Surveillance data on high school adolescent sexual activity, including teenaged pregnancy rates and incidence of sexually transmitted infections (STIs), require pediatricians and other youth providers to be competent and confident in addressing sexual and reproductive health care needs in adolescent and/or young adult populations. The American Academy of Pediatrics has published guidelines, recommendations, clinical reports, and resources on the promotion of healthy sexual development in clinical settings, encouraging sexual health assessments that are inclusive of HIV and STI testing as an integral component of comprehensive health visits. The need for a more determined effort to address sexual health as it relates to HIV specifically is evidenced by a decrease in the number of in-school youth reporting ever being tested, 15- to 24-year-olds representing 21% of new infections, and estimates that >40% of youth with HIV are undiagnosed. Ending the HIV epidemic requires adherence to published HIV testing recommendations, sexual health assessments, screening for STIs, and appropriate primary and secondary prevention education. Preexposure prophylaxis, an efficacious biomedical prevention intervention for reducing HIV acquisition, was approved in July 2012 and in May 2018 was authorized for use in minors. This state-of-the-art review article provides background information on preexposure prophylaxis, current guidelines and recommendations for use, and strategies to introduce and implement this valuable HIV prevention method in clinical practice with adolescents and young adults.

Sexual exploration and sexual debut are a normal part of the adolescent developmental trajectory. Sexual activity is often unplanned and sometimes unwanted. Data from the 2017 Youth Risk Behavior Survey show that 39.5% of high school students have had sexual intercourse and that sexual activity predictably increases with age: 20.4% of ninth-graders, 36.2% of 10th-graders, 47.3% of 11th-graders, and 57.3% of 12th-graders. Sexual activity in the past 3 months was reported by 28.7% of respondents, with similar increases seen by age (eg, 12.9% of ninth-graders versus 44.3% of 12th-graders). Stratification by sexual orientation shows slightly higher rates of current sexual activity among those who identify as gay, lesbian, or bisexual (33.7%) compared with those identifying as heterosexual (28.5%). Among those who are currently sexually active, just over half (53.8%) report using a condom with their partner during the last sexual intercourse, and 18.8% reported that they had used drugs or alcohol just before sex.1  Thus, the expected onset of sexual activity during adolescence coupled with substance use experimentation and low rates of condom use render adolescents to be among the groups that are most vulnerable to infection with HIV and other sexually transmitted infections (STIs).

The Centers for Disease Control and Prevention (CDC) estimates that although youth ages 15 to 24 represent only one-quarter of the sexually active population, they account for half of the 20 million new STIs that occur in the United States each year. Rates of Chlamydia, gonorrhea, and syphilis have increased for adolescent males and females over the past several years. For example, between 2013 and 2017, the rate of gonorrhea cases among 15- to 24-year-old females increased 24.1% and increased 51.6% for males. Furthermore, rates of primary and secondary syphilis increased 83.3% for females and 50.9% for males over the same period.2  Unfortunately, the epidemiological synergy that exists between STIs and HIV infection is well known, with asymptomatic, undiagnosed infections (including those in extragenital sites) increasing the risk of HIV acquisition.

In 2017, 21% of new HIV diagnoses in the United States were among youth ages 13 to 24. Although trends over the past several years have shown an overall 6% decrease in new HIV diagnoses among youth, these trends vary dramatically for different groups of youth. For example, new diagnoses among women have declined 32% since 2010, but those among young men remain stable. Among young gay and bisexual men, new diagnoses among African American youth are down 5%, whereas an increase of 17% was seen among Latino youth.3  Despite almost one-quarter of new HIV infections occurring among youth, only 9.3% of students completing the Youth Risk Behavior Survey had ever been tested for HIV. Furthermore, trend analyses indicated that during 2005 to 2017, a significant linear decrease (11.9%–9.3%) occurred in the overall prevalence of having ever been tested for HIV.1  Among the estimated 50 000 youth who are currently living with HIV in the United States, only 56% are aware that they have the virus.3 

Adolescent and young adult care providers need to be on the front line in the fight against the HIV epidemic by using widely available and rapidly expanding prevention strategies. Such intervention begins by taking complete sexual histories with adolescent patients, having discussions about sexual health that include STI and HIV prevention, and offering HIV preexposure prophylaxis (PrEP) to those who may benefit.

