The AAP has encouraged HIV testing of all sexually active youths for the past two decades.
A new clinical report reflects changes in epidemiology and advances in diagnostic testing. It offers updated recommendations for HIV testing and postexposure prophylaxis (PEP) as well as new guidance for pre-exposure prophylaxis (PrEP) in youths at risk of acquiring HIV infection.
The report, Adolescents and Young Adults: The Pediatrician’s Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis, from the Committee on Pediatric AIDS, is available at https://doi.org/10.1542/peds.2021-055207 and will be published in the January issue of Pediatrics.
Best practices, challenges
Pediatricians play a key role in preventing and controlling HIV infection by routinely assessing for high-risk behaviors, promoting risk reduction and offering HIV testing and prophylaxis to their adolescent patients. Early identification, linkage to care and rapid initiation of treatment of youths with a positive HIV test support them in achieving and sustaining viral suppression. These efforts not only benefit individual health and well-being, but also help prevent HIV transmission to partners and within the community, since having undetectable viral load effectively means the HIV infection is untransmittable from one person to another through sexual contact.
Diagnosing people as early as possible and preventing new transmissions are among the key national strategies to achieve control of the HIV epidemic in the United States by 2030.
Despite recommendations for routine HIV testing of adolescents from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention, most youths are not tested by 12th grade. Evidence shows, however, that routinizing testing and making testing access easier with newer, less invasive (non-blood draw) methodologies can improve HIV testing rates.
The report also addresses complex issues of consent, confidentiality and coverage that pediatricians face in promoting routine testing and prophylaxis for their patients. Resources summarize state-specific laws pertaining to HIV care and treatment.
A negative HIV test result in youths at risk for HIV acquisition is a critical moment for reinforcing the need for repeat testing over time and consideration of biomedical prevention interventions. The clinical report summarizes guidance for indications and use of HIV PrEP medications and clinical monitoring.
Recommendations
The clinical report reviews epidemiologic data and provides recommendations for pediatricians, including the following:
- Create an environment where sensitive issues can be discussed confidentially with youths.
- Screen all youths ages 15 years or older for HIV at least once.
- Rescreen youths at increased risk, including those who are sexually active, at least annually.
- Rescreen those at very high risk, including males reporting male sexual contact, active injection drug users, transgender youths and youths exchanging sex for drugs or money, as frequently as every three to six months.
- Routinely offer youths at substantial risk for HIV acquisition PrEP and potentially PEP as indicated following high-risk exposures.
- Test youths of any age who request HIV screening, even in the absence of reported risk factors. HIV testing should be accessible at outpatient clinics, inpatient wards, emergency departments and urgent care facilities to reach those who may not seek routine primary care.
- For youths who test positive in any setting, facilitate and confirm prompt linkage to age-appropriate HIV specialty care.
- Counsel youths with a negative HIV test result on sexual and reproductive health and risk behaviors. All youths at risk for HIV acquisition should be offered HIV PrEP as part of a comprehensive prevention strategy that includes adherence to daily administration and safer sex practices, including barrier protection, to reduce the risk of sexually transmitted infections.
- Preventive care and screening should include universal coverage and adequate payment for confidential HIV testing, related counseling, PEP and PrEP.
Drs. Hsu and Rakhmanina are lead authors of the clinical report. They are members of the Committee on Pediatric AIDS, which Dr. Rakhmanina now chairs.
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