation HIV testing), nested in the same adolescent clinic. METHODS: We conducted a retrospective chart review of HIV screening trends among 13- to 24-year-old patients tested for HIV during periods of January 2010 to June 2011 (18 months pre-AAP recommendations period) and July 2011 to December 2012 (18-month period, which included 15 months after the AAP recommendations). RESULTS: During the period of January 2010 to June 2011, there were 22 tests/1,000 medical visits (N = 824 of 37,520 medical visits), and during the period of July 2011 to December 2012, there were 27 tests/1,000 medical visits (N = 1,068 of 38,763 medical visits) (p < 0.0001, odds ratio [OR] 1.26). The number of 13- to 18-year-old patients screened in the pre-AAP period was 150, compared to 297 in the second 18-month period (X 2 = 43.3, df = 1, p < 0.0001). A summative risk profile score of 0-9 was created in the form of a continuous variable, with a risk score of 0 for those with no risk factor identified and 1 point for each risk behavior identified. The proportion of HIV test clients with zero-specified risk (a risk score of "0") increased from 2010 to 2012. CONCLUSION: Release of the 2011 AAP HIV testing guidelines was associated with a modest increase in HIV screening and a shift toward testing younger people and away from risk-based screening.

Primary care for children and adolescents living with HIV.

PURPOSE OF REVIEW: Advances in HIV treatment, including simplified and better tolerated antiretroviral drug regimens, have led to increasing numbers of HIV-positive children and adolescents surviving into adulthood. Effective pediatric and adolescent primary care provided by pediatricians working together with an HIV specialist can help to optimize their current and future health. RECENT FINDINGS: New data are showing youth with HIV may be at increased risk for early cardiovascular disease and metabolic derangements as compared with their uninfected peers. Both the virus itself and complications of antiretroviral medications are implicated in these findings. SUMMARY: In addition to standard age-appropriate healthcare maintenance, care of HIV-positive children and adolescents should have special emphasis on evaluation for possible cardiovascular and metabolic complications of HIV infection and its treatment. Goals of care are moving toward chronic disease management and improved long-term health.

Perceived peer safer sex norms and sexual risk behaviors among substance-using Latino adolescents.

We investigated the association between perceived peer norms and safer sexual behaviors among substance using Latino youth. Between 2005 and 2006, cross-sectional data were collected from 92 Latino adolescents recruited from clinic- and community-based settings in two U.S. cities. Separate multivariate logistic regression models were used to assess the relationship between perceived peer norms around safer sex and two different outcomes: consistent condom use and multiple sexual partnerships. Among these participants, perceived peer norms encouraging safer sex were associated with consistent condom use even after controlling for individual- and partner-related factors. Perceived peer norms supporting safer sex were inversely associated with recently having two or more sexual partners after controlling for demographic characteristics. Perceived peer norms around safer sexual behavior contribute to a lower likelihood of engaging in two HIV/STI risk behaviors: inconsistent condom use and multiple partnering. These findings suggest that further development of peer-based interventions for Latino youth is warranted.

Acceptability and feasibility of rapid HIV testing in an adolescent clinic setting: youth testing attitudes, knowledge, and behaviors.

PURPOSE: To assess youths' attitudes, knowledge, and behaviors regarding rapid HIV testing (RHT) and measure acceptability and feasibility of RHT in an adolescent clinic setting. METHODS: A 2007-2008 project introduced free RHT at an urban, hospital-based adolescent and young adult clinic in Boston, MA. Patients and HIV testing clients were offered either free nonrapid tests or fingerstick RHT. An anonymous questionnaire assessed youths' testing attitudes, knowledge, and behaviors (N = 127). Ordinal logistic regression model was used to determine associations with youth demographic characteristics and testing experience. RESULTS: Most participants valued rapid results. A minority desired confidentiality from parents and insurance providers. Older youth were more likely to know about testing methods (OR: 1.25; CI: 1.04-1.51) and plan for follow-up (OR: 1.43; CI: 1.14-1.81). Age, gender, and race were unrelated to testing facilitators such as rapidity, confidentiality, and cost, although younger clients were more likely to prefer noninvasive methods. Individuals with previous testing experience were more likely to say that they would contribute to expenses and value rapidity over cost. CONCLUSION: There was strong support for RHT among youth receiving HIV testing. Offering RHT to youth may facilitate routine testing. Future research should focus on increasing RHT access among diverse populations of youth.