In 2012, the US Food and Drug Administration (FDA) approved the use of once-daily emtricitabine and tenofovir (Truvada) as oral PrEP for HIV prevention in adults. Open-label effectiveness studies have demonstrated that PrEP reduces the risk of HIV by >95% when taken consistently.4,5  On May 15, 2018, the FDA expanded the indication to include adolescents weighing at least 35 kg who are at risk for HIV infection.

The expanded indication for PrEP was based on 2 adolescent-focused safety studies: Adolescent Medicine Trials Network for HIV/AIDS Interventions 113 (ATN 113) and PlusPills. In ATN 113, PrEP was found to be safe and well tolerated among a cohort of racially diverse young men who have sex with men (YMSM) ages 15 to 17. The majority of participants had adherence levels that were commensurate with HIV protection over the first 12 weeks of the study, but adherence began to decrease at week 24 and continued to decline for the remainder of the study. The most common reasons for missing PrEP doses included being away from home, being too busy, and forgetting to take it. Furthermore, participants who were worried that PrEP use would make others think they had HIV were less adherent.6  The PlusPills study was conducted in South Africa among adolescent boys and girls ages 15 to 19. In this study, PrEP use was also found to be safe, acceptable, and tolerable for the PlusPills participants, but adherence dropped in the second half of the study in a pattern similar to what was seen in ATN 113.7 

In addition to a once-daily regimen, on-demand PrEP has been shown to be effective. In the IPERGAY (Intervention Préventive de l’Exposition aux Risques avec et pour les Gays) study, taking 2 pills before sex and 2 single doses 24 and 48 hours after sex (“on-demand dosing” or “2-1-1”) was shown to be highly effective (86%) among men who have sex with men (MSM).8  Subsequent open-label trials also support the efficacy of on-demand PrEP, with no HIV infections reported in either the daily or on-demand arm of the Prevenir study.9  Despite data that support intermittent dosing strategies, intermittent strategies have not yet been examined nor recommended for use in adolescents. In July 2019, the World Health Organization updated its PrEP guidance to include the use of event-driven PrEP by MSM.10  However, once-daily oral dosing is the only regimen currently approved by the FDA.11 

In addition to clinical recommendation by the CDC, the US Preventive Services Task Force recently released an “A” rating for PrEP for adolescents and adults who are at high risk of HIV acquisition.11,12  Since the FDA approved PrEP for adolescents, the Society for Adolescent Health and Medicine (SAHM) released a position paper that includes special considerations for pediatricians and adolescent medicine providers to improve provider comfort and address low rates of PrEP provision among youth.13  The SAHM position states that “adolescent and young adult health professionals should develop evidence-based, developmentally appropriate, culturally sensitive, and accessible PrEP service delivery models as part of routine care offered to adolescents and young adults.” To achieve this goal, providers are encouraged to counsel patients about PrEP, describe it as a safe and effective HIV prevention strategy in combination with condoms, and refer patients to available providers for initiation and monitoring of PrEP.

Despite strong safety and efficacy data, along with clinical guidance and grassroots campaigns, PrEP does not yet appear to be easily accessible for those who are most in need. The CDC estimates that >1.1 million people in the United States would benefit from PrEP, yet <200 000 people have received PrEP to date. Of those prescriptions, nearly 75% went to white gay or bisexual men, predominantly living in the Northeast or on the West Coast.14  In the Southern United States, where the incidence of HIV is the highest, the number of PrEP prescriptions and the rate of retention in PrEP care are lower than the national average. Medication cost, stigma, and medical mistrust prevent at-risk people of color from obtaining and benefiting from PrEP.15 

National US pharmacy data have shown interesting PrEP prescription patterns for youth. From 2012 to 2017, of just over 177 000 prescriptions, only 2590 (∼1.5%) were for youth <18 years of age, and 83.5% of those prescriptions were for females.16  Pediatricians were the leading prescribers of PrEP for adolescents but made up less than half of prescribers (38%), followed by those in emergency medicine (22%), family practice (13%), and other areas (22%). In 2018, an additional 348 PrEP prescriptions were filled by adolescents with an almost even distribution by gender (48.6% female and 51.4% male; S. McCallister, MD, personal communication, 2019).

The limited number of prescriptions overall that are provided to youth may be directly related to a lack of provider knowledge about PrEP and discomfort with prescribing PrEP. Several studies focused on pediatric and adolescent providers have found a lack of familiarity with PrEP in general and safety concerns for adolescents in particular. One study of primary care physicians’ attitudes regarding PrEP use for adolescents found that just 37% of clinicians were somewhat or very familiar with PrEP. The primary physician-identified barriers to PrEP for adolescents included concerns about patient adherence (79%), concerns about safety and side effects (76%), concerns about parents as a barrier (50%), and a lack of physician knowledge about PrEP (45%).17  A similar study of adolescent and young adult HIV care providers found that clinicians reported greater intention to prescribe PrEP to adult versus adolescent MSM and transgender women.18  Finally, an online survey of adolescent and young adult providers found that willingness to prescribe PrEP was strongly associated with the belief that the provider had enough knowledge to safely provide PrEP to adolescents and young adults and that adolescents would be adherent.19 

Sexual activity is prevalent in adolescent and young adult populations. The CDC and majority of national specialty and subspecialty organizations strongly recommend the assessment of sexual health as an essential part of comprehensive health examinations for everyone. Both the American Academy of Pediatrics (AAP) and the SAHM support universal access to sexual and reproductive health care services for adolescents that acknowledges the need for confidentiality in delivering these services.20  Confidentiality is critical to building an effective patient-provider alliance. The assurance, in the presence of the parent and/or legal guardian, that discussions between the adolescent and provider will not be breached unless “reportable” events such as abuse or suicidal and/or homicidal thoughts are disclosed encourages adolescents over time to seek health care and respond candidly to potentially sensitive topics. Such topics may include sexual activity, sexuality and/or gender identity, STI concerns, substance use, pregnancy concerns, dating violence, and contraception. Bright Futures, a national health promotion and prevention initiative led by the AAP, encourages the office policy regarding confidentiality be discussed at the 11- to 14-year-old patient visit.21 

Providers should also be familiar with their states’ minor consent laws and share this information with office and/or practice staff, patients, parents, and/or legal guardians. A summary of consent and/or confidentiality laws by state is available from the Guttmacher Institute.22  Currently, all 50 states and the District of Columbia allow minors (age varies from 12 to 14 years) to consent to testing and treatment of STIs without requiring parental notification by providers, and consent for HIV testing and/or treatment is currently allowed by 32 states, including the District of Columbia. Further discussion with both the adolescent and parent and/or legal guardian regarding the provision of confidential services may clarify potential future obstacles to providing sexual and reproductive health care services. Regarding PrEP specifically, the FDA indication for PrEP in adolescents who are ≥35 kg is relatively new, and most states have not explicitly addressed whether this prevention tool is covered under existing legal statues.

Sexual history is 1 aspect of a broader psychosocial risk assessment that should be obtained at the initial visit and updated during subsequent visits. The psychosocial assessment tool HEEADSSS (which stands for “home, education and/or employment, eating, activities, drugs, sexuality, suicide and/or depression, and safety”) provides a conversational framework for soliciting information about the spheres of the patient’s life, including sexuality and other risk behaviors.23  The CDC recommends using the “5 P’s” pneumonic (partners, prevention of pregnancy, protection from STIs, practices, and past history of STDs) to guide providers in obtaining a thorough sexual history.24 

A complete sexual history assists the provider in identifying risks and determining further therapeutic decisions and the content of prevention education information. Preface the sexual history by informing the adolescent or young adult that you will be asking some personal questions and that you ask these of all your patients. Creating a more engaged, comfortable environment can be facilitated by not typing or writing and giving the patients permission to decline answering any questions they are not comfortable discussing without explanation. Patients should be asked if they have ever had sex with men or women or both and, if affirmative, asked to identify the type(s) of sexual experiences they have had. It may be helpful to say, “What I am asking is if you have ever had or experienced oral (mouth on penis, mouth on vagina, or mouth on anus), vaginal, anal insertive (top), or anal receptive (bottom) sex; masturbated; or engaged in mutual masturbation with another person(s) with anything other than your hands or mouth.” It is important to recognize that anal receptive intercourse is the highest-risk sexual behavior or practice for acquisition of HIV but does not identify the adolescent or young adult in regards to their sexuality (heterosexual, bisexual, gay, or other), gender identity (male, female, both, or neither), or gender expression (way one presents themselves, acts, or communicates). Studies have estimated that 29% of HIV infections in women are linked to sex with MSM, and more than one-third of women report having had anal sex.25-27 

HIV testing and counseling provides a perfect segue to discuss HIV prevention options, including PrEP. The AAP recommends that routine HIV screening be offered to all adolescents at least once by 16 to 18 years of age and all sexually active adolescents.28  However, only 13% of US high school seniors (12th-graders) have been tested for HIV, and young women are being tested at a significantly higher rate than young men are (15.8% vs 10.2%). Rates of HIV testing are also low (20%) for youth who identify as gay, lesbian, or bisexual.1  Rates of HIV testing must increase, and providers should particularly consider youth with any of the following characteristics: inconsistent condom use, history of an STI, requests for a pregnancy test, history of any receptive or insertive anal sex, young men who have sex with other men (regardless of sexual identity), current substance use, or a history of incarceration.