A comparison of weight-related behaviors among high school students who are homeless and non-homeless.

BACKGROUND: Previous research has shown that youth who are homeless engage in high-risk behaviors. However, there has been little information published on nutritional and physical activity behaviors in this population, and studies comparing homeless youth in school with their non-homeless peers are scarce. This study compares weight-related risk behaviors of public high school students in Massachusetts based on homeless status. METHODS: We obtained data from 3264 9th through 12th grade students who participated in the 2005 Massachusetts Youth Risk Behavior Survey. Multivariable logistic regression, controlling for gender, grade, race/ethnicity, and sexual orientation, was performed to assess the relationship between homeless status as defined by the McKinney-Vento Homeless Assistance Act and weight-related indicators. Analyses were weighted and adjusted for the multistage complex sampling design. RESULTS: Of this sample, 4.2% reported being homeless (n = 152). Higher prevalence of homelessness was found among males, racial/ethnic minorities, sexual minorities, and students who were not in a traditional grade level. The distribution of body mass index was similar among students who were homeless and non-homeless (underweight 4.0 and 3.0%, and overweight 27.1 and 27.1%, respectively). Homeless students were more likely than non-homeless students to report disordered weight-control behaviors including fasting (aOR 2.5, 95% CI 1.4-4.5) and diet pill use (aOR 3.3, 95% CI 1.6-6.9). CONCLUSIONS: More than 4% of public high school students in Massachusetts meet the federal definition of homelessness. These students are at high risk for disordered weight-control behaviors. Policy decisions at the school, state, and federal levels should make a concerted effort to target these students with social services and nutritional interventions.

Use of human immunodeficiency virus postexposure prophylaxis in adolescent sexual assault victims.

OBJECTIVES: To describe the use of human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) in adolescent survivors of sexual assault and to explore barriers to PEP completion in this population. DESIGN: Chart review. SETTING: Two academic medical centers in Boston, Mass, between July 1, 2001, and June 30, 2003. PARTICIPANTS: Adolescents presenting to 2 urban pediatric emergency departments within 72 hours of a penetrating sexual assault. Of 177 charts reviewed, adequate documentation of the sexual assault and medical management was available for 145 patients. INTERVENTION: Provision of HIV PEP. MAIN OUTCOME MEASURE: Documented completion of a 28-day course of PEP. RESULTS: Among the 145 patients, 96% were female, 38% were black, and 14% were Hispanic. Many patients were uncertain regarding their exposures: 27% were unsure whether a condom had been used, 54% were unsure whether ejaculation had occurred, and 21% had blacked out during the assault. One hundred ten (76%) received HIV PEP. Of the 97 patients referred for follow-up at the academic centers, 37 returned for at least 1 visit and 13 completed a 28-day course of PEP. Sixteen (46%) of those taking PEP who returned for follow-up developed an adverse reaction to medication. Forty-seven percent of adolescent sexual assault survivors had carried a psychiatric diagnosis before the assault; adherence to PEP was lower among these adolescents. CONCLUSIONS: We observed low rates of PEP completion among adolescent sexual assault survivors. Potential difficulties of using PEP in this population include uncertainties regarding exposure, high rates of psychiatric comorbidity, and low rates of return for follow-up care.

Outreach, mental health, and case management services: can they help to retain HIV-positive and at-risk youth and young adults in care?

OBJECTIVES: To assess the impact of outreach, mental health, and case management services on retention in primary care of HIV+ and at-risk youth and young adult clients of the Boston HAPPENS program, a comprehensive adolescent HIV prevention and care network of agencies. METHODS: Providers at 8 urban sites used standard data forms at each visit to collect background and service receipt information on at-risk clients aged 12-24 years. Data were aggregated across all visits for each client to create summary variables for the number of times each client received each type of service. The retention measure was the number of days between a client's first and last visits during the 4-year data collection period. Kaplan-Meier survival curve and Cox proportional hazards regression analyses were used to assess the association between receipt of the support services of interest and the retention measure. RESULTS: The median retention times were 21 days for male clients (range, 0-1406, N = 512), and 26 days for female clients (range, 0-1577, N = 914). Among males, 45% were retained beyond a month, 24% beyond a year, and 10% beyond 2 years. Similar proportions of females were retained beyond a month and a year, but more females were retained beyond 2 years (15%). After adjusting for other covariates, both male and female clients had significantly longer retention times if they received > or = 2 outreach contacts, or case management at > or = 3 visits. Among males, receipt of mental health counseling at > or = 2 visits also increased retention times. CONCLUSIONS: These findings suggest that provision of outreach, mental health, and case management services can improve retention in care of at-risk youth and young adults.

Postexposure prophylaxis: an intervention to prevent human immunodeficiency virus infection in adolescents.

Postexposure prophylaxis is an effective intervention to prevent transmission of the human immunodeficiency virus (HIV). Administration of antiretroviral medications within 72 hours of a percutaneous or mucous membrane exposure to HIV can prevent infection. The use of postexposure prophylaxis for occupational and perinatal HIV exposures is well established. Its efficacy for nonoccupational exposures has only recently been studied. To date in the United States, there are no national guidelines regarding postexposure prophylaxis for nonoccupational exposures. Decisions regarding its use should be made after weighing the risks of seroconversion for a given exposure, the risks of HIV in the source, and the potential toxicities of the antiretroviral medications. Several state guidelines may also serve as important resources. Clinicians should consider initiating postexposure prophylaxis in adolescents for any oral, anal, or vaginal exposure to definitely or possibly HIV-infected blood or body fluids. Adolescents treated should be followed closely for medication toxicity, acute seroconversion, and risk-reduction counseling. Further studies are needed to characterize the use and efficacy of postexposure prophylaxis in an adolescent population.

Boston HAPPENS Program: HIV-positive, homeless, and at-risk youth can access care through youth-oriented HIV services.

The Boston HAPPENS Program is a collaborative network of care consisting of multiservice outreach agencies; community health centers; and hospitals for HIV-positive, homeless, and hard-to-reach youth. In four years of data collection, the program served more than 2,000 youth, including 54 HIV-positive youth. The youth were 19.9 +/- 2.9 years old; 64 percent female; 45 percent youth of color; 11 percent gay/lesbian, bisexual, or undecided; and 13 percent homeless or runaway. Homeless youth were much more likely to have been involved with a mental health system (47% vs. 12%, P < 0.001), the criminal justice system (20% vs. 2%, P < 0.001), high-risk sexual behaviors (21% vs. 3%, P < 0.001), and substance abuse (25% vs. 6%, P < 0.001) than were other youth served by the program. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect under-served youth to health care. Outreach and human immunodeficiency virus (HIV) counseling and testing services can offer important portals of entry into health services for at-risk youth. Support services such as outreach, case management, and mental health services are needed to complement medical services by all youth at-risk for contracting HIV. Support services are necessary for the initiation and retention of youth in care so that early case identification and complex treatment regimens can be initiated and tailored to the individual.

Initiation of services in the Boston HAPPENS Program: human immunodeficiency virus-positive, homeless, and at-risk youth can access services.

This study evaluates the factors associated with initiation of services in the Boston HAPPENS Program, which is a collaborative network of care consisting of multiservice outreach agencies, community health centers and hospitals, for human immunodeficiency virus (HIV)-positive and hard to reach youth who are 12-24 years old. The program served 2116 youth who were 19.8 +/- 2.9 years old; 64% female; 45% youth of color; 16% gay/lesbian, bisexual, or undecided; and 10% homeless or runaway. At first contact with the program, 56% received outreach services; and 91% received a health intervention. Among those receiving a health intervention, 55% had HIV counseling and testing services, 49% medical care, 24% case management, and 9% mental health services. HIV-positive youth needed more contacts before a first medical visit than those who were HIV-negative or untested (p < 0.001). Different kinds of service sites reached different populations of at-risk youth. Logistic regression modeling showed that for young women, older age, lesbian-bisexual orientation, substance use, high-risk sexual behaviours, and receiving outreach services at first contact were independent predictors of initiation of services at outreach agencies; however, unprotected sex with males, and pregnancy were associated with a greater likelihood of care at hospitals or community health centers. For young men, older age, Asian/other ethnicity, and substance abuse were associated with care at outreach agencies; however, positive HIV status and unprotected sex with females were associated with care at hospitals or community health centers. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect underserved youth to health care.