When conducting HIV testing, providers need to be prepared for the possibility of a positive test result and be comfortable counseling adolescents on the meaning of such results. If HIV care services are not available in the primary care setting or if the provider is not comfortable providing such care, knowledge of available resources and an established referral plan for prompt linkage to an experienced HIV care provider are critical.

The receipt of a negative HIV test result offers the provider an opportunity to ask about future HIV prevention plans and discuss all available options. The introduction of HIV prevention modalities, including PrEP, into clinical settings should be considered an educational service announcement that is provided to patients, parents, and legal guardians. Suggestions for introducing HIV testing and PrEP in clinical practice can be seen in Table 1.

TABLE 1

Establishing HIV Prevention and PrEP in the Clinical Setting

Description
Educate “The American Academy for Pediatrics recommends that an HIV test should be offered to all adolescents at least once 16–18 years of age because many youth that have HIV or other sexually transmitted infections don’t know that they have it.” 
Follow-up The provision of an HIV-negative test result could be followed with, “Now that we know you do not have HIV, what are your plans to stay HIV-negative?” 
Normalize “Our practice likes to provide updates about current health-related topics as part of the clinical visit. PrEP is a health promotion tool available for anyone.” 
Introduce Introduce PrEP at the beginning of the clinical visit before asking the parent or legal guardian to leave the examination room. “The FDA approved PrEP in July 2012 for adults and in May 2018 for those adolescents who weigh at least 77 pounds. PrEP is a pill you can take once a day to help prevent HIV.” 
Reintroduce Reintroduce PrEP with the adolescent alone (during interview or examination): “So had you ever heard about PrEP?”; “What do you think about it?"; “Do you think PrEP might be something for you?” 
Supply Place youth-friendly brochures in waiting areas and/or examination rooms. 
Highlight Hang posters about PrEP; wear buttons that say, “Ask me about PrEP”. 
Show Videos are available to run on office televisions or monitors, or links can be given to patients or parents to view (eg, www.whatisprep.org). 
Provide Write a prescription for PrEP or provide a warm handoff to a colleague or clinic that is comfortable prescribing PrEP. 
Remind Tell patients that PrEP is an HIV prevention tool and does not prevent other STIs or pregnancy. Offer condoms and/or contraceptives. 
Stay informed Make use of resources for providers, including toolkits and consultation service hotlines (www.cdc.gov/hiv/risk/prep/index.html). 
Description
Educate “The American Academy for Pediatrics recommends that an HIV test should be offered to all adolescents at least once 16–18 years of age because many youth that have HIV or other sexually transmitted infections don’t know that they have it.” 
Follow-up The provision of an HIV-negative test result could be followed with, “Now that we know you do not have HIV, what are your plans to stay HIV-negative?” 
Normalize “Our practice likes to provide updates about current health-related topics as part of the clinical visit. PrEP is a health promotion tool available for anyone.” 
Introduce Introduce PrEP at the beginning of the clinical visit before asking the parent or legal guardian to leave the examination room. “The FDA approved PrEP in July 2012 for adults and in May 2018 for those adolescents who weigh at least 77 pounds. PrEP is a pill you can take once a day to help prevent HIV.” 
Reintroduce Reintroduce PrEP with the adolescent alone (during interview or examination): “So had you ever heard about PrEP?”; “What do you think about it?"; “Do you think PrEP might be something for you?” 
Supply Place youth-friendly brochures in waiting areas and/or examination rooms. 
Highlight Hang posters about PrEP; wear buttons that say, “Ask me about PrEP”. 
Show Videos are available to run on office televisions or monitors, or links can be given to patients or parents to view (eg, www.whatisprep.org). 
Provide Write a prescription for PrEP or provide a warm handoff to a colleague or clinic that is comfortable prescribing PrEP. 
Remind Tell patients that PrEP is an HIV prevention tool and does not prevent other STIs or pregnancy. Offer condoms and/or contraceptives. 
Stay informed Make use of resources for providers, including toolkits and consultation service hotlines (www.cdc.gov/hiv/risk/prep/index.html). 

Finally, the ability of adolescents to adhere to a daily medication regimen and persist in their use of PrEP during times of HIV risk is an important consideration as well. In a US cohort study following YMSM, approximately one-third of those who had tried PrEP discontinued it, and 79% of those who discontinued never spoke to a doctor about doing so. The primary reasons for discontinuation included the following: trouble getting to doctor’s appointments (21.5%), issues related to insurance coverage or loss (20.0%), and not feeling that they are at risk for HIV (18.5%).29  For youth who are interested in PrEP but need additional support, some special considerations for improving adherence and communication around adherence can be found in Table 2.

TABLE 2

Adherence Support for Adolescents on PrEP

Description
Frequency of contact Adolescents may need to be seen more frequently to maximize PrEP engagement and adherence. 
 Ask a young person, “When would you like to come back?” 
 Offer interim contact if desired, including text messages or phone calls. 
Counseling strategies The relationship between the practitioner and the patient is a critical component of success. Trust has to be earned through genuine and nonjudgmental interactions. 
 More directive approaches to counseling may be preferred for adolescents. 
 Skill-building activities can be included in counseling with adolescents (eg, role play, decisional balance activities, or homework). 
Additional support Discuss supportive others in the adolescent’s life; explore who might be a PrEP ally for them, including parents or legal guardians. 
 Consider peer-support strategies, such as adherence buddies, social support groups, and adherence clubs. 
 Provide adherence tools that are adolescent friendly, such as pill containers that are key chains or lipstick holders. 
Description
Frequency of contact Adolescents may need to be seen more frequently to maximize PrEP engagement and adherence. 
 Ask a young person, “When would you like to come back?” 
 Offer interim contact if desired, including text messages or phone calls. 
Counseling strategies The relationship between the practitioner and the patient is a critical component of success. Trust has to be earned through genuine and nonjudgmental interactions. 
 More directive approaches to counseling may be preferred for adolescents. 
 Skill-building activities can be included in counseling with adolescents (eg, role play, decisional balance activities, or homework). 
Additional support Discuss supportive others in the adolescent’s life; explore who might be a PrEP ally for them, including parents or legal guardians. 
 Consider peer-support strategies, such as adherence buddies, social support groups, and adherence clubs. 
 Provide adherence tools that are adolescent friendly, such as pill containers that are key chains or lipstick holders. 

We recommend the following.

  1. Obtain a complete sexual history at each clinical encounter. Sexual experiences, practices, and identity may be fluid. Further clinical management and prevention messages and/or activities will be determined by the history obtained at the current visit.

  2. Provide HIV testing. Normalize the testing process by informing patients and parents and/or legal guardians that “our practice follows the recommendation that testing for HIV be offered to all adolescents and young adults at least once.” More frequent testing is indicated for youth who are identified to be at increased risk, such as YMSM, those with a history of condomless vaginal or anal intercourse, and/or those with an STI diagnosis. These are also scenarios that should trigger conversations about PrEP.

  3. Discuss PrEP as prevention. Providers should present PrEP to patients and parents and/or legal guardians as an effective HIV prevention method that is available for anyone who desires a proven method to prevent HIV acquisition.

Current surveillance data continue to reinforce the reality that adolescents and young adults are significantly impacted by STIs, including HIV. A range of highly effective biomedical, behavioral, and structural approaches can be integrated into clinical practices that address HIV prevention and provide early identification of HIV infection among youth. Pediatricians and adolescent medicine providers have all the tools they need to make significant contributions toward ending the HIV epidemic in youth populations.

Drs Hosek and Henry-Reid conceptualized, drafted, reviewed, and revised the manuscript; and both authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

COMPANION PAPER: a companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-3172

AAP

American Academy of Pediatrics

ATN 113

Adolescent Medicine Trials Network for HIV/AIDS Interventions 113

CDC

Centers for Disease Control and Prevention

FDA

US Food and Drug Administration

MSM

men who have sex with men

PrEP

preexposure prophylaxis

SAHM

Society for Adolescent Health and Medicine

STI

sexually transmitted infection

YMSM

young men who have sex with men

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